The intractable problems with brain death and possible solutions

Abstract

Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an ‘operational definition’ of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing.

The challenging moral experience of cardiac replacement

“…The adoption of brain death as death has been challenged as failing to signify the death of the organism (not true biological death), too valuesbased (not scientific enough), or misleading (testing does not measure "whole brain death"). 10 Perhaps most importantly to the public (and families), what our intuitions expect of a dead body is incongruent with what may be found at the bedside. A patient pronounced dead by neurologic criteria and yet, still connected to "life-supporting" technologies, appears very much alive: warm, with pink skin, a rising chest, and a beating heart.…”

“…Cardiopulmonary death – where the pulse fades and the chest ceases its rise and fall – is often thought of as the gold standard definition of death, while death by neurological criteria – or brain death – where the brain stem is irreversibly lost and consciousness with it, is often thought of as the enigmatic interloper. The adoption of brain death as death has been challenged as failing to signify the death of the organism (not true biological death), too values‐based (not scientific enough), or misleading (testing does not measure “whole brain death”) 10 . Perhaps most importantly to the public (and families), what our intuitions expect of a dead body is incongruent with what may be found at the bedside.…”

Should the Criterion for Brain Death Require Irreversible or Permanent Cessation of Function? Irreversible

“…Death is a biological, unidirectional, ontological, physiologic event. 1 Being dead is a state of an organism, an existential reality, not a social contrivance or a normative concept. 1 A living organism is "an integrated functioning organism as a whole, a localized pocket of antientropy achieved by maintaining internal homeostasis while resisting chemical and thermal equilibrium with the external environment."…”

“…1,p.2 A dead organism has had "irreversible cessation of the integrated functioning of the organism as a whole, such that the organism no longer has the capacity to restore homeostasis and thereby resist entropy." 1 In this essay, I will argue that death is irreversible and not merely permanent. Irreversible means a state cannot be reversed and entails permanence.…”

Brain death and organ and tissue donor management in the Intensive Care Unit

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