Whole-brain Death Research Articles

Editors' Note: Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria: A Systematic Review and Meta-analysis.

In “Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria: A Systematic Review and Meta-analysis,” Briard et al. report that based on a review of 21 studies, the prevalence of (1) infratentorial brain injury among patients with suspected death by neurologic criteria (DNC) was 2%–16% and (2) isolated brainstem death was 1%–4%. Machado pointed out that a series of 4 patients with infratentorial brain injury who initially had isolated brainstem death subsequently progressed to whole-brain death. The study on these patients was included in Briard's review. He also commented that Jahi McMath, who was declared dead by neurologic criteria based on both clinical evaluation and ancillary testing after hypoxic-ischemic brain injury, had a lesion in her pons and was not dead by neurologic criteria because she did not have a complete intracranial circulatory arrest. This case has been discussed extensively in the literature, but Briard and Chassé did not offer comments on it. However, they agree with Machado that additional research is needed to understand the determination of DNC in patients with infratentorial brain injury. In “Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria: A Systematic Review and Meta-analysis,” Briard et al. report that based on a review of 21 studies, the prevalence of (1) infratentorial brain injury among patients with suspected death by neurologic criteria (DNC) was 2%–16% and (2) isolated brainstem death was 1%–4%. Machado pointed out that a series of 4 patients with infratentorial brain injury who initially had isolated brainstem death subsequently progressed to whole-brain death. The study on these patients was included in Briard's review. He also commented that Jahi McMath, who was declared dead by neurologic criteria based on both clinical evaluation and ancillary testing after hypoxic-ischemic brain injury, had a lesion in her pons and was not dead by neurologic criteria because she did not have a complete intracranial circulatory arrest. This case has been discussed extensively in the literature, but Briard and Chassé did not offer comments on it. However, they agree with Machado that additional research is needed to understand the determination of DNC in patients with infratentorial brain injury.

Reader Response: Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria: A Systematic Review and Meta-analysis.

The article by Briard et al.1 affirmed that infratentorial brain injury is relatively uncommon among patients suspected of death by neurologic criteria (DNC) and that isolated brainstem death seems to progress to whole-brain death in most cases.

Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria: A Systematic Review and Meta-analysis.

There is a paucity of data on the frequency and prognosis of infratentorial brain injury among patients suspected of death by neurologic criteria (DNC), which likely contributes to scientific uncertainty regarding the role of isolated brainstem death in DNC determination. Our aim was to synthesize the prevalence, characteristics, and evolution of infratentorial brain injury, including isolated brainstem death, among patients suspected of DNC. We conducted a systematic review by searching Medline, Embase, EBM Reviews, CINAHL Complete, and the gray literature from inception to March 26, 2021. We selected cohort and cross-sectional studies, case reports, and case series that included patients suspected of DNC. Two study investigators independently performed study selection, data collection, and risk of bias assessment. Our primary outcomes were the respective prevalence of infratentorial brain injury and isolated brainstem death, which we meta-analyzed using mixed-effects Bayesian hierarchical models with diffuse priors. Our secondary outcomes were the characteristics and evolution of patients with infratentorial brain injury and isolated brainstem death. Twenty-one studies met the selection criteria, most of which were of moderate to high risk of bias. Among patients suspected of DNC, the prevalence of infratentorial brain injury ranged from 2% to 16% (n = 3,602, mean prevalence: 6.3%, 95% highest density interval [2.4%-14.2%]), whereas the prevalence of isolated brainstem death ranged from 1% to 4% (n = 3,692, mean prevalence: 1.5%, 95% highest density interval [0.5%-3.9%]). A total of 38 isolated brainstem death cases with data on clinical characteristics and/or evolution were included. All had infratentorial strokes. Twenty patients had EEG background activity in the α or θ frequencies, 19 had preserved cerebral blood flow, 2 had preserved supratentorial cerebral perfusion, 2 had cortical responses to visual evoked potentials, and 1 had cortical responses to somatosensory evoked potentials. At the latest follow-up, 28 had progressed to whole-brain death. Studies with moderate to high risk of bias suggest that infratentorial brain injury is relatively uncommon among patients suspected of DNC. Isolated brainstem death is rarer and seems to carry a high risk of progression to whole-brain death. These findings require further high-quality investigation.

