D. ALAN SHEWMON and R. SPAEMANN
As a former advocate of the concept of brain death and one who has
studied the vast literature on this subject in great depth, I understand well
the reasons for the wide consensus that brain death is death. Nevertheless,
an accumulation of clinical evidence and incoherencies in the rationale
have led me to reject this equation. I take respectful issue with a number of
points in the majority statement, which will be identified below by the subheadings
in that document.
Brain Death is Death
I disagree that neurologists 'are perhaps in the best position to clarify
the pitfalls of this controversial issue'. Neurological knowledge is obviously
integral to the controversies, but the essence of life and death are ultimately
philosophical concepts. Neurological expertise is clearly necessary
for designing reliable criteria that the brain is dead, but neurologists have
no particular expertise for explaining why a dead brain equals a dead
patient, and in fact there is no consensus among neurologists regarding the
rationale for that equation, since it is ultimately a philosophical question.
Many embrace a philosophical rationale that is incompatible with Catholic
anthropology. The final sentence of the subsection is not 'an important initial
clarification' but a lin,auistic confusion between certain words ('brain
death' and 'death') and their referents.
Death is the End of a Process
The Summary Statement refers to a process involving . . . the failure of
the integrative functions exerted by the brain and brain stem on the body.
It ends with brain death and thus the death of the individual'. The body has
many integrative functions not mediated by the brain, including those of
the spinal cord. Failure of brain-mediated integrative functions certainly
produces a very sick organism, but the preservation of at least some nonbrain-
mediated holistic integrative functions means that it is indeed a sick
organism and not a non-organism (i.e., a dead organism). The Summary
Statement gives no reason for limiting the relevant integrative functions to
only brain-mediated ones.
The Consensus on Brain Death
The consensus is superficial and fraile. In the UK and certain commonwealth
countries, only the brain stem counts, whereas most other countries
require the entire brain to be irreversibly nonfunctional. In Japan,
brain death is legal death only if the patient is to become an organ donor,
but not otherwise. In Germany, the law does not state that brain death is
legal death, but rather that organs can be legally removed from brain-dead
patients (parliament could not bring itself to state explicitly that brain death
is death). The Danish Council of Ethics rejected brain death as death.
Moreover, the general consensus concerns the proposition that death can be
diagnosed by brain-based criteria, but there is no consensus whatsoever
regarding the reason why death of the brain (or of the brainstem) should be
death. The Chairman of the Harvard Committee, among others, opined that
the definition of death is essentially arbitrary and based on societal convention
and utility. The mainstream, quasi-official rationale is loss of integrative
unity of the body. For many health professionals, including many neurologists,
their personally held rationale is that brain destruction entails a loss of
personhood due to permanent unconsciousness (regardless of the biological
lifeldeath status of the body), entailing the logical implication that patients
in a permanent vegetative state are also 'dead'. Surveys of health professionals,
including those involved in transplantation, have revealed a disturbing
lack of agreement and logical incoherence regarding the lifeldeath status of
brain-dead and other neurologically devastated patients.
384
Statistics on Brain Death
The Summary Statement exaggerates the amount of 'uncertainty'
regarding the diagnosis of brain death in the Repertinger case. People with
long, illustrious careers built on a given idea are often close-minded to
empirical challenges to that idea, and they will grasp at straws to discredit
even the most impressive contradictory evidence. The Repertinger case
holds the record in terms of survival duration, but many cases of brain
death have been reported with survival durations longer than the usually
cited 'few days', many of them hom Japan, where the social ethos provides
motivation to maintain these patients much more than in Western countries.
As of 1998, I found some 175 reported cases of brain death with survivals
longer than one week. The maintainers of the 'party-line' sweepingly
dismiss most or all of these cases as 'undocumented', which in effect means
that they themselves did not have the opportunity to personally examine
each patient and the corresponding medical records.
Regarding the penultimate sentence in this subsection, it is not true that
'the brain stem and hypothalamus' cany out 'the integration and coordination
of all the subsystems of the body'. (emphasis mine) There are many
subsystems that integrate through their mutual interactions in the absence
of brain function.
Long-surviving cases of brain death are so rare in the Western world,
not because the body loses its integrative unity without brain function, but
rather because there is no therapeutic motivation to sustain these patients:
almost invariably, very soon after the diagnosis of brain death is made,
either they become organ donors or intensive care is stopped. Within the
small subpopulation where there is motivation to maintain such patients
(as in Japan, in cases of pregnant women, or in exceptional family situations
like the Repertinger case), prolonged s u ~ v a lasr e actually not so rare
as the collective experience of experts would lead one to believe. Be that as
it may, it is not the long survival duration per se of such cases that 'disturbs
the conceptual validity of brain death', but rather the many integrative
functions at the level of the organism as a whole that these bodies demon- .
strate, if anyone would care to look.
The Apnea Test
The Summary Statement downplays the potential risks inherent in the
apnea test, even when performed properly. The risks of acidosis, hypotension
and cardiac arrhythmias have been described even in textbooks of
DISSENTING STATEMENT 385
some of the signers of the Statement. Informed consent is required for
many medical procedures that entail less risk, yet informed consent for the
apnea test is neither solicited nor given. Moreover, no defender of mainstream
brain-death practice has yet given an adequate and reassuring reply
to Dr. Cicero Coirnbra's published concern about the apnea test further raising
intracranial pressure in a theoretical subset of patients who appear clinically
brain dead, but who still have marginal cerebral blood flow (what
Coimbra calls 'global ischemic.penumbral), resulting in the apnea test actually
precipitating the very brain death that it is supposed to be diagnosing.
Antidiuretic and Other Pituitary Hormones
Why should these somatically integrative functions be dismissed as
'spurious', and all the emphasis be given to somatically non-integrative
brain-stem reflexes, if the rationale for equating brain death with death is
supposedly the loss of somatic integrative unity? Moreover, these functions
are not necessarily 'transient,' as this subsection states.
The Loss of Heart Activity
It may be true that the diagnosis of an irreversibly nonfunctioning brain
can be made with greater certainty than that of an irreversibly nonfunctioning
heart (although this no doubt depends on the details of the cases
being compared). Nevertheless, the diagnosis of death is much less certain
in the case of brain death, because it hinges on philosophical rationales
(often tacit), on which there is no consensus among either philosophers or
medical professionals, rationales which by nature are not susceptible to
empirical verification.
I disagree that 'the reluctance to accept brain death may be mostly related
to the fact that it is a relatively new concept'. Its novelty per se is not a
reason for the reluctance; many other novelties over the last 40 years have
been accepted more readily and more universally than brain death. I would
posit, rather, that the reluctance is mostly related to the fact that the braindeath
notion is counterintuitive, and no amount of rhetoric or propaganda
will succeed in convincing the 'common man . . . that a deep sleep-like state
with a heartbeat ... is death' - and not only with a heartbeat, but with normal
functioning of other vital organs as well, apart from the brain. (Cf. subsections
'A Counterintuitive Reality' and 'Education and Brain Death'). The
Summary Statement fails to explain why total brain infarction is so radi386
D. ALAN SHEWMON and R. SPAEMANN
cally different from not-quite-total brain infarction, so that the presence or
absence of a non-somatically-integrating brainstem reflex could make the
difference between a state of very deep coma and death itself.
It is not at all true that the brain has 'the role . . . as the generator of the
functioning of essential organs'. The signatories of the Summary Statement
know this perfectly well, and it is disingenuous for them to write such a
misleading sentence in such a document. The only organ that the brain
'generates the functioning of is itself. By a stretch of language, one could
argue that the brain generates (in the sense of proximately causes) the functioning
of muscles and of the pituitary gland. It modulates the functioning
of many organs, but certainly does not 'generate' the functioning of the
heart, lungs, kidneys, liver, and other essential organs, which can operate
quite normally on their own in the complete absence of brain function, so
long as ventilation is artificially maintained.
m e Loss of Breathing
'If one proposes that the loss of spontaneous breathing defines death,
then all brain-dead patients are, by definition, "dead. Who would ever
make such an outlandish and oversimplified proposal? That would make
not only all brain-dead patients 'dead' but also all apneic, ventilator-dependent
patients 'dead', including conscious patients with high spinal cord injury,
amyotrophic lateral sclerosis (Lou Gehrig's disease) or diaphra,gnatic paralysis,
as well as many cases of coma short of brain death.
No Ventilator, No Heart Activity
'If one removes the ventilator from a brain-dead patient, the body
undergoes the same sequence of events . . . as occurs in an individual who
has undergone loss of heart activity'. The same could be said about removing
the ventilator from any ventilator-dependent, non-brain-dead patient.
Obviously the heart needs oxygenated blood to continue functioning. So
what? This is hardly an argument that the patient is already dead before the
ventilator is removed.
Artificial Instnlrnents
'Thus, it is as illogical to contend that death is the loss of heart activity
as it is to affirm that the loss of kidney activity is death'. The Summary
DISSENTING STATEMENT 387
Statement seems to implicitly attribute such a contention to the critics of
brain death. I agree that it would be iuogical, and I do not know any critic
of brain death who contends 'that death is the loss of heart activity'. The
irreplaceability of the brain is a spurious argument; if the brain is in fact
not necessary for the integrative unity of the body, then its irreplaceability
is irrelevant to the lifefdeath status of the body.
No Circtilation to the Brain Means Brain Death
This is so obvious that it hardly needs stating. No circulation to any
organ means death of that organ. On the other hand, the essential role of
the brain in the cognitive life of the individual, as described in the third sentence
of this subsection, does not imply that the absence of 'all sensory, cognitive,
and emotional e'qeriences' should constitute death itself, as opposed
to a deep coma.
The Camotrflaging of Death
I agree that this can be the situation in some cases of brain death -
namely those involving supracritical multi-system damage (including the
brain), resulting in loss of bodily integrative unity. In cases where the pathology
is limited to the brain, however, there is no loss of somatic unity, and the
ventilator is not camouflaging anything, no more than the ventilator camouflages
'death' in every non-brain-dead, ventilator-dependent patient.
The opinions expressed with absolute freedom during the presentation of
the papers of this meeting, although published by the Academy, represent
only the points of view of the participants and not those of the Academy.
Acknowledgements
I would like to thank the following people for their valuable work on this volume:
Dott. Lorenzo Rumori (layout, graphic design, conference photographs
and index structure), Gabriella C. Marino (language revision, transcripts,
proofreading and index structure), Dott.ssa Barbara Pelinka (German transcripts
and translations), Dott.ssa Alessandra Petrillo (proofreading), Prof.
Matthew Fforde (revision), Archiv. Aldo Cicinelli and Dott.ssa Sirnonetta
Ulisse (Secretariat).
M.S.S.
ISBN 978-88-7761-090-4
63 Copyright 2007
AU rights reserved. No part of this publication may be reproduced, stored in a retrieval system.
or transmitted in any form, or by any means, electronic, mechanical, recording, photocopying
or otherwise without the expressed written permission of the publisher.
PONTIFICIA ACADEMIA SCIENTIARUM
VATICAN CITY
Friday, September 30, 2011
Silence: Context To Hear The Word
"Silence and Word: path of evangelization."
"The extraordinarily varied nature of the contribution of modern communications to society highlights the need for a value which, on first consideration, might seem to stand in contra-distinction to it," the Vatican communiqué noted. "In the thought of Pope Benedict XVI, silence is not presented simply as an antidote to the constant and unstoppable flow of information that characterizes society today but rather as a factor that is necessary for its integration.
"Silence, precisely because it favors habits of discernment and reflection, can in fact be seen primarily as a means of welcoming the word."
The Vatican message discouraged a "dualism" in considering the elements of silence and communication, instead highlighting their complementary nature -- "two elements which when they are held in balance serve to enrich the value of communication and which make it a key factor that can serve the new evangelization."
