March 24, 2021 // Perspective
When are you really dead?
In 1968 a consensus opinion paper was published called “A Definition of Irreversible Coma.” The purpose of the paper was to define death by neurological criteria. It came to be known as The Harvard Criteria since this group of scholars was brought together by Harvard Medical School. Interestingly, this was at the same time that organ transplantation began to take off. The medical community needed guidelines to follow as to when a person could be declared dead even though their heart was still beating and their vital organs were still functioning.
Death had previously been clear — the heart stops beating, respirations cease and all the vital organs of the body stop functioning together.
On Aug. 29, 2000, the Holy Father, St. John Paul II, addressed the 18th International Congress of the Transplantation Society. He felt obligated to help guide these physicians from a Catholic perspective. Here are some excerpts from that address.
“Transplants are a great step forward in science’s service of man, and not a few people today owe their lives to an organ transplant. Increasingly, the technique of transplants has proven to be a valid means of attaining the primary goal of all medicine — the service of human life.
“Acknowledgement of the unique dignity of the human person has a further underlying consequence: vital organs which occur singly in the body can be removed only after death, that is, from the body of someone who is certainly dead. This requirement is self-evident, since to act otherwise would mean intentionally to cause the death of the donor in disposing of his organs. This gives rise to one of the most debated issues in contemporary bioethics, as well as to serious concerns in the minds of ordinary people. I refer to the problem of ascertaining the fact of death. When can a person be considered dead with complete certainty?
“In this regard, it is helpful to recall that the death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person. The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly.
“It is a well-known fact that for some time certain scientific approaches to ascertaining death have shifted the emphasis from the traditional cardio-respiratory signs to the so-called “neurological” criterion. Specifically, this consists in establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity.
“With regard to the parameters used today for ascertaining death — whether the ‘encephalic’ signs or the more traditional cardio-respiratory signs — the Church does not make technical decisions. She limits herself to the Gospel duty of comparing the data offered by medical science with the Christian understanding of the unity of the person, bringing out the similarities and the possible conflicts capable of endangering respect for human dignity.
“Here it can be said that the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology. Therefore, a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgement which moral teaching describes as “moral certainty.” This moral certainty is considered the necessary and sufficient basis for an ethically correct course of action. Only where such certainty exists, and where informed consent has already been given by the donor or the donor’s legitimate representatives, is it morally right to initiate the technical procedures required for the removal of organs for transplant.”
Many believed that in this address Pope St. John Paul II had, in essence, accepted the concept of death by neurologic criteria. Let us take a closer look at what St. John Paul II said: “The death of a person is a single event, consisting of the total disintegration of that unitary and the integrated whole that is the personal self. The death of a person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly.”
The living human being has been defined by many scientists to require the integration and cooperation of all the major organs. This also appeared to be what St. John Paul II was intimating as he goes on to say: “the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum, and brain stem). This is then considered a sign that the individual organism has lost his — and I emphasize this phrase — “integrated capacity.”
The Harvard Criteria was a paradigm shift. It basically declared that the brain is in control and if the brain is dead, then the person is dead. It is true that in most cases of whole brain death, it is not long before the other organs deteriorate and stop functioning and one can be reassured that the patient has indeed died.
Part 2
There have been some notable cases over the years that made some physicians question the brain death concept. Probably one of the most striking is the case where a 4-year-old boy contracted meningitis and became comatose. His brain was completely destroyed by an overwhelming infection and he met all of the criteria for brain death. His family refused to withdraw ventilator support and he survived another 20 years with the help of a ventilator. His organ systems remained integrated and functioning over all that time, which by many defines life. He maintained blood pressure stability, was able to mount an immune response to infection, and he continued to grow. Yet, at autopsy, there was no functioning brain. All that was found was a small, shrunken hard piece of mummified tissue.
Another remarkable case occurred in December of 2013 that seriously questions the accuracy of the diagnosis of brain death. A 13-year-old young lady by the name of Jahi McMath underwent a tonsillectomy. While still in the hospital she had a massive bleed and a cardiac arrest. She was successfully resuscitated and placed on a ventilator for support. Three independent neurologists examined her, and all found her brain dead and therefore, by California law, legally dead. A death certificate even was issued.
Her family refused to accept that she was dead, since she still had a beating heart and other functioning organs. She remained on life support but received no nutrition for about one month as a fierce court battle ensued. The state of California argued it was unethical to demand that physicians continue to care for a corpse. The courts refused the family’s request for a feeding tube to provide nutrition and a tracheostomy to continue ventilator support.
The family was successful in getting their child transferred to New Jersey where state law allows families to refute death by neurologic criteria (brain death). Jahi was rapidly deteriorating and her functioning organs were dying as she arrived in New Jersey. As soon as she received nutrition from the emergently placed feeding tube, her body stopped its rapid decline and stabilized. She remained in a coma but continued to grow as her bodily function remained integrated. She was documented to go through puberty and lived another five years, succumbing to liver failure in June 2018.
