Brain death is verifiable with proper testing

A recent article in Legatus Magazine raises the question of “whether a person declared ‘brain dead’ is, in fact, dead.” The M.D.-author does not appear to dispute the claim that the complete and irreversible cessation of all brain function constitutes death, but instead suggests that clinical testing as a means of determining brain death may be unreliable.

In our recent analysis of these same questions in the National Catholic Bioethics Quarterly, however, we reached a very different conclusion — namely, that no compelling grounds exist for doubting that patients who have suffered a devastating brain injury have, in fact, died when careful and detailed neurological testing reveals that the irreversible cessation of all brain function has occurred.

“The doctor-author’s core argument involves the observation that “when a computer crashes, it initially boots up into safe mode. Safe mode has reduced functionality. Once the operating system is repaired in safe mode, the computer can return to full function. Similarly, when the brain is injured, it may initially enter a ‘safe mode’ during which functionality is substantially decreased, but brain viability is preserved. This condition is called global ischemic penumbra (GIP) and can last up to two days. It is important to note that during the period of GIP a person will meet all the criteria for brain death as defined by the American Association of Neurology.”

The problem with this claim is that individuals who fulfill all the criteria for brain death as defined by the American Academy of Neurology do not, in fact, manifest reduced functionality of the brain and hence their situation does not parallel the safe mode of computers. Instead, their situation involves a complete and irreversible loss of function, and the bedside clinical tests carried out by physicians are designed precisely to assess this absence of all coordinated brain activity.

Confirmatory brain-imaging technologies, especially the technetium-99 brain scan or the four-vessel cerebral angiogram, can reliably detect the reduced levels of blood flow associated with global ischemic penumbra, and distinguish such a situation from brain death with its oft-seen absence of blood flow to the brain, loss of all integrated activities, and the death of the entire organ. Patients experiencing global ischemic penumbra retain functional brain regions and are not deceased, while those who fulfill all the criteria for brain death represent individuals who have perished due to the irreversible nature of their catastrophic cerebral injuries.

In a culture that is becoming ever less attentive to protecting human life and dignity, concerns arise when some clinicians may not be fastidious about applying the testing criteria and may end up “cutting corners” during brain death assessments. Accounts of patients continuing on a ventilator for many months or years after being declared brain dead, or cases in which patients are declared brain dead, wake up, and then leave the hospital to return to a largely normal existence, typically indicate a grave failure to apply the required tests with proper attentiveness and rigor.

Clinicians have a solemn duty to achieve moral certitude when it comes to making clinical assessments of death. Such determinations require a specialized skill set that includes knowledge of the pathophysiology of brain death, knowledge of the 25 different assessments and verifications that the guidelines require, as well as experience in making these determinations.

As long as thorough and accurate medical testing is performed, the Church recognizes the validity of determining death based on neurological criteria. The American Academy of Neurology guidelines, when followed assiduously, remain a broadly reliable approach in these difficult situations.

Fr. Tadeusz Pacholczyk, Ph.D., earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, Mass., and serves as the director of education at The National Catholic Bioethics Center in Philadelphia.

Stephen Hannah, M.D., is a pulmonary and critical care medicine physician practicing at Health Park Medical Center in Fort Myers, Fla. He is the president of the Southwest Florida Guild of the Catholic Medical Association and is on the speakers bureau of the National Catholic Bioethics Center.