Interview: All in the Mind
Brain Death, with Alan Shewmon
Interview: All in the Mind
Brain Death, with Alan Shewmon
Guests on this program:
Alan Shewmon
Professor of Neurology and Pediatrics, University of California (Los Angeles) School of Medicine
Ray Raper
Intensive care specialist, Royal North Shore Hospital, Sydney
Jim Hughes
Bioethicist, Trinity College, Hartford CA
All in the Mind: 2 February 2003 - Summer Series 6: Brain
Death
Natasha Mitchell: Hi, this is All In The Mind, and Natasha Mitchell with
you for the final in our Summer Series of popular highlights. Next week I’ll be
back with all new shows for 2003.
Today we’re looking at brain death.
You may not know this, but the medical diagnosis of brain
death has a relatively short history. It came into being just thirty-five years
ago now, when a committee of experts was asked to come up with a new definition
of death based on brain criteria. Ever since then, and increasingly over the
past decade, the critics of brain death have been growing. It’s true they’re
still in the minority, but they are asking some very interesting questions. For
example: if the brain dead aren’t really dead, then what does that mean for
transplant surgery – which is very much dependent on dead donors? Today, Radio
National’s Wendy Carlisle goes in search of some answers.
NEWSREEL MUSIC
ARCHIVE: Presenter: Our guest of
honour, Professor Christian Barnard.
Christian Barnard: People often ask me what was really the dramatic event
in the heart transplant. Of course, the stage when we had to move the heart of
the patient and inside his chest, inside the sac, where you usually find the
heart, there was just an empty sac with no heart there, and it was really
fantastic when we applied a shock to the transplanted heart and the heart
started to beat.
=====================================================
RADIO INTERVIEW
Wendy Carlisle: Dr. Christian Barnard, who performed the first heart
transplant in South Africa in 1968. It was in that year that a group based at
the Harvard Medical School in the US was asked to come up with a new criterion
for assessing whether or not someone was dead. The reason for this was driven by
new technology. Respirators developed during the polio epidemics of the 1950s
were now keeping patients alive who were in otherwise hopelessly vegetative
states. And a new field of medicine, transplant surgery, needed a supply of
organs from dead donors with beating hearts. And so the Harvard Medical
Committee came up with a diagnostic criterion for death called “brain death” –
the term used when brain function is deemed to have ceased totally and
irreversibly. Dr. Ray Raper is an intensive care specialist, and he’s written
about brain death for the National Health & Medical Research Council.
Ray Raper: The original discussion of this in the medical literature is
about a concept of coma depassé, some French literature which is trying
to recognize the state beyond coma when treatment could be withdrawn. But in
fact the Harvard criteria listed two reasons for trying to sort out brain
function criteria for certification of death. The first criterion was the burden
of futile treatment. The second listed criterion was facilitation of organ
donation. Now, you might say that’s a contrivance, but it nevertheless was the
way it was published, those two indications and in that order.
Wendy Carlisle: But clearly the two are linked, though.
Ray Raper: Oh, they’re linked, they’re linked. There’s no doubt they’re
linked, historically and practically. But they are not inexorably linked.
Wendy Carlisle: But according to Jim Hughes, who’s a bio-ethicist at
Trinity College in the United States, the idea of brain death has distinctly
cultural, utilitarian origins.
Jim Hughes: Well, organ donation right now is predicated on “cavaderic”
donation – both the donation of organs from actual cadavers, those who have
always been considered dead, and those who have suffered severe brain traumas,
whose organs we are able to maintain in a heart-beating body, breathing body,
until we are ready to turn off that switch, take out those organs and put them
in somebody else. That was the whole rationale, really, for this transition to
this new definition of death, a definition of death which I think always made
sense. There have always been people who were permanently unconscious, who were
as good as dead, and so I wouldn’t argue that it was simply a crass or an
illogical thing for us to do. But there wasn’t a real motivation to do it until
we had the organ transplantation from these bodies that we couldn’t kill,
because under the law and under our general moral revulsion to the idea, we
didn’t want to kill somebody to take their organs out. So what we did instead is
that we declared them dead.
Wendy Carlisle: So you’re saying that from your point of view, which is a
sociological-cultural-anthropological point of view, brain death as it was
imagined by the Harvard Committee in 1968, that’s not a medical fact, that’s
kind of a social compromise.
Jim Hughes: Well, Engels put it actually, one hundred and fifty years
ago, he said that death was a process. And that’s been an observation for many.
