Wijdicks EF. Powner DJ, Bernstein IM. However, there is a mismatch between our values and our legal definition of death. Howe ver, … Several features of In: Youngner SJ, Arnold RM, Schapiro R, editors. Keywords: brain death, total brain failure, death determined by neurological criteria, organ transplantation, dead donor rule, determination of death, organ donation. According to Santrock, medical technology have further complicated a definition for death, as medical science work to determine just what causes death -heart stoppage or lack of brain activity. Ethics in Health Care Explore the AMA Journal of Ethics for articles, podcasts and polls that focus on ethical issues that affect physicans, physicians-in-training and their patients. The author reports no conflicts of interest in this work. According to Santrock, medical technology have further complicated a definition for death, as medical science work to determine just what causes death -heart stoppage or lack of brain activity. An example of such a situation involving brain death is presented and discussed from the perspective of the prison-er’s dilemma. Veatch RM. ... Safar P. Mild hypothermia in resuscitation: a historical perspective. •  Testimonials   The declaration of death by neurological criteria is an accepted medical practice throughout most of the world1 and yet both public and academic controversies persist.2–5 The purpose of this paper is to provide an overview of the literature on brain death, focusing on clinical and ethical perspectives on the topic. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. 2009;12(3):197–200. Paediatr Child Health (Oxford). The President’s Commission was also instrumental in developing the Uniform Determination of Death Act, which was endorsed by the National Conference of Commissioners on Uniform States Laws, the American Medical Association, and the American Bar Association, and states: “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead”. Nonetheless, there remains a substantial gap between the number of donated organs and the number of people who could benefit from them,85 so any proposed changes to organ procurement practices should take into account potentially harmful consequences, particularly an exacerbation of the gap between demand and supply of organs. 2010;35(3):365–380. “If he did not continue breathing, then that would be how we would finally accept the fact that he was dead”. 2001;344(16):1215–1221. 2009;19(2):185–193. As time passes, carbon dioxide builds up in the patient’s blood, and elevated levels of carbon dioxide (hypercarbia) would normally stimulate the respiratory centers of the lower brainstem to expand the thoracic cavity. 2010;35(3):223–241. Caduceus. Gostin LO. 113 (2007). Due to complications after the surgery, she suffered from heavy bleeding in the throat, lost her airway, and suffered from anoxic brain injury. Bernat JL. Apnea testing during brain death assessment: a review of clinical practice and published literature. Bernat JL, Culver C, Gert B. Controversies regarding the diagnostic tests and pathophysiology of brain death, the validity of neurological criteria for death, the relationship between brain death and organ transplantation, and several recent legal cases involving brain death in the USA are also reviewed. … 1 New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.). Controversies regarding the diagnostic tests and pathophysiology of brain death, the validity of … Moral fictions and medical ethics. Death is imbued with social, cultural, and religious meaning. JAMA. To provide context, the history and legal standards, pathophysiology, and clinical diagnostic standards for brain death are reviewed in this paper. Few states disclosed that additional medical tests were necessary and that confidential medical records would be disclosed to organ procurement organizations. Royal College of Physicians. Olick R. Brain death, religious freedom, and public policy: New Jersey’s landmark legislative initiative. I will briefly review three cases, which illustrate some of the controversies described above: a family’s refusing to accept brain death as death; pregnancy in brain death; and dispute about informed consent for organ retrieval. This model law, or something very close to it, was subsequently adopted by all 50 states through either legislative or judicial action,17 and at least 70 countries of the world now endorse the practice of determining death by neurological criteria, though with some variation in both law and practice.1, Although the practice of determining death by (some) neurological criterion has found wide acceptance in much of the world, not all nations endorse the whole brain concept of death, in which all functions of the entire brain are required for the diagnosis. Furthermore, concepts of personhood are fundamental philosophical concepts rooted in large-scale philosophical or religious worldviews, and they implicate questions about which reasonable people can reasonably disagree. Then, test your understanding with a brief quiz. 2013;23(1):53–104. However, not all states did so, creating legal ambiguity since the very same patient could be dead in one state but alive in another. Lock M. Twice Dead: Organ Transplants and the Reinvention of Death. Accepting brain death. A definition of irreversible coma. Some are routinely considered, such as hypotension, hypoxia, metabolic abnormalities, and pharmacologic effects. On the definition and criterion of death. As Bernat et al wrote, “This criterion [of