Emerging from a reverie, a seven-year-old friend once asked me whether music had been discovered or invented. My reply was the ever popular, ``I'm not sure. . . . It depends.'' The same question can be asked about brain death. Is there an objective reality to be unearthed? Or is brain death a construct, used by consensus to designate a patient as being dead? In Brain Death, edited by E.F.M. Wijdicks, a group of respected authors argue that a clear clinical entity exists. In the end, their arguments are not persuasive. Moreover, references to the quest for organ procurement add a note of urgency to the debate.
Wijdicks states his position in the preface. ``Some intellectuals believe brain death is not a fixed absolute and continue to debate the concept.'' He is not one of them. For him, it is ``obvious to the point of platitude'' that the loss of brain function is the loss of human life. Most chapters refer to this ``fixed absolute.'' In discussions of the historical perspective of, the philosophical and ethical aspects of, and the pathophysiological responses to brain death, the references are implicit. By providing the sensitivity and specificity of several tests, the chapters on confirmatory testing in adults and children imply the existence of a gold standard, as do the references elsewhere to criteria that are ``reliable'' or ``inaccurate'' or that ``eliminated error in classifying a living individual as dead.''
But the authors never provide a gold standard -- a clear clinical or anatomical description. They refer to the loss of ``neurological,'' ``critical,'' ``clinical,'' ``relevant,'' and ``all'' functions of the brain. The Uniform Determination of Death Act proposes that the ``irreversible cessation of all functions of the entire brain, including the brain stem'' is an adequate definition, but one author insists that it is ``perfectly clear that the word `functions' applies only to clinical functions.'' One author believes that, ``of course, the patient is not dead until the brain has been totally infarcted,'' and others use terms such as ``total brain necrosis'' or ``the brain [that] has been completely destroyed.'' Yet another notes that ``some portions of the brain [can] remain relatively intact.''
The book makes clear that some persons reliably defined as brain dead have clinically significant residual function, as evidenced by electroencephalographic activity, cerebral blood flow, unexpected survival, brain-stem auditory evoked potentials, normal pituitary-gland function, attempts to sit up, reproducible eye opening in response to pain, head movements in response to stimulation, and in one child, normal results on positron-emission tomography. Most perplexing, children who have been given a diagnosis of brain death continue to grow, and pregnant women have delivered healthy infants up to four months after being given a diagnosis of brain death.
Controversies about ``whole-brain,'' ``brain-stem,'' and ``neocortical'' death are referenced but never explained completely or consistently. In one chapter, brain-stem death is described as having ``been accepted in the United Kingdom and rightly so, because no survivor has been reported.'' Another chapter states that, ``brainstem death is not as coherent as whole-brain death as a formulation of human death.''
When any concept of brain death is introduced, all the proposed elements concern either severity or prognosis. Taken separately, neither of these variables can be used to justify a claim that a patient is dead. Irreversible loss of all cognition, such as occurs in a persistent vegetative state, is not a widely accepted definition of death, and the use of the term ``an extremely poor prognosis'' is a veiled reference to the futility argument. The authors simply assert that, taken together, the two can be used to declare a patient dead.
Although their definitions of brain death vary, the authors generally agree about the need for the concept as an important means for limiting treatment. They cite burdens placed on the patients and their loved ones, the inappropriate allocation of resources, and ``the futility of existence of such people.'' Several comments are quite forceful. ``Japan has been slow to catch up with the rest of the world,'' and ``a cardiocentric view may be prevalent in uneducated Japanese.'' In America, ``fringe religions and cultural beliefs may object to the determination of brain death and express a desire to try all possible care.'' Requests for the support of patients with brain death are ``related to alleged religious or cultural objections or to physicians' capitulation to the unreasonable demands of family members.''
Why the intransigence? It is about organ procurement. The book begins with a dedication to organ donors and ends with a chapter, the second longest in the book, entitled ``Organ Procurement and Preparation for Transplantation.'' Some references to organ procurement are intrusive. With respect to diagnosis, for example, the book states that ``the observation period can certainly be shortened if a recipient is waiting'' and that a second opinion is not recommended because it may ``jeopardize harvesting of vital organs.''
I am no vitalist, have no desire to intervene aggressively on behalf of permanently unconscious people, and recognize the extreme value of donor organs. But patients' family members have so often demonstrated different beliefs, genuine good intentions, and tormented ambivalence that hurry seems wrong. Furthermore, I believe that a body without cognition can possess value and identity.
The book has several strengths. The chapters on confirmatory testing and states that resemble brain death link neuropathological discussions with practical clinical advice. The effects of severe brain injury on somatic homeostasis, the historical perspective, and the review of legal aspects are fascinating. For example, according to a New Jersey law, a person can be declared brain dead unless he or she is from a religious or cultural tradition that does not recognize this convention. The object of this law was to honor the beliefs of some Orthodox Jews. I came away with a message other than what the authors intended, however, and I believe a better title would have been Brain Death and Organ Procurement. In the end, if asked to define brain death, I would reply, ``I'm not sure. . . . It depends.''
Thomas E. Finucane, M.D.
Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