What Should We Do About the Mismatch Between Legal Criteria for Death and How Brain Death Is Diagnosed?

Mismatch between whole-brain death criteria embedded in statutes and accepted tests physicians use to diagnose brain death have clinical and ethical implications that could undermine public trust in death pronouncements. We consider merits and drawbacks of 4 ways to address this problem.

Whole-brain death and integration: realigning the ontological concept with clinical diagnostic tests.

For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. However, a series of recent cases in which individuals were declared brain dead yet physiologically maintained for prolonged periods of time has challenged the status quo. This signals a need for deeper reflection and reexamination of the underlying philosophical, scientific, and clinical issues at stake in defining death. In this paper, I consider four levels of philosophical inquiry regarding death: the ontological basis, actual states of affairs, epistemological standards, and clinical criteria for brain death. I outline several candidates for the states of affairs that may constitute death, arguing that we should strive for a single, unified ontological definition of death as a loss of integrated functioning as a unified organism, while acknowledging that two states of affairs (cardiopulmonary death and whole-brain death) may satisfy this concept. I argue that the clinical criteria for determining whole-brain death should be bolstered to meet the epistemic demand of sufficient certainty in defining death by adding indicators of cerebro-somatic dis-integration to the traditional triad of loss of consciousness, loss of brainstem function, and absence of confounding explanations.

When is somebody just some body? Ethics as first philosophy and the brain death debate.

I, along with others, have been critical of the social construction of brain death and the various social factors that led to redefining death from cardiopulmonary failure to irreversible loss of brain functioning, or brain death. Yet this does not mean that brain death is not the best threshold to permit organ harvesting-or, aspeople today prefer tocall it, organ procurement. Here I defend whole-brain death as a morally legitimate line that, once crossed, is grounds for families to give permission for organ donation. I do so in five moves. First, I make the case that whole-brain death is a social construction that transformed one thing, coma dépassé, into another thing, brain death, as a result of social pressures. Second, I explore the way that the 1981 President's Commission tried to establish the epistemological certainty of brain death, hoping to avoid making arcane metaphysical claims and yet still utilizing metaphysical claims about human beings. Third, I explore the moral meaning of the social construction of a definition that cannot offer metaphysical certainty about the point at which somebody becomes just some body. Fourth, I describe how two moral communities-Jewish and Catholic-actually ground their metaphysical positions with regard to brain death in the normativity of prior social relations. Finally, I conclude with a reflection on the aesthetic-moral enterprise of the metaphysical-epistemological apparatus of brain death, concluding that only such an aesthetic-moral approach is sufficiently strong to stave off the utility-maximizing tendencies of late-modern Western cultures.

The ethical problems of death pronouncement and organ donation: A commentary on Peter Singer’s article

Abstract The article is a critical commentary on Peter Singer’s thesis that the brain death definition should be replaced by a rule outlining the conditions permitting organ harvesting from patients who are biologically alive but are no longer persons. Largely agreeing with the position, I believe it can be justified not only on the basis of utilitarian arguments, but also those based on Kantian ethics and Christianity. However, due to the lack of reliable methods diagnosing complete and irreversible loss of consciousness, we should refrain from implementing upper brain death into medical practice. Organs also should not be harvested from people in a persistent vegetative state or from anencephalic children, for similar reasons. At the same time, patients who suffered from whole-brain death should not be artificially sustained; in light of current knowledge they can be declared dead and become organ donors.

Reader response: An interdisciplinary response to contemporary concerns about brain death determination.