Tuesday, September 27, 2011
Brain Death Controversy: John Paul II/Benedict XVI - Shewmon/Spaemann
Recent Magisterial Remarks on Brain Death: John Paul II and Benedict XVI
John Paul II: 2000
ADDRESS OF JOHN PAUL II
TO THE 18th INTERNATIONAL CONGRESS
OF THE TRANSPLANTATION SOCIETY
Tuesday 29 August 2000
Distinguished Ladies and Gentlemen,
1. I am happy to greet all of you at this International Congress, which has brought you together for a reflection on the complex and delicate theme of transplants. I thank Professor Raffaello Cortesini and Professor Oscar Salvatierra for their kind words, and I extend a special greeting to the Italian Authorities present.
To all of you I express my gratitude for your kind invitation to take part in this meeting and I very much appreciate the serious consideration you are giving to the moral teaching of the Church. With respect for science and being attentive above all to the law of God, the Church has no other aim but the integral good of the human person.
Transplants are a great step forward in science's service of man, and not a few people today owe their lives to an organ transplant. Increasingly, the technique of transplants has proven to be a valid means of attaining the primary goal of all medicine - the service of human life. That is why in the Encyclical Letter Evangelium Vitae I suggested that one way of nurturing a genuine culture of life "is the donation of organs, performed in an ethically acceptable manner, with a view to offering a chance of health and even of life itself to the sick who sometimes have no other hope" (No. 86).
2.As with all human advancement, this particular field of medical science, for all the hope of health and life it offers to many, also presents certain critical issues that need to be examined in the light of a discerning anthropological and ethical reflection.
In this area of medical science too the fundamental criterion must be the defence and promotion of the integral good of the human person, in keeping with that unique dignity which is ours by virtue of our humanity. Consequently, it is evident that every medical procedure performed on the human person is subject to limits: not just the limits of what it is technically possible, but also limits determined by respect for human nature itself, understood in its fullness: "what is technically possible is not for that reason alone morally admissible" (Congregation for the Doctrine of the Faith, Donum Vitae, 4).
3. It must first be emphasized, as I observed on another occasion, that every organ transplant has its source in a decision of great ethical value: "the decision to offer without reward a part of one's own body for the health and well-being of another person" (Address to the Participants in a Congress on Organ Transplants, 20 June 1991, No. 3). Here precisely lies the nobility of the gesture, a gesture which is a genuine act of love. It is not just a matter of giving away something that belongs to us but of giving something of ourselves, for "by virtue of its substantial union with a spiritual soul, the human body cannot be considered as a mere complex of tissues, organs and functions . . . rather it is a constitutive part of the person who manifests and expresses himself through it" (Congregation for the Doctrine of the Faith, Donum Vitae, 3).
Accordingly, any procedure which tends to commercialize human organs or to consider them as items of exchange or trade must be considered morally unacceptable, because to use the body as an "object" is to violate the dignity of the human person.
This first point has an immediate consequence of great ethical import: the need for informed consent. The human "authenticity" of such a decisive gesture requires that individuals be properly informed about the processes involved, in order to be in a position to consent or decline in a free and conscientious manner. The consent of relatives has its own ethical validity in the absence of a decision on the part of the donor. Naturally, an analogous consent should be given by the recipients of donated organs.
4. Acknowledgement of the unique dignity of the human person has a further underlying consequence: 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. This gives rise to one of the most debated issues in contemporary bioethics, as well as to serious concerns in the minds of ordinary people. I refer to the problem of ascertaining the fact of death. When can a person be considered dead with complete certainty?
In this regard, it is helpful to recall that the death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person. The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly.
Yet human experience shows that once death occurs certain biological signs inevitably follow, which medicine has learnt to recognize with increasing precision. In this sense, the "criteria" for ascertaining death used by medicine today should not be understood as the technical-scientific determination of the exact moment of a person's death, but as a scientifically secure means of identifying the biological signs that a person has indeed died.
5. It is a well-known fact that for some time certain scientific approaches to ascertaining death have shifted the emphasis from the traditional cardio-respiratory signs to the so-called "neurological" criterion. Specifically, this consists in establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity.
With regard to the parameters used today for ascertaining death - whether the "encephalic" signs or the more traditional cardio-respiratory signs - the Church does not make technical decisions. She limits herself to the Gospel duty of comparing the data offered by medical science with the Christian understanding of the unity of the person, bringing out the similarities and the possible conflicts capable of endangering respect for human dignity.
Here it can be said 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. Therefore a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgement which moral teaching describes as "moral certainty". This moral certainty is considered the necessary and sufficient basis for an ethically correct course of action. Only where such certainty exists, and where informed consent has already been given by the donor or the donor's legitimate representatives, is it morally right to initiate the technical procedures required for the removal of organs for transplant.
6. Another question of great ethical significance is that of the allocation of donated organs through waiting-lists and the assignment of priorities. Despite efforts to promote the practice of organ-donation, the resources available in many countries are currently insufficient to meet medical needs. Hence there is a need to compile waiting-lists for transplants on the basis of clear and properly reasoned criteria.
From the moral standpoint, an obvious principle of justice requires that the criteria for assigning donated organs should in no way be "discriminatory" (i.e. based on age, sex, race, religion, social standing, etc.) or "utilitarian" (i.e. based on work capacity, social usefulness, etc.). Instead, in determining who should have precedence in receiving an organ, judgements should be made on the basis of immunological and clinical factors. Any other criterion would prove wholly arbitrary and subjective, and would fail to recognize the intrinsic value of each human person as such, a value that is independent of any external circumstances.
7. A final issue concerns a possible alternative solution to the problem of finding human organs for transplantion, something still very much in the experimental stage, namely xenotransplants, that is, organ transplants from other animal species.
It is not my intention to explore in detail the problems connected with this form of intervention. I would merely recall that already in 1956 Pope Pius XII raised the question of their legitimacy. He did so when commenting on the scientific possibility, then being presaged, of transplanting animal corneas to humans. His response is still enlightening for us today: in principle, he stated, for a xenotransplant to be licit, the transplanted organ must not impair the integrity of the psychological or genetic identity of the person receiving it; and there must also be a proven biological possibility that the transplant will be successful and will not expose the recipient to inordinate risk (cf. Address to the Italian Association of Cornea Donors and to Clinical Oculists and Legal Medical Practitioners, 14 May 1956).
8. In concluding, I express the hope that, thanks to the work of so many generous and highly-trained people, scientific and technological research in the field of transplants will continue to progress, and extend to experimentation with new therapies which can replace organ transplants, as some recent developments in prosthetics seem to promise. In any event, methods that fail to respect the dignity and value of the person must always be avoided. I am thinking in particular of attempts at human cloning with a view to obtaining organs for transplants: these techniques, insofar as they involve the manipulation and destruction of human embryos, are not morally acceptable, even when their proposed goal is good in itself. Science itself points to other forms of therapeutic intervention which would not involve cloning or the use of embryonic cells, but rather would make use of stem cells taken from adults. This is the direction that research must follow if it wishes to respect the dignity of each and every human being, even at the embryonic stage.
In addressing these varied issues, the contribution of philosophers and theologians is important. Their careful and competent reflection on the ethical problems associated with transplant therapy can help to clarify the criteria for assessing what kinds of transplants are morally acceptable and under what conditions, especially with regard to the protection of each individual's personal identity.
I am confident that social, political and educational leaders will renew their commitment to fostering a genuine culture of generosity and solidarity. There is a need to instil in people's hearts, especially in the hearts of the young, a genuine and deep appreciation of the need for brotherly love, a love that can find expression in the decision to become an organ donor.
May the Lord sustain each one of you in your work, and guide you in the service of authentic human progress. I accompany this wish with my Blessing.
Benedict XVI: Nov. 7, 2008
Benedict XVI on Organ Donation
"A Unique Testimony of Charity"
"A Gift for Life. Considerations on Organ Donation."
With frequency, organ transplantation takes place as a completely gratuitous gesture on the part of the family member who has been certifiably pronounced dead. In these cases, informed consent is a precondition of freedom so that the transplant can be characterized as being a gift and not interpreted as a coercive or abusive act. In any case, it is useful to remember that the various vital organs can only be extracted "ex cadavere" [from a dead body], which posses it's own dignity and should be respected. Over recent years science has made further progress in ascertaining the death of a patient. It is good, then, that the achieved results receive the consensus of the entire scientific community in favor of looking for solutions that give everyone certainty. In an environment such as this, the minimum suspicion of arbitrariness is not allowed, and where total certainty has not been reached, the principle of caution should prevail.
For this it is useful to increment interdisciplinary research and study in such a way that the public is presented with the most transparent truth on the anthropologic, social, ethical and legal implications of a transplant. In these cases respect for the life of the donor should be assumed as the primary criterion, in such a way so that the extraction of the organs only take place after having ascertained the patient's true death (cf. Compendium of the Catechism of the Catholic Church, No. 476).
The act of love, which is expressed with the gift of one's own vital organs, is a genuine testament of charity that knows how to look beyond death so that life always wins. The recipient should be aware of the value of this gesture that one receives, of a gift that goes beyond the therapeutic benefit. What they receive is a testament of love, and it should give rise to a response equally generous, and in this way grows the culture of gift and gratitude.
The path that must be followed, until science discovers new and more advanced possible therapies, needs to be that of the formation and diffusion of a culture characterized by solidarity and that opens itself to others without excluding anyone. Organ transplants that are in line with ethic of giving require the commitment of all sides to invest every possible effort in formation and information, so as to increasingly awaken consciences to a problem that directly affects the lives of so many.
It would be necessary, then, to overcome prejudices and misunderstanding, dispel suspicions and fears and substitute them with certainties and guarantees, so as to create in all people an awareness, ever more widespread, of the great gift of life.
For this it is useful to increment interdisciplinary research and study in such a way that the public is presented with the most transparent truth on the anthropologic, social, ethical and legal implications of a transplant. In these cases respect for the life of the donor should be assumed as the primary criterion, in such a way so that the extraction of the organs only take place after having ascertained the patient's true death (cf. Compendium of the Catechism of the Catholic Church, No. 476).
The act of love, which is expressed with the gift of one's own vital organs, is a genuine testament of charity that knows how to look beyond death so that life always wins. The recipient should be aware of the value of this gesture that one receives, of a gift that goes beyond the therapeutic benefit. What they receive is a testament of love, and it should give rise to a response equally generous, and in this way grows the culture of gift and gratitude.
The path that must be followed, until science discovers new and more advanced possible therapies, needs to be that of the formation and diffusion of a culture characterized by solidarity and that opens itself to others without excluding anyone. Organ transplants that are in line with ethic of giving require the commitment of all sides to invest every possible effort in formation and information, so as to increasingly awaken consciences to a problem that directly affects the lives of so many.
It would be necessary, then, to overcome prejudices and misunderstanding, dispel suspicions and fears and substitute them with certainties and guarantees, so as to create in all people an awareness, ever more widespread, of the great gift of life.
I
Recent Pro-Statement on Brain Death as Valid Definition of Death
“WHY THE CONCEPT OF BRAIN DEATH
IS VALID AS A DEFINITION OF DEATH
Statement by Neurologists and Others
A. BATTRO, J.L. BERNAT, M.-G. BOUSSER, N. CABIBBO,
CARD. G. COTTIER, R.B. DAROFF, S. DAVIS , L. DEECKE, C.J. ESTOL,
W. HACKE, M.G. HENNERICI, J.C. HUBER, CARD. A. LÓPEZ TRUJILLO,
CARD. C.M. MARTINI, J. MASDEU, H. MATTLE, J.B. POSNER,
L. PUYBASSET, M. RAICHLE, A.H. ROPPER, P.M. ROSSINI,
M. SÁNCHEZ SORONDO, H. SCHAMBECK, E. SGRECCIA , P.N. TANDON,
R. VICUÑA, E. WIJDICKS, A. ZICHICHI
The Notion of Brain Death
The notion of ‘brain death’ was introduced to refer to a new criterion for
the ascertainment of death (able to go beyond the criteria relating to the
heart and breathing and the criteria relating to the destruction of the soma)
that had become evident with new discoveries about the working of the
brain and its role within the body, as well as necessary with the changed
clinical situations brought about by the use of the ventilator and the possibility
of sustaining human organs despite the loss of the unity of the organism
as a whole.
