Brain Death and True Patient Care

Abstract

The "brain death" standard as a criterion of death is closely associated with the need for transplantable organs from heart-beating donors. Are all of these potential donors really dead, or does the documented evidence of patients destined for organ harvesting who improve, or even recover to live normal lives, call into question the premise underlying "brain death"? The aim of this paper is to re-examine the notion of "brain death," especially its clinical test-criteria, in light of a broad framework, including medical knowledge in the field of neuro-intensive care and the traditional ethics of the medical profession. I will argue that both the empirical medical evidence and the ethics of the doctor-patient relationship point to an alternative approach toward the severely comatose patient (potential braindead donor).Lay Summary: Though legally accepted and widely practiced, the "brain death" standard for the determination of death has remained a controversial issue, especially in view of the occurrence of "chronic brain death" survivors. This paper critically re-evaluates the clinical test-criteria for "brain death," taking into account what is known about the neuro-critical care of severe brain injury. The medical evidence, together with the understanding of the moral role of the physician toward the patient present before him or her, indicate that an alternative approach should be offered to the deeply comatose patient.

Finding a Bridge to Somewhere: An Ethical Framework for Veno-Arterial Extracorporeal Membrane Oxygenation Decisions

“…However, this leads to deeper philosophical discussions as to what counts as "living" and whether brain death criteria should be used for purposes of organ procurement from patients, let alone ECMO patients. Furthermore, there is evidence in the past decade or so that patients, who were initially declared brain dead based on neurological standards, narrowly "escaped" organ harvesting by waking up prior to or during operating room preparations [15][16][17][18][19] or had reversible "brain death" determinations [15,19,20]. Although these "narrow escape" cases are few, they should give healthcare professionals pause in relying on existing brain death criteria and neurological testing.…”

“…With further scientific data to validate clinical tests used with any brain-injured patient, as well as those specifically on ECMO for both acute and prolonged periods of time, as well as more consistency among medical professionals in determining brain death, the threshold of uncertainty may be reduced, thus minimizing, if not eliminating, potential direct harms to patients, and subsequent emotional, social, and financial harms to their families and potential organ recipients. Nguyen [15] also adds that there have been logical and scientific inconsistencies when reasoning brain death at the bedside, as well as a general lack of understanding of the pathophysiology of the brain, where an absence of evidence of brain functions is not necessarily the equivalent to irreversible loss or death of the brain.…”

“…Furthermore, in his brief ethical assessment of care for the patient with (possible) brain death, Nguyen [15] emphasizes the importance of the physician's moral attitudes and subsequent actions to reflect caring for the patient, motivated by the inherent value of the patient as person, and not by a set of ethical rules or principles. However, Nguyen, a Catholic physician, who is guided by non-secular ethics, also argues that brain death cannot be equated with the biological death of the person; harvesting organs from brain death donors, thus, "brings about their true and premature death."…”

Pope John Paul II and the Neurological Standard for the Determination of Death: A Critical Analysis of his Address to the Transplantation Society

“…26. For a detailed discussion on the problems with the clinical tests for "brain death," see Nguyen (2016). 27.…”

“…58. For a more detailed discussion on improved outcome in comatose patients with bilateral fixed and dilated pupils, see Nguyen (2016 …”