Is the Brain Dead Person Really Dead?

Pope Francis’s monthly intention for March is “A Christian Response to Bioethical Challenges” and the question of “brain death” continues to challenge Christian bioethicists like in the following example:

Karla’s was happy, eager to help and willing to brighten everyone’s day. She had a fondness for children. and worked in a day-care center with hopes of being a pediatric nurse. She had a 2-year-old daughter, Genesis, and was pregnant with a boy, who she planned to name Angel.[1] Karla was 22 years old and 22 weeks pregnant when she experienced a sudden, severe headache. Karla collapsed and never woke up. She was rushed to the hospital and placed on a ventilator. A CT scan revealed a massive brain hemorrhage that was beyond any surgical intervention. As the pressure inside her head increased, Karla’s brain function deteriorated, leading doctors to eventually declare that she was “brain dead.”

Yet, baby boy Angel remained alive in her womb. At 22 weeks gestation, Angel was not developed enough to survive outside the womb, so Karla was kept on life support for another 54 days while Angel continued to grow.[2] A ventilator delivered oxygen to her lungs; carbon dioxide was sent back in return. Karla’s heart pumped blood carrying oxygen and nutrients to her body and by way of the placenta, to Angel’s body.

Karla remained stable for almost 8 weeks, but when her heart and other organs began to deteriorate, Angel was delivered by cesarean section at 30 weeks, 3 days, weighing in at just under 3 pounds. Angel became the world’s sixteenth baby to be born alive after somatic support during pregnancy. After Angel was born, Karla’s heart, liver and kidneys were donated for transplant. Two months later, Angel was released to the care of his grandparents where he continues to thrive along with his sister, Genesis.

Most people are probably familiar with the term “brain dead” yet are uncertain what that really means. Is a “brain dead” person really dead? Karla’s case challenges the current medical and legal positions that someone who is brain dead is dead and serves as a starting point to explore the medical, moral and philosophical questions about death.

Theological and Historical Background

While alive on earth, humans are meant to be an indivisible union of body and soul, and the resurrection is the perfect realization of this harmony.[3] Death is the necessary event linking these two states. The event of death is therefore an ontological change, one that has profound theological implications. Despite its ontological status, however, the starting point of the Christian understanding of death is biological. According to Ratzinger, death is the “physical process of disintegration which accompanies life. It is felt in sickness and reaches its terminal point in physical dying.”[4] Death may be an ontological change, but it is one that can be inferred by biological indicators.

But the dying of a human cannot be confined to the moment of clinical death. Humans are forced to accept the fact that their lives are not under their own power. They can respond in one of two ways. They can defiantly seek to gain power over their own existence, but this is an exercise in futility, leading ultimately to anger, frustration and despair. The alternative response to death is to trust the power that actually controls their existence. “And in this second case, the human attitude towards pain, towards the presence of death within living, merges with the attitude we call love.”[5] The confrontation with physical death is the confrontation with the basic question of human existence.

For the Christian, “physical death is met with in the daring of that love which leaves self behind, giving itself to the other.”[6] The God who died in the person of Jesus is the source of this love. When Christians die, they die into the death of Christ himself. “Death is vanquished when people die with Christ and into him. This is why the Christian attitude must be opposed to the modern wish for instantaneous death, a wish that would turn death into an extensionless moment and banish from life the claims of the metaphysical.”[7]

It is only in the last 100 years, however, that the Christian understanding of death has been challenged by technological advances. Prior to the availability of mechanical ventilation during the 1920s, the process of dying ended when individuals could no longer breathe on their own and the heartbeat ceased. This is known as the “cardiovascular criteria” for death. To determine death, physicians would feel for the pulse, listen for breathing, hold a mirror before the nose to test for condensation, and look to see if the pupils were fixed.

The sophistication of mechanical ventilation and other means of artificial life-support continued to advance, and by the 1950s a human with severe brain injury could be sustained for up to a few days before the circulatory system failed and the patient ultimately died. In the days preceding circulatory collapse, clinicians also observed the absence of typical signs of neurological function, leading to the development of clinical criteria of death by neurological standards, also known as “brain death.”[8] By and large, however, the need for determining death by neurological standards had very limited clinical utility as ultimately circulatory collapse occurred within a few days.