Brain Death is Death
Brain death has been a highly important and useful concept for clinical
medicine, but it continues to meet with resistance in certain circles. The reasons
for this resistance pose questions for medical neurologists, who are
perhaps in the best position to clarify the pitfalls of this controversial issue.
To achieve consistency, an important initial clarification is that brain death
is not a synonym for death, does not imply death, or is not equal to death,
but ‘is’ death.
‘Coma’, the ‘Persistent Vegetative State’, and the ‘Minimally Conscious State’
are not Brain Death
The inclusion of the term ‘death’ in brain death may constitute a central
problem, but the neurological community (with a few exceptions) acknowledges
that something essential distinguishes brain death from all other types
of severe brain dysfunction that encompass alterations of consciousness (for
example, coma, vegetative state, and minimally conscious state). If the criteria
for brain death are not met, the barrier between life and death is not
crossed, no matter how severe and irreversible a brain injury may be.
Brain Death is the Death of the Individual
The concept of brain death does not seek to promote the notion that there
is more than one form of death. Rather, this specific terminology relates to a
particular state, within a sequence of events, that constitutes the death of an
individual. Thus brain death means the irreversible cessation of all the vital
activity of the brain (the cerebral hemispheres and the brain stem). This
involves an irreversible loss of function of the brain cells and their total, or
near total, destruction. The brain is dead and the functioning of the other
organs is maintained directly and indirectly by artificial means. This state
results solely and specifically from the use of modern medical techniques and,
with only rare exceptions, it can only be maintained for a limited time.
Technology can preserve the organs of a dead person (one appropriately pronounced
dead by neurological criteria) for a period of time, usually only hours
to days, rarely longer. Nevertheless, that individual is dead.
Death is the End of a Process
This process begins with an irreversible fact of health, namely the beginning
of the failure of the integrative functions exerted by the brain and brain
stem on the body. It ends with brain death and thus the death of the individual.
Generally, this process involves an uncontrollable and progressive brain
edema, causing the intracranial pressure to rise. When the intracranial pressure
exceeds the systolic blood pressure, the heart is no longer capable of
pumping blood through the brain. The swollen brain becomes compressed
within its rigid ‘shell’, the skull, and herniates through the tentorium and the
foramen magnum, which eventually totally blocks its own blood supply.
Brain death and the death of the individual takes place as the end of this
process. There is a second process which begins with the death of the individual
and involves the decomposition of the corpse and the dying of all the
cells. The ancients were aware of these two processes and knew, for example,
that hair and nails continue to grow for days after death. To think today
that it is necessary to maintain the sub-systems of a corpse receiving artificial
support, and to wait for the death of all the cells in the body before pronouncing
the death of an individual would be to confuse these two processes.
This latter approach has been termed ‘exaggerated treatment’ or, more
specifically, the slowing down of the inexorable decomposition of a corpse
through the use of artificial instruments.
The Consensus on Brain Death
The criterion of brain death as the death of an individual was established
about forty years ago and since that time consensus on this criterion has
increasingly grown. The most important academies of neurology in the world
have adopted this criterion, as have most of the developed nations (the USA
Unfortunately, there is insufficient explanation by the scientific world of this
concept to public opinion which should be corrected. We need to achieve a
convergence of views and to establish an agreed shared terminology. In addition,
international organizations should seek to employ the same terms and
definitions, which would help in the formulation of legislation. Naturally, public
opinion must be convinced that the application of the criterion of brain
death is carried out with the maximum rigour and efficacy. Governments
should ensure that suitable resources, professional expertise and legislative
frameworks are provided to ensure this end.
Statistics on Brain Death
In the USA
brain death since its full definition, its application, and the clinical histories
involved are generally available in organ procurement offices. The Mayo
Clinic has information on about 385 cases (years 1987-1996). Flowers and
Patel (Southern Medical Journal 2000; 93:203-206), reported on 71 individuals
who met the clinical criteria of brain death and then were studied by the
use of radionuclide brain scans. No blood flow was demonstrated in 70
patients and in 1 patient arterial blood flow was present on the initial evaluation
but disappeared 24 hours later. The authors concluded that using established
medical criteria the accuracy of the diagnosis of brain death was
100%. The famous Repertinger meningitis case ironically demonstrates that
it is possible to keep a body and organs perfused for a long period of time.
One possibility is that this patient may not have been brain dead for a long
period of time (cf. the detailed discussion on this possibility during the meeting
and question 15, p. LXIX ff.). Another possibility is that this represents a
valid case of brain death since all of the clinical tests were performed to
ascertain brain death except the apnea test. The absent evoked potentials and
the flat EEG were consistent with brain death. If this was a validly documented
case of brain death, it makes the point that in extraordinarily rare exceptions
this kind of case occurs. However, many years have passed since this
case, there is a great deal of uncertainty about it, and one cannot generalise
from it to invalidate the criteria for brain death. With the technologies available
in modern intensive care units, we may see more of such prolonged
cases, as technological capacity develops to reproduce some of the functions
of the brain stem and hypothalamus in the integration and coordination of
all the sub-systems of the body. The neurological community does not believe
that this case disturbs the conceptual validity of brain death as being equivalent
to human death.
A Counterintuitive Reality
The history of science and of medicine contains many discoveries that
are contrary to our perceptions and seem counterintuitive. Just as it was difficult
for common sense to accept, at the time of Copernicus and Galileo, that
the earth was not stationary, so it is sometimes difficult now for people to
accept that a body with a pumping heart and a pulse is ‘dead’ and thus a
corpse; ‘heart-beating death’ appears to defy our common sense perceptions.
In part, this is because the dead brain, like the moving earth, cannot be seen,
conceptualised, or experienced by the onlooker. Indeed, the common man
does not easily accept that a deep sleep-like state with a heartbeat, accompanied
by electrocardiogram activity, is death. Since the use of medical technology
is so ubiquitous, it is easy to fail to comprehend that a ventilator machine
is a necessary intermediary in maintaining this state. This may give rise to a
deep-seated reluctance both to abandon brain-dead individuals and to accept
the removal of organs from their bodies for the purposes of transplantation.
Organ Transplantations
The concept of brain death has been at the centre of a philosophical
and clinical debate, especially after advances made in the field of transplan-
tations. In particular, it has been asked whether this criterion – and this is
the view, for example, of Hans Jonas – was introduced to favour organ
transplantations and is influenced by a dualistic vision of man that identifies
what is specific to man with his cerebral activities. Yet, as emerged during
discussions of the meeting, the criterion of brain death is compatible at
a philosophical and theological level with a non-functionalist vision of
man. St Augustine
mind or the soul, was able to say that when ‘the brain by which the body is
governed fails’, the soul separates from the body: ‘Thus, when the functions
of the brain which are, so to speak, at the service of the soul, cease completely
because of some defect or perturbation – since the messengers of the
sensations and the agents of movement no longer act –, it is as if the soul
was no longer present and was not [in the body], and it has gone away’ (De
Gen. ad lit., L. VII, chap. 19; PL 34, 365).
Indeed, the criterion of brain death is in conformity with the ‘sound anthropology’ of John Paul II, which sees death as the separation of the soul from the body, ‘consisting in the total disintegration of that unitary and integrated whole that is the personal
self’. Thus, in relation to the criterion of brain death, the Pope was able
to declare: ‘the criterion adopted in more recent times for ascertaining the
fact of death, namely the complete and irreversible cessation of all brain
activity (in the cerebrum, cerebellum and brain stem) if rigorously applied,
does not seem to conflict with the essential elements of a sound anthropology’
(Cf. Address of 29 August 2000 to the 18th International Congress of
the Transplantation Society).
From a clinical point of view, almost the whole of the medical community
agrees that the concept of brain death as death should not serve an ulterior
purpose (specifically: organ transplantation). Indeed, the ascertainment
of brain death, which in historical terms was the result of the independent
study of the brain, preceded the first transplantation procedures and thus
was (and therefore is) unconnected with the related subject of transplants
(cf., e.g., S. Lofstedt and G. von Reis, ‘Intracranial lesions with abolished
passage of X-ray contrast throughout the internal carotid arteries’, PACE,
1956, 8, 99-202). Few physicians are convinced that the removal of organs
from brain-dead individuals amounts to murder, and there is no reasonable
legislation that adopts this point of view. The advent of cardiac and hepatic
transplantation in the 1960s, and the need for organs from heart-beating
donors to ensure successful results, generated an evident relationship
between brain death and transplants. In the future, it is possible and to be
hoped, that this relationship will diminish with new discoveries in the use of
natural non-human and artificial organs.
Unsound Arguments
Most of the arguments against brain death are not sustainable and are
incorrect diversions when scrutinised from a neurological perspective. For
example, the erroneous or imprecise application of the criteria of brain
death, the fact that the neurological examination in individual cases may be
misinterpreted, or variations in the criteria chosen by specialist groups, can
all too easily be used as spurious arguments against the concept.
The Apnea Test
The claims that apnea testing poses a risk to the patient are largely
invalid when the testing is performed properly. Authorities should ensure
that apnea testing is always carried out with the maximum of professional
and technological expertise, and dedicate resources to this end.
Irreversible Situations: All Death is Brain Death
Assertions as to the existence of ‘awakenings’ from brain death have
been used to discredit the concept and to prolong artificial ventilation, feeding
and medical support in the hope of a recovery. A small number of cases
of brain-dead individuals maintained in this state with ventilators and other
medical measures for weeks, or even years, have given rise to unfounded
claims that these subjects were in conditions other than death. In reality, as
observed above in the section on ‘statistics on brain death’, where the proper
diagnostic criteria have been employed all such assertions are not valid.
Pregnancy
Pregnancies have been carried to term in brain-dead mothers. These
cases are exceptional and do not involve potentially reversible conditions
different from brain death. The mother’s uterus and other organs are being
supported as a technical vessel for pregnancy, in much the same way that
the heart or the kidneys are kept perfused. Thus, it is possible for an individual
who is brain dead to give birth, if maintained with a ventilator, or other
measures, for a certain period.
Antidiuretic and Other Pituitary Hormones
Other spurious arguments, such as the residual excretion of antidiuretic
and other pituitary hormones in some cases of brain death, refer to transient
phenomena, and are technical arguments that can be dealt with on a
practical level. There is no need for every single cell inside the cranium to be
dead for brain death to be confirmed.
Axon Regeneration
Recent reports of axon regeneration in patients with severe brain damage
(which require corroboration and more study) are not pertinent to brain death.
Recovery Excluded
It follows, as mentioned earlier, that there is no chance of recovery from
brain death and that discussions regarding recovery from various states of
coma must be distinguished from brain death.
The Need for an Expert Neurological Examination
If the criteria of brain death are correctly applied, and if the neurological
examination is carried out correctly by an experienced physician, then
full reliability can be achieved. As mentioned above, there have been no documented
exceptions. The neurological examination evaluates consciousness
and reflexes to confirm death of the neurons involved in these functions.
Although every neuron in the central nervous system is not assessed during
the examination, as stated earlier it is not necessary for absolutely all neurons
to be dead for brain death to be reliably diagnosed. In a sedated or previously
sedated patient, the lack of perfusion of the brain must be demonstrated
for brain death to be ascertained beyond all doubt.
The Loss of Heart Activity
When the cardiologist pronounces death as a result of cardiac standstill,
the diagnosis is less certain than in the circumstance of brain death.
