The concept of brain death did not evolve to benefit organ transplants

Brain death/death by neurologic criteria: What you need to know

ABSTRACT

Since the beginning of time, man has been intrigued with the question of when a person is considered dead. Traditionally, death has been considered the cessation of all cardiorespiratory function. At the end of the last century a new definition was introduced into the lexicon surrounding death in addition to cessation of cardiac and respiratory function: Brain Death/Death by Neurologic Criteria (BD/DNC). There are medical, legal, ethical, and even theological controversies that surround this diagnosis. In addition, there is no small amount of confusion among medical practitioners regarding the diagnosis of BD/DNC. For families enduring the devastating development of BD/DNC in their loved one, it is the duty of the principal caregiver to provide a transparent presentation of the clinical situation and clear definitive explanation of what constitutes BD/DNC. In this report, we present a historical outline of the development of BD/DNC as a clinical entity, specifically how one goes about making a determination of BD/DNC, what steps are taken once a diagnosis of BD/DNC is made, a brief discussion of some of the ethical/moral issues surrounding this diagnosis, and finally the caregiver approach to the family of a patient who had been declared with BD/DNC. It is our humble hope that with a greater understanding of the myriad of complicated issues surrounding the diagnosis of BD/DNC that the bedside caregiver can provide needed closure for both the patient and the family enduring this critical time in their life.

A Biophilosophical Approach to the Determination of Brain Death

Technical and clinical developments have raised challenging questions about the concept and practice of brain death, culminating in recent calls for revision of the Uniform Determination of Death Act (UDDA), which established a whole brain standard for neurologic death. Proposed changes range from abandoning the concept of brain death altogether to suggesting that current clinical practice simply should be codified as the legal standard for determining death by neurologic criteria (even while acknowledging that significant functions of the whole brain might persist). We propose a middle ground, clarifying why whole brain death is a conceptually sound standard for declaring death, and offering procedural suggestions for increasing certainty that this standard has been met. Our approach recognizes that whole brain death is a functional, not merely anatomic, determination, and incorporates an understanding of the difficulties inherent in making empirical judgments in medicine. We conclude that whole brain death is the most defensible standard for determining neurologic death-philosophically, biologically, and socially-and ought to be maintained.

Rethinking Brain Death-Why "Dead Enough" Is Not Good Enough: The UDDA Revision Series

The emergence of cases of so-called "chronic brain death" seems to undermine the biophilosophical justification of brain death as true death, which was grounded in the idea that death entails the loss of integration of the organism. Severely neurologically damaged patients who can persist for years with proper support seem to be integrated organisms, and common sense suggests that they are not dead. We argue, however, that mere integration is not enough for an organism to be alive, but that living beings must be substantially self-integrating (i.e., a living organism must itself be the primary source of its integration and not an external agent such as a scientist or physician). We propose that irreversible apnea and unresponsiveness are necessary but not sufficient to judge that a human being has lost enough capacity for self-integration to be considered dead. To be declared dead, the patient must also irrevocably have lost either (1) cardiac function or (2) cerebrosomatic homeostatic control. Even if such bodies can be maintained with sufficient technological support, one may reasonably judge that the locus of integration effectively has passed from the patient to the treatment team. While organs and cells may be alive, one may justifiably declare that there is no longer a substantially autonomous, whole, living human organism. This biophilosophical conception of death implies that the notion of brain death remains viable, but that additional testing will be required to ensure that the individual is truly brain dead by virtue of having irrevocably lost not only the capacity for spontaneous respiration and conscious responsiveness but also the capacity for cerebrosomatic homeostatic control.

Eugène Bouchut's (1818-1891) Early Anticipation of the Concept of Brain Death

The conventional historical account of the concept of brain death credits developments and discoveries of the twentieth century with its inception, emphasizing the role of technological developments and professional conferences, notably the 1968 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. This essay argues that the French physician Eugène Bouchut anticipated the concept of brain death as early as 1846. Correspondence with Bouchut's understanding of brain death and one important contemporary concept of brain death is established then contrasted with current trends of defining death as the death of the brain. The philosophical factors that influenced Bouchut and the later developments of concepts of brain death are considered, with special reference to mechanistic philosophy and vitalism.

