Brain Death - Too Flawed to Endure, Too Ingrained to Abandon

Department of Medical Ethics, Anesthesia, and Pediatrics at Harvard Medical School, Boston, MA, USA.
The Journal of Law Medicine &amp Ethics (Impact Factor: 1.1). 02/2007; 35(2):273-81. DOI: 10.1111/j.1748-720X.2007.00136.x
Source: PubMed


The concept of brain death has become deeply ingrained in our health care system. It serves as the justification for the removal of vital organs like the heart and liver from patients who still have circulation and respiration while these organs maintain viability. On close examination, however, the concept is seen as incoherent and counterintuitive to our understandings of death. In order to abandon the concept of brain death and yet retain our practices in organ transplantation, we need to either change the definition of death or no longer maintain a commitment to the dead donor rule, which is an implicit prohibition against removing vital organs from individuals before they are declared dead. After exploring these two options, the author argues that while new definitions of death are problematic, alternatives to the dead donor rule are both ethically justifiable and potentially palatable to the public. Even so, the author concludes that neither of these approaches is likely to be adopted and that resolution will most probably come when technological advances in immunology simply make the concept of brain death obsolete.

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    • "Over the next 12 years or so , a consensus emerged that this idea both was reasonable and justifiable , eventually leading to the adoption of state laws that recognized this clinical state as another form of death ( Bernat 2009 ; Wijdicks 2001 ; Bioethics 2008 ) . While there appears to be a societal agreement with this idea , there are dissenters , but they are a distinctly minority view ( Truog 2007 ) . No one would argue that brain dead people are not biologically alive , in any real or even philosophical sense . "
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    ABSTRACT: For many years a debate has raged over what constitutes futile medical care, if patients have a right to demand what doctors label as futile, and whether physicians should be obliged to provide treatments that they think are inappropriate. More recently, the argument has shifted away from the difficult project of definitions, to outlining institutional policies and procedures that take a measured and patient-by-patient approach to deciding if an existing or desired intervention is futile. The prototype is the Texas Advance Directives Act, but similar procedures have been widely implemented both with and without the protection of the law. While this method has much to recommend it, there are inherent moral flaws that have not received as much discussion as warranted. Because these strategies adopt a semblance of procedural justice, it is assumed that the outcomes of such proceedings will be both correct and fair. In this paper, I argue that there are three main irremediable defects in the policy approach: there is the potential for arbitrary decision-making about futility in specific cases; there are structural, pre-ordained consequences for ethnic minorities who would be disproportionately affected by the use of these procedures; and the use of rationing justifications to support the use of these policies. These flaws detract so much from any benefit that could be derived that they make such strategies more harmful than helpful.
    HEC Forum 08/2012; 25(3). DOI:10.1007/s10730-012-9194-9
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    • "Hence, the process of becoming dead, in a wider sense, is no longer non-debatable, at any rate within the context of hightech hospital care. Before embarking on the discussion, it is essential to emphasize that we do not wish to enter into the metaphysical discussions which in recent years has beset the brain deathconcept (Veatch 1999; Youngner, Arnold, and Schapiro 1999; Chiong 2005; Bernat 2006; Truog 2007), or question the predominantly positive attitudes people harbour towards transplantation medicine. Nor is it our aim to erode the general public's trust in the medical profession by raising doubts about doctors' possible double role as providers of care and procurers of organs. "
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    ABSTRACT: HADDERS H and ALNAES AH. Nursing Inquiry 2012 [Epub ahead of print] Enacting death: contested practices in the organ donation clinic Based on the fieldwork at two Norwegian Intensive Care Units, we wish to discuss the sometimes inconsistent manner in which death is handled, determined and made real by nurses and other healthcare personnel in high-tech hospital situations. These discrepancies draw our attention towards different ways of attending to the dying and dead and views about appropriate or inappropriate codes of professional behaviour. As we will argue below, the analytical tools developed by Annemarie Mol are useful for sharpening our understanding of the enactment of multiple ontologies of death as they are enacted within the ICU. Annemarie Mol and John Law's notion of 'ontological politics' increases our awareness about the non-arbitrary way some but not other practices are considered self-evident whereas others are denigrated as muddled and illogical.
    Nursing Inquiry 05/2012; 20(3). DOI:10.1111/j.1440-1800.2012.00603.x · 1.44 Impact Factor
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    ABSTRACT: In 1968, the Harvard criteria equated irreversible coma and apnea (i.e., brain death) with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism (locked-in syndrome), minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. (1) Brain death does not disrupt somatic integrative unity and coordinated biological functioning of a living organism. (2) Neurological criteria of human death fail to determine the precise moment of an organism’s death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75s to 5min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. (3) Brain-based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. (4) Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. (5) The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs. KeywordsBrain death-Circulatory death-Ethics-Heart-beating organ procurement-Impaired consciousness-Non-heart-beating organ procurement-Neurological criteria of death-Organ transplantation-Physician-assisted death-Vegetative state
    Medicine Health Care and Philosophy 11/2009; 12(4):409-421. DOI:10.1007/s11019-009-9204-0 · 0.91 Impact Factor
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