Many documented cases exist of patients pronounced dead after failure of
cardiac resuscitation who have subsequently been discovered to be alive.
It should be further stated that the traditional definition of natural loss of
heart activity as ‘death’ is not satisfactory because it is now possible to
keep the heart beating by artificial means and blood circulation to the
brain can be maintained artificially to a brain that is dead. Confusion arises
from the presence of mechanical systems that artificially replace the
role of the brain as the generator of the functioning of essential organs
Therefore, brain death is a much more certain diagnosis than heart death.
The reluctance to accept brain death may be mostly related to the fact that
it is a relatively new concept (the invention of the ventilator by Ibsen took
place fifty-six years ago) compared to the traditionally accepted notion of
cardiac and respiratory arrest.
The Loss of Breathing
If one proposes that the loss of spontaneous breathing defines death,
then all brain-dead patients are, by definition, ‘dead’. When the patient has
been pronounced dead after the application of the appropriate criteria of
brain death, the decision to continue with ventilation can only be justified
with reference to the life and wellbeing of another person.
No Ventilator, No Heart Activity
If one removes the ventilator from a brain-dead patient, the body undergoes
the same sequence of events and physical dissolution as occurs in an
individual who has undergone loss of heart activity.
Artificial Instruments
Thus, it is as illogical to contend that death is the loss of heart activity
as it is to affirm that the loss of kidney activity is death. Indeed, both renal
activity (through dialysis) and heart activity (with a non-natural instrument)
can be supported artificially, something that is impossible in the case of the
brain: no artificial instrument exists that can reactivate or replace the brain
after it has died.
No Circulation to the Brain Means Brain Death
One does not have to be a Cartesian to assert the central importance of
the brain. Today, after advances in our knowledge of the workings of the
brain, it is the medical-philosophical view that the body is ‘directed’ by that
marvellous organ, the brain. Certainly, we are not a ‘brain in a vat’ but it has
to be recognised that the brain is the receiving centre of all sensory, cognitive,
and emotional experiences and that the brain acts as the neural central driving
force of existence. We must acknowledge that the loss of circulation to the
brain causes death. This loss of circulation can be documented in virtually all
cases of brain death if tests are performed at the proper time.
The Camouflaging of Death
In reality, the ventilator and not the individual, artificially maintains the
appearance of vitality of the body. Thus, in a condition of brain death, the
so-called life of the parts of the body is ‘artificial life’ and not natural life. In
essence, an artificial instrument has become the principal cause of such a
non-natural ‘life’. In this way, death is camouflaged or masked by the use of
the artificial instrument
.
Education and Brain Death
One of the tasks of physicians in general and neuroscientists is to educate
the public about discoveries in this field. As regards the concept that all
death is brain death, this task may be difficult, but it is our duty to continue
in such an endeavour.
At a specific level, the relatives of brain-dead individuals should be told
that their relative has died rather than that he is ‘brain-dead’, with the
accompanying explanation that the support systems produce only an
appearance of life. Equally, the terms ‘life-support’ and ‘treatment’ should
not be employed because in reality support systems are being provided to
a corpse.
* * * * * * * * *
RESPONSE TO THE STATEMENT AND COMMENTS
OF PROF. SPAEMANN AND DR. SHEWMON
A. BATTRO, J.L. BERNAT, M.-G. BOUSSER, N. CABIBBO,
CARD. G. COTTIER, R.B. DAROFF, S. DAVIS , L. DEECKE, C.J. ESTOL,
W. HACKE, M.G. HENNERICI, J.C. HUBER, CARD. C.M. MARTINI, J.C. MASDEU, H. MATTLE, M. SÁNCHEZ SORONDO, H. SCHAMBECK,E. SGRECCIA, J.B. POSNER, L. PUYBASSET , M.E.
A.H. ROPPER, P.N. TANDON, R. VICUÑA, A. ZICHICHI
Dr. Shewmon criticizes many of the conclusions of the statement ‘Why
the Concept of Brain Death is Valid as a Definition of Death’ and some of the
views expressed during the general discussion. His points could be considered
contributions to the debate. Aristotle teaches us to be grateful not only
to those whose views we share but also to those who express different opinions,
because they too have contributed to the stimulation of reflection.1 We
regret that Dr. Shewmon could not attend the PAS in September, so that we
could have debated his criticism in person, rather than in retrospect.
Dr. Shewmon and Prof. Spaemann may never agree that death of the
brain is the death of the individual. However, there are certain statements
upon which we all agree:
1. Meeting the clinical criteria for brain death establishes that that individual
will never, ever, recover any semblance of consciousness or conscious
activity.
2. The vast majority of bodies meeting the brain death criteria will suffer
multi-organ failure including cardiac arrest within a short period of time,
despite major efforts to preserve somatic organs. This is true despite the
original injury being restricted to the brain, as for example a massive
cerebral haemorrhage.
3. In a small minority of such bodies, somatic organs, including the heart,
may be kept functioning for a period of time, usually a few days, some-
times weeks and in extremely rare instances for an extended period. No
matter how long somatic function is sustained, when brain death has
been appropriately diagnosed, no semblance of consciousness or conscious
activity will ever occur.
1 Cf. Met., II, 1, 993 b 12 ff.
4. That the phrase ‘physiological decapitation’ applied to brain death should
be avoided because a decapitation is contrary to physiology, which refers
to the normal functions of living organisms and their parts, and because
brain dead subjects can still, indeed, have heads.
An overwhelming number of medical experts, including those attending the
Vatican Symposium, agree with the above propositions. One finds it difficult
to understand why Dr. Shewmon and Prof. Spaemann, while accepting these
statements about brain death, do not accept that brain death is the death of
the individual. However, we can say that their refusal is based on personal
physical/biological and philosophical views. From the physical/biological
point of view, they affirm that the integration and coordination of the bodily
sub-systems are not performed exclusively by the brainstem and hypothalamus.
And thus for them, there is a holistic vital unity of the organs of a body
without the brain.
Perhaps this point can be further clarified if we contrast brain death with
a vegetative state. Why is the persistent vegetative state different from brain
death? Given the same supportive care as a brain-dead body, a patient in a
vegetative state is unlikely to die, suggesting that the brainstem, and particularly
the lower brainstem, is important for the integrative function of the rest
of the body, whereas the cerebral hemispheres are not.
There are other differences between the vegetative state and brain death.
1) Functional MRI suggests that elements of consciousness may be present
in patients who are vegetative. 2) There are reports describing recovery of at
least minimal consciousness after many months in a vegetative state. Thus,
we should not make the diagnosis of a ‘persistent’ vegetative state for the first
three months, and for the first year following head trauma. 3) Several papers,
addressing the issue of keeping somatic organs functioning after the brain
has died, demonstrate that it is extremely difficult and, with rare exceptions
(not, as Dr. Shewmon suggests, ‘common’ exceptions), fails after a few days.
This contrasts with the relative ease of maintaining individuals with severe
brain or spinal cord injury who are not brain dead. That an individual whose
spinal cord has been severed at the high cervical level and is ventilatordependent,
can be sustained to live and work at home, indicates the importance
of the brain in the integrative function of the rest of the body. That it is
easier to maintain the somatic organs of a vegetative patient than those of a
brain dead subject also attests to the importance of the brain, in this case the
brainstem, in integrating the function of the remainder of the body, which, in
part, explains why the vegetative state is not equated with death.
Thus we believe that once the clinical criteria for brain death are present,
the individuals are as dead as if their hearts had stopped.
In addition, as regards the precise issue of whether the brainstem and
hypothalamus are the integrators of ‘all’ bodily function, Dr. Shewmon seeks
to present evidence that the integration and coordination of the bodily subsystems
are not performed exclusively by the brainstem and hypothalamus.
To what kind of integration and coordination does he refer? The vast majority
of neurologists believe that all of the functions relevant to the state of life
are performed there, in the brainstem and hypothalamus, structures that are
indeed the integrators of the main systems and sub-systems of the body. The
brain integrates all functions of the body, through nerves, neural transmitters
and secreted substances, the latter a process that Dr. Shewmon ignores when
he compares spinal cord sectioned individuals with those who are brain
dead. Thus, it is unclear as to what sub-systems Dr. Shewmon is referring; the
rare subjects who are brain dead, but whose organs survive for weeks or
months, indicate that some organs such as the kidney and the digestive system
can function independently of the brain, but whether they can integrate
with each other is less clear. For that matter, as certain papers demonstrated,
if the technical support is adequate, one can maintain certain organs (i.e.
heart) isolated from the body in a system of perfusion for days. Thus, it
should not be surprising that if these organs are perfused within the soma
(their natural location), they can remain active within a corpse. One can
accept that the holistic physiological properties of the soma in a brain dead
subject are greater than in a collection of perfused organs, i.e. that the interaction
between organs within the ventilated soma is greater than that occurring
with separated organs maintained in a vat. However, these experiments
do not imply that an integration and co-ordination exists without the brain.
Whatever ‘integrative sub-systems’ the rest of the body may have, they are
few, fragile, and poorly coordinated, and one cannot sustain them once the
brain has died. The other bodily structures that effect some integration
(nerves in the heart and bowel or bones that make up the skeleton, for example)
are entirely irrelevant in discussions about brain death as the death of
the individual. The ancients knew about these other integrative forms
through their observation of hair and nail growth in corpses, but did not
doubt that the individual was dead. Thus, in opposition to Dr. Shewmon’s
affirmations, with the death of the brain an inexorable process of disintegration
of the body begins that a ventilator can only slow down. Therefore, as
affirmed in the Statement, this process of disintegration is different from the
death of the individual, which begins with an irreversible fact of health and
ends with brain death and thus the death of the individual.
Moreover, if it is asserted that the brain in the embryo does not ‘mediate’
the integrative unity of the organism, then it is evident that the word ‘organism’
is being used in an inappropriate way. The embryo is the first stage in
the development of a multi-cellular organism (it immediately follows the
fusion of the pronuclei in the ovule) but it is not properly an organic body.
What is specifically called an organic body is one that has a diversity of
organs. This is not the case with an embryo because it has not yet developed
a system of organs. Thus there cannot be mediation between the organs,
either between the brain and the other organs or between the various organs,
because the organs have not yet developed and are still in potency. There is,
therefore, a radical difference, from the point of view of integration, between
a situation of brain death and that of an embryo that has not yet developed
its organs. This fact invalidates the parallel made between the embryo and a
brain-dead body.
At this point, given their gross underestimation of the importance of the
brain for the integrative function of the rest of the body, Prof. Spaemann and
Dr. Shewmon affirm that the adoption of brain death as death by neurologists
is not physical/biological but philosophical. In other words, according to Prof.
Spaemann and Dr. Shewmon, since neurologists are not able to justify the presumed
sub-integration of the body without the brain, to state that brain death
is the death of the individual, neurologists are compelled to identify the brain
with the mind or personhood, which is a philosophical statement.
It was clear from the direction of the meeting that the task was to focus
first and foremost on the scientific approaches. Indeed, the only philosophical
paper was that given by Prof. Spaemann who opposed brain death as the
criterion for death. However, from the discussions during the meeting, it
emerged (a point not answered by Prof. Spaemann) that although the mind
is not the same as the brain, one cannot today reasonably doubt that human
intelligence (and in part personhood) depend on the brain as the centre of the
nervous system and other biological systems. Although we certainly do not
currently have a detailed understanding of the physical modalities of human
thought, it is an established scientific fact that human intelligence depends
on the support of nerve cells and the organisation of billions of connections
between the billions of neurons that make up the human brain and its ramifications
within the human body. This does not mean that one could conclude
in haste that contemporary neuroscience has definitively demonstrated
the truth of a materialistic monism and rejected the presence of a spiritual
reality in man.