Allow me to quote St. John Paul II one final time: “Here it can be said that the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of sound anthropology.” I believe the pope purposefully used the word “seem” knowing that questions would arise in the future about whether brain death meant true death in all cases and therefore defined when the soul left the body.
A requirement for considering brain death is that there has been a catastrophic neurologic event consistent with causing brain death. The Harvard Criteria set reasonably strict guidelines to diagnose brain death by bedside exam but suggested that neurologists use ancillary tests like the EEG (brain wave) and brain blood flow tests to help confirm brain death.
Over the past several decades some thought leaders in neurology have focused on the bedside neurological exam to diagnose brain death. They have moved away from these ancillary tests, although many neurologists still use them when the exam is equivocal. Not only have there been significant variances and inconsistencies between individual neurologists but also between medical societies and countries. Therefore, The World Brain Project was formed with representatives from multiple international professional societies. They met recently and published their recommendations in a paper called “Determination of Brain Death/Death by Neurological Criteria.” Allow me to get technical and review their published criteria.
Bedside exam findings must include irreversible coma and no brainstem reflexes. The pupils need to be fixed and dilated. The corneal, oculovestibular, and oculocephalic reflexes are absent. There is no gag or cough reflex. There is no facial movement or limb movement to noxious stimuli. Finally, there must be no spontaneous breathing with disconnecting the respirator. These findings can be in error if the comatose individual is hypothermic, sedated by various medications or are receiving paralytic drugs. These conditions must be excluded to be able to confirm the diagnosis of brain death.
I believe the World Brain Project is an important and significant undertaking to try to better clarify and establish more uniform criteria for whole brain death, but in my opinion these experts should have more strongly suggested the performance of ancillary testing to be confident that brain death was present. Instead, they seemed to favor these tests only if the bedside neurological exam could not be completed.
Unfortunately, there have been documented cases where a neurologist diagnosed brain death only to later discover that there were sedative or paralytic meds on board that invalidated the findings.
A Catholic anesthesiologist at The Ohio State University shared some of his experiences in The Linacre Quarterly: Journal of the Catholic Medical Association with providing anesthesia to brain dead patients as their organs were harvested for transplantation. He opines about whether it should even be necessary to anesthetize someone who has been declared dead.
He has observed (as multiple physicians and nurses have) that there can be bodily movement as incisions are made as well as significant fluctuations in blood pressure. The usual explanation of why there is movement by our neurology colleagues is that these are spinal cord reflexes. Let us just say that observing a person move in the operating room after being declared dead can only be described as very disturbing.
That Catholic anesthesiologist subsequently refused to take part in future organ harvesting operations. He was greatly chastised by some of his colleagues and nearly lost his job over his decision.
One of my observations over the many years I practiced is that sometimes physicians, powers of attorney and even family members seem to be in a hurry to decide that there is no chance of recovery. They may contemplate withdrawing life support just 24-48 hours after a severe brain injury. On some occasions they may sense pressure from the transplant team to harvest the organs of a young person who has been declared brain dead by a neurologist.
For several days after a severe brain injury the brain can shut down and go into what is called Global Ischemic Penumbra. In this state, brain death can be declared prematurely and be wrong. In my opinion, we should take the time needed to make sure that the right decision is made. Waiting a little longer after a catastrophic brain injury, to be sure there is no chance of brain recovery, seems like a reasonable decision. I believe that almost everybody would agree that if there has been severe, irreversible brain injury and the person cannot breathe on his/her own without a respirator, it would then be acceptable to withdraw life support and allow natural death.
The U. S. Conference of Catholic Bishops has stated it would be considered extraordinary and too burdensome to have to continue ventilatory life support in this situation. I have discussed end-of-life wishes with countless patients of mine over the years and have yet to encounter anyone who informed me that they wanted to be kept alive indefinitely by the use of a ventilator.
My goal in this article was to have my readers be aware of the controversies that still surround the diagnosis of brain death. In general, I am in support of the transplant programs across our great country that save and enhance lives every day. But we cannot harvest organs until we are sure that the individual is dead. Sometimes physicians will actually disagree with each other as to whether a person is dead or not. Is brain death really synonymous with death? Does the soul leave the body at brain death?
The truth is that we do not know for sure. Let’s try to be as confident as we can when these difficult situations arise that our loved ones are dead, and that it is their time to enter the Kingdom of God. This will allow us to embrace their death and to better celebrate their earthly life as they move on to eternal life with our Creator.
I would like to thank my colleague, fellow Catholic and neurologist, Dr. Natalie Manalo, who reviewed this article for me. Also, a huge thank you to Lisa Everett, director of Marriage and Family Ministry for the Diocese of Fort Wayne–South Bend, who reviewed, corrected and gave counsel on every article I have published in Today’s Catholic over the years. I will be taking a break from writing. It has been an honor to share these articles with you.
Dr. David Kaminskas is a board-certified cardiologist and member of the Dr. Jerome Lejeune Catholic Medical Guild of Northeast Indiana, www.fortwaynecma.com.
The best news. Delivered to your inbox.
Subscribe to our mailing list today.