Brain death

Overview
Brain death is a legal definition of death that emerged in the 1960's as a response to the ability to resuscitate individuals and mechanically keep the heart and lungs working. In simple terms, brain death is the irreversible end of all brain activity. It should not be confused with a persistent vegetative state.

Legal history of brain death
Traditionally, both the legal and medical community determined death through the end of certain bodily functions, especially respiration and heartbeat. With the increasing ability of the medical community to resuscitate people with no heart beat, respiration or other visible signs of life, the need for a better definition of death became obvious. This need gained greater urgency with the widespread use of life support equipment, which can maintain body functions indefinitely, as well as rising capabilities and demand for organ transplantation.

In the U.S., an ad hoc committee at Harvard Medical School published a pivotal 1968 report to define irreversible coma. The Harvard criteria gradually gained consensus toward what is now known as brain death. In the wake of the 1976 Karen Ann Quinlan controversy, state legislatures moved to accept brain death as an acceptable indication of death. Finally, a presidential commission issued a landmark 1981 report — [http://www.bioethics.gov/reports/past_commissions/defining_death.pdf ''Defin­ing Death: Medical. Legal, and Ethical Issues in the Determination of Death.''] — that rejected the "higher brain" approach to death in favor of a "whole brain" definition. This report was the basis for the Uniform Definition of Death Act, which is now the law in almost all fifty states.

Today, both the legal and medical communities use "brain death" as a legal definition of death. Using brain-death criteria, the medical community can declare a person legally dead even if life support equipment keeps the body's metabolic processes working. The first nation to adopt brain death as a legal definition death was Finland in 1971. In the United States, Kansas enacted a similar law earlier.

Religion and brain death
Despite the adoption of whole brain criteria in the United States and "brainstem" criteria in the United Kingdom, there has been opposition to brain death criteria from the beginning. Traditionalist Orthodox Jews have staunchly defended the traditional conception of death in the U.S. and Israel (See Time of Death by J. David Bleich.) Conversely, some modern Orthodox rabbis and Israel's Chief Rabbinate have adopted determinations of death based on brain function. (See Moshe Tendler's elucidation of Rabbi Moshe Feinstein's responsa.) As a result, Orthodox Jewish ethics has been sharply divided over key death-related policies. Tactically, Orthodox Jewish opponents to brain death have requested waivers from state law, as a matter of religious freedom, so as to continue relying on traditional indicia. Meanwhile, proponents have been active in advocating organ donations and transplants.

Similarly, Islamic views on brain death are mixed. ("Views of Muslim scholars on organ donation and brain death" Transplantation Proceedings, Volume 29, Issue 8, December 1997, Page 3217. Faroque A. Khan, The Definition of Death in Islam: Can Brain Death Be Used as A Criteria of Death in Islam? Farhat Moazam, Bioethics and Organ Transplantation in a Muslim Society: A Study in Culture, Ethnography, and Religion, Indiana University Press, 2006, p.32ff.)

The 1981 federal report, Defin­ing Death, found that Catholic and Protestant theologies did not object to brain death criteria. Indeed, Dennis Horan, president of the pro-life group American Citizens United for Life, stated: "Legislation limiting the concept of brain death to the irreversible cessation of total function of the brain, including the brain stem, is beneficial and does not undermine any of the values we seek to support."

More recently, the findings of the 1981 President's Commission Report have been questioned (Beyond Brain Death). The new attack on brain death criteria has been multi-pronged. First, the view that brain death marks the end of the integrated unity of the human organism has been questioned. Alan Shewmon ("Chronic 'Brain Death': Meta-analysis and Conceptual Consequences") has argued that the body as a whole is the central integrator of the organism rather than the brain. He appeals to, among other reasons, brain dead pregnant women who have lived up to 200+ days and given birth to healthy children, as well as to a brain dead boy who lived over fourteen years on a ventilator and with basic nursing support. Others, such as David Evans (in Beyond Brain Death and in Finis Vitae: Is Brain Death Still Life), have argued that there is insufficient evidence that the entire brain is dead in a brain dead individual. Some brain dead individuals have continuing EEG activity ("Brief Review: The role of ancillary tests in the neurological determination of death" by Young, Shemie, and Doig) and others maintain normal or near-normal body temperature, implying continuing hypothalamic function ("The brain and somatic integration" by Shewmon).

In Catholic medical ethics, Pope Pius XII stated that death is determined by medical experts and it "does not fall within the competence of the Church." (See, "The Prolongation of Life" in The Pope Speaks 4:4 1958) Advocates of brain death criteria have claimed that this implies that the church is bound to support the view of the medical community on this issue. More recently, the Pontifical Academy of Science has upheld Catholic doctrine. ("The determination of brain death and its relationship to human death." Working Group, 10-14 December 1989, pp. xxvii-210 ) Nevertheless, there was  some Catholic dissent on neurological criteria for death, e.g., see  "Brain death is not death" essay. This was not without controversy, as a volume by opponents of brain death criteria who participated in a 2005 conference at the Pontifical Academy of Sciences was published in 2006 by a publisher outside the Vatican (Finis Vitae: Is Brain Death Still Life).

Medical criteria for determining brain death
A brain-dead individual has no clinical evidence of brain function upon physical examination. This includes no response to pain and no cranial nerve reflexes. Reflexes include pupillary response (fixed pupils), oculocephalic reflex, corneal reflex, no response to the caloric reflex test and no spontaneous respirations.

It is important to distinguish between brain death and states that mimic brain death (e.g., barbiturate intoxication, alcohol intoxication, sedative overdose, hypothermia, hypoglycemia, coma or chronic vegetative states). Some comatose patients can recover, and some patients with severe irreversible neurologic dysfunction will nonetheless retain some lower brain functions such as spontaneous respiration, despite the losses of both cortex and brainstem functionality. Thus, anencephaly, in which there is no higher brain present, is generally not considered brain death, though it is certainly an irreversible condition in which it may be appropriate to withdraw life support.

Note that brain electrical activity can stop completely, or drop to such a low level as to be undetectable with most equipment. This includes a flat EEG during deep anaesthesia or cardiac arrest. However, the EEG is not required in the United States, but is considered to have confirmatory value.

The diagnosis of brain death needs to be rigorous to determine whether the condition is irreversible. Legal criteria vary, but it generally requires neurological exams by two independent physicians. The exams must show complete absence of brain function, and may include two isoelectric (flat-line) EEGs 24 hours apart. The proposed Uniform Determination Of Death Act in the United States attempts to standardize criteria. The patient should have a normal temperature and be free of drugs that can suppress brain activity if the diagnosis is to be made on EEG criteria.

Alternatively, a radionuclide cerebral blood flow scan that shows complete absence of intracranial blood flow can be used to confirm the diagnosis without performing EEGs.

Brain death and consciousness
It is presumed that a permanent cessation of electrical activity indicates the end of consciousness. Those who view the neo-cortex of the brain as solely responsible for consciousness, however, argue that electrical activity there should be the only consideration when defining death. In many cases, especially when elevated intracranial pressure prevents blood flow into the brain, the entire brain is nonfunctional; however, some injuries may affect only the neo-cortex.

Brain death and organ donation
Most organ donation for organ transplantation is done in the setting of brain death. In some nations (for instance, Belgium, Brazil, Poland, Portugal and France) everyone is automatically an organ donor, although some jurisdictions (such as Singapore) allow opting out of the system. Elsewhere, consent from family members or next-of-kin is required for organ donation. The non-living donor is kept on ventilator support until the organs have been surgically removed. If a brain-dead individual is not an organ donor, ventilator and drug support is discontinued and cardiac death is allowed to occur.