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
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