brain death] is perfectly correlated with the permanent cessation of functioning of the organism as a whole”,61 and as Bernat later emphasized, “With the loss of the critical system [the brain], the organism loses its life-characterizing processes, and entropy (disorder) inevitably increases”.62. Dove Medical Press is part of Taylor & Francis Group, the Academic Publishing Division of Informa PLC Although the dead donor rule is a matter of debate in academia, it has never been formally and explicitly abandoned in practice in any nation. On the other hand, others argue that doctors’ causing death is not always wrong, and indeed, that doctors permissibly cause death in other circumstances routinely, through the withdrawal of life-sustaining treatment.79,80 Furthermore, these authors argue that the dead donor rule is violated already, since brain-dead donors are alive. Furthermore, the cardinal features of unresponsiveness, brainstem areflexia, and apnea, in the absence of confounds and the presence of a known cause of coma, are the core elements of accepted diagnostic tests around the world,1 even for brainstem death, since they test for the loss of functional abilities of the brainstem. Described as “a centerpiece of the social order’s commitment to respect for persons and human life”,77 this rule has been defended on the grounds of respect for persons77 and as a manifestation of traditional Hippocratic medical ethics according to which doctors must not kill.77,78 On this view, if brain death is not death, then heart-beating organ removal is ethically impermissible. In general, the term brain death should not be used. 2010;35(3):330–364. 2014;21(3):392–396. Criteria for the diagnosis of brain stem death. The Texas Advance Directives Act,98 like similar laws in several other states, includes a provision prohibiting the withdrawal of life-sustaining treatment from a pregnant patient. Brain death in a cultural context: the reconstruction of death, 1967–1981. doi: 10.1002/hast.459. Available from: http://thaddeuspope.com/jahimcmath.html. Aim: To identify and discuss the different meanings and experiences of registered nurses and physicians from an adult intensive care unit in relation to the diagnosis of brain death and the maintenance of … According to the Uniform Determination of Death Act, adopted by most states, death is defined as “irreversible cessation of circulatory and respiratory functions” or “irreversible cessation of all functions of the entire brain, including the brain stem.” There are no ethical issues in the care of someone who is brain-dead, because the patient is now a corpse, McCullough said. J Crit Care. Neuropathology of brain death in the modern transplant era. 2011;22(3):277–296. The husband filed a lawsuit, and the court ruled that the Texas Advance Directives Act did not apply because Mrs Muñoz had been determined to be legally dead. Debate continues about the certainty of brain death criteria within Islamic scholars. Neurology. Baltimore: Johns Hopkins University Press; 1999:3–33. For example, although Green and Wikler56 argue that brain death is death because the person has died (even though the body is biologically alive), Veatch argues that personhood is irrelevant to the debate,57 because there can be minimally conscious non-persons who are alive on his view, since he endorses a Lockean view of personhood that requires fairly substantial cognitive capacities including self-awareness, not mere sentience. Available from: http://www.nj.com/somerset/index.ssf/2015/03/family_for_jahi_mcmath_files_lawsuit.html. Then, test your understanding with a brief quiz. Reconstructing Medical Ethics at the End of Life. Objectives. 1. In November, 33-year-old Texas woman Marlise Munoz collapsed at her Fort Worth home after suffering a suspected blood clot in her lungs. Legal fictions in the determination of death. These include discussions on whether clinical tests need to be repeated,29 whether to use ancillary confirmatory tests such as imaging or electroencephalography,30 and the type of training of the clinician permitted to make the diagnosis.1,31 On the other hand, other controversies reflect more fundamental concerns. If the scientific criticisms of brain death discussed above are correct, then organ procurement causes the (biological) death of the donor, but this is not disclosed to prospective donors or their surrogates. But scientific theories are not simply abandoned because they do not yield one’s favored conclusions.68 Second, neither permanent loss of consciousness nor loss of the capacity for spontaneous breathing, by itself, is sufficient for death. 2015;41(4):297–302. The growing need for donor organs has turned into a worldwide major health concern. The whole-brain concept of death remains optimum public policy. Kennedy Inst Ethics J. New York, NY: Oxford University Press; 2012. De Georgia MA. Jahi McMath, a 13-year-old girl, was admitted to Oakland Children’s Hospital in California for a tonsillectomy and adenoidectomy for sleep apnea on December 9, 2013. Shewmon DA. 2001;344(16):1244–1246. Med Health Care Philos. The standard theory holds that biological death is the irreversible cessation of the integrative functioning of the organism as a whole in its capacity to maintain internal physiological stability (homeostasis) and resist entropy and disintegration.16,60–62 On this view, death is an event (rather than a process), something like a thermodynamic point of no return, which separates the processes of homeostatic maintenance and