But if you look at extreme cases, you can see that there are transitional
states, grey states, between being alive and being dead. And the decision to
declare a certain line is not completely arbitrary, but it is culturally
specific, and it has certain motivations behind it. In this case, the
motivations were very clear. The motivations were to save lives and to serve the
needs of the living, the clearly living, taking the organs.
Wendy Carlisle: In the last decade, especially, there’s been a small but
growing collection of voices questioning whether the brain dead are really dead
at all. One of those dissenters is Alan Shewmon, Professor of Neurology and
Pediatrics at UCLA Medical School in the United States.
Alan Shewmon: Well, the term itself is kind of ambiguous from the start,
because in one sense it could simply mean death of the brain as an organ, just
like you can have necrosis or death of a finger, if you cut off the blood supply
to it. So the brain itself can die due to lack of blood supply. So one sense of
the term ‘brain death’ simply means that: total necrosis of the brain, if you
want a medical equivalent of it. The term is also used more colloquially to mean
death of the patient diagnosed in a neurological manner, and death due to some
neurological cause that results in brain destruction.
Wendy Carlisle: So is brain death the death of the person, in your
opinion?
Alan Shewmon: I used to think that it was. But in fact, during the 1980s
and early 90s I read a number of articles and gave lectures supporting that
idea, and since then I have had to change my opinion about it due to an
accumulation of evidence to the contrary.
Wendy Carlisle: What kind of evidence are you talking about here?
Alan Shewmon: Well, the theory is that the brain is the central
integrating organ of the body, and without brain function the body literally
disintegrates into a collection of organs and tissues, and is not a unified
organism any more. And that is the main line theory for why brain death is
supposed to be death. But I came across increasing reason to believe that
patients in this state did have signs of, let’s say, “living function” at the
level of the organism as a whole, and not just life in individual organ systems.
It is clear that hearts can beat independently without brain function, and many
other organs continue on their own, even without life in the remainder of the
body. But what we’re talking about here is not just the functioning of
individual organs or tissues, but a more unified holistic functioning. Many
patients in the state of brain death, if they get through the initial period of
acute dysfunction that requires quite intensive care, they often will stabilize.
So these are deeply comatose patients, so I would say that these patients are
deeply comatose, permanently comatose but they’re still living human beings.
Wendy Carlisle: I think you’ve actually called somewhere the notion of
brain death a medical fiction.
Alan Shewmon: A legal fiction.
Wendy Carlisle: A legal fiction. What does that mean, then, in your
opinion for the whole donor debate?
Alan Shewmon: I guess it’s also a medical fiction. You’re right.
Wendy Carlisle: Death, let alone brain death, is a difficult concept to
grasp and not everybody agrees with the views of Professor Alan Shewmon. Dr. Ray
Raper again.
Ray Raper: If you go back to the original Harvard criteria, that was a
group of people not just from the Harvard Medical School, but also from the
Divinity School, I think, and from Ethics and from Law. It was a bunch of people
who got together to try to nut out a problem, or to think about a problem, and I
think to say what they came up with is a contrivance merely to serve the
interests of organ donation is unfair. I can understand people having problems
with accepting that those who’ve lost all brain function are in fact, dead. But
I think it really does come back to how we see ourselves. And I think for a lot
of people, when all brain function has irreversibly ceased, they do see that as
the death of the person. The idea that death has to be something that we can
recognize, that because there’s such a contrast between life and death, those
two states are clearly different, we think we ought to be able to recognize very
easily the point of transition between life and death. But that’s not
historically the case, and we’ve used different ways of thinking about death and
dying. Some of my favourites are John Donne:
As virtuous men pass mildly away,
And whisper to their souls to go,
Whilst some of their sad friends do say
“The breath goes now”, and some say “no”.
That’s an elegant way of talking about this ambiguity of the transition between
life and death. So for practical reasons we, as a society, have had to define
life and death, and we do it in all sorts of different ways. I believe in New
Zealand law you’re dead when a doctor certifies you’re dead. And that’s the
criterion. In New South Wales law, you’re certified dead when all brain function
is irreversibly ceased, and that’s the notion that we’ve been talking about – or
when their circulation has irreversibly ceased. But that doesn’t mean that
that’s the end of a process. It’s a point in a process. Some tissues remain
viable for many hours after the heart has ceased. Corneas can be retrieved for
transplantation as viable tissues, and so can skin, for even up to twenty-four
hours after death in a conventional sense. And skin and hair continue to grow
after death in a conventional sense for many hours. So that there is some
function in the body, even when we define death in the conventional sense of no
breathing and no circulation. So I don’t think we should get too caught up in
the fact that this brain death notion, or certifying death based on a brain
function criterion, is a contrivance. Of course, it is in the sense that we have
to arbitrarily define this in some way, because if we waited until every cell in
the body had died, until every single function in the body had died, it would be
very difficult for us to certify that anyone was dead that hadn’t actually
structurally decomposed.