However, in a singular event that raised questions about the reliability of the cardiovascular standard, the need for neurological criteria for death was pushed to the clinical forefront. In 1967, Christiaan Bernard performed the first successful human heart transplant. While the patient died 18 days later, this event marked the beginning of heart transplantation. Over 100 additional heart transplants were attempted within the following year. Many of the early failures were attributed to donor organ deterioration that occurs while waiting a sufficient time after cardiac arrest to ensure that the donor would not spontaneously resuscitate.[9] Barnard’s own account of the first heart transplant reveals that he waited about three minutes after the donor heart stopped beating before proceeding with its removal.[10]

Barnard’s choice of three minutes, however, raises a question: is three minutes enough time to declare confidently that the donor is in fact beyond the point of spontaneous resuscitation? Before the possibility of organ donation, “close enough” criteria may have been sufficient to declare death. The possibility of donation, however, creates a pressing need for more a precise standard. The reason stems from the Dead Donor Rule, which states that: “Vital organs which occur singly in the body can be removed only after death, that is from the body of someone who is certainly dead. This requirement is self-evident, since to act otherwise would mean intentionally to cause the death of the donor in disposing of his organs.”[11] To abide by the Dead Donor Rule, it is therefore important to know exactly when a patient has died.

The following year, the Harvard Ad Hoc Committee to Study the Problems of the Hopelessly Unconscious Patient convened to propose new diagnostic criteria for determining death. The finished work of the committee was published in the Journal of the American Medical Association as “A Definition of Irreversible Coma.”[12] and suggested replacing the cardiovascular criterion with a neurological criterion. Over time, the Harvard criterion for determination of brain death has become widely accepted. Currently, the majority of transplanted organs come from individuals who were declared “brain dead.”

Catholic Magisterial Teaching

Both John Paul II and Benedict XVI appear to endorse the concept of brain death. That might make it seem as if the magisterial teaching on brain death is closed. Crucially, however, both John Paul II and Benedict XVI refuse to endorse the Harvard criterion without qualification. That means that the magisterial teaching is not as closed as it may first appear to be.

In his address to the International Congress of the Transplantation Society, John Paul describes death as an event that no scientific technique can directly identify. It is the total disintegration of the integrated whole that is the human being. He describes death as the separation of the soul from the corporal reality of the human. Yet, John Paul also acknowledges the need for “scientifically secure means of identifying the biological signs that a person has indeed died.”[13] He states that “the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology.”[14]

John Paul also notes, however, that the Church does not make technical decisions regarding the definition of death and depends upon science to guide it in how it understands criteria for death. Benedict XVI has likewise affirmed the value of organ transplantation and, much like John Paul, gives qualified acceptance of brain death criterion: “In an area such as this, in fact, there cannot be the slightest suspicion of arbitration and where certainty has not been attained the principle of precaution must prevail.”[15]

It may seem then, that the magisterial teaching on brain death is settled. However, it is no small detail that John Paul qualifies his remarks with “does not seem.” Like John Paul, Benedict also leaves room for further debate, warning against the slightest suspicion of arbitration and the need for certainty in certifying the death of the patient. And indeed, John Paul himself says that the “acquisition of new data can stimulate and refine moral reflection.”[16] As new data are acquired regarding the definition of death, further moral reflection is therefore necessary and the moral certainty John Paul describes may be revisited in light of this new data.

Current Status of Brain Death

A number of non-dissenting Catholics have raised concerns regarding the validity of brain death as a legitimate definition of death.[17] This concern has been echoed by secular medical ethicists.[18] Karla’s case, while rare, is not unique; dozens of pregnant women declared “brain dead” have been sustained on life-support while the baby continues to develop in the womb.[19] Prolonged survival after declaration of brain death has been documented in many other cases.[20]

One particularly notable case involved a boy who at age four became brain dead secondary to meningitis and survived an additional 20 years with medical support. Subsequent autopsy revealed a calcified intracranial shell with no recognizable neural elements grossly or microscopically.[21]

There is growing evidence that many patients declared dead by neurologic criteria actually have a small portion of the brain that is still functional.[22] The hypothalamus is a structure in the brain stem involved with a number of functions, including regulation of hormones, fluid balance, blood pressure and body temperature. This realization has created a conundrum for clinicians, as the Universal Declaration of Death Act (UDDA) requires that the entire brain, including the brainstem, must be irreversibly dead in order to declare someone dead using neurologic criteria.[23]

This has led some groups, including the American Academy for Neurology,[24] to suggest that a functioning hypothalamus should not exclude someone from being declared brain dead.[25] This proposal smacks of utilitarianism: a functioning hypothalamus prevents declaration of brain death; the Dead Donor Rule requires a person to be dead before harvesting their organs; exclude the hypothalamus from the definition of death so that organs can still be harvested.