According to the post-Second Vatican Council and contemporary
Catechism of the Catholic Church, ‘The unity of soul and body is so profound
that one has to consider the soul to be the “form” of the body:2 i.e., it is
because of its spiritual soul that the body made of matter becomes a living,
human body’ (n. 365). So, from a philosophical and theological point of view,
it is the soul that confers on the body the unity and the essential quality of
the human body, which are reflected in the dynamic unity of the cognitive
(and inclinational) activities with the sensitive and vegetative activities that
not only co-exist, but can also work together in a participation of the nervous
system with the senses and the intellect (and in a participation of the biological
and sensitive inclinations with the will). Thus, Aristotle, using a geometric
analogy of contemporary relevance that is explicitly appropriate for this
operative order as well, declared that the vegetative is in the sensitive and this
is in the intellective in the same way that a triangle is in a square and this is
in a pentagon, because this last contains the square and even more.3 This
dynamic organic unity between the activity of the intellect, the senses, the
brain and the body does not exclude but, on the contrary, postulates, at a biological
and organic level, that there is an organ which has the role of directing,
coordinating and integrating the activities of the whole body. Each specific
function carries out its activity as an integral part of the whole. In contrary
fashion, the fact of suggesting a sort of equivalence or equality of functions
and of their activities leads us to acknowledge their relative independence,
which is contradictory to the idea of ‘organism’. So the brain is the centre
of the nervous system but it cannot function without the essential parts of
its connectivity throughout the organism, in the same way as the organism
cannot function without its centre. We are not brains in a vat, but neither are
we bodies without a brain.
Therefore, brain function is necessary for this dynamic and operative
physiological unity of the organism (over and above its role in consciousness),
but not for the ontological unity of the organism, which is directly conferred
by the soul without any mediation of the brain, as is demonstrated by
the embryo. However, if the brain cannot assure this functional unity with
the organic body because the brain cells are dead or the brain has been separated
from the organism, the capacity of the body to receive the being and
the unity of the soul disappears, with the consequent separation of the soul
from the body, i.e. the death of the organism as a whole.
The formula constituting the source of the definition of the Council of
dynamic point of view, the other formula of St Thomas
cited by Prof. Spaemann) to the effect that ‘the government of the body
belongs to the soul in that it is its motor and not its form’4 and thus ‘between
the soul and all the body, in that it is a motor and the principle of operations,
occurs something intermediary, because, through a first part moved first, the
soul moves the other parts to their operations’ (‘inter animam secundum quod
est motor et principium operationum et totum corpus, cadit aliquid medium;
quia mediante aliqua prima parte primo mota movet alias partes ad suas operationes’).5
Thus the overall formula obscured by tradition and by Prof.
Spaemann is: ‘the soul unites to the body as a form without an intermediary,
but as a motor it does this through an intermediary’ (anima unitur corpore ut
forma sine medio, ut motor autem per medium).6 Therefore, when the cells of
the brain die, the individual dies, not because the brain is the same as the
mind or personhood, but because this intermediary of the soul in its dynamic
and operative function (as a motor) within the body has been removed –
‘that disposition by which the body is disposed for union with the soul’.7 One
must see this intermediation of the brain not as delegation from outside but
as a part of reality and this is what the traditional notion of ‘principal organ’
or ‘instrumentum coniunctum’ seeks to express. St Augustine
source of this Thomistic doctrine of the government of the body by the soul
through an organ which is the principal instrument, is very clear in asserting
avant la lettre that brain death is the death of the individual: ‘Thus, when the
functions of the brain which are, so to speak, at the service of the soul, cease
completely because of some defect or perturbation – since the messengers of
the sensations and the agents of movement no longer act –, it is as if the soul
was no longer present and was not [in the body], and it has gone away’
(Denique, dum haec eius tamquam ministeria vitio quolibet seu perturbatione
omni modo deficiunt desistentibus nuntiis sentiendi et ministris movendi,
tamquam non habens cur adsit abscedit [anima]).8
2 Cf. Council of Vienna
3 Cf. De Anima, II, 3, 414 b 20-32.
4 St Thomas Aquinas, Q. de spiritualibus creaturis, a. 2 ad 7.
5 Ibid., Q. de Anima, a. 9.
6 Loc. cit.
7 St Thomas Aquinas, S.Th., I, 76, 7 ad 2.
8 De Gen. ad lit., L. VII, chap. 19; PL 34, 365. It would appear that St. Thomas Aquinas
arrived at the same conclusion about the centrality of the head when he stated: ‘The head
has three privileges in relation to the other members. Firstly, it is distinguished from the
others in the order of dignity because it is the principle and it presides. Secondly, because
objections to the criterion of brain death as death advanced by Prof.
Spaemann and Dr. Shewmon do not hold up either at a physical/biological or
a philosophical level.
We also disagree with Dr. Shewmon’s conclusion that the worldwide consensus
on the equivalency of brain death with human death is ‘superficial
and fragile’. Although practices vary between countries, there does exist a
consensus of sufficient strength to permit the successful declaration of brain
death in dozens of countries in the developed Western world and the non-
Western and developing world that have addressed this question and possess
the necessary state-of-the-art technology.
of its fullness of senses in that all senses are in the head. Thirdly, because of a certain influence
of sense and movement on the members’: ‘Caput enim respectu aliorum membrorum
habet tria privilegia. Primo, quia distinguitur ab aliis ordine dignitatis, quia est principium et
praesidens; secundo in plenitudine sensuum, qui sunt omnes in capite; tertio in quodam
influxu sensus et motus ad membra’ (Super Colossenses, cap. 1, lect. 5, Marietti, Rome
vol. 2, p. 135, n. 47).
Statement Opposing Brain Death Criteria (2000-)
*You can read papers on the anti-brain death movement in Japan
Below is a position statement, signed by over 120 people from 19 nations, including physicians, philosophers, and theologians, opposing brain death criteria for human death. It has been released through the auspices of Earl Appleby, Jr. of Citizens United Resisting Euthanasia (cureltd@ix.netcom.com; he would have the most updated list of those who signed the statement), but those who signed the list are a very diverse group. I hope that the list both stimulates discussion and makes the wider community aware that there are a large number of individuals who believe that there are good reasons for opposing brain death criteria.
Michael Potts, Ph.D., Associate Professor of Philosophy, Methodist College , Fayetteville , NC
"Brain Death" - Enemy of Life and Truth
Pope John Paul II's August 29, 2000, address to the International Congress of the Transplantation Society has awakened renewed interest in the ongoing controversies surrounding "brain death" and organ transplantation. Inasmuch as these controversies quite literally involve matters of life and death physical and spiritual, a clear understanding of their nature is vital to the survival of both life and truth, life's guardian. Since the question of organ transplantation cannot be properly judged either logically or ethically in the absence of what the Pope describes as "a scientifically secure means of identifying the biological signs that a person has indeed died" (4), we must first examine the concept of "brain death," which serves as the rationalization for the removal of vital organs from those described as "donors."
"Brain Death"
Noting a shift in emphasis in the determination of death "from the traditional cardio-respiratory signs to the so-called " neurological criterion," the Holy Father states that this change consists in "establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum, and brain stem)." (5) The parameters variously set forth for declaring a person "brain dead," however, are neither "clearly determined" nor are they "commonly held" by the scientific community. Rather the myriad permutations of "brain death" criteria introduced since the publication of the revealingly titled "A Definition of Irreversible Coma" in 1968 -more than 30 sets in the first decade alone have grown increasingly permissive. At the same time, a growing number of members of the scientific community have taken a closer look at "brain death" and are voicing their concerns. To know with moral certainty that "the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum, and brain stem)" has occurred would require the total absence of all circulation and respiration. Confirmation of this absence would necessitate that the cerebrum, cerebellum, and brain stem have been destroyed and the circulatory and respiratory systems as well. None of the shifting sets of "so-called neurological criterion" for determining death fulfills the Pope's requirement that they be "rigorously applied" to ascertain "the complete and irreversible cessation of all brain activity." (5) In fact, "brain death" is not death, and death ought not to be declared unless the entire brain and the respiratory and circulatory systems have been destroyed.
Organ Transplantation
Reiterating his words in Evangelium Vitae (86), the Holy Father "suggested that one way of nurturing a genuine Culture of Life is the donation of organs, performed in an ethically acceptable manner." (1) A manner that is "ethically acceptable" is one that corresponds to the Natural Moral Law and its four axioms: (1) Good ought to be done, and evil must be avoided. (2) Good may not be withheld. (3) Evil may not be done. (4) Evil may not be done that good might come of it. Thus the harvesting of organs in a manner that would bring about the debilitating mutilation or the death of the "donor" would not be "ethically acceptable." Describing the decision to donate an organ quite aptly as "a decisive gesture," the Pope cautioned, "The human authenticity of such a decisive gesture requires the individuals to be properly informed about the processes involved, in order to be in a position to consent or decline in a free and conscientious manner." (3) To be properly informed, the person considering organ donation should be educated about the nature of organ transplantation. In particular, he should be advised that prior to excision, his heart is healthy and capable of normal circulation and respiration, but after any vital organ necessary and required to live has been moved from his body, he will die. The prospective "donor" should also be informed that a paralyzing agent will be administered to prevent him from moving when the incision is made and advised whether anesthesia will be administered to him prior to the excision of his organs, as has been recommended by anesthesiologists. Lest freedom be confused with license, it must be noted that freedom consists in the liberty to exercise one's free will in accordance with right reason, which seeks good and avoids evil. To murder oneself or another can never be in accord with right reason. The Holy Father makes a critical restriction on the removal of organs in light of "the unique dignity of the human person," stipulating that "vital organs which occur singly in the body can be removed only after death, that is from the body from someone who is certainly dead." (4) He goes on to add that "the requirement is self-evident, since to act otherwise would mean intentionally to cause the death of the donor in disposing of his organs." (4) For vital organs to be suitable for transplantation, however, they must be living organs removed from living human beings. Moreover, as noted above, persons condemned to death as "brain dead" are not "certainly dead" but, to the contrary, are certainly alive. Thus adherence to the restrictions stipulated by the Pope and the prohibitions imposed by God Himself in the Natural Moral Law precludes the transplantation of unpaired vital organs, an act which causes the death of the "donor" and violates the fifth commandment of the divine Decalogue, "Thou shalt not kill" (Deut. 5:17).