On Neurorights

In recent years, philosophical-legal studies on neuroscience (mainly in the fields of neuroethics and neurolaw) have given increasing prominence to a normative analysis of the ethical-legal challenges in the mind and brain sciences in terms of rights, freedoms, entitlements and associated obligations. This way of analyzing the ethical and legal implications of neuroscience has come to be known as “neurorights.” Neurorights can be defined as the ethical, legal, social, or natural principles of freedom or entitlement related to a person’s cerebral and mental domain; that is, the fundamental normative rules for the protection and preservation of the human brain and mind. Although reflections on neurorights have received ample coverage in the mainstream media and have rapidly become a mainstream topic in the public neuroethics discourse, the frequency of such reflections in the academic literature is still relatively scarce. While the prominence of the neurorights debate in public opinion is crucial to ensure public engagement and democratic participation in deliberative processes on this issue, its relatively sporadic presence in the academic literature poses a risk of semantic-normative ambiguity and conceptual confusion. This risk is exacerbated by the presence of multiple and not always reconcilable terminologies. Several meta-ethical, normative ethical, and legal-philosophical questions need to be solved in order to ensure that neurorights can be used as effective instruments of global neurotechnology governance and be adequately imported into international human rights law. To overcome the shortcomings above, this paper attempts to provide a comprehensive normative-ethical, historical and conceptual analysis of neurorights. In particular, it attempts to (i) reconstruct a history of neurorights and locate these rights in the broader history of idea, (ii) outline a systematic conceptual taxonomy of neurorights, (iii) summarize ongoing policy initiatives related to neurorights, (iv) proactively address some unresolved ethico-legal challenges, and (v) identify priority areas for further academic reflection and policy work in this domain.

A Framework for Revisiting Brain Death: Evaluating Awareness and Attitudes Toward the Neuroscientific and Ethical Debate Around the American Academy of Neurology Brain Death Criteria

BACKGROUND

There remains a lack of awareness around the American Academy of Neurology (AAN) procedural criteria for brain death and the surrounding controversies, leading to significant practice variability. This survey study assessed for existing knowledge and attitude among healthcare professionals regarding procedural criteria and potential change after an educational intervention.

METHODS

Healthcare professionals with increased exposure to brain injury at Mayo Clinic hospitals in Arizona and Florida were invited to complete an online survey consisting of 2 iterations of a 14-item questionnaire, taken before and after a 30-minute video educational intervention. The questionnaire gathered participants' opinion of (1) their knowledge of the AAN procedural criteria, (2) whether these criteria determine complete, irreversible cessation of brain function, and (3) on what concept of death they base the equivalence of brain death to biological death.

RESULTS

Of the 928 people contacted, a total of 118 and 62 participants completed the pre-intervention and post-intervention questionnaire, respectively. The results show broad, unchanging support for the concept of brain death (86.8%) and that current criteria constitute best practice. While 64.9% agree further that the loss of consciousness and spontaneous breathing is sufficient for death, contradictorily, 37.6% believe the loss of additional integrated bodily functions such as fighting infection is necessary for death. A plurality trusts these criteria to demonstrate loss of brain function that is irreversible (67.6%) and complete (43.6%) at baseline, but there is significantly less agreement on both at post-intervention.

CONCLUSION

Although there is consistent support that AAN procedural criteria are best for clinical practice, results show a tenuous belief that these criteria determine irreversible and complete loss of all brain function. Despite support for the concept of brain death first developed by the President's Council, participants demonstrate confusion over whether the loss of consciousness and spontaneous breath are truly sufficient for death.

Jahi McMath, a New Disorder of Consciousness

In this paper, I review the case of Jahi McMath, who was diagnosed with brain death (BD). Nonetheless, ancillary tests performed nine months after the initial brain insult showed conservation of intracranial structures, EEG activity, and autonomic reactivity to the “Mother Talks” stimulus. She was clinically in an unarousable and unresponsive state, without evidence of self-awareness or awareness of the environment. However, the total absence of brainstem reflexes and partial responsiveness rejected the possibility of a coma. Jahi did not have uws because she was not in a wakefulness state and showed partial responsiveness. She could not be classified as a LIS patient either because LIS patients are wakeful and aware, and although quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements or blinking, and respire on their own. She was not in an MCS because she did not preserve arousal and preserved awareness only partially. The CRS-R resulted in a very low score, incompatible with MCS patients. mcs patients fully or partially preserve brainstem reflexes and usually breathe on their own. MCS has always been described as a transitional state between a coma and UWS but never reported in a patient with all clinical BD findings. This case does not contradict the concept of BD but brings again the need to use ancillary tests in BD up for discussion. I concluded that Jahi represented a new disorder of consciousness, non-previously described, which I have termed “reponsive unawakefulness syndrome” (RUS).

