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Serious questions about brain death in new article

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.

Comments (19)

If one considers the soul to be (among other things) the principle of integration of the body, it would seem that the disintegration of the body is a more sure sign of death than brain activity. I would be wary of destroying a body that is not showing signs of disintegrating any time soon. But I think hylomorphism is going out of style...

I'm a substance dualist rather than a hylomorphist, and I agree with you. The whole project of attempting to remove vital organs from anything other than a corpse that has achieved room temperature (at which point, I understand, the organs would not be usable anyway) seems to me fraught with great problems. I would go even farther than that, but that, at least, seems to me something that should have been questioned a lot more at the outset.

Lydia,

You are correct that the media are sloppy when reporting on this issue. Persistent vegetative state is frequently reported as brain death, and the two are certainly not the same, although they do fall on a continuum of severe brain damage.

What can be confusing is that the line between life and death is not absolute. A body that is in rigor mortis is certainly dead, but a person that was recently alive yet has no heartbeat or respirations is technically dead but can be resuscitated. Death is a process.

Brain death is a clinical diagnosis that can be determined by physical exam alone, and most institutions require two physicians to independently make this diagnosis. Another method is to perform a cerebral blood flow study, which is simple to perform and the results are difficult if not impossible to misinterpret. In my opinion, blood flow studies should be used in addition to the two examinations, as this reduces potential errors of subjective judgment.

In the USA, brain death equals death. That is, if a person is brain dead the physicians can remove life support and allow the rest of the body to die, even against the objections of the family. This rarely happens, as most physicians are sensitive enough to follow the wishes of the family. Even with life support, a brain dead patient's body will not continue to function for long, which is in contrast to a PVS.

I understand this is a sensitive subject. I agree that determination of brain death should be strict and rigorous. However, if the criteria are irrationally altered, say to require death of the heart as well as the brain, then organ donations would be severely limited, which would lead to more suffering.

Robert, I'm well aware of the legal situation in America. One of my greatest concerns, as you can tell, is that we not _loosen_ the legal definition of 'death' for purposes of vital organ removal. The whole brain death definition is, at least, a sort of watershed to hold back the evil of beginning to take vital organs from people diagnosed as PVS, Alzheimer's patients, and the like. And this is not alarmism, for such things have indeed been proposed.

What I am saying in this piece, however (and what for some strange reason you do not acknowledge), is that there are some very serious questions being raised as to whether it is indeed possible reliably and objectively to diagnose brain death. This has been a question in many people's minds for a long time. There was a young man not long ago diagnosed as brain dead both clinically and by at least one blood flow scan. I believe the blood flow scan was a PET (I've been meaning to re-look up this case), and I know that at least one commentator on Secondhand Smoke said that this was the wrong scan and known to be unreliable. In any event, the young man began moving voluntarily and is now up, talking, and recovering. Obviously, you can say a mistake was made. But what the article I cite is questioning is how good such diagnoses _ever_ are. Nor is this guy some sort of pro-life warrior. Far from it, as the end of my post shows. Nor is he the first one in a medical, peer-reviewed journal to raise such questions. He cites Truog and Robinson repeatedly.

The pain-like responses during organ removal cited in the BBC article are _very_ disturbing and have disturbed us mere laymen for quite some time. What is interesting is that now the medical professionals themselves are starting openly to question how good a brain-death diagnosis is, even when done according to all the protocols. This means that the statement that it would be "irrational" to require heartbeat cessation as well for the definition of death is a rather tendentious thing to say. Again, there are serious questions here as to whether people diagnosed as brain dead, even rigorously diagnosed, are indeed physically dead. That is interesting, to say the least. I think it should interest everybody, given how widespread it is for people to be carrying cards around agreeing to be organ donors if they should be in an accident, etc.

Lydia,

Actually, the main purpose of my comment was to acknowledge that it is indeed not possible to objectively diagnose brain death. That is to say, brain death cannot ever be declared with absolute certainty.

Well, why is this so? Because determining brain death is a scientific enterprise, and by definition anything scientific is provisional and uncertain. The best science can do is say that something is very likely to be the case, or very probably true. Brain death is somewhere on a continuum.

We all live with uncertainty, and this is the case in medicine more than most people are willing to admit. We do our best to reduce the degree of uncertainty.

After looking up tendentious, I realize I have not been clear. My use of the word irrational was not meant to offend. This is what I am trying to get across. What makes us us is our brain, not our heart. I think you would agree that if Joe received a heart transplant, he would still be Joe. But if Joe's body received a brain transplant, we would no longer consider that body and brain to be "Joe".

In fact, a brain transplant is the only organ donation where you would rather be the donor than the recipient!