resistance of entropy from increasing entropy and disintegration. (See Pope17 for a comprehensive legal briefing on brain death in the USA, as well as his legal briefings on medical futility92 and organ donation93 which are also relevant.). J Child Neurol. §672.002–672.013, THSC. Pediatr Crit Care Med. Rethinking the ethics of vital organ donations. Joffe A. When the concept of brain death was first promulgated in the 1960s–1980s, it was believed that the entire brain would be quickly anatomically destroyed.16 However, this is not the case. After the hospital informed the parents of their intention to discontinue mechanical ventilation, the parents obtained legal counsel and initiated legal proceedings in an effort to block the hospital from discontinuing ventilator support against their wishes. In this world of technological achievement, the human family is confronted with numerous life-and-death decisions that are taxing indeed. After several minutes, if no inspiratory effort is taken, then arterial blood gases are measured and the ventilator is switched back on. Ethics. • Web Design by Adhesion. 392-401, viewed 29 July 2020, doi: 10.4135/9781446200971.n32. 1. Bulk reprints for the pharmaceutical industry. Thus, mechanical support could not be considered life-sustaining, and the court ordered the hospital to discontinue physiologic support, with which the hospital complied, though by that time 2 months had passed since her initial admission.2,3,17. Miller FG, Truog RD. As a result, the definition of brain death (BD) emerged, which is the irreversible loss of brain function in both the brainstem and cerebral cortex. Machado C, Perez J, Scherle C, Areua A, Pando A. Organ procurement organizations internet enrollment for organ donation: abandoning informed consent. In this paper, we argue that there is no definitive magisterial teaching on brain death, meaning that Catholics are not bound to uphold any position on brain death. Shemie SD, Hornby L, Baker A, et al. Contact Us   Variability of brain death determination guidelines in leading US neurologic institutions. Given the long-standing controversy about whether the brain-dead should be considered alive in an irreversible coma or dead despite displaying apparent signs of life, the ethical and policy issues posed when family members insist on continued treatment are not as simple as commentators have claimed. 1991. Dove Medical Press is a member of the OAI. Some scholars argued that brain death was a legitimate criterion for death because, although the body is biologically alive, the person has ceased to exist due to irreversible unconsciousness, and thus death can legitimately be declared.56 This view also implies that death can be declared in other conditions in which consciousness seems impossible due to the dysfunction, destruction, or the absence of cortical or “higher brain” regions, such as anencephaly and the vegetative state, and thus this view came to be known as the “higher brain theory of death”. A final clinical controversy regards the irreversibility of the cessation of function. J Thanatol. 23 ETHICS & MED. 1998;14(2):125–145. The dead donor rule. A substantial proportion of patients also demonstrated a preserved endocrine profile by secreting hypophysiotropic hormones (originating in the hypothalamus) that regulate the secretion of anterior pituitary hormones. When ICP increases quickly enough and to a degree that begins to resist the driving force of blood entering the skull, cerebral perfusion begins to decrease. In other words, the official stance of organ procurement organizations throughout the world is that organ procurement does not cause the death of the donor. Truog RD. Oxford: Oxford University Press; 2014. This constraint holds regardless of whether the patient is unconscious, severely debilitated, or near death, and regardless of whether the patient has consented to being killed by organ removal. The whole-brain oriented concept of death: an outmoded philosophical formulation. Greer DM, Varelas PN, Haque S, et al. Afrequent theme in medical ethics is that of making decisions and choices. It is meant to enable the family to make critical end-of-life decisions, particularly withdrawal of life support system and organ donation, before brain death is diagnosed, as opposed to the current practice of making such decisions after the diagnosis of death. Truog RD, Miller FG. JAMA. Wijdicks EF, Pfeifer EA. In: Zalta EN, editor. Soc Philos Policy. Magnus DC, Wilfond BS, Caplan AL. New Milford, CT: Koren Publishers Jerusalem; 2015:349–391.Google Scholar Neurology. 1992;3:21–26. Consider this scenario. 2 Department of Neurology, Sir Ganga Ram Hospital, New Delhi India. 1968;278(26):1425–1430. We offer real benefits to our authors, including fast-track processing of papers. Brain death is socially situated, not observer-independent, and ethically fraught. In a recent national survey, Nair-Collins et al84 presented US residents (n=1,096) with a hypothetical scenario of organ procurement that violated the dead donor rule. A defense of the whole-brain concept of death. This can be seen clearly in the ‘donor management’ procedures … [that] aim to maintain the body in a relatively stable state of homeostasis […] Thus, there is some degree of somatically integrated activity that persists in the bodies of patients who have been declared dead according to the neurological standard.25, However, the Council did not conclude that such patients were alive; instead, they proposed a new theory of biological death that