Paul A. Byrne, M.D., FAAP, Past President, Catholic Medical Association, Oregon , Ohio
Walt F. Weaver, M.D., FACC, Clinical Associate Professor, School of Medicine , University of Nebraska , Omaha , Nebraska
Prof. Josef Seifert, Ph.D., Rector, International Academy for Philosophy, Furstentum , Liechtenstein
Mercedes Arzu Wilson, L.H.D., President, Family of the Americas Foundation, Dunkirk , Maryland
Bishop Fabian Wendelin Bruskewitz, Diocese of Lincoln, Lincoln , Nebraska
Bishop Robert F. Vasa, Diocese of Baker, Baker, Oregon
Julie Grimstad, Director, Center for the Rights of the Terminally Ill, Stevens Point , Wisconsin
Earl E. Appleby, Jr., Director, Citizens United Resisting Euthanasia, Berkeley Springs , West Virginia
Neleide Abila, Professor of Law, Universidade Paranaense, Guiara , Brazil
Marcos Antonio Aranda, M.D., Director, ICU Chief, Department of Pulmonology, Hospital Clinicordis, S?o Paulo , Brazil
Christopher R. Bell, President, Good Counsel, Inc., Hoboken , New Jersey
Joan Andrews Bell, Director, PIETA Mission , Hoboken , New Jersey
Yuri Belozorov, Director, Choose Life, Vladivostock , Russia
Fr. Frederick Bentley, OHI, Anglican Priests for Life, Edinboro, Pennsylavania
Robin Bernhoft, M.D., FACS, Chairman, National Parents Commission, Johnstown , Pennsylvania
Giuseppe Bertolini, M.D., Specialist in Anesthesia and Resuscitation, Ospidali Riunti di Roma, Rome , Italy
Cledson Ramos Bezerra, Attorney at Law , Jo?o Pessoa , Brazil
Jerrold G. Black, M.D., Family Practice Physician, Lincoln , Nebraska
Wallace L. Boever, M.S., Clinic Manager, Holy Family Medical Specialties, Lincoln , Nebraska
Massimo Bondi, M.D., L.D., Former General Surgeon, Medical Board, Sydney, Australia; Professor of Surgical Pathology Universit? degli Stud? "La Sapienza", Rome , Italy
Michael Brear, MB, BS, DTM&H, LMCC, General Practitioner, Vancouver , Canada
William Brennan, Ph.D., Professor, School of Social Service , St. Louis University , St. Louis , Missouri
Paul R. Bruch, M.D., Past President, Connecticut Right to Life Corporation, Southbury , Connecticut
L?o Brust, Attorney at Law, Porto Alegre , Brazil
Fr. Christian Marie Charlot, Professor of Bioethics, President, World for Children, Bagnoregio , Italy
Helen Cindrich, Executive Director, People Concerned for the Unborn Child, Pittsburgh , Pennsylvania
Celso Galli Coimbra , Attorney at Law, Porto Alegre , Brazil
Cicero Galli Coimbra, M.D., Ph.D., Associate Professor, Department of Neurology and Neurosurgery, Federal University of Sao Paulo, S?o Paulo, Brazil
Greg Clovis, Executive Director, Human Life International-UK, London , England , UK
Kurt Clyne, M.S., PharmD., Director, Pharmacy, St. Elizabeth Regional Medical Center, Lincoln , Nebraska
Dr. A.P. Cole, FRCP, RFCPCH, Director, Lejeune Clinic, London , England , UK
Kathy Coll, Director, Pro-Life Coalition, Havertown , Pennsylvania
William F. Colliton, Jr., M.D., FACOG, Clinical Professor Emeritus of Obstetrics and Gynecology, George Washington University
Carlito V. Cruz, M.D., General Surgeon, St. John Hospital and Medical Center, Detroit, Michigan
Gregg Cunningham, Esq., Executive Director, The Center for Bio-Ethical Reform, Los Angeles , California
Joseph W. Cunningham, Esq., President, The Society of Blessed Gianna Beretta Molla, Philadelphia , Pennsylvania
Lorna L. Cvetkovitch, M.D., Obstetrician and Gynecologist, Lincoln , Nebraska
Michael Davies, President, International Una Voce Federation, London , England , UK
Dr. Michael Delany, London , England , UK
Robert Desmond, M.D., Emergency Department, Wood County Hospital , Bowling Green , Ohio
Marie Dietz, Director, Center for Pro-Life Studies, North Troy , Vermont
Dr. Bert P. Dorenbos, President, Schreeow Om Leven, Hilversum , Netherlands
John F. Downs, Director, Partners in the Cross, Mt. Jackson , Virginia
Jim Dowson, National Organizer, Precious Life Scotland , Cumbernauld , Scotland
Sr. Lucille Durocher, Founder, St. Joseph 's Workers for Life & Family, Vanier , Canada
Cheryl Eckstein, R.N., Founder and President, Compassionate Health Care Network, Surrey , Canada
David Wainwright Evans, M.D., FRCP, Fellow Commoner of Queens' College, Cambridge , England , UK
Martyn Evans, B.A., Ph.D., Swansea , Wales , UK
Joseph C. Evers, M.D., FAAP, Pediatrician, McLean , Virginia
Timothy R. Fangman, M.D., FACC, Cardiovascular Medicine, Omaha , Nebraska
Sydney O. Fernandes, M.D., M.B.B.S., F.C.P.S., ABIM, ABFP, Internal Medicine, Oregon , Ohio
Vera Maria Vargas Ferreira, Attorney, Porto Alegre , Brazil
Timothy H. Fisher, M.D., Family Practice Physician, Lincoln , Nebraska
Jeffrey L. Fortenberry, M.S., M.A., Member, Lincoln City Council, Lincoln , Nebraska
Elizabeth Fox-Genovese, Ph.D., Professor of History and Humanities, Emory University , Atlanta , Georgia
Nelson Fragelli, Director, Droit de Na?tre, Paris , France
Luigi Gagliardi, M.D., Head Physician, Department of Thoracic Surgery (retired), Ospidale Forlalini di Roma;
Professor Emeritus, Universit? degli Stud? di Roma "La Sapienza", Rome , Italy
Fr. Benedict J. Groeschel, CFR, Ed.D., Director, Office for Spiritual Development, Archdiocese of New York , Larchmont , New York
Karel F. Gunning, M.D., President, World Federation of Doctors Who Respect Human Life, Rotterdam , Netherlands
Denny Hartford , Director, Vital Signs Ministries, Omaha , Nebraska
Lucky M. Hatta, Founder and President, Pro Life Indonesia , Turanggaa Bandung , Indonesia
The Rt. Rev. Mark Haverland, Ph.D., Bishop Ordinary, Diocese of the South, Anglican Catholic Church, Athens, Georgia
Paul L. Hayes, M.D., Obstetrician and Gynecologist, Lincoln , Nebraska
David J. Hill, M.A., FRCA, Emeritus Consultant Anaesthetist, Cambridge , England , UK
Helen Hull Hitchcock, Director, Women for Faith & Family, St. Louis , Missouri
James Hitchcock, Ph.D., Professor of History, St. Louis University , St.Louis, Missouri
Benno Hofschulte, Director, Aktion SOS LEBEN, Frankfurt am Main , Germany
The Reverend Canon Eric Jarvis, M.A., Canon Emeritus, Cathedral Church of St. Peter and St. Winfred, Ripon , England , UK
Fr. David Albert Jones, O.P., M.A., Director designate, Linacre Centre for Healthcare Ethics, London, England, UK
Anthony M. Kam, M.D., FACS, Chief of Staff, Sheridan Community Hospital , Sheridan , Michigan
M.A. Klopotek, Dr. Eng. Habil., Professor, Institute of Computer Science, Akademia Polska, Siedice , Poland
Paul Lagan, President, Alliance for Life Ministries, Madison , Wisconsin
Thomas H. Lieser, M.D., MPH, FACOEM, Board Certified, Family Practice and Occupational and Environmental Medicine; Adjunct Faculty, Medical College of Ohio , Toledo , Ohio
Johann Loibner, M.D., General Practitioner, Graz , Austria
Luiz Anderson Lopes, M.D., Pediatric Department, Ecola Paulista de Medicina, Universidade Federal S?o Paulo; Professor of Pediatrics, Universidade de Santo Amoro, S?o Paulo , Brazil
Prof. Roberto de Mattei, Professor of Modern History, University of Cassino , Cassino , Italy
Maria Cristina Mattioli, Federal Labor Judge, Federal Labor Court of the 15th Circuit, Campinas , Brazil
Fr. Daniel Maurer, C.J.D., Canons Regular of Jesus the Lord, Vladivostok , Russia
Philip D. McNeely, M.D., Family Practice Physician, Lincoln , Nebraska
Walter Menz, Attorney at Law, Porto Alegre , Brazil
Judge Joseph Moylan, Omaha , Nebraska
Nerina Negrello, President, Lega Nazionale Contro la Predazione di Organi e la Morte A cuore Battente, Bergamo , Italy
Dr. Claude E. Newbury, M.B.B.Ch., D.T.MTH., D.O.H., M.F.G.P., D.P.H., D.A., D.C.H., M.Prax. Med., President, Pro-Life South Africa , Johannesburg , South Africa
Richard G. Nilges, M.D., FACS, Neurosurgeon, Valparaiso , Indiana
Dr. Peggy Norris, MD, ChB, BAO, Chairman, A.L.E.R.T.; Hon. Secretary, Doctors Who Respect Life, London , England , UK
Marquis Luigi Coda Nunziante di San Fernando , President, Famiglia Domani, Rome , Italy
Dr. Charles OfDonnell, MRCP, DA, EDIC, FFAGM, Consultant in Emergency and Intensive Care Medicine, Whipps Cross Hospital , London , England , UK
Ruth D. Oliver, M.D., FRCP(C), Psychiatry, Surrey , Canada
Tony C. Palmer, ScD, FRCVS, Veterinary Neurologist, University of Cambridge , England , UK
Larry Parsons, M.D., Family Practice Physician, Board Certified, Omaha , Nebraska
Captain (Ret.) Charles J. Pelletier, II, President, Mother and Unborn Baby Care of Northern Texas, Fort Worth , Texas
Mary Patricia Pelletier, Vice President, Raphael (God Heals) of Northern Texas, Inc., Fort Worth , Texas
Luca Poli, M.D., Neurologist Boselga de Pin?, Trento , Italy
Michael Potts, Ph.D., Associate Professor of Philosophy, Methodist College , Fayetteville , North Carolina
Walter Ramm. Director, AKTION LEBEN, e.V., Absteinach , Germany
Marlene Reid, President, Human Life Alliance , St. Paul , Minnesota
Charles E. Rice, Ll.M., J.S.D., Professor Of Law, University of Notre
Fr. George M. Rinkowski, Toledo , Ohio
Maria Luisa Robbiati, M.D., General Medicine and Specialist in Anesthesia and Resuscitation, Rome , Italy
Gelson Luis Roberto, Clinical Psychologist, Associa??o Brasileira de Etnopsiquiatria e Psiquiatria Social, Porto Alegre , Brazil
Gilson Luis Roberto, M.D., Clinical Medicine, Medical Clinic, Porto Alegre , Brazil
Jaqui Rose, Catholic Action Life League, Cape Town , Republic of South Africa
Derek Sakowski, Seminarian, Pontifical College Josephinum, Columbus , Ohio
Rich Scanlon, Executive Director, Human Life Alliance , St. Paul , Minnesota
Joseph M. Scheidler, Executive Director, Pro-Life Action League, Chicago , Illinois
Ingolf Schmid-Tannwald, M.D., Professor of Gynecology and Obstetrics, Medical School University of Munich; President, ?rtze f?r das Leben e.V., Munich , Germany
Elida Seguin, Ph.D., Professor of Law, Universidade Federal do Rio de Janeiro , Rio de Janeiro , Brazil
Mary Senander, Minneapolis , Minnesota
Giueseppi Sermonti, Professor Emeritus of Genetics, Universities of Palermo and Perugia , Editor, Rivista di Biologia, Rome , Italy
Rogerio Passos Severo, MA, Professor of Philosophy of Law and Logic, Faculdades Ritter dos Reis, Porto Alegre, Brazil
Jerome T.Y. Shen, M.D., FAAP, Clinical Professor Emeritus of Pediatrics, St. Louis University School of Medicine, St. Louis, Missouri
Saulo Sirena, Attorney at Law, Porto Alegre , Brazil
Fr. Robertas Gedydas Skrinskas, President, Pro Vita, Kauno , Lithuania
Dick Sobsey, Professor of Educational Psychology, University of Alberta , Alberta , Canada
Robert Sutherland, President, Right to Life Association of Thunder Bay and Area, Thunder Bay , Canada
Dr. Pravin Thevatathasan, MRC Psych., MSc., Consultant Psychiatrist, London , England , UK
Fr. Hugh S. Thwaites, S.J., Bexhill , England , UK
Adrian Treloar, MRCP, MRC Psych., Consultant and Senior Lecturer in Old Age Psychiatry, Guys, Kings, and St. Thomas Hospital, London, England, UK
Sue Turner, M.Sci., Troy , Alabama
Dr. Cristina Valea, President, Pro Vita Medica, Timasoara , Romania
Sr. Paula Vandegaer, SSS, LCWS, Founder, Scholl Institute of Bioethics, President, International Life Services, Los Angeles , California
Josephine Venn-Treloar, MRCGP, General Practioner, London , England , UK
Prof. Guido Vignelli, Director, SOS Ragazzi, Rome , Italy
Dr. Paul Vooht, Stevenage Herts , England , UK
Yoshio Watanabe, M.D., FACC, Professor Emeritus of Medicine, Fujita Health University; Consultant Cardiologist, Chiba Tokushu-kai Hospital, Funabashi, Japan
Germaine Wensley, R.N., B.S., Immediate Past President, California Nurses for Ethical Standards, Los Angeles , California
John W.S. Yun, M.D., FRCP(C), Internal Medicine and Medical Oncology, Richmond Health Science Centre, Richmond , Canada
II
Brain Death is Not Death!