So, I acknowledge that this is a sensitive subject. Whether or not we ought to transplant organs is not a scientific question, but rather a metaphysical one. In my opinion, we ought to transplant organs if brain death is declared by two physicians along with a brain scan that shows no blood flow to the brain. In such a situation, the person and personality is almost certainly gone from that body.

If we are not comfortable with "almost certainly", then we ought never transplant organs.

Well, to make it personal, with my father being an organ donor and suffering from Alzheimer's but otherwise being bodily healthy, I am most definitely NOT "comfortable" with "almost certainty" where the diagnosis of death is concerned.

Better people die a natural death of heart disease than possibly kill someone still living, or even cause terrible suffering to someone "almost" dead, to get them a new heart. And yes, I would refuse receiving donor organs myself, or for my family members, with this lack of certainty before me.

I'll write more later, but briefly: If we were talking about "almost certainly," a lot fewer people would be bothered. After all, we're pretty far from "almost certainly" when you have supposedly dead bodies "lacrimating" while their organs are being removed, their blood pressure and pulse going up in response to the knife, and so forth. _Very_ far from "almost certain." Actually, epistemology is an area of special study for me. I have my own purely ethical questions about taking vital organs even from unquestionably dead bodies. But I'm setting those aside for purposes of this post. If it's just a matter of dealing with probabilities, that's not a problem. I understand full well the difference between absolute certainty and what we might call "practical certainty"--some very high degree of probability. In fact, the article makes it pretty clear that even if we accept that the total cessation of all functions of the whole brain, including the brain stem, equals physical death, there are real questions about the reliability of the tests _for_ such total cessation. The tests conflict with one another, the movements in people who have been diagnosed using the tests do not appear to be correctly attributed to the spinal cord, functions of the brain (such as hypothalmic functions) appear to be continuing after diagnosis, and so forth. So this is not a matter of "almost certain."

Okay, that was longer than I meant to write.

"Practical certainty" is better phrasing and conveys more accurately what I am clearly failing to get across.

"Brain Dead" is a phrase physicians use to describe a particular state of a brain. Like all words and phrases, it does not have an inherent meaning, rather the meaning comes from how it is used. As it is currently used by physicians in the USA, "brain dead" means that when we perform a particular set of neurological tests we get a particular set of results. That, by definition, is what brain dead means.

Now it seems you want to say that what physicians are calling "brain death" might not be REAL brain death. OK, that's fine. As I have said, death is a process. It is a continuum. Reasonable people frequently disagree about where we draw a line on a continuum.

However, if your definition of REAL brain death includes a metaphysical notion, then no legitimate physician will be able to determine brain death with any practical certainty.

Well, supposedly what 'brain dead' meant as a _scientific_ or _medical_ term was that the whole brain, including the brain stem, had entirely and permanently ceased functioning. You'll find that definition all over the place. The tests are supposed to be ways of finding out if that has really happened. They are criteria, not definitions. You can call "permanent cessation of all functioning of the brain, including the brain stem" a "metaphysical" idea if you like, but it was supposed to be an objective statement of what is, in fact, the case in the physical world. After all, if you said of a body that was decaying and had had no heartbeat for three days, "The brain of this body has ceased its functioning in all parts of the brain, including the brain stem," no one would say that this was some sort of wussy metaphysical statement. It would be taken for a bare statement of physical fact.

Yikes. It may be that meaningful communication between us is just not be possible.

Yes, brain dead means permanent cessation of brain function. But in a practical sense, how can we make that determination? Well, some people claim they have "other ways of knowing". I myself, do not have these powers. Rather, I determine the brain state by performing a test. A test that to a high degree of practical certainty indicates that the brain in question will never again function.

Some patients that are brain dead may have limb movements. They may have tearing. They may shrug. However, none of those things indicates brain function. Heck, most brain dead patients retain the common knee jerk reflex. But the knee jerk tests the spinal cord and not the brain. It is the brain that makes us us, not the spinal cord.

Now, if you have another way of determining the state of the brain, I would love to know it. After all, what I believe is provisional, and based on the best available evidence. Your statement that organ donation should be delayed until the donor's body reaches room temperature seems bizarre and arbitrary. Why should the timing of the procedure be determined by the setting on a thermostat?

If you know of a case where a patient's brain resumed functioning after failing the practice guidelines for determining brain death as outlined by The American Academy of Neurology, please share it.

We seem to perceive this issue so differently. I know of no single case where proper guidelines were followed and brain death was declared in error. Yet people die every single day because they can't get a transplant. These people are children and parents and siblings and spouses. They suffer. Their family's suffer.

In contrast, a body with a non-functioning brain does not suffer. Also, family members of donors report that their grief is reduced when they learn that their loved one's gift has saved lives.

The guidelines should be followed with care and rigor, no question. But I am aware of no evidence that inappropriate transplants are occurring in the US. On the contrary, organs that could save lives and reduce suffering are being wasted. I think that's tragic.

