Respecting Life While Determining Death
By Christina M.H. Powell
Even a child quickly learns to differentiate between living beings and inanimate objects. Intuitively, a child understands that her pet hamster is alive while her stuffed teddy bear comes to life only in her imagination. If you ask her to define “alive,” she will most likely list some qualities of life — the hamster eats, breathes, and runs around on his own without batteries. Her definition of life will be correct but probably not comprehensive.
Bioethicists seek comprehensive definitions for living and nonliving to determine the status of people who medical technology has stranded at death’s doorstep. Doctors treating these people find that differentiating between alive and not alive requires great care.
Organ donation saves lives. Organs from one donor can often help as many as 50 people. The main source of vital organs for transplantation is bodies whose higher and lower brain functions have irreversibly ceased but whose hearts still beat when a ventilator makes breathing possible. When removed from the ventilator, the heart would quickly stop beating, making the determination of death straightforward. Yet, even just a few minutes of oxygen deprivation can damage organs and render them unusable for transplantation. The ethical need to properly determine the death of the organ donor exists in tension with the desire to preserve the vitality of the organs intended for donation.
In difficult times of decision, family members of a dying patient often call their pastor for guidance. By understanding the bioethical issues at hand, a pastor can help the family make a decision that will lead to peace for the family. Let us take a look at the key components to respecting life while determining death.
Since ancient times people have defined death as the irreversible loss of circulation (heartbeat) and respiratory functions (breathing). In 1968, a faculty committee at Harvard Medical School recommended that doctors adopt a second definition of death in response to the technological advance of the mechanical ventilator, which externally supports a patient’s breathing. This new criterion for ascertaining death was the absence of all brain function, including loss of spontaneous breathing functions and brain stem reflexes. At the time, doctors called the condition, characterized by a flat brain wave, an irreversible coma.1 Today doctors use the term brain death to describe this condition.
Of course, as Alan Rubenstein, a senior consultant to the President’s Council on Bioethics who was involved in production of the 2008 report, “Controversies in the Determination of Death,” so eloquently states, “Death accepts no modifiers. There is only one death. Has it occurred or not? Alive or dead?”2 Brain death is either the same as death determined by circulatory and respiratory criteria or brain death is not truly death.
While the traditional definition of death as the irreversible cessation of circulation remains a valid criterion for determining a person’s death, technological advances have helped us realize that the loss of a heartbeat is merely a mechanism of death. Only if circulation stops long enough for critical centers in the brain stem to die does loss of a heartbeat lead to death. Loss of the function of the brain stem is irreversible in a way that the loss of a heartbeat is not. A patient can regain a heartbeat and a ventilator can maintain breathing, but no mechanical replacement exists for loss of brain stem function.
What makes an organism alive and more than just a collection of living organs and tissues is the integration of all the functions of the organs to make one body. For years, doctors thought the brain stem accomplished this critical integrative function. However, accumulating clinical evidence suggests that some integrated bodily functions persist even in the absence of a functioning brain stem. Some bioethicists view such evidence as a reason to reconsider whether brain death does indeed constitute death.
Other bioethicists want to broaden the definition of death to include patients who no longer function as “persons” because of the loss of certain mental capacities. Thus bioethicists would consider individuals who have lost higher brain functions but not brain stem function, such as individuals in a persistent vegetative state (PVS) or anencephalic infants, acceptable sources of organs for transplantation.
Understanding Total Brain Failure
A better term for “brain death” that describes the condition without declaring whether or not the state represents death is total brain failure. Total brain failure means that the whole brain, including the brain stem, no longer functions and will never function again. As a result of profound injury, there is no oxygen or blood flow to the brain. The three most common injuries that lead to total brain failure are head trauma from an accident, stroke, and oxygen deprivation as a result of a heart attack.
We best understand total brain failure as the endpoint of a cascade of events that occurs after the initial injury. The skull is rigid; thus, when the brain swells as a result of injury to brain tissue, pressure in the cranial cavity that holds the brain will increase. Rising pressure in the cranial cavity prevents oxygen-laden blood from entering the cavity and bringing essential nutrients to brain tissues. Deprived of oxygen and nutrients, more brain tissue becomes damaged, leading to further swelling and increased intracranial pressure. This process becomes a vicious cycle resulting in blood no longer entering the cranial cavity and brain herniation that can crush the brain stem. Once this cascade of events has run its course, total brain failure results.
