December 6, 2023

When the brain “dies”, is a person still inside?

An academic debate with real-world consequences
To the layman, "brain dead" means either a blood-spattered zombie film or well and truly dead, ie, no longer alive. Dead enough, in fact, for grieving relatives to authorise the removal of organs for other needy patients. So it is unsettling to read in the leading journal Spinal Cord that the death of the brain may not actually mark the death of the person. Brain dead patients typically are said to have no brain activity. However, Dr K.G. Karakatsanis, of the Aristotle University of Thessaloniki, in Greece, argues that at least some patients who meet the current criteria for brain death are still alive – even if they may never recover.

He is not alone. A few other scientists and doctors share his misgivings, amongst them Professor Robert Truog, of Harvard Medical School, and Professor Alan Shewmon, of UCLA School of Medicine. They have all pointed out that the term originated in the 1960s as part of a drive by transplant surgeons to obtain vital organs. The stakes are high: if a brain-dead person isn’t really dead, then the removal of vital organs is tantamount to homicide.

Dr Karakatsanis’s particular contribution to the debate is that so-called spinal reflexes observed in patients who have been labelled “brain dead” may in fact originate in the brainstem. But there are other arguments, too, apart from evidence of brain activity. For one, there is no world consensus on what human death is, which makes all subsequent discussion of “brain death” incoherent. As well, it is impossible to test whether brain functions are absent with a bedside examination because the brainstem is no longer connected to the cerebrum in these patients. As Dr Shewmon points out, “mere absence of evidence does not constitute evidence of absence”. Finally, “not one” of the various tests to confirm brain death is 100% accurate. They can only prevent misdiagnosis by revealing unsuspected brain activity.

There is no question that nearly all brain dead patients are severely and permanently impaired. But Dr Karakatsanis suggests that the term “brain dead” should be done away with because it confuses the public. In the interests of greater openness and honesty, he suggests that the older term “irreversible apneic coma” be revived (irreversible cessation of lung and heart function). This is a highly controversial issue and the article is sure to kindle a lively debate. Hollywood probably prefers the current term. Flesh-eating irreversible apneic coma zombies just won’t cut it at the box office. ~ Spinal Cord, June 2008

One thought on “When the brain “dies”, is a person still inside?

  1. Michael, the term brain death is confusing. The usual criteria for death of the patient are known as the cardiorespiratory criteria. Today, with the advent of life support systems, these criteria cannot be used in patients on life support. Therefore, in such cases, the intensivists use “the neurological criteria of death.” I have written on this concept and I take issue with Shewmon. Medics & Ethics discussed the question many months ago. I cannot download the full article that you have quoted from Spinal Cord. The Intensive Care societies of Australia and New Zealand have produced an excellent document on this subject.

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