In medicine we protect, preserve, and prolong life and postpone death . . . Our goal is to keep body and soul united. When a vital organ ceases to function, death can result. On the other hand, medical intervention can sometimes restore the function of the damaged organ, or medical devices (such as pacemakers and heart-lung machines) can preserve life. The observation of a cessation of functioning of the brain or some other organ of the body does not in itself indicate destruction of even that organ, much less death of the person.
Dr Paul Byrne
By Paul A. Byrne,
On February 3-4, the Pontifical Academy of Sciences, in cooperation with World Organization for the Family, hosted a meeting at the
The meeting was convened at the request of Pope John Paul II to re-assess the signs of death and verify, at a purely scientific level, the validity of brain-related criteria for death, entering into the contemporary debate of the scientific community on this issue.
In a message to the Pontifical Academy of Sciences, made public at the February meeting, the Holy Father said that the Church has consistently supported "the practice of transplanting organs from deceased persons." However, he cautioned that transplants are acceptable only when they are conducted in a manner "so as to guarantee respect for life and for the human person."
The Pope cited his predecessor, Pope Pius XII, who said that "it is for the doctor to give a clear and precise definition of death and of the moment of death." He encouraged the
Background
In 1968 the “Harvard criteria” for determining brain death were published in the Journal of the American Medical Association, under the title of “A Definition of Irreversible Coma.” This article was published without substantiating data, either from scientific research or from case studies of individual patients. For this reason, a majority of the presenters at the conference in
In 2002 the results of a worldwide survey were published in Neurology, concluding that the use of the term “brain death” worldwide is “an accepted fact but there was no global consensus on the diagnostic criteria” and there are still “unresolved issues worldwide.” In fact between 1968 and 1978 at least 30 disparate sets of criteria were published, and there have been many more since then. Every new set of criteria tends to be less rigid than earlier sets and none of them is based on the scientific method of observation and hypothesis followed by verification).
Attempts to compare the newer criteria with the time proven, generally accepted criteria for death--the cessation of circulation, respiration, and reflexes--show that these criteria are distinctly different. This has resulted in an unhappy situation for the medical profession. Many physicians, who feel that the Hippocratic Oath is being violated by acceptance of such disparate sets of criteria, feel the need to expose the fallacy of “brain death,” because the noble reputation of the medical profession is at stake.
Philosophical considerations
In his presentation to the Pontifical Academy, Robert Spaemann--a noted former professor of philosophy from the University of Munich--cited the words of Pope Pius XII, who declared that "human life continues when its vital functions manifest themselves, even with the help of artificial processes.”
Professor Spaemann observed: "The cessation of breathing and heartbeat, the ‘dimming of the eyes,’ rigor mortis, etc. are the criteria by which since time immemorial humans have seen and felt that a fellow human being is dead." But the Harvard criteria "fundamentally changed this correlation between medical science and normal interpersonal perception." As he put it:
Scrutinizing the existence of the symptoms of death as perceived by common sense, science no longer presupposes the “normal” understanding of life and death. It in fact invalidates normal human perception by declaring human beings dead who are still perceived as living.
The new approach to defining death, the German scholar continued, reflected a different set of priorities:
It was no longer the interest of the dying to avoid being declared dead prematurely, but other people’s interest in declaring a dying person dead as soon as possible. Two reasons are given for this third party interest:
1) guaranteeing legal immunity for discontinuing life-prolonging measures that would constitute a financial and personal burden for family members and society alike,
and
2) collecting vital organs for the purpose of saving the lives of other human beings through transplantation. These two interests are not the patient’s interests, since they aim at eliminating him as a subject of his own interests as soon as possible.
The arguments against the use of "brain death" as a determination of death are being made, Spaemann noted, "not only by philosophers, and, especially in my country, by leading jurists, but also by medical scientists." He quoted the words of a German anesthesiologist who wrote, "Brain-dead people are not dead, but dying."
Medical evidence
Dr. Paul Byrne, a neonatologist fromToledo , Ohio
The arguments against the use of "brain death" as a determination of death are being made, Spaemann noted, "not only by philosophers, and, especially in my country, by leading jurists, but also by medical scientists." He quoted the words of a German anesthesiologist who wrote, "Brain-dead people are not dead, but dying."
Medical evidence
Dr. Paul Byrne, a neonatologist from
When organs are removed from a "brain dead" donor, all the vital signs of the “donors” are still present prior to the harvesting of organs, such as: normal body temperature and blood pressure; the heart is beating; vital organs, like the liver and kidneys, are functioning; and the donor is breathing with the help of a ventilator.
Furthermore, Bryne told the Academy, that approach is required for most transplant surgery, because vital organs deteriorate very quickly after a patient dies. "After true death," he said, "unpaired vital organs (specifically the heart and whole liver) cannot be transplanted.”
Transplantation of unpaired vital organs is legal in most Western countries, including the United States, and in some developing nations like Brazil, but the important question for anyone is: “is it morally permissible to terminate a life to save another?" Pope John Paul II has repeatedly said as recently as February 4, 2003 message to the World Day of the Sick: “It is never licit to kill one human being in order to save another." The Catechism of the Catholic Church clearly states (2296): “It is morally inadmissible directly to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons.”
"In medicine we protect, preserve, and prolong life and postpone death," Byrne said. "Our goal is to keep body and soul united." When a vital organ ceases to function, he argued, death can result. On the other hand, medical intervention can sometimes restore the function of the damaged organ, or medical devices (such as pacemakers and heart-lung machines) can preserve life. He said: "The observation of a cessation of functioning of the brain or some other organ of the body does not in itself indicate destruction of even that organ, much less death of the person."
Defending the criteria
Some participants in the February meeting defended the use of the "brain death" criteria. Dr. Stewart Youngner of
Dr. Conrado Estol, a neurologist from Buenos Aires, explained the steps that should be followed in determining the "brain death" of a prospective organ donor. Dr. Estol, who is strongly in favor of harvesting human organs to extend the life of other patients, presented a dramatic video of a person diagnosed as “brain dead” who attempted to sit up and cross his arms, although Dr. Estol assured the audience that the donor was a cadaver. This produced an unsettling response among many participants at the conference.
A French transplant surgeon, Dr. Didier Houssin, acknowledged the difficulties that arise because of the discrepancies between the different criteria for brain death. He observed that "death is a medical fact, a biological process, and a philosophical question, but it is also a social fact. It would be difficult for a society to admit that a man could be said alive in one place and dead in another place. However, as a proponent of transplants, he said that it is important for society to trust doctors.
Another French physician, Dr. Jean-Didier Vincent of the Institut Universitaire, emphasized that a “brain dead” person has suffered complete and irreversible destruction of the brain. Dr. Vincent was questioned closely about the case of a pregnant women, diagnosed as brain-dead, who continues her pregnancy while on life-support system, even producing breast milk for her unborn child. He admitted that the mother produces milk, but regards that production as an inhibited mechanical reflex rather than a sign of enduring human life. When reminded that the production of breast milk results from the signal sent from the anterior lobe of the pituitary that stimulates the secretion of milk, and possibly breast growth, thus requiring a functioning brain, he replied that there could be some minimal hormonal production in the brain. The apnea test
In his presentation at the conference, Dr. Cicero Coimbra, a clinical neurologist from the Federal University of Sao Paolo, Brazil denounced the cruelty of the apnea test, in which mechanical respiratory support is withdrawn from the patient for up to 10 minutes, to determine whether he will begin breathing independently. This is part of the procedure before declaring a brain-injured patient “brain dead.” Dr. Coimbra explained that this test significantly impairs the possible recovery of a brain-injured patient, and can even cause the death of the patients. He argued:
. A large number of brain-injured patients, even in deep coma, can recover to lead a normal daily life; their nervous tissue may be only silent, not irreversibly damaged, as a consequence of a partial reduction of the blood supply to the brain. (This phenomenon, called “ischemic penumbra,” was not known when the first neurological criteria for brain death were established 37 years ago.) However, the apnea test (considered the most important step for the diagnosis of “brain death” or brain-stem death) may induce irreversible intra-cranial circulatory collapse or even cardiac arrest, thereby preventing neurological recovery.
· During the apnea test, the patients are prevented from expelling carbon dioxide (CO2), which becomes a poison to the heart as the blood CO2 concentration rises.
· As a consequence of this procedure, the blood pressure drops, and the blood supply to the brain irreversibly ceases, thereby causing rather than diagnosing irreversible brain damage; by reducing the blood pressure, the “test” further reduces the blood supply to the respiratory centers in the brain, thereby preventing the patient from breathing during this procedure. (By breathing, the patient would demonstrate that he is alive.)
· Irreversible cardiac arrest (death), cardiac arrhythmias, myocardial infarction, and other life-threatening detrimental effects may also occur during the apnea test. Therefore, irreversible brain damage may occur during and before the end of the diagnostic procedures for “brain death.”
Dr. Coimbra concluded by saying that the apnea test should be considered unethical and declared illegal as an inhumane medical procedure. If family members were informed of the brutality and risk of the procedure, he stated, most of them would deny permission.
He pointed out that when a heart attack patient is admitted to the emergency room he is never subjected to a stress test in order to verify that he is suffering from heart failure. Instead the patient is given special care and protection from further stress to the heart.
In contrast when a brain-injured patient is subjected to the apnea test, further stress is placed on the organ that has already been injured, and additional damage can endanger the patient’s life. Dr. Yoshio Watanabe a cardiologist from Nagoya , Japan
The question of a brain-injured patient's possible recovery also concerned Dr. David Hill, a British anesthetist and lecturer atCambridge
"The deception"
Dr. Hill recalled that the earliest attempts at transplanting vital organs often failed because the organs, taken from cadavers, did not recover from the period of ischemia following the donor's death. The adoption of brain-death criteria solved that problem, he reported, "by allowing the removal of vital organs before life support was turned off--without the legal consequences that might otherwise have attended the practice.”
While it is remarkable that the public has accepted these new criteria, Dr. Hill remarked, he attributed that acceptance in large part to the favorable publicity for organ transplants, and in part to public ignorance about the procedures.
The question of a brain-injured patient's possible recovery also concerned Dr. David Hill, a British anesthetist and lecturer at
"The deception"
Dr. Hill recalled that the earliest attempts at transplanting vital organs often failed because the organs, taken from cadavers, did not recover from the period of ischemia following the donor's death. The adoption of brain-death criteria solved that problem, he reported, "by allowing the removal of vital organs before life support was turned off--without the legal consequences that might otherwise have attended the practice.”
While it is remarkable that the public has accepted these new criteria, Dr. Hill remarked, he attributed that acceptance in large part to the favorable publicity for organ transplants, and in part to public ignorance about the procedures.
"It is not generally realized," he said, that life support is not withdrawn before organs are taken; nor that some form of anaesthesia is needed to control the donor whilst the operation is performed.” As knowledge of the procedure increases, he observed, it is not surprising that--as reported in a 2004 British study--"the refusal rate by relatives for organ removal has risen from 30 percent in 1992 to 44 percent." Dr. Hill also suggested that when relatives see with their own eyes the evidence that a potential organ donor is still alive, they harbor enough doubts so that they are not ready to consent to the organ removal.