The rise of organ donation after circulatory death: a narrative review

Solid organ transplantation saves and transforms lives. The original type of organ donation from deceased patients was controlled donation after circulatory death, previously referred to as non-heart beating organ donation. The rise of donation after circulatory death in the UK came about through advances in critical care and transplant medicine and support from several key organisations in developing a robust ethical, legal and professional framework. The transplant waiting list reached a historic peak in 2009-2010 of 8000 patients, but fell by 25% to 6000 in 2017-2018. There has also been a steady rise in the number of deceased donors and the number of donations after circulatory death. The contribution of donation after circulatory death to the total number of donations rose steadily between 2000 and 2012 and has remained about 40% since. Although the situation has improved for patients waiting for a transplant, deaths and long waits remain common. Changes to legislative, technical and peri-mortem procedures may greatly change future practices in donation after circulatory death in the UK.

Seven Faces of a Fatwa: Organ Transplantation and Islam

A new fatwa was announced by the British National Health Service (NHS) in June 2019 to clarify the Islamic position on organ donation. Additionally, the NHS promotional material presents brief arguments for and against organ donation in Islam. However, to date, research into the various fatwas on organ donation is required. This article goes beyond the dichotomous positions mentioned by the NHS and goes on to explore and summarise seven conflicting views on the issue extrapolated from an exhaustive reading of fatwas and research papers in various languages since 1925. Our discussion is circumscribed to allotransplant and confined to the gifting of organs to legally competent adult donors at the time of consent. These arguments include an analysis of the semantic portrayal of ownership in the Qur’an; considering the net benefit over the gross harm involved in organ donation; balancing the rights of the human body with the application of the rule of necessity; understanding the difference between anthropophagy and organ transplantation; understanding of death, and the conceptualisation of the soul. We argue that, given the absence of clear-cut direction from Muslim scripture, all seven positions are Islamic positions and people are at liberty to adopt any one position without theological guilt or moral culpability.

Brain Death and Organ Donation Rates in a City Hospital: A Retrospective Study

Introduction

Although organ donation rates have been increasing over the years, the lack of organ donation remains the most important problem in transplantation. By changing strategies, the Cekirge City Hospital in Bursa/Osmangazi has achieved a cadaveric donor rate of 24.9 per one million individuals in 2016; this rate is 21.5 in England, 20.9 in Norway, 14.7 in the Netherlands, and 10.6 in Germany.

Methods

Brain death cases were retrospectively evaluated between January 1, 2011, and December 31, 2016.

Results

There were a total of 137 brain death cases. Three of eight cases, five of 12 cases, three of 13 cases, 13 of 25 cases, 16 of 29 cases, and 21 of 50 cases became a donor in 2011, 2012, 2013, 2014, 2015, and 2016, respectively.

Conclusion

Deceased organ donation rates have increased over the years; however, the number of brain dead patients and the acceptance of organ donation by families have been increasing, but the percentage of brain death donations did not increase. We suggest that the reason for this situation is that well-trained and educated physicians diagnose more brain death cases and have a greater desire to treat end-stage organ failure patients, but the tendency of the public to donate has not increased as hoped. Donation and transplantation rates may be increased with a combination of well-trained, educated, and dedicated physicians with public education.

Are Brain Dead Individuals Dead? Grounds for Reasonable Doubt

According to the biological definition of death, a human body that has not lost the capacity to holistically organize itself is the body of a living human individual. Reasonable doubt against the conclusion that it has lost the capacity exists when the body appears to express it and no evidence to the contrary is sufficient to rule out reasonable doubt against the conclusion that the apparent expression is a true expression (i.e., when the conclusion that what appears to be holistic organization is in fact holistic organization remains a reasonable explanatory hypothesis in light of the best evidence to the contrary). This essay argues that the evidence and arguments against the conclusion that the signs of complex bodily integration exhibited in ventilated brain dead bodies are true expressions of somatic integration are unpersuasive; that is, they are not adequate to exclude reasonable doubt against the conclusion that BD bodies are dead. Since we should not treat as corpses what for all we know might be living human beings, it follows that we have an obligation to treat BD individuals as if they were living human beings.