Wendy Carlisle: There are some people out there who think that in the
not-too-distant future, the line between life and death will become more blurry
than it is now. One of those people is Jim Hughes – who, I should also mention,
is Secretary of the Trans-Human Society in the United States. Well, Jim believes
that medical science will keep pushing the limits.
Jim Hughes: Well, the second thing that’s going to happen, and is already
happening, is that brains which have had a cascade of destruction throughout
them – such that in the past they would have gone completely necrotic, and the
entire brain would have been unusable after a certain point – we are now
increasingly able to take those brains, stop the cascade of death in the brain,
and potentially now bring back neurological activity, bring back neural cell
growth, re-introduce stem cells which will apparently magically find their way
to the parts of the brain that are damaged, and attach themselves, and begin to
function in the way they’re supposed to function and begin to pick up a role in
the brain. We are also beginning to be able to introduce silicon computer
interfaces with the brain, that could in say five, ten years allow the brain to
interface with an advanced computer, and the computer could begin to take on
various aspects of neurological function – and, of course, do many other things
as well. So those technologies – the organic technologies, the pharmaceutical
technologies, the cybernetic technologies of neural remediation – will mean that
if you got brought in and you had a severe head injury, you’re no longer going
to be considered automatically dead. There’s going to be a period in which you
have to be subjected to a series of tests, and potentially a rather protracted
series of tests, to see whether there’s enough of you left in your brain after
we try to bring it back. Just as we do now with concussions; when a brain comes
in with concussion, and they’re unconscious, we wait a couple of weeks to see
whether they wake up, and see what’s left of their memories, to see how
neurologically damaged they are. It’s going to become even more complicated in
the future, because in addition to, during that waiting period, we’re going to
be introducing all these technologies to see if we can bring anything back, and
so even someone that we would consider brain dead today, may in the future
simply be nominally dead until we can really figure out if they’re dead or not.
Death is going to be increasingly like someone who’s missing in war and you just
have to wait until the war’s over and see if they wander out of the battlefield
or wander out of the concentration camp someplace. It’s going to be a matter of…
there’ll still be grieving, there’ll still be great uncertainty and unhappiness,
but eventually something may wander back out. Now, the question is: What is it
when it wanders back out, if the person has lost all of their memory? If they
still have some of their habits, some of their preferences, if they still
remember their name but they’ve lost their entire childhood, they don’t remember
you any more, are they still the same person? Those kinds of questions about
what is a person will become increasingly central.
Wendy Carlisle: Well, that might sound like science fiction from Jim
Hughes, but then science fiction has an uncanny knack of predicting the future.
So what does Dr. Ray Raper think? Could the new medical technologies of the
future bring the brain dead back to life?
Ray Raper: No.
Wendy Carlisle: That’s just science fiction?
Ray Raper: That’s just science fiction. Or miracles, I suppose. But no,
that’s not possible, because it’s never going to be possible to regenerate… it
may be possible to regenerate nervous tissue at some stage in the future. It’s
never going to be possible to regenerate the entire brain of a person. When I
say that, I mean not in anything like a foreseeable, reasonable, scientific
future. Because the way that this occurs, is that there’s a massive injury to
the brain, which results in massive swelling of the brain, which results in an
increasing pressure inside the skull, which reduces the blood flow to the brain.
And the context in which all brain function is documented to have irreversibly
ceased, is when the brain cells collectively have been deprived of oxygen. So
many, all, of the brain cells themselves are dead. And that’s the basis on which
all brain function ceases.
Wendy Carlisle: What about the miracle of what we hear could be in the
future for stem cell research?
Ray Raper: Then you would be presumably trying to grow a new brain, and
that’s certainly in the realm of science fiction, and I can’t imagine it ever
happening. But if you developed a new brain from a stem cell, are you then
proposing that we would graft this onto the old body in some fashion? That’s
certainly not possible at the moment, but is really in the realm of science
fiction, not of reality.
Wendy Carlisle: In Australia there are two and a half thousand people on
the transplant waiting list, but there are less than two hundred donors a year,
and that number is falling. The pressure to increase organ retrieval is
increasing, and people like Dr. Alan Shewmon believe the consequences of
challenging the brain death notion are quite profound.