The brain stem regulates breathing, sleep/wake cycles, and consciousness, among other important functions. When a patient loses brain stem function, he no longer will attempt to breathe on his own. The loss of spontaneous breathing happens in patients with conditions other than total brain failure. For example, patients with spinal cord injuries may be unable to breathe without a ventilator. However, these patients retain full or partial consciousness. The hallmark of a patient with total brain failure is both loss of consciousness and loss of spontaneous breathing, with no hope that either ability will ever be regained.
The reason some doctors question whether or not we should use total brain failure as a criterion to determine death is that “brain dead” patients maintained on mechanical ventilation sometimes retain vital functions such as regulating hormones and body temperature, wound healing, and a mounting immune response to infections. Children diagnosed with total brain failure continue to grow and develop. Babies have continued to develop for several months in the wombs of pregnant women diagnosed with total brain failure. How can a dead body perform these functions?
Understanding Higher Brain Failure
As demonstrated by focus groups and surveys, people often confuse brain death (total brain failure) with persistent vegetative state (PVS). The two conditions, however, have some important differences. The lower brain stem fully functions in patients diagnosed with PVS. As a result, patients diagnosed with PVS breathe spontaneously and have sleep-wake cycles, whereas patients diagnosed with total brain failure depend on artificial ventilation to breathe. Patients in persistent vegetative states have experienced higher brain failure, but not total brain failure.
A minimal level of consciousness may be present in some PVS patients. Researchers using functional neuroimaging technology have gained new insights into cerebral activity in patients with severe brain damage. For example, recent studies using functional magnetic resonance imaging (fMRI) show that some patients in a vegetative state may be able to understand spoken words, including their own name.3
Consciousness is difficult to assess. Doctors can observe whether or not a patient responds to stimuli, but no person really knows what is going on in another person’s mind. Neuroimaging gives doctors some insight into a patient’s ability to think that may still be present even when the doctor’s bedside observations indicate that a patient is unresponsive.
While family members may decide, in accordance with a patient’s previously stated wishes, to withdraw treatment and allow death to come for a patient diagnosed with PVS, the patient is still very much alive, even if he appears to lack consciousness. An independently breathing human being, who sleeps and opens his eyes, is not a candidate for burial. Yet, if lack of consciousness and higher brain function become a criterion for determining death, such a patient would have the legal status of a corpse.
In cases of brain-damaged patients still dependent on the ventilator, yet not meeting the criterion for total brain failure because brain stem function remains, organ donation after cardiac death (DCD) may be possible. In such situations, the decision to withdraw treatment should be made independently of the decision to donate organs. When doctors remove a patient from life support, his cardiac and respiratory functions cease and the doctor declares the patient dead after the passage of sufficient time after cardiac arrest, usually 5 to 10 minutes. At this point, the doctors harvest the organs.
Currently, donation of organs necessary for life only can occur after doctors have declared the donor dead. We call this ethical requirement the dead donor rule. Thus, DCD requires that the organ donor meet the criterion for circulatory death, namely a determination that the heart has beaten for the last time in the donor once doctors withdraw life support. The waiting period between the last heartbeat and organ procurement is necessary to ensure the heart does not start again on its own, a phenomenon known as autoresuscitation.
