On brain death, a reader's rebuttal
My last comment on “brain death” and organ transplants drew a strong response from one reader, Dr. Michael DiPietro, who has considerable expertise in the field. Because his argument was quite cogent, and because my goal here is to stimulate debate on an important subject, I asked for permission to reproduce his message in its entirety, and Dr. DiPietro was kind enough to grant it. What follows, then, is his rebuttal to my piece:
Dear Mr. Lawler: I am a pulmonary critical care physician, I have also trained in neurology and have practiced pulmonary and critical care medicine for over 2 decades, including 3 years doing only neurologic critical care. I am actively involved in teaching medical students and residents and hold a clinical faculty appointment at Thomas Jefferson University School of Medicine. I also try to be a fairly orthodox Catholic, I am a member of the Catholic Medical Association, and have spoken in my diocese about end of life decisions as well as in opposition to embryonic stem cell research. Still I routinely pronounce individuals brain dead. I think you are badly mistaken about this concept and in fact would tell you all death is physiologically brain death.
In reality the only reason anyone dies with no heart beat and respiration is because there is no blood flow and oxygenation to the brain and brain death follows, If the brain does not die you do not die regardless of what happens to the heart and lungs. This is easily demonstrated.
First let’s stipulate that in theory an orthodox Catholic can certainly hold that brain death is a reasonable concept as per John Paul II. As you know, and in fact you quote, he said in speaking to a transplant group: "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 judgment which moral teaching describes as moral certainty."
With that in the background let us think about death a little bit. The only other traditional signs of death are loss of heart beat and respiration. However this can not be "death" since we know it is possible to have lost both and--having neither pulse nor respiration, nor any substitution for these for prolonged periods of time--yet still wake up and return to normal functioning. That is, we observe people who meet all the criteria for traditional death--they are pulseless, they are not breathing and they are asystolic (flat line on the EKG) with fixed and dilated pupils and are unresponsive, they appear by all measurements to be dead. Yet they are not dead; with treatment they will regain all of these things including consciousness. This phenomena is observed when people, especially children, drown in cold water. They are not dead, because the cold protects the brain. Hypothermia lowers the metabolic demands of the brain and protects it from the lack of cerebral blood flow. In fact during certain surgical procedures deliberate cooling and circulatory arrest are induced for a time in order to complete the surgery. It should be obvious from this that, unless there are routinely people rising from the dead, cessation of heart and lung function are not "death.” In fact the reason heart and lung function are relevant at all is because when they no longer work cerebral death rapidly ensues unless the brain is protected from the effects,...
Taking this one step further, one can imagine a situation in which there were neither heart nor lungs even present and yet the person was not dead. It is possible to maintain both circulation and oxygenation using a mechanical device similar to a heart-lung machine. Imagine the following thought experiment. Someone is awaiting a heart lung transplant, they are placed on ECMO (extracorporal membrane oxygenation). The functions of the heart and lung are replaced; in theory the person could be maintained like this even if the heart and lungs were removed. Now imagine the same situation, and the person is decapitated. Granted, a ghoulish thought, but I would make the point that it should be obvious here, at that point the person would be dead. Once decapitated they are obviously dead because although there may be other tissues being kept alive, the brain is no longer one of them, no longer getting the artificially provided blood flow and oxygen.
Indeed, however, this ghoulish situation is what brain death is. Typically patients with brain death lack cerebral blood flow, so while they may be artificially ventilated and while drugs may stimulate the heart to beat (or the heart may temporarily beat on its own, since it has its own intrinsic pacemaker if ventilation is maintained) the brain is typically not getting any blood flow, and in fact this is demonstrated with a confirmatory test (a cerebral blood flow study). It is physiologically as if one were decapitated. Maintaining a person who is brain-dead alive is physiologically not different from maintaining the decapitated person’s corpse on the ECMO machine; the only difference is that in one case the persons head could be lying on a table somewhere, while in the brain dead case the "head" is still attached. The amount of blood flow the brain is getting is identical in both cases and for identical reasons the "person" is no longer present, although a corpse with artificially maintained circulation and other functioning organs (liver, kidneys making urine, a gut digesting food) might very well be present in both cases.
