Whenever I say anything on the Internet on the subject of brain death, I'm always looking, or even pushing, in two directions at once.
On the one hand, it's overwhelmingly important to resist the misuse of the term 'brain dead' by the media and ill-informed people to refer simply to a lack of mental consciousness and as roughly synonymous with what is called a "permanent vegetative state." The intent in diagnosing brain death is to diagnose physical death, not any degree or type of lack of consciousness per se, and the inability to breathe on one's own (to give just one example) is an absolute sine qua non for the diagnosis. People in a so-called "permanent vegetative state," on the other hand, are usually breathing on their own and are not in any sense whatsoever physically dead. If we do not hold that line and correct the sloppy terminology, we will have people saying that living, breathing, moving human beings are 'dead', which is a very bad thing indeed.
On the other hand, when I say all of that, I worry that it will give the impression that I think the diagnosis of whole brain death is straightforward and unproblematic, whereas in fact I don't think that at all.
And my reservations about the diagnosis of brain death have recently been strengthened.
Via Wesley J. Smith comes the report of a just-out peer-reviewed article summarizing a whole bunch of evidence about the diagnosis of brain death. The article is "'Brain Death: Should it Be Reconsidered?" by KG Karakatsanis, in Spinal Cord (2008) 46:396-401. The article is not available on-line, but if I don't get overwhelmed with requests (which I don't expect I will), I'll send you a PDF copy upon request.
Karakatsanis writes in medical-ese, so I may have missed some things, but here are a few of the things I got: Patients diagnosed as brain dead continue to manifest functions normally attributed to the hypothalmus, which should be impossible if their entire brains had ceased functioning as is supposedly the case in brain death (p. 399). Patients diagnosed as brain dead often make movements which are put down to being sustained purely by the spinal cord, but the patterns involved do not correspond to those found in patients with high spinal cord injuries, as they should do if the brain is truly non-functional and the movements are explained as originating in the spinal cord (p. 397). Some patients diagnosed as brain dead cry (he calls it "lacrimation") during the early stages of organ removal (p. 399). Blood flow tests are sometimes used to diagnose the complete absence of blood going to the brain to confirm brain death. But in a number of cases where supposedly tests had determined that there was no blood flow to the brain, the brain continued to manifest EEG activity, showing a disturbing inconsistency in various tests for brain death (p. 399).
I was interested to notice that Karakatsanis does not mention what is apparently fairly well-known clinically--that anesthesia is sometimes used during organ removal in order to prevent supposedly brain-dead patients from moving around. In this BBC news article, an anesthetist is quoted as saying, "Nurses get really, really upset. You stick the knife in and the pulse and blood pressure shoot up."
Probably the one question that remains is what all of this means. There are a number of possibilities. Perhaps it really is possible for the whole brain, including the brain stem, to have permanently ceased functioning, while the heart continues to beat (sustained by a ventilator), and it really is possible to diagnose this objectively, but doctors are simply not using the right tests or not using them consistently. Perhaps there is some reliable test that has not yet been discovered or that is used only rarely. Perhaps there simply is no human physical state in which the whole brain has died but the heart continues to beat, even with mechanical aid. Perhaps such a state is very rare. Or perhaps there is such a state but there is no way that will ever be available to other human beings to diagnose such a state reliably.
In any event, all of this should raise sobering questions about the entire vital organ donation enterprise. As Wesley Smith notes, Karakatsanis goes in exactly the wrong direction: He suggests that we should just admit that patients diagnosed as brain dead are really physically alive and promote "openness and honesty" about this, allowing patients who want to donate their organs to give their consent ahead of time to having their organs taken while they are believed to be still physically alive. Consent is supposed to make it all okay. But Smith is entirely correct to point out that this would be a disastrous course of action to take. For one thing, it would amount to a statement that the distinction between physically dead people and physically alive people is morally irrelevant, which would, of course, open the door to the taking of organs from people who are unambiguously physically alive, whom no one can even possibly or plausibly claim are physically dead--the unconscious but breathing, the severely mentally disabled, and so forth. All under the specious moral disinfectant of "consent."
Whatever else we do, we must never, never go down that road.