We disagree with redefining death “based on loss of clinical function of the heart and lungs or the brain,”1 because it deviates from the legal definition of irreversible cessation of cardiorespiratory function or of all functions of the brain, including the brainstem. The latter was intended to protect the general public from injury and harm due to incorrect death declaration. The contemporary clinical criteria have been challenged on scientific, philosophical, legal, and religious grounds.2–4 Lewis et al. reduce this opposition to “moral or religious beliefs, hope that a patient will recover, or a lack of acceptance that a determination of brain death is the legal equivalent of a determination of cardiopulmonary death.”1 Religious objection stems from incongruence with the hylomorphic Thomistic concept of death (body-soul connection) underlying Abrahamic faith traditions. The “lack of acceptance” originates from low-level supporting scientific evidence and absence of a coherent philosophical rationale.4 Furthermore, American Academy of Neurology practice guidelines are more consistent with the brainstem rather than the whole-brain death definition.

Neuroscience and Brain Death Controversies: The Elephant in the Room

The conception and the determination of brain death continue to raise scientific, legal, philosophical, and religious controversies. While both the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in 1981 and the President’s Council on Bioethics in 2008 committed to a biological definition of death as the basis for the whole-brain death criteria, contemporary neuroscientific findings augment the concerns about the validity of this biological definition. Neuroscientific evidentiary findings, however, have not yet permeated discussions about brain death. These findings have critical relevance (scientifically, medically, legally, morally, and religiously) because they indicate that some core assumptions about brain death are demonstrably incorrect, while others lack sufficient evidential support. If behavioral unresponsiveness does not equate to unconsciousness, then the philosophical underpinning of the definition based on loss of capacity for consciousness as well as the criteria, and tests in brain death determination are incongruent with empirical evidence. Thus, the primary claim that brain death equates to biological death has then been de facto falsified. This conclusion has profound philosophical, religious, and legal implications that should compel respective authorities to (1) reassess the philosophical rationale for the definition of death, (2) initiate a critical reappraisal of the presumed alignment of brain death with the theological definition of death in Abrahamic faith traditions, and (3) enact new legislation ratifying religious exemption to death determination by neurologic criteria.

The Case for Reasonable Accommodation of Conscientious Objections to Declarations of Brain Death.

Since its inception in 1968, the concept of whole-brain death has been contentious, and four decades on, controversy concerning the validity and coherence of whole-brain death continues unabated. Although whole-brain death is legally recognized and medically entrenched in the United States and elsewhere, there is reasonable disagreement among physicians, philosophers, and the public concerning whether brain death is really equivalent to death as it has been traditionally understood. A handful of states have acknowledged this plurality of viewpoints and enacted "conscience clauses" that require "reasonable accommodation" of religious and moral objections to the determination of death by neurological criteria. This paper argues for the universal adoption of "reasonable accommodation" policies using the New Jersey statute as a model, in light of both the ongoing controversy and the recent case of Jahi McMath, a child whose family raised religious objections to a declaration of brain death. Public policies that accommodate reasonable, divergent viewpoints concerning death provide a practical and compassionate way to resolve those conflicts that are the most urgent, painful, and difficult to reconcile.

Defending a Functionalist View of Higher Brain Death

We provide a brief overview of the history of brain death showing how the cardiopulmonary model (CPM) of death became problematic due to the technological innovation of mechanical ventilation beginning with its use in the 1950s. We then examine difficulties that emerged with what was to become the received view of brain death known as Whole Brain Death (WBD). We argue that these challenges were never satisfactorily met by defenders of WBD. We also argue that a return to a CPM leads to even greater conceptual difficulties. Given that there are serious difficulties with both WBD and the CPM, we introduce a new version of higher brain death which we refer to as a functionalist view. We argue that a functionalist view of higher brain death can be defended more consistently than WBD and the CPM. Our defense introduces the notion of basing death on mental processing as opposed to traditional notions of higher brain death which used problematic and imprecise concepts such as consciousness and personhood.

