SOURCE FOR OTHER ARTICLES ON PVS (BMJ FEB/2001) AND LINKS AT END OF "UNDERSTANDING BRAIN DEATH"
The term "brain-dead" was coined In 1965, when a renal transplant took place using organs donated from a patient with no recorded brain function. To review the full article see: Definition Of Death Debated
We live in a "disposable society", where it is common to discard whatever is useless or no longer functions. When a determination of "death" is based on cessation of brain functions, the individual is determined to be "dead" (though he is often treated as "alive" until it is more convenient to excise organs or do research.) This represents a major and, and we think unacceptable change in the patient-doctor contract, as well as in patient-hospital, doctor-hospital relations and in social relations generally.
Brain death, or more accurately stated, brain-related criteria for death, revolves around the fact of death. Other issues that are frequently brought to mind in such discussions include the use or non-use of a particular treatment, e.g., a ventilator. It is not our position that everyone be placed on a ventilator before death, nor do we contend that a ventilator cannot be stopped until there is putrefaction or gangrene. The use or non-use of a ventilator is a topic separate from brain-related criteria for death. Organ transplantation is another issue. We are not opposed to organ transplantation, but we are opposed to removing a vital organ from someone, who if he or she is not yet dead, he or she will certainly be dead after the organ has been removed. We are opposed to research on those determined to be dead based on cessation of brain functions, but otherwise alive.
|DYING-BUT NOT DEAD|
The pronouncement of death has changed radically over the past 10-15 years. Before that, the physician and other interested parties had only one objective, i.e., to be sure that a person not be buried or cremated alive. The new approach is not as sure--now, there is needless risk of one patient's life to benefit another. For example, the expense of medical care may be a factor for the relatives or those who pay the bills, or another patient may benefit through organ transplantation, or the physician himself might benefit. Often the liability for death of a patient is less than the liability for continued life with a handicap. Or how about the benefit of all mankind? Research has been done after a determination of death which was based on cessation of brain functions.
|DEAD-TREATED AS ALIVE|
Is the person dead? If the answer is no, then he is still alive and must be treated as such. If we don't know the answer, we are not free to remove organs or carry out research that will kill the person if not yet dead. If the answer is yes, then the question is "which set of criteria was used to make the determination of death?"
Brain-related criteria revolve around 3 kinds of observations: The first is clinical observation of an absence of certain brain functions, e.g., shining a light in the eye and observing no pupil response, or putting ice water in the ear and observing no eye movement. Another is doing an electroencephalogram, commonly known as an EEG. The EEG is a recording of electrical activity from the surface of the brain. Little or no information is obtained from deeper in the brain. The Minnesota and British Criteria do not even include the EEG. Some of the criteria use a technique to evaluate absence of circulation to the brain. These tests are not absolute and at times might actually result in the side-effect of spasm of the vessels--thus, causing what is being searched for, i.e., no circulation to the brain.
The new criteria confound loss of function with physical destruction. For example, a computer cannot function without electrical current. During sleep there is loss of some brain functions which recover, with or without an alarm clock. Narcotics and toxins result in cessation of many brain functions. An antidote or body metabolism restores these functions. Destruction includes alteration of the basic-structure, i.e. structural or organic change resulting in losing the capacity to function. The new criteria are for cessation of functions. None of the criteria are for destruction of even the brain, much less destruction or death of the organism.
|SUSPECT CRITERIA -- 30 WAYS TO BE DEAD|
|BENDING THE CRITERIA|
If one uses the Minnesota Criteria, the British Criteria, and now the published Guidelines of the President's Commission, it is not necessary to include EEG evaluation in determining death. In which case, if the cortex is still functioning, but is wholly cut off from manifesting its activity clinically by damage elsewhere in the brain--something that does occur and which an EEG can clearly show--then this functioning (which could involve memory, feelings, emotion, etc.) is suddenly irrelevant to the person's life or death. According to the Collaborative Study, 8% of those declared dead on the basis of those criteria omitting the EEG, still have cortical activity when evaluated by non-clinical means (EEG). Thus, action such as excision of a beating heart results in killing at least one in twelve under such circumstances. As Dr. A.E. Walker (Clinical Neurosciences, 1975) has written, this represents " . . .an anomalous and undesirable situation." Will not the general public have stronger words?