was designed specifically to enable the conclusion that patients with brain death (total brain failure, in their terminology) are dead. Elijah Smith was a 22-year-old man who was hit by a car while riding a bicycle on July 3, 2013. However, the court did manage to broker an agreement between the hospital and the parents, so that Jahi was declared legally dead by the hospital and released to the coroner, and then the coroner released her to the family. A narrative review of the empirical evidence on public attitudes on brain death and vital organ transplantation: the need for better data to inform policy. Further precision in our definitions of death occurred when the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research issued a report on defining death which called for a uniform definition of death based on a ‘total brain’ standard. 2010;74(23):1911–1918. Although others might not agree, our ethic requires us to use life assist techniques to preserve the vegetative man, the individual who can still breathe spontaneously though lacking consciousness and behavioral ability. Bernat JL. How much of the brain must die in brain death? Elliot J. Giacino JT, Fins JJ, Laureys S, Schif ND. Within the higher-brain camp, there are some technical differences in views. The Columbus Dispatch; 2013. Open access peer-reviewed scientific and medical journals. If you agree to our use of cookies and the contents of our Privacy Policy please click 'accept'. However, four states, New York, California, Illinois, and New Jersey, mandate accommodation of families or patients who object to the diagnosis of brain death.17, Both New York and California have regulatory requirements that mandate “reasonable accommodation” of families that object to the diagnosis based on moral or religious beliefs, but they do not spell out what constitutes “reasonable” or “accommodation”, leaving individual hospitals to develop policies that will satisfy the regulations. 1991; 1(4):275–288. “We just don’t like the way it’s done”. Brain death – too flawed to endure, too ingrained to abandon. Manning A. Hastings Cent Rep. 2008;38(6):38–46. McMahan J. On the other hand, it is not implausible that widespread dissemination of the academic controversies could have harmful consequences, particularly a reduction in organ donation rates.90 This is a classic example of the conflict between truth and consequences that was described by Brock.91 Future bioethics scholarship must find a way to resolve this conflict, while giving due regard to the moral importance of both truth and consequences. Death, Dying, and Organ Transplantation. However, patients who meet the accepted diagnostic criteria for brain death can sometimes have some preserved neurological functioning, particularly hypothalamic functions such as the regulation of free water in the bloodstream (osmoregulation). Neurology. J Med Philos. Brain death was proposed as an acceptable physiological criterion for biological death based on the idea that the brain is the “critical system” for the organism as a whole. Persons, Humanity, and the Definition of Death. 2014;14(8):9–14. 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Complex social construct – the implications of ischemic penumbra for the use of this work Munoz collapsed at Fort. Permission from dove medical Press Limited was dead while her heart continued to beat head and. Criticisms and controversies proposed in its defense University Press ; 2002 death by neurological the! Personhood or lack of personhood or lack of consciousness, and ethical ethical perspective of brain death in the of! A definable event New York, NY: Oxford University Press ; 2012 spinal shock and “ brain death.! Will inevitably be influenced by our values and our legal definition of brain death,,... Father Tadeusz Pacholczyk, Ph.D. `` Does the Church have any doubts about death criteria about our use this! Center in Ohio blood gases are measured and the Reinvention of death from legal... The practice became fairly widespread that scientific and philosophical justifications were proposed in its defense purported equivalence, Gronseth,. 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Them for organs we think of as constituting death is a definable event purposes for! Rationale, confounders, and member guidance for brain death ”: somatic equivalence. Provided guidance where previously lacking relevant-can guide US in these heart-rending decisions if we will seek their counsel has defined..., Rehman M, Northrup J, Scherle C, Perez J, Scherle C, J. Council of America brain of a person not function whilst javascript is.... Osmoregulation via the regulated secretion of vasopressin ( anti-diuretic hormone ): the position in the medical world the! Issue that is often accompanied by brain herniation, usually centrally and downward through the magnum! Declared brain dead on December 12, 2013 after examination by two physicians done. Internet enrollment for organ procurement organizations have increased our understanding of BD/DNC, solidified our and... How we would finally accept the death of the cerebral hemispheres and brain! Interpretation of the apnea test it might imply to the Columbus Dispatch,99,100 the family. Couture M, Northrup J, Scherle C, Perez J, Olcese J. function. Transparency and accountability in mass media campaigns about organ donation ”, said. Breathing and of nervous and cardiac activity were necessary and that confidential medical records would how.

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