One might argue that in the current environment--where many physicians are pro-abortion and in other ways do not adhere to a Catholic or even theistic conception of man--that you do not trust them to make this decision. But one might as well just say you simply do not trust doctors, period, because many of them are immoral. This of course can be a charge levied at any number of groups, including clergy, given the recent abuse crisis. At some level this is probably not a fair way to proceed. I too have grave differences with my colleagues on the "life issues" but it has been my observation that very few make the diagnosis of brain death lightly. It seems pretty clear to me that even if some physicians make the diagnosis incorrectly this does not mean the concept itself is in error. People have misdiagnosed even traditional death by heart-lung criteria; this did not mean people don't die.
Perhaps some of this concern over "brain death" is because of objections to those in the academic medical community who wish to expand the definition of brain death to include the severely brain damaged. (Declaring brain dead those with minimal higher brain function, not only those who have permanently lost all brain function including the brain stem). I would also object to that, but I think stating that one can see no difference between the 2 states ironically plays into the hands of those who would declare the severely brain damaged as "brain dead." The only difference is that you would somehow see an ontological significance to a heartbeat or breathing that can be replaced by a mechanical device and as such can not be something that defines a human being as alive or dead. In any case I would hope you give this some thought. I think Blessed John Paul II was correct in his assessment of brain death and we face enough battles on the right to life front without tilting at this windmill.
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Posted by: Pseudodionysius -
Apr. 28, 2012 11:24 AM ET USA
After reading Fr Nicanor Austriaco OP's excellent arguments disputing "brain death" as an acceptable criterion for death, I side with Phil Lawler on this debate. Well done, Phil.
Posted by: dagbat -
Apr. 17, 2012 2:02 AM ET USA
Thank you for this most informative update by Dr. DiPietro. I must admit that the original article by Phil Lawler left me a little uneasy as it seemed to imply that there were almost no instances when one could be certain of death, and therefore the concept of organ transplants appeared suspect from a Catholic morals perspective. This was especially bothersome to me since our family knows first hand the huge benefits of organ transplantation as our two sons’ lives were saved by liver transplants. Now after reading Dr. DiPietro’s outstanding medical synopsis of what constitutes death and also his reference to Pope John Paul’s interpretive statement on transplantation, I feel much better as this reinforces my original thinking on organ transplants – that they pose no moral issues.
Posted by: koinonia -
Apr. 14, 2012 9:25 PM ET USA
Thank you for including this. Things are not always as they seem in medicine. The certitude of some of the non-medical individuals in addressing these issues belies a certain ignorance of the tremendous complexities of human physiology. Life and death are still largely mysteries. Are there principles that may be applied in medical ethics? Certainly. This does not mean there are always easy answers. Today, we are still learning alot about cellular metabolism as AHA guidelines clearly indicate.
Posted by: bkmajer3729 -
Apr. 11, 2012 9:36 PM ET USA
Debate? What debate? Death is clearly measurable - like it or not. Are mistakes made? Of course; And not east to accept especially when injust is involved. But we put trust (I don't mean blind) in medical professionals experience and expertise. No offense intended here; when does "religious thinking" get in the way of the facts? Phil, in this case your position seems to me bordering on "throwing the baby out with the bath water"...
Posted by: spledant7672 -
Apr. 11, 2012 2:36 PM ET USA
These two articles provide an interesting and well informed debate. Phil, you make an argument for personal opposition to organ transplants based of brain death that is as well defined as can be. The rebuttal by the reader with expertise addresses every crucial point successfully on its own terms. I found it very helpful on the issue and an excellent example of such dialogue. Sincere thanks for living your convictions with courage, including continued openness to dialogue based on truth.