A Thomistic defense of whole-brain death

Michel Accad critiques the currently accepted whole-brain criterion for determining the death of a human being from a Thomistic metaphysical perspective and, in so doing, raises objections to a particular argument defending the whole-brain criterion by Patrick Lee and Germain Grisez. In this paper, I will respond to Accad's critique of the whole-brain criterion and defend its continued validity as a criterion for determining when a human being's death has occurred in accord with Thomistic metaphysical principles. I will, however, join Accad in criticizing Lee and Grisez's proposed defense of the whole-brain criterion as potentially leading to erroneous conclusions regarding the determination of human death. Lay summary: Catholic physicians and bioethicists currently debate the legally accepted clinical standard for determining when a human being has died-known as the "wholebrain criterion"-which has also been morally affirmed by the Magisterium. This paper responds to physician Michel Accad's critique of the whole-brain criterion based upon St. Thomas Aquinas's metaphysical account of human nature as a union of a rational soul and a material body. I defend the whole-brain criterion from the same Thomistic philosophical perspective, while agreeing with Accad's objection to an alternative Thomistic defense of whole-brain death by philosophers Patrick Lee and Germain Grisez.

Lived Experiences of Iranian Nurses Caring for Brain Death Organ Donor Patients: Caring as "Halo of Ambiguity and Doubt"

Background:

Brain death is a concept in which its criteria have been expressed as documentations in Harvard Committee of Brain Death. The various perceptions of caregiver nurses for brain death patients may have effect on the chance of converting potential donors into actual organ donors.

Objective:

The present study has been conducted in order to perceive the experiences of nurses in care-giving to the brain death of organ donor patients.

Methods:

This qualitative study was carried out by means of Heidegger’s hermeneutic phenomenology. Eight nurses who have been working in ICU were interviewed. The semi-structured interviews were recorded by a tape-recorder and the given texts were transcribed and the analyses were done by Van-Mannen methodology and (thematic) analysis.

Results:

One of the foremost themes extracted from this study included ‘Halo of ambiguity and doubt’ that comprised of two sub-themes of ‘having unreasonable hope’ and ‘Conservative acceptance of brain death’. The unreasonable hope included lack of trust (uncertainty) in diagnosis and verification of brain death, passing through denial wall, and avoidance from explicit and direct disclosure of brain death in patients’ family. In this investigation, the nurses were involved in a type of ambiguity and doubt in care-giving to the potentially brain death of organ donor patients, which were also evident in their interaction with patients’ family and for this reason, they did not definitely announce the brain death and so far they hoped for treatment of the given patient. Such confusion and hesitance both caused annoyance of nurses and strengthening the denial of patients’ family to be exposed to death.

Conclusion:

The results of this study reveal the fundamental perceived care-giving of brain death in organ donor patients and led to developing some strategies to improve care-giving and achievement in donation of the given organ and necessity for presentation of educational and supportive services for nurses might become more evident than ever.

East-West differences in perception of brain death. Review of history, current understandings, and directions for future research

The concept of brain death as equivalent to cardiopulmonary death was initially conceived following developments in neuroscience, critical care, and transplant technology. It is now a routine part of medicine in Western countries, including the United States. In contrast, Eastern countries have been reluctant to incorporate brain death into legislation and medical practice. Several countries, most notably China, still lack laws recognizing brain death and national medical standards for making the diagnosis. The perception is that Asians are less likely to approve of brain death or organ transplant from brain dead donors. Cultural and religious traditions have been referenced to explain this apparent difference. In the West, the status of the brain as home to the soul in Enlightenment philosophy, combined with pragmatism and utilitarianism, supports the concept of brain death. In the East, the integration of body with spirit and nature in Buddhist and folk beliefs, along with the Confucian social structure that builds upon interpersonal relationships, argues against brain death. However, it is unclear whether these reasoning strategies are explicitly used when families and medical providers are faced with acknowledging brain death. Their decisions are more likely to involve a prioritization of values and a rationalization of intuitive responses. Why and whether there might be differences between East and West in the acceptance of the brain death concept requires further empirical testing, which would help inform policy-making and facilitate communication between providers and patients from different cultural and ethnic backgrounds.

Ethical controversies at end of life after traumatic brain injury: defining death and organ donation

Death is more than a mere biological occurrence. It has important legal, medical, and social ramifications that make it imperative that those who are responsible for determination of death be accurate and above suspicion. The medical and legal definitions of death have evolved to include consideration of such concepts as loss of integration of the whole organism, loss of autonomy, and loss of personhood. Development of the concept of brain death coincided with advances in medical technology that facilitated artificial ventilation and organ transplantation. More recently, the process of "timed" death with subsequent organ donation (controlled donation after cardiac death transplantation) has raised controversial questions having to do with the limits of treatments that facilitate organ transplant but might hasten death, and the duration of cardiac arrest necessary for declaration of death and the commencement of organ procurement. In this review, we discuss the background and ethical ramifications of the concepts of brain death, and of controversies involved in controlled donation after cardiac death organ transplantation.