In theUnited Kingdom
Bishop Fabian Bruskewitz of Lincoln, Nebraska, addressed the issue of the donor's consent. “As far as I know," he told thePontifical Academy
The bishop went on to observe that current technology enables doctors only to monitor brain activity "in the outer 1 or 2 centimeters of the brain." He asks: "Do we have then, moral certitude in any way that can be called apodictic regarding even the existence, much less the cessation of brain activity?” From the perspective of Catholic moral teaching the bishop said:
The dignity and autonomy of a human being--whether zygote, blastocyst, embryo, fetus, newborn, infant, adolescent, adult, disabled or handicapped adult, aged adult, adult in a comatose or (so-called) persistent vegetative state, etc--are viewed, as they have been viewed throughout the history of the Catholic Church, as worthy of respect and entitled to protection from untoward human intervention effecting the termination of human life at any of those stages.
In light of the serious questions about the validity of the "brain death" criteria, Professor Josef Seifert from the International Academy of Philosophy in Liechtenstein argued that medical ethicists should invoke the true and evident ethical principle (emphasized by the whole Church tradition of moral teachings), that "even if a small reasonable doubt exists that our acts kill a living human person, we must abstain from them.”
The Signs of Death
In the
Bishop Fabian Bruskewitz of Lincoln, Nebraska, addressed the issue of the donor's consent. “As far as I know," he told the
The bishop went on to observe that current technology enables doctors only to monitor brain activity "in the outer 1 or 2 centimeters of the brain." He asks: "Do we have then, moral certitude in any way that can be called apodictic regarding even the existence, much less the cessation of brain activity?” From the perspective of Catholic moral teaching the bishop said:
The dignity and autonomy of a human being--whether zygote, blastocyst, embryo, fetus, newborn, infant, adolescent, adult, disabled or handicapped adult, aged adult, adult in a comatose or (so-called) persistent vegetative state, etc--are viewed, as they have been viewed throughout the history of the Catholic Church, as worthy of respect and entitled to protection from untoward human intervention effecting the termination of human life at any of those stages.
In light of the serious questions about the validity of the "brain death" criteria, Professor Josef Seifert from the International Academy of Philosophy in Liechtenstein argued that medical ethicists should invoke the true and evident ethical principle (emphasized by the whole Church tradition of moral teachings), that "even if a small reasonable doubt exists that our acts kill a living human person, we must abstain from them.”
The Signs of Death
Conclusions reached after examination of Brain-Related Criteria for death, at the Pontifical Academy of Sciences meeting
1. On the one hand the Church recognizes, consistent with her tradition, that the sanctity of all human life from conception to natural end must absolutely be respected and upheld. On the other hand, a secular society tends to place greater emphasis on the quality of living.
2. The Catholic Church has always opposed the destruction of human life before being born through abortion and she equally condemns the premature ending of the life of an innocent donor in order to extend the life of another through unpaired vital organ transplantation. "It is morally inadmissible directly to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons." “It is never licit to kill one human being in order to save another."
3. "Nor can we remain silent in the face of other more furtive, but no less serious and real forms of euthanasia. These could occur for example when, in order to increase the availability of organs for transplants, organs are removed without respecting objective and adequate criteria which verify the death of the donor."
4. "The death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person." Pope Pius XII declared this same truth when he stated that human life continues when its vital functions manifest themselves even with the help of artificial processes.
5. "Acknowledgement of the unique dignity of the human person has a further underlying consequence: 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.” Natural moral law precludes removal for transplantation of unpaired vital organs from a person who is not certainly dead. The declaration of "brain death" is not sufficient to arrive at the conclusion that the patient is certainly dead. It is not even sufficient to arrive at moral certitude.
6. Many in the medical and scientific community maintain that brain-related criteria for death are sufficient to generate moral certitude of death itself. Ongoing medical and scientific evidence contradicts this assumption. Neurological criteria alone are not sufficient to generate moral certitude of death itself, and are absolutely incapable of generating physical certainty that death has occurred.
7. It is now patently evident that there is no single so-called neurological criterion commonly held by the international scientific community to determine certain death. Rather, many different sets of neurological criteria are used without global consensus.
8. Neurological criteria are not sufficient for declaration of death when an intact cardio-respiratory system is functioning. These neurological criteria test for the absence of some specific brain reflexes. Functions of the brain not considered are temperature control, blood pressure, cardiac rate and salt and water balance. When a patient on a ventilation machine is declared “brain dead," these functions not only are present but also are frequently active.
9. The apnea test--the removal of respiratory support--is mandated as a part of the neurological diagnosis and it is paradoxically applied to ensure irreversibility. This significantly impairs outcome, or even causes death, in patients with severe brain injury.
10. There is overwhelming medical and scientific evidence that the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem) is not proof of death. The complete cessation of brain activity cannot be adequately assessed. Irreversibility is a prognosis, not a medically observable fact. We now successfully treat many patients who in the recent past were considered hopeless.
11. A diagnosis of death by neurological criteria alone is theory, not scientific fact. It is not sufficient to overcome the presumption of life.
12. No law whatsoever ought to attempt to make licit an act that is intrinsically evil. "I repeat once more that a law which violates an innocent person's natural right to life is unjust and, as such, is not valid as a law. For this reason I urgently appeal once more to all political leaders not to pass laws which, by disregarding the dignity of the person, undermine the very fabric of society."
13. The termination of one innocent life in pursuit of saving another, as in the case of the transplantation of unpaired vital organs, does not mitigate the evil of taking an innocent human life. Evil may not be done that good might come of it.
Signatories:
J.A. Armour, physician, University of Montreal Hospital of the Sacred Heart,
Fabian Bruskewitz, Bishop of Lincoln, Nebraska
Paul A. Byrne, past president, Catholic Medical Association, US.
Pilar Mercado Calva, professor, School of Medicine,
Cicero G. Coimbra, professor of Clinical Neurology, Federal University of Sao Paolo, Brazil.
William F. Colliton, retired professor of Obstetrics and
Joseph C. Evers, clinical associate professor of Pediatrics, Georgetown University School of Medicine, Washington, DC.
David Hill, emeritus consultant anesthetist, at Addenbrooke’s Hospital, and associate lecturer,
Ruth Oliver, psychiatrist,
Michael Potts, head of Religion and Philosophy Department,
Josef Seifert, professor of Philosophy at the International Academy of of Philosophy, Vaduz, Liechtenstein; honorary member of the Medical Faculty of the Pontifical Catholic University of Chile in Santiago, Chile.
Robert Spaemann, professor emeritus of Philosophy,
Robert F. Vasa, Bishop of the Diocese of Baker,
Yoshio Watanabe, consultant cardiologist,
Mercedes Arzú. Wilson, president, Family of the Americas Foundation and World Organization for the Family.
Source: Essay - meeting of the Pontifical Academy
Dr Paul Byrne, to The Compassionate Healthcare Network, March 29, 2005 via e-mail
Dr Paul Byrne, to The Compassionate Healthcare Network, March 29, 2005 via e-mail
Remarks from the blogger:
1) Keep in mind that Robert Spaemann is the philosopher most trusted by Benedict XVI. He is opposed to the brain death criterion.
2) In the group’s critique of Shewmon and Spaemann, what becomes evident that the issue is to be resolved on the epistemological prism that is used. As Benedict wrote in his most recent remarks to the Bundestag in Berlin
“In other words, according to Prof. Spaemann and Dr. Shewmon, since neurologists are not able to justify the presumed sub-integration of the body without the brain, to state that brain death
is the death of the individual, neurologists are compelled to identify the brain
with the mind or personhood, which is a philosophical statement.
It was clear from the direction of the meeting that the task was to focus
first and foremost on the scientific approaches. Indeed, the only philosophical
paper was that given by Prof. Spaemann who opposed brain death as the
criterion for death. However, from the discussions during the meeting, it
emerged (a point not answered by Prof. Spaemann) that although the mind
is not the same as the brain, one cannot today reasonably doubt that human
intelligence (and in part personhood) depend on the brain as the centre of the
nervous system and other biological systems. Although we certainly do not
currently have a detailed understanding of the physical modalities of human
thought, it is an established scientific fact that human intelligence depends
on the support of nerve cells and the organisation of billions of connections
between the billions of neurons that make up the human brain and its ramifications
within the human body. This does not mean that one could conclude
in haste that contemporary neuroscience has definitively demonstrated
the truth of a materialistic monism and rejected the presence of a spiritual
reality in man.
The dye is already case epistemologically. Hear the remark of Benedict at the Bundestag: “The positivist approach to nature and reason, the positivist world view in general, is a most important dimension of human knowledge and capacity that we may in no way dispense with. But in and of itself it is not a sufficient culture corresponding to the full breadth of the human condition. Where positivist reason considers itself the only sufficient culture and banishes all other cultural realities to the status of subcultures, it diminishes man, indeed it threatens his humanity.”
Consider this observation of Adrian Walker: “Any attempt to address the question of the ontological status of the ANT product necessarily brings into play a trans-experimental criterion. Such a criterion, moreover, inevitably both judges the relevant empirical data to mean that a human organism is or is not present and guides the selection of which data re relevant to deciding the question in the first place. By the same token, it would be naïve or disingenuous to defend ANT from the kind of critique I will be laying out here on the grounds that I am presuming to pre-judge the scientific evidence on the basis of some trans-empirical philosophical claim. The fact of the matter is that both I and the proponents of ANT are pre-judging the scientific evidence on the basis of what is, in the loose sense at least, a philosophical criterion. The question at issue between us, then, is not whether philosophical reflection should be admitted into the discussion, but, given the already philosophical character of the discussion, which of the respective trans-empirical criteria for judging organismic status – mine or theirs – is true?
“As it turns out, the proposal of ANT explicitly assumes a certain ‘mereology,’ that is, a certain (in the loose sens at least) philosophy of the relationship between parts and wholes. Although proponents of ANT explicitly disavow old-fashioned mechanism, this mereology, I hope to show, is subtly, but decisively, mechanistic: the coordinated all-at-onceness of the organism, they seem to hold, is just the sum of its interlocking partial subsystems – so that ‘the whole is the sum of its parts,’ classic mechanistic maneuver," Communio 31 (Winter 2004) 653-654.
Consider this observation of Adrian Walker: “Any attempt to address the question of the ontological status of the ANT product necessarily brings into play a trans-experimental criterion. Such a criterion, moreover, inevitably both judges the relevant empirical data to mean that a human organism is or is not present and guides the selection of which data re relevant to deciding the question in the first place. By the same token, it would be naïve or disingenuous to defend ANT from the kind of critique I will be laying out here on the grounds that I am presuming to pre-judge the scientific evidence on the basis of some trans-empirical philosophical claim. The fact of the matter is that both I and the proponents of ANT are pre-judging the scientific evidence on the basis of what is, in the loose sense at least, a philosophical criterion. The question at issue between us, then, is not whether philosophical reflection should be admitted into the discussion, but, given the already philosophical character of the discussion, which of the respective trans-empirical criteria for judging organismic status – mine or theirs – is true?
“As it turns out, the proposal of ANT explicitly assumes a certain ‘mereology,’ that is, a certain (in the loose sens at least) philosophy of the relationship between parts and wholes. Although proponents of ANT explicitly disavow old-fashioned mechanism, this mereology, I hope to show, is subtly, but decisively, mechanistic: the coordinated all-at-onceness of the organism, they seem to hold, is just the sum of its interlocking partial subsystems – so that ‘the whole is the sum of its parts,’ classic mechanistic maneuver," Communio 31 (Winter 2004) 653-654.
Subscribe to:
Posts (Atom)