Dr. Frost wrote in the Journal of Pediatrics in January 1981, there is "deep disagreement. . . whether brain-death is synonymous with death. Death of the brain is not the same as death in a traditional sense." While there is such disagreement, already more than 30 states have a cessation of brain function law that was passed either through statute or a state supreme court ruling.
|DEAD MOTHER-LIVE BABY|
The Uniform Determination of Death Act (UDDA) has been supported by the AMA, the ABA, and the Uniform Law Commissioners, as well as others.
The UDDA accepts two separate, readily distinguishable, clinical situations as death, both of which can be manifested successively in the same individual. For example, an individual can be determined to be "dead" based on any one of more than thirty, non-identical sets of criteria (which in itself should cause considerable concern) for determining "irreversible cessation of all brain functions." At that point, in practice, the ventilator will often be continued. Everyone in attendance can witness the intact circulatory system via the sound or oscilloscopic display of the beating heart, as well as the recordable blood pressure. The intact respiratory system is manifest through the normal color of the skin. The exchange of oxygen and carbon dioxide can be verified by determining blood gases (pH, pCO2, and pO2). The intact interdependence of circulatory and respiratory systems can be observed easily, by any and all, merely by applying pressure to the skin, resulting in blanching, only to be followed by a normal color within a few seconds after removal of the pressure. With more sophistication, and intact endocrine system (pituitary, thyroid and adrenal hormone production) can often be demonstrated. Detoxification by the intact liver can be documented through appropriate testing. If the individual declared brain-dead is pregnant, then the mother and the fetus can be maintained until the fetus matures and is better able to adjust to an extrauterine environment (JAMA, Sept. 3, 1982).
Clearly there are many signs, including the vital signs, which both physicians and laymen are accustomed to associate with being alive. When support by the ventilator is gradually reduced or, more often, when it is turned down abruptly, everything else may stop or, sometimes, the individual resumes spontaneous breathing. On the other hand, whether or not the support is gradually reduced or abruptly stopped, if the beating heart is excised and no substitute is implanted, the other set of criteria acceptable according to the UDDA will be fulfilled, at which time the individual manifests the findings more universally identified with the fact of death. Are we not being asked to accept two medically clearly distinguishable situations as equivalent and identical?
|1. To say a patient with a beating heart, a
normal pulse, a normal blood pressure, a normal color, and a normal
temperature is dead is false.
|2. A cessation-of-brain-function law is not
needed to stop a ventilator.
|3. If brain-related criteria are not based on
valid scientific data, action that is taken results in killing.
|4. Cessation-of-brain-function laws, when
followed by living will and death-with-dignity laws, are a part of, or lead
"Great care must be taken not to declare a person dead even one moment before death has actually occurred. Death should only be declared after, not before, the fact, as to declare death prematurely is to commit a fundamental injustice. A person who is dying is still alive, even a moment before death, and must be treated as such."
"In conclusion, we believe that destruction of the entire brain can occur, but that criteria to determine this state reliably have not been established. Cessation of brain function is not the same as destruction. In the present state of the art of medicine, a patient with destruction of the entire brain is, at the most, mortally wounded, but not yet dead. Death ought not be declared unless and until there is destruction of the entire brain, and of the respiratory and circulatory systems as well."(4)
1. Byrne, P.A., O'Reilly, S., and Quay, P.M., "Brain Death - An Opposing Viewpoint", JAMA, 242; 1985-1990, 1979.
2. Byrne, P.A., O'Reilly, S., Quay, P.M., and Salsich, P., "Brain Death - The Patient, The Physician", and Society, Gonzaga Law Review, 18/3, 429-516, 82/83.
3. Byrne, P.A., and Quay, P.M., "On Understanding Brain Death", 1 - 45, 1983. Available by calling (402) 477-3993.
4. Evers, J.C., and Byrne, P.A., "Brain Death - Still A Controversy", The Pharos of Alpha Omega Alpha 53/4, 10 - 12, 1990.
5. Byrne, P.A., and Nilges, R.G., "The Brain Stem in Brain Death". Issues in Law & Medicine, 9(1), 3-21, 1993.
6. Byrne, P.A., Nilges, R.G., and Evers, J.C., "Anencephaly - Organ Transplantation?", Issues in Law & Medicine, 9 (1), 23-33, 1993.
7. Quay, P.M., "Utilizing the Bodies of the Dead", St. Louis University Laws Journal, 28/4, 889-927, 1984.
BMJ 2001;322:352-354 ( 10 February ) Education and debate Ethical issues
in diagnosis and management of patients in the permanent vegetative state http://www.bmj.com/cgi/content/full/322/7282/352
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