Diagnosis of brain death

Brain death (BD) should be understood as the ultimate clinical expression of a brain catastrophe characterized by a complete and irreversible neurological stoppage, recognized by irreversible coma, absent brainstem reflexes, and apnea. The most common pattern is manifested by an elevation of intracranial pressure to a point beyond the mean arterial pressure, and hence cerebral perfusion pressure falls and, as a result, no net cerebral blood flow is present, in due course leading to permanent cytotoxic injury of the intracranial neuronal tissue. A second mechanism is an intrinsic injury affecting the nervous tissue at a cellular level which, if extensive and unremitting, can also lead to BD. We review here the methodology of diagnosing death, based on finding any of the signs of death. The irreversible loss of cardio-circulatory and respiratory functions can cause death only when ischemia and anoxia are prolonged enough to produce an irreversible destruction of the brain. The sign of such loss of brain functions, that is to say BD diagnosis, is fully reviewed.

The political economy of death and the history of its criteria

This paper argues for a constitutive link between ecologies of social interests and the social receptivity, if not also the formation, of some recent criteria of death. It maintains that these criteria have been embraced by ecologies that have been dominated by certain economic interests in pronouncing some patients dead. Moreover, the very same ecologies have also embraced philosophical representations of those criteria, but only such that were able to conceal these interests and thereby legitimize and reaffirm their hegemony. Based on this observation, the paper concludes that the current criteria of death and their philosophical representations are ideological constructs in the strict Marxian sense. They may or may not be 'really' true, but they are 'necessarily false' in one respect: they owe their social status to the fact that their self-professed role-pronouncing dead those who are dead-is not in accord with their objective, i.e., social, role-pronouncing dead those who should be dead.

Towards an effective definition of death and disorders of consciousness

There exists much controversy in providing an effective definition of human death, largely due to the lack of a rigorous separation and ordered formulation of three distinct elements: a universally accepted definition of death, the medical criterion (anatomical substrata) for determining that death has occurred, and the tests to prove that the criterion has been satisfied. The papers herein review medical standards, philosophical arguments, neurophysiological knowledge, behavioural and cognitive theory and the legal ramifications of the brain-oriented standards of death (whole brain, brainstem and higher brain). The papers examine the notion of connectivities and networks of conscious experience in order to formulate an effective definition of death, based on the basic physiopathological mechanisms of consciousness. We cannot simply differentiate and locate arousal as a function of the ascending reticular activating system, and awareness as a function of the cerebral cortex. Substantial interconnections among the brainstem, subcortical structures, and the neocortex are essential integrating components of human consciousness. This paper attempts to reconcile the brain-oriented standards that are currently inconsistent. The thread of the arguments is the basis for a standard of human death that includes consciousness as the most important function of the body, because it provides the capacity for integrating the functions of the body. The notion of consciousness as the ultimate integrative function is more consistent with the biologically-based systems than the more philosophically-based notions of personhood. Both sides of the argument are presented herein.

'Brain death': should it be reconsidered?

OBJECTIVE

To evaluate whether current clinical criteria and confirmatory tests for the diagnosis of 'brain death' satisfy the requirements for the irreversible cessation of all functions of the entire brain including the brainstem.

DATA SOURCES

Medical, philosophical and legal literature on the subject of 'brain death'.

DATA EXTRACTION/SYNTHESIS

We present four arguments to support the view that patients who meet the current operational criteria of 'brain death' do not necessarily have the irreversible loss of all brain (or brainstem) functions. First, many clinically 'brain-dead' patients maintain residual vegetative functions that are mediated or coordinated by the brain or the brainstem. Second, it is impossible to test for any cerebral function by clinical bedside exam, because the tracts of passage to and from the cerebrum through the brainstem are destroyed or nonfunctional. Furthermore, since there are limitations of clinical assessment of internal awareness in patients who otherwise lack the motor function to show their awareness, the diagnosis of 'brain death' is based on an unproved hypothesis. Third, many patients maintain several stereotyped movements (the so-called complex spinal cord responses and automatisms) which may originate in the brainstem. Fourth, not one of the current confirmatory tests has the necessary positive predictive value for the reliable pronouncement of human death.

CONCLUSION

According to the above arguments, the assumption that all functions of the entire brain (or those of the brainstem) in 'brain-dead' patients have ceased, is invalidated. Reconsideration of the current concept of 'brain death' is perhaps inevitable.