A Thomistic Defense of Whole-Brain Death

Michel Accad critiques the currently accepted whole-brain criterion for determining the death of a human being from a Thomistic metaphysical perspective and, in so doing, raises objections to a particular argument defending the whole-brain criterion by Patrick Lee and Germain Grisez. In this paper, I will respond to Accad's critique of the whole-brain criterion and defend its continued validity as a criterion for determining when a human being's death has occurred in accord with Thomistic metaphysical principles. I will, however, join Accad in criticizing Lee and Grisez's proposed defense of the whole-brain criterion as potentially leading to erroneous conclusions regarding the determination of human death. Lay summary: Catholic physicians and bioethicists currently debate the legally accepted clinical standard for determining when a human being has died-known as the "wholebrain criterion"-which has also been morally affirmed by the Magisterium. This paper responds to physician Michel Accad's critique of the whole-brain criterion based upon St. Thomas Aquinas's metaphysical account of human nature as a union of a rational soul and a material body. I defend the whole-brain criterion from the same Thomistic philosophical perspective, while agreeing with Accad's objection to an alternative Thomistic defense of whole-brain death by philosophers Patrick Lee and Germain Grisez.

An elusive brain death diagnosis: You can't get there from here.

I read with great interest the case report by Story and Winter.1 Their patient was brain dead clinically but confirmatory testing in the form of CT angiography and EEG was requested, which failed to document whole-brain death. One might argue that they would not have encountered this medical, ethical, and legal quandary if the concept of brain stem death was adopted and accepted universally as opposed to whole-brain death, which is the currently accepted criterion in the United States. Electrocerebral inactivity or electrocerebral silence in a brain death EEG is defined as no EEG activity over 2 uV when recording from scalp electrode pairs 10 or more cm apart with interelectrode impedances under 10,000 Ohms (10 KOhms) but over 100 Ohms. It is a well-known fact that pockets of brain activity may persist in a patient who is clinically (all brain stem reflexes absent and apnea test positive) brain dead. These islands of brain activity may yield a …

Reviving Brain Death: A Functionalist View

Recently both whole brain death (WBD) and higher brain death (HBD) have come under attack. These attacks, we argue, are successful, leaving supporters of both views without a firm foundation. This state of affairs has been described as "the death of brain death." Returning to a cardiopulmonary definition presents problems we also find unacceptable. Instead, we attempt to revive brain death by offering a novel and more coherent standard of death based on the permanent cessation of mental processing. This approach works, we claim, by being functionalist instead of being based in biology, consciousness, or personhood. We begin by explaining why an objective biological determination of death fails. We continue by similarly rejecting current arguments offered in support of HBD, which rely on consciousness and/or personhood. In the final section, we explain and defend our functionalist view of death. Our definition centers on mental processing, both conscious and preconscious or unconscious. This view provides the philosophical basis of a functional definition that most accurately reflects the original spirit of brain death when first proposed in the Harvard criteria of 1968.

Persons and evidence for death: A reply to Bulzacchelli.

This article is a reply to Bulzacchelli's argument via two routes. First, I argue that Bulzacchelli has not clarified what he means by the two key terms in his argument: person and reduction. Second, and more importantly, I argue that Bulzacchelli's argument involves a contradiction. He seems to think that determining death on the basis of physiological evidence (i.e. the cessation of organismic functioning) is reductionistic. But he also endorses arguments against whole brain death (WBD) and those arguments maintain that because organ systems function (with external support) in the setting of WBD, the person still exists. But to say that the person still exists simply in virtue of organ systems still functioning is the very reduction Bulzacchelli intimates is a problem.

Commentary on the Concept of Brain Death within the Catholic Bioethical Framework

Since the introduction of the concept of brain death by the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death in 1968, the validity of this concept has been challenged by medical scientists, as well as by legal, philosophical, and religious scholars. In light of increased criticism of the concept of brain death, Stephen Napier, a staff ethicist at the National Catholic Bioethics Center, set out to prove that the whole-brain death criterion serves as good evidence for death in the Catholic bioethical framework, on the grounds that when whole-brain death has occurred the soul has already departed from the body. Opponents have argued that (1) brain death does not disrupt the somatic integrative unity and coordinated biological functioning of a living organism and (2) clinical tests outlined in the practice guidelines for determining brain death lack sufficient power to exclude persisting function and fail to detect elements of the brain that, although currently functionless, may retain potential for recovery under conditions of optimal medical care. It is therefore possible that heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of active euthanasia and physician-assisted death, both of which, either concealed or overt, the Catholic Church opposes.