When a doctor declares that a donor is dead by the total brain failure criterion (neurological standard for determining death), the donor remains on ventilator support after determination of death to ensure the organs receive sufficient oxygen until doctors can remove them. To recover a heart after cardiac death, doctors must remove the heart as quickly as possible to avoid the risk of damage from oxygen deprivation. Shortening the time to declare a patient dead after the last heartbeat would improve the outcome of heart transplantation after DCD. Yet, shortening the interval too much might compromise the certainty of the death of the donor. Ethical controversy arises when too short of a time interval lapses between the last heartbeat and organ retrieval. For example, in two cases of infant heart transplantation, doctors waited only 75 seconds after the last heartbeat before removing the heart instead of the 5 minutes recommended by the Institute of Medicine. These cases sparked a discussion in the New England Journal of Medicine about the ethical issues surrounding DCD.4
Respect for the life of the donor means that the doctors must not bring about the donor’s death by removing organs, thus violating the dead donor rule. To do so would turn organ procurement into a form of euthanasia. The dead donor rule helps maintain public trust in the organ procurement system. This trust is the key to a voluntary system of organ donation. When people sign donor cards stating their willingness to become organ donors, they trust that medical professionals respect life and will not hasten their death to obtain their organs. People trust that their death will precede organ donation instead of organ donation becoming the cause of death. Laws against killing another person apply even if a person is unconscious and approaching death.
Another category of patients that tests the limits of the dead donor rule is anencephalic infants. These babies are born without an upper brain and thus will never develop higher brain function. However, they possess a fully functioning brain stem, which means doctors cannot declare them dead by current “brain death” standards.
The need for donor organs of appropriate size for infants and children with life-threatening illnesses is great. Organ donation often gives meaning and comfort to the family whose infant has died. Yet, making an exception to the dead donor rule for marginal cases such as anencephalic infants raises serious ethical concerns. One such ethical concern is the danger of setting a precedent for harvesting organs from other severely brain-damaged living patients.
Another ethical concern is that such a protocol would violate long-standing codes of medical ethics. From the Hippocratic Oath to present-day opposition to active euthanasia and physician participation in capital punishment, codes of medical ethics denounce killing by physicians. Preserving the role of physicians as healers who will not harm a patient remains in society’s best interest. Finally, harvesting organs from living patients, no matter how seriously disabled, devalues the irreplaceability and inherent worth of each human life.
How do we respect life while determining death? Perhaps we need to begin by seeing death as a process as well as a moment in time. From a spiritual standpoint, death occurs when a person’s spirit leaves his body permanently — a moment in time. From a biological standpoint, death of the various tissues that make up the human body is a process. When a person’s brain is destroyed to the point that the person has irretrievably lost any ability to interact with the outside world, including the most basic ability of taking in life-giving oxygen through spontaneous breathing, a person has died. A mechanical ventilator simply slows down the death process of the various tissues of the human body. Thus, the heart still beats and some bodily functions continue, although eventually death will come to all the organ systems.
In unclear cases, we must err on the side of life, recognizing the limits of medical science. We must be willing to revise protocols for determining death should researchers make discoveries that clarify our understanding of the border between life and death. We must avoid taking a solely utilitarian approach to ethical issues surrounding organ donation. While the organs from one person nearing death may save three or more lives, we must never view people as commodities. Each human life is irreplaceable. Human life is valuable even when the human being is debilitated. Intentional killing violates the law of God (James 2:10,11), thus we must proceed with great caution when establishing criteria for organ donation.
Finally, chaplains, pastors, and medical professionals must exhibit the utmost sensitivity when dealing with the family members of an individual diagnosed with total brain failure. Respect for life includes respecting the emotional, intellectual, and spiritual process that the patient’s family members must go through to accept the reality of their loved one’s death. When family members see their loved one’s heart still beating, they may struggle to accept that death has come. As they stand by their loved one’s bedside, they face the truth that enhanced medical technology has not improved our ability to distinguish between living beings and inanimate objects. Instead, the words found in Ecclesiastes 1:18 ring true, “For with much wisdom comes much sorrow; the more knowledge, the more grief.”
1. Ad Hoc Committee of the Harvard Medical School To Examine the Definition of Brain Death, “A Definition of Irreversible Coma,” JAMA 205(6) (1968):337–40.
2. A. Rubenstein, “What and When Is Death?” The New Atlantis 24 (2009):29–45.
3. H.B. Di et al., “Cerebral Response to Patient’s Own Name in the Vegetative and Minimally Conscious States,” Neurology 68(12) (2007):895–9.
4. G.D. Curfman et al., “Cardiac Transplantation in Infants,” NEJM 359(7) (2008):749,750.