Well, for one thing, Robert, it appears to me that you aren't paying attention even to the arguments I put in the main post from the article. As a doctor or medical person (which I'm guessing you are) you probably have easy access to this article, and to Truog and Robinson's, too. Maybe you should read them. The article I'm citing _questions_ the claim that all the movements in question can be attributed to the spinal cord, and it questions it on the grounds that the pattern should be identical to those in people with high spinal cord injuries, where there are several days of complete flaccidity before spinal-cord mediated movements set in, but this is not what we find in supposedly brain-dead people who move. So the attribution to the spinal cord of the movements is called into question. The appearance of hypothalmic function is another reason to question the validity of the tests even when applied rigorously. And whence comes your high confidence that tearing--and note, tearing apparently _in response to_ the knife--and similarly, elevated heart rate and blood pressure in response to the knife, are not evidence of brain function? They sure as heck sound like it to me. Isn't absence of deep pain response supposed to be one of the tests for brain death?

You see the point? It isn't that I question whether the tests done are the best available. That may well be true. It's that I question whether they are good enough, given these specific, empirical reasons to think that there *is brain function going on* when the brain death tests are telling us that there is no such function.

There actually have been cases where people were diagnosed as brain dead and resumed function. This is the most dramatic:

http://www.woai.com/mostpopular/story.aspx?content_id=76901869-2a7e-4e9a-ba69-caa4157319be

If you research the story further, you will find that a blood-flow test had been done. As I said, a commentator on a different thread opined that a different blood-flow test should have been done instead. In any event, there seems to be no question that he passed all the clinical tests for brain death and that at least one blood flow test of some kind was performed and shown to his relatives. He was diagnosed as brain dead by doctors who were trying to be careful and rigorous. You can say they weren't careful and rigorous enough. In fact, that's what you have to say given your position. But I think you should be a lot more cautious than that, given in addition the considerations I have raised above.

A neurologist's in-depth assessment of the Zack Dunlap case can be read here:

http://www.theness.com/neurologicablog/?p=258

And whence comes your high confidence that tearing--and note, tearing apparently _in response to_ the knife--and similarly, elevated heart rate and blood pressure in response to the knife, are not evidence of brain function? They sure as heck sound like it to me. Isn't absence of deep pain response supposed to be one of the tests for brain death?

Yeah, I need to read the article. I have no clue what the brain death criteria are in Greece. I found the abstract and I'll try to hunt down the whole thing. I'm an internist not a neurologist, so the journal Spinal Cord
is not something I normally read.

If science has taught us anything, it is that the world is not as it seems. It seems like the Sun rises. It does not. It seems like my desk is solid. It's not, it's mostly empty space. It seems like a flower is solid yellow. It's not, to a bee it's multi-colored and striped. It seems like time passes at the same rate. It does not, time varies with speed. It seems like the earth's gravity pulls on the ball you drop. It does not, the earth curves space and the ball follows the curve. It seems like the metal spoon is colder than the wooden spoon. It's not.

A human body that cries, and moves, and shrugs, and grimaces may seem like a living person. But if the brain has no function, no metabolism, no blood flow . . . then whatever it was that made that body a person is no more.

Am I absolutely certain? No, because I'm just a man. But I'm certain enough.

Just to clarify, Robert, the business about the heart rate and blood pressure was something I was pulling in from the anesthetist's quotations in the BBC article I also link, not from the Greek article in _Spinal Cord_.

I appreciate the analysis of the Zack Dunlap case. And you know what? He may be right. But I also note that he himself says that what they obtained on the PET scan did "meet the criteria" for brain death. In other words, while the author himself would have done the diagnosis differently--waited longer, for example, before making the diagnosis--he cannot say that the doctors in question were seriously negligent or did not go through a normal set of steps. There is, obviously, some flex in how all of this is diagnosed, and they simply weren't as conservative about it as he would have been, though they were indeed trying to be careful and conservative.

Nothing I say here is meant to indicate that I agree with you that "your brain makes you who you are." I'm a dualist, so I think your mind makes you who you are. I do, however, agree that an entirely decapitated body is indeed biologically dead, and on that basis I have previously been willing to accept that a body with _whole brain_ death (including brain stem) is indeed biologically dead. The question that is arising here is the reliability of that diagnosis.

Nothing I say here is meant to indicate that I agree with you that "your brain makes you who you are." I'm a dualist, so I think your mind makes you who you are.

I understand, and that's why I used the phrase "whatever it was" above. We call it different things - soul, mind, essence, epi-phenomenon, or emergant property - regardless of the name, it is something.