Reversal to Whole-Brain Death Criteria After 15-Year Experience With Brain Stem Death Criteria in Poland

Polish brain-death criteria, similar to the original Harvard criteria, were published in 1984. In 1990, they were converted to brainstem death criteria, and were revised twice, in 1994 and in 1996. However, they could not be used in many complicated clinical situations such as intoxication, metabolic alterations, major facial injury, infratentorial lesions, and cervical spinal cord injury. The new Polish Transplant Act, passed by the Polish Parliament in 2005, recommends implementation of criteria for whole-brain death for brain-death diagnosis. In 2007, the Polish Ministry of Health Commission outlined new Polish brain-death criteria. Optional use of instrumental confirmatory tests was implemented in the new Polish national code of practice for the diagnosis of brain death in adults. In children up to age 2 years, instrumental tests are obligatory. Initially, there were problems in understanding the new, slightly more complicated classifications of primary and secondary brain injuries, infratentorial and supratentorial processes, modified apnea test. A broad commentary that addressed the most frequently asked questions was published in Anesthesiology and Intensive Therapy, the official journal of the Polish Society of Anaesthesiology and Intensive Therapy. This article dealt with most of the problems associated with implementation of the new criteria for diagnosis of brain death.

Conflict rationalisation: How family members cope with a diagnosis of brain stem death

Brain death, whether it be brain stem death in the UK, or whole-brain death in the USA, is a prerequisite for heart-beating organ donation. Understanding how brain death is perceived by family members approached about organ donation, its significance to them, and if it is accepted by them, are, therefore, important issues to explore as biomedicine expands the range of end of life technologies that blur the demarcation between life and death. To explore the concept of brain stem death and its meaning to family members the following research questions were posed: (i) what does the diagnosis of death based on brain stem testing mean to bereaved family members who have been approached and asked to consider a donation from a deceased relative, and (ii) how do family members understand the concept of brain stem death? To address these research questions, a secondary analysis of 28 interviews sorted from two primary datasets was carried out. The primary datasets contained longitudinal and cross-sectional interviews carried out in the UK with family members who had been approached about organ donation and agreed to donate their relatives' organs. Data analysis was guided by constructionist grounded theory method and resulted in the theory of Paradoxical Death. In this process, family members and health professionals engage in a series of practical and psychological activities aimed at rationalising real or potential emotional and cognitive conflict resulting from a brain-based diagnosis of death, whilst faced with the physical image of a functioning body. Rationalising emotional and cognitive conflict is how family members and health professionals appeared to process this paradoxical death, a death that is contrary to conventional opinion.

Bench-to-bedside review: When is dead really dead – on the legitimacy of using neurologic criteria to determine death

This review explores the legitimacy of the whole brain death (WBD) criterion. I argue that it does not fulfill the traditional biologic definition of death and is, therefore, an unsound clinical and philosophical criterion for death. I dispute whether the clinical tests used to diagnose WBD are sufficient to prove all critical brain functions have ceased, as well as examine the sets of brain functions that persist in many WBD patients. I conclude that the definition of death must be modified from a biologic to an ontologic model if we intend to maintain the WBD criterion.

The Death of Whole-Brain Death: The Plague of the Disaggregators, Somaticists, and Mentalists

In its October 2001 issue, this journal published a series of articles questioning the Whole-Brain-based definition of death. Much of the concern focused on whether somatic integration-a commonly understood basis for the whole-brain death view-can survive the brain's death. The present article accepts that there are insurmountable problems with whole-brain death views, but challenges the assumption that loss of somatic integration is the proper basis for pronouncing death. It examines three major themes. First, it accepts the claim of the "disaggregators" that some behaviors traditionally associated with death can be unbundled, but argues that other behaviors (including organ procurement) must continue to be associated. Second, it rejects the claims of the "somaticists," that the integration of the body is critical, arguing instead for equating death with the irreversible loss of "embodied consciousness," that is, the loss of integration of bodily and mental function. Third, it defends higher-brain views against the charge that they are necessarily "mentalist," that is, that they equate death with losing some mental function such as consciousness or personhood. It argues, instead, for the integration of bodily and mental function as the critical feature of human life and that its irreversible loss constitutes death.