So where do we go from here? Both John Paul II and Benedict XVI have described organ donation as an act of love, but both also caution that before organs are taken, the individual must be unequivocally dead. Brain death criteria are widely accepted yet with the advent of new technology, both secular and non-dissenting Catholic ethicists have raised legitimate concerns. For now, a Catholic in good conscience may donate his or her organs and health-care workers may use these criteria with moral certainty and, as John Paull II has stated, the criteria are a “necessary and sufficient basis for and ethical correct course of action.”[26]

However, magisterial teaching in this area may need to be refined. There is precedence for refinement of Catholic teaching that should and does occur in the complex areas of bioethics. Dignitas Personae is an example of how the Church appropriately updated teachings from Donum vitae regarding procreation:

The Church’s Magisterium has frequently intervened to clarify and resolve moral questions in this area. The Instruction Donum vitae was particularly significant. And now, twenty years after its publication, it is appropriate to bring it up to date . . .The teaching of Donum vitae remains completely valid, both with regard to the principles on which it is based and the moral evaluations which it expresses. However, new biomedical technologies which have been introduced in the critical area of human life and the family have given rise to further questions . . . These new questions require answers.

The issue of brain death is not an esoteric subject of limited interest to most people. New questions arise and these require answers. The moments of conception and death mark the beginning and end of our earthly existence, so determining when a person has died carries the same weightiness of determining when an individual comes into existence. Just as technology has pushed against the moral boundaries at the beginning of life, so too does technology force us to reassess the ethical issues at the end of life.

[3] The sections “Theological and Historical Background” and “Catholic Magisterial Teaching” were adapted from Doran SE, Vukov JM. Organ Donation and Declaration of Death: Combined Neurologic and Cardiopulmonary Standards. The Linacre Quarterly. 2019;86(4):285-296.

[4] Joseph Ratzinger, Eschatology: Death and Eternal Life (Washington DC: CUA, 2007) 95

[8] Mollaret P, Goulon M. 1959. « Le coma depasse (memoire preliminaire). » Rev Neurol. 101: 3-15.

[9] D. Scott Henderson, Death and Donation: Rethinking Brain Death as a Means for Procuring Transplantable Organs (Eugene OR: Pickwick) 2.

[10] Christiaan Barnard and Bill Pepper Curtis, One Life (Oxford: Macmillian) 360.

[12] « A definition of irreversible coma: report of the ad hoc committee of the Harvard medical school to examine the definition of brain death. » JAMA. 205. (1968): 337-40.

[13] John Paul II, op. cit.

[14] John Paul II, op. cit.

[15] Benedict XVI 2008, Address to International Congress of the Transplantation Society : A Gift for Life.

[16] John Paul II. 1990. “Determining the moment when death occurs.” Origins 19: 23-25.

[17] Nicanor Austriaco, “Is the brain-dead patient really dead?” StMor 41: 277-308.

[18] D. Scott Henderson, op. cit.

[19] M. Esmaelzadeh et al., “One Life Ends, another begins: Management of a brain-dead pregnant mother-A systematic review,” BMC Medicine: 74.

[20] DA Shewmon, Recovery from “Brain Death”: A Neurologist’s Apologia, The Linacre Quarterly. 1997;64(1):30-96.

[21] S. Repertinger, et. al., « Long term survival following bacterial meningitis-associated brain destruction. » J Child Neurol. 21: 591-95.

[22] Michael Nair-Collins et. Al., “Hypothalamic-Pituitary Function in Brain Death: A Review,” Journal of intensive care medicine.

[23] President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research 1981, Defining Death: Medical, Legal and Ethical Issues in the Determination of Death [On-line].

[24] “Brain death, the determination of brain death, and member guidance for brain death accommodation requests,” AAN position statement, Neurology Jan 2019, 92 (5) 228-232

[25] Richard Ariane Lewis, “It’s Time to Revise the Uniform Determination of Death Act,” Ann Intern Med.2020;172:143-144.

[26] John Paul II, op. cit.