New evaluation of brain death?
By Carolyn Hughes
Correspondent
New Jersey residents have until July 14 to comment on the N.J. State Board of Medical Examiners’ proposal to change the two-doctor requirement when determining brain death in patients. The board’s currently requires two doctors to make the determination; of the two, one must be a neurologist.
Until the late 1960s, death was declared based on upon the basis of cardio-respiratory criteria: the heart stopped and the patient ceased breathing.
According to Peter Cataldo, ethicist and director of research for the National Catholic Bioethics Center, Philadelphia, “brain death” — the cessation of all neurological activity in the entire brain — became the method to determine death since a Harvard Medical School group published what is called the Harvard Criteria in 1968, determining death neurologically.
Under the board’s new proposition, physicians who are not neurologists would be able to confirm brain death. Other specialists, among them trauma surgeons, critical care doctors and any doctor granted privileges to declare brain death by a hospital, would also be able to do so — alone.
The exception would be in the case of infants between two and 12 months old, when the examining physician would have to be a specialist in pediatric critical care, pediatric neurology or pediatric neurosurgery. An exemption to accommodate personal religious beliefs is also included in the proposal.
In these cases, cardio-respiratory criteria would be used to declare death. In addition, any doctor directly involved in organ donation for transplantation cannot be authorized to declare brain death in that patient.
A complex issue
The issue of using neurological criteria rather than declaring death by traditional means is complex. Experts agree that the utmost care must be taken to ensure that this final decision is arrived at ethically; not all agree that the proposition is a good idea.
Dr. Amar S. Bukhari, chief of the division of pulmonary critical care and sleep medicine and a member of the ethics committee at Saint Peter’s University Hospital, New Brunswick, has made the determination of brain death several times. “I think it is always better to have that safeguard by having more than one physician involved in the process” of determining brain death, he said.
He pointed out the “other side” of the issue, when patients’ families have to wait, sometimes up to 24 hours, before a second physician can corroborate a brain death determination. Some families have complained about the difficulty caused by such delays, he said.
While it is not necessary for the physician determining brain death to be a neurologist, Dr. Bukhari believes a neurologist can play a key role in the process; however, it is while the patient is deteriorating that a neurologist can “give very important advice and input to people’s families.”
Father John N. Fell, also a SPUH ethics committee member and pastor, Our Lady of Perpetual Help Parish, Bernardsville, said, “When we talk about brain death, we are talking about real death . . . It is just two different ways of measuring it, of looking for the signs.”
Father Fell emphasized the importance of “balance” in this “hugely significant” decision. “You don’t want to declare death prematurely because of our respect for life. You don’t want living people to be harvested for parts,” he said.
At the same time, the declaration of death should not be prolonged because it causes the ongoing suffering of the patient and the family, as well as ongoing cost, he said.
Father Fell believes that sufficient safeguards have been included in the new proposal, and that “if there is any complicating factor, then you trust that the doctor will turn to his or her colleagues to get further information.” Jennifer Ruggiero, diocesan director of pro-life activities, affirmed that the determination of brain death is a pro-life issue. “Our pro-life office’s efforts to promote the sanctity and to safeguard the dignity of human life includes dealing with end-of-life issues such as ‘brain death’ and organ transplantation. These are complex and often times controversial issues, which require careful examination. When dealing with these matters of life and death, we need to
always exercise responsible stewardship and good sense,” she said.
N.J. Right to Life opposes the relaxation in the board’s requirement for determining brain death. “The decision to declare brain death is an irreversible
decision and diagnosis. Therefore, every precaution should be taken to ensure a higher standard of certainty. Individuals who have contracted certain diseases such as Guillain-Barré syndrome can quite easily be mistaken as brain dead,” said executive director Marie Tasy.
“We believe it is not too great a burden to require an attending physician’s finding of brain death to be confirmed by a neurologist or neurosurgeon who has specific training and is better qualified in the field to determine whether irreversible cessation of all brain function has occurred,” Tasy said.
William F. Bolan, Jr., executive director of the N.J. Catholic Conference, said the proposition is being reviewed by the bishops’ statewide medical morality committee. That review will form the basis for the NJCC’s comments on this proposition.
The NJCC provides a means for the state’s bishops to speak on public policy issues. It addresses a wide range of issues in the areas of morality, health, welfare, education, and human and civil rights.
The N.J. State Medical Board of Examiners proposal can be accessed at www.state.nj.us/lps/ca/proposal/bmepro515.htm.
Comments may be submitted electronically online from the Web site or sent to William Roeder, Executive Director, Board of Medical Examiners, 140 East Front St., PO Box 183, Trenton, NJ 08625.
What is ‘brain death?’
To what does the expression “brain death” refer?
“Brain death” refers to the medical judgment that a person is dead by using
“neurological criteria.” Properly diagnosed, “brain death” refers to the complete
cessation of all organized neurological activity throughout the entire brain, including the cerebrum, cerebellum and brain stem. At this point, the body irrevocably ceases to function as a unified whole. The appropriate phraseology here is “the determination of death using neurological criteria.”
Is it appropriate to use neurological criteria to determine death?
The customary criteria for determining death are “cardiopulmonary,” i.e., death is declared after breathing and heartbeat cease. Technological advancements in critical care, however, have made continued circulation and respiration possible through mechanical means even after brain function has ceased.
The use of neurological criteria for the determination of death is legitimate according to the Catholic Church. Pope John Paul II approved this approach in an August 2000 address given to the 18th Inter national Conference of Organ Transplant Specialists. Neurological criteria consist of four key signs: coma or unresponsiveness, absence of cerebral motor responses to pain in all extremities, absence of brain stem reflexes, and apnea. Pope Pius XII and Pope John Paul II both said the Church has no competency in determining death; this properly belongs to medical science.
May I receive organs for transplant from those declared dead using neurological criteria?
Yes, a faithful Catholic may receive organs from a donor who is declared dead by
neurological criteria. A faithful Catholic may also make provisions for the donation of his own organs in the event of his death whether it is determined by cardiopulmonary or neurological criteria.
Why does the use of neurological criteria remain controversial?
As mentioned above, when a person suffers total loss of brain function, the heart may continue to beat with the assistance of mechanical ventilatory support. In such cases, this artificial support may cause the victim to appear alive visually and to the touch. Medical evidence, indicated by the four signs listed above, shows that this is not the case.
Why does the Church accept this definition of death?
This is not a new definition of death but rather of the use of new signs to determine that death has occurred. The Christian understanding of death has always been that it is the separation of the soul from the body. The Catholic Church looks to the medical community to determine the biological signs that indicate with moral certainty that this event has already occurred. In recent years, medical research has indicated that the irreversible loss of brain function provides a firm indicator that death has already occurred.
What does Catholic theology say about this definition of death?
Neurological criteria are compatible with Catholic teaching that a human being is a substantial union of body and rational soul. When all brain function is completely and irreversibly lost, this may be taken as a reasonable indicator that the rational soul is no longer present.
Does the use of “brain death” criteria cause the death of the patient?
The use of brain death criteria does not cause the death of the patient, but only assesses whether that death has already occurred. This is analogous to the way that cessation of heartbeat and respiration have traditionally been used to make that assessment.
Source: The National Catholic Bioethics Center (NCBC). For more information, visit www.ncbcenter.org.
*The attached/referenced article was originally published in The Catholic Spirit, the official newspaper of the Diocese of Metuchen, and is protected under U.S. and international copyright law