Tuesday, February 21, 2017

By:  AMFS Internal Medicine and Medical Ethics Expert

The dramas that swirled in the news regarding two recent cases of brain death – those of Jahi McMath in California and Marlise Munoz in Texas – brought to public attention a subject not used to quite so much public scrutiny.  Indeed, cases of brain death happen routinely in the United States, and typically are known to hospital staff and family alone.  Brain death cases have become, in fact, routine in American hospitals.

This is not to say, however, that brain death is non-controversial and fully accepted by all parties, as it is not.  It is, very much though, part of the routine in American healthcare.  It is, to extend a metaphor, a statue on a fractured base.

Brain death is better known to ethicists of today as DDNC – the Determination of Death by Neurologic Criteria.  That is to say that it is not just the brain that has died, while the rest of the body is fine.  Rather, it is the notion that once the whole brain has suffered complete and irreversible damage that is sufficiently severe, it is justifiable to denote the entire organism as dead.  What constitutes sufficient severity to make this determination is not at all controversial.  Indeed, the American Academy of Neurology has issued guidelines with updates on this subject that address the technical aspects of the diagnosis of DDNC in a checklist format.  The checklist entails a detailed neurologic examination that surveys from the cerebral cortices down to the brain stem, and in which the absolute lack of any function must be recorded for a positive exam, that is, excluding spinal reflexes which may remain positive.  Once this exam has been completed by TWO different providers, an apnea exam is done – a separate determination that the respiratory drive center of the brain has also stopped functioning and that the body is not capable of independent breathing at all.  Once all three of these are completed, a pronouncement of death can be made in all 50 states – the Determination of Death by Neurologic Criteria.  What remarkably separates this determination of death from the traditional one is that the heart may remain beating. 

In this tragic circumstance, hospital staff typically meet with family and discuss the fact that their loved one has died by neurologic criteria.  In most cases, family accept the diagnosis with some level of skepticism – but accept it nonetheless.  The opportunity is made for family to allow the donation of organs, particularly if the patient was known to have registered as a potential donor prior to death.  This then allows conformity with what is known as the “Dead Donor Rule,” – which is to say that the harvesting of a donor heart should never be done from a living donor.  Whether the concept of brain death evolved solely to further organ donation, or emerged for its own reasons, but contemporaneously with the rise of organ donation, is a matter of some debate.  Regardless, most members of society accept the notion that while brain death might not be 100% equivalent to whole body death (indeed, some bodies have been continued on organ-support machines for decades in this state) it is equivalent enough to accept.  Implicit in this acceptance is also a recognition of the societal benefits of increased organ availability that follow, and some semblance of comfort from that.

However, not all in American society make this acceptance.  Several demographic groups in particular and individuals in general take issue with the definitions and standards utilized by healthcare professionals.  Medicine may often be at odds with religious or other deeply held beliefs, while some individuals and groups may simply be suspicious of our healthcare system and individual providers.

These particular problems, while not necessarily representing the whole of American society, certainly come from significant portions of it – and with the public notoriety, the potential for even greater parts of society objecting exists.  While the two cases of the past year brought legal and ethical conflict over brain death to public attention, they actually did little to clarify the conflicts that exist, or to ameliorate them.  That work remains to be done.