Alan Shewmon: Well, I think it means that we have to re-think the basis
for donation. My interest is as a neurologist, and about the validity of this
concept of brain death and the consequences of that, need to be studied
carefully by people who are involved in transplants. An ethicist, that’s outside
my own field so to speak, but I don’t think it necessarily causes a death blow
to organ donation, especially if there is more research into methods of
preserving organ viability after cessation of circulation. I think this is most
important for heart transplant. Already they have pretty good methods of
preserving organs in the case of kidney donors, even after cessation of
circulation. So these transplants, I mean the non-heart transplants, don’t
depend as much on the notion of brain death being death as heart transplants do.
But even with heart, with some creative re-looking at the situation, there may
be ways around that.
Wendy Carlisle: Where do you think it’s going to end? Do you think there
is a movement towards doing away with the idea of brain death?
Alan Shewmon: Well, there’s certainly a movement about it. I’m not the
only one, and the number of critics of brain death seems to be growing
significantly, especially over the last decade. And it’s interesting that
criticisms of the concept come from quite different directions, and there are
more and more who have come along and pointed out inconsistencies between the
standard theory and the claims of whole brain death versus the diagnostic
criteria. So that what is actually diagnosed in practice doesn’t necessarily
correspond to what it’s supposed to be in theory, or is in the statutory law. In
this country, for example, and most other countries that have a “whole brain
death” standard, although the law defines it as irreversible non-function of the
entire brain, the diagnostic criteria don’t look at all the functions of the
entire brain, but look only at brain stem functions – and they allow for some
functions of the brain, such as hypothalamic function, which regulates the
pituitary gland and some electrolyte balance.
Wendy Carlisle: Professor Alan Shewmon, with some of the inconsistencies
in the diagnosis of brain death in the United States. What about here in
Australia? Do we test all brain functions when ascertaining brain death?
Ray Raper: No, the definition of death doesn’t require us to test all
brain functions. The definition of death requires that we certify that all brain
function is irreversibly ceased. How that was to be certified was not prescribed
in law, and neither was it prescribed by the Law Reform Commission when they
drafted this definition of death originally. That was left up to professional
consensus.
Wendy Carlisle: That’s not a massive loophole is it?
Ray Raper: I don’t think so. I don’t think it’s a massive loophole. You
do run into problems of: What do you mean by “function”, and how does that
interact with activity? And I certainly think that the way we practise in
Australia is defendable in terms, or is consistent with the definitions, and it
has certainly stood the test of time over many, many years now. So from a legal
point of view, when we certify somebody dead based on the brain function
criterion, they aren’t as good as dead, they are dead.
Wendy Carlisle: Do you believe that somebody has to be dead to be an
organ donor?
Ray Raper: Let me say that a lot of organ donors aren’t dead, those are
the living donors. You can donate blood, bone marrow, even kidneys and even part
of your liver as a living donor.
Wendy Carlisle: But heart donors do, don’t they?
Ray Raper: Heart donors have to be dead, yes. And do I believe that’s
necessary? There are a lot of difficulties if we move away from that concept,
but no, I don’t it’s absolutely essential that we define it in those ways. We
could define things differently. We could write things up differently. We could
say “that one can be an organ donor if you fulfill certain criteria, and one can
be buried if you fulfill certain criteria”, and those two criteria don’t
necessarily have to be the same thing. And there would be some utility in that.
There would be some major philosophical problems associated with it that would
need to be worked through, but it wouldn’t be an impossible proposition.
Wendy Carlisle: So what do you think the impediments are to uncoupling
brain death and organ donation? Is it too radical?
Ray Raper: It’s certainly radical. The problem is that you then run this
risk of people being concerned about their own futures, I think. There is a
certainty about the process now, that in requiring that all organ donors be
dead, there’s a certainty about that that’s reassuring for some potential
donors. That is, for you and me walking around in the streets, I guess.
Wendy Carlisle: What, that doctors won’t kill them to get their organs?
Ray Raper: Something like that, or something of that nature. Not everyone
would agree with that, and there is a philosophical issue in there, about using
people for the benefit of others prior to their death, and so on.
Natasha Mitchell: Dr. Ray Raper, Intensive Care Specialist at Sydney’s
Royal North Shore Hospital, speaking with Wendy Carlisle who produced today’s
feature. That’s all for this week – thanks today to David Rutledge to Jenny
Parsonage for studio production. Starting next week: a whole new feast of
programming for 2003.
Guests on this program:
Alan Shewmon
Professor of Neurology and Pediatrics, University of California (Los Angeles) School of Medicine
Ray Raper
Intensive care specialist, Royal North Shore Hospital, Sydney
Jim Hughes
Bioethicist, Trinity College, Hartford CAhttp://www.abc.net.au/rn/science/mind/s746719.htm
Source:
© 2007 Australian Broadcasting Corporation
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