In such situations, physicians are wise to seek guidance from the philosopher or theologian. If there is something about us that is transcendent, science cannot determine exactly when the immaterial separates from the physical. The current neuro-scientific consensus considers the mind an emergent property of the brain. The mind is what the brain does. I'm sure that's overly reductionist to you, it sometimes is even to me. But in my line of work we must be pragmatic, and so are forced to make such reductions. So when brain function ceases, the mind either is destroyed or separates, if you wish.

Novella appropriately hedged his analysis, as the data to determine what really happened is just not available. Unfortunately, the real story likely will not ever come out because of legal issues. That is a shame, as the case might teach us something important.

I have only worked in a few hospitals, but in all of them brain death determination was a team diagnosis that required strict protocol. I'm sure that is not so everywhere, but it should be.

Thanks for hashing this out with me. It's good for me to read this blog. It's intellectually challenging, well written, but from a world view entirely alien to me.


I read Mr Wesley Smith’s comments concerning my article published recently in Spinal Cord 2008;46(6):396-401.
If Mr Smith had studied carefully my article –especially the last paragraph in the epilogue- he would not have given such a mistaken information regarding my “philosophical reaction to organ donation”; my attitude on organ donation is easily presumed from the article, especially from the last paragraph (which, unfortunately, was not presented by Mr Smith); this paragraph is the following: “However, others consider –on philosophical grounds- that they are not justified in taking their own life for any reason; nevertheless, they would agree with the donation of one of the paired vital organs or part of a single organ from healthy volunteers or of whatever organ from donors who are already irreversibly dead (according to the cardiopulmonary criterion of death) and have given their informed consent at an earlier time”. Therefore, Mr Smith, isolating one paragraph from my article, is being unfair to me and gives mistaken information to his readers –I believe unintentionally.
I understand the great problem that face all these who have accepted the term “brain death” as synonymous to biological death; in case one accepts that the “brain dead” patients are alive, the dead donor rule has to be abandoned. In this case, I think that the “cure” is “Openness and honesty”; that is: a) informing the public that “brain dead” patients are not really dead –rather, they are suffering from “irreversible apneic coma”, a condition leading, after some time, to death and b) that, according to several investigators, the concept of “brain death” was developed to permit vital organ transplantations. Should this crucial information is given to public, people could freely decide what their legislation –concerning organ transplantation- would be.


I appreciate your commenting here, Dr. Karakatsanis. I read your article all the way through and also Wesley J. Smith's post. I'm not sure why you think he has misunderstood you. As I understand both him and this comment of yours, you think that the dead donor rule should be abandoned if indeed brain dead is not dead. You must of course realize that there is another possibility--the transplant of vital organs that must come from people who are not _corpses_ in the strong sense could simply be stopped. Obviously this is a very radical idea in our present society, but it is not impossible. Moreover, here is the sentence in your article immediately before the one you quote:

The harvesting of vital organs for transplantation from patients suffering from 'irreversible apneic coma' (an identical clinical condition to 'brain death)-who had already given their informed consent for this purpose at an unsuspected time-would be socially and morally acceptable in societies which consider that the autonomy of the person justifies such a donation.

This is what WJS calls "terminal non-judgmentalism." In other words, you are just laying out the options: Some people might give their consent to live organ donation, while others might not.

That is what concerns Smith.

I myself certainly think that the abandonment of the dead donor rule would be a disaster. You must surely realize that at that point it would be pointed out that there was no strong reason in principle to restrict live donation to those in the condition that _used to be called_ "brain death" rather than extending it (as has been proposed by others) to those who are breathing on their own and whom no one could ever even try to claim are physically dead--e.g., those in what is called a permanent vegetative state. I realize as well as Smith does that you have not proposed that, but the abandonment of the dead donor rule would beyond all question open the door to it.

I would like a copy of the article Brain death: should it be reconsidered?

If you don't mind, I'll like to fill you in on why I'm interested. My best friend overdosed this morning. He is in a coma and brain dead. When I was talking to him, he had tears falling down his face. I'm eager to learn if this means anything substantial. The doctors are going to pronounce him tomorrow if nothing changes. I really don't want that to be the case. Could these tears mean he is still there?

My daughter also was pronounced dead after an overdose and same as you said, she too had tears which has always put doubt in my mind as we agreed to her organs been taken.

The ongoing argument about brain death is the chief reason to abandon organ donation. No one knows for sure if a donor feels this horrific procedure (emotionally and physically). Until someone comes back from the dead (or is re-transplanted with his own organs) and tells us how it is, that part has to stay unproven and deactivated. There *are* those who have a fetish interest in organ transplant/donation and there are those who enjoy the Munschausen by proxy syndrome satisfactions from it. These people can give organs if they wish. They know about the pain. They wouldn't have it any other way. In every other case, let patients and their families either remove life support, or be granted treatment towards recovery and rehabilitation.

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