Catholic Culture Overview
Catholic Culture Overview

Recovery from “Brain Death”: A Neurologist’s Apologia – Revisited After 27 Years

by D. Alan Shewmon, M.D.

Description

The author explains the genesis of this study on brain death as follows:

In February 1997, my article “Recovery from ‘Brain Death’: A Neurologist’s Apologia” was published in the Linacre Quarterly 64(1):30-96 (the official journal of the Catholic Medical Association). It recounts my conceptual journey from being a vocal advocate of “brain death” to a vocal critic.

The article explains my early interest in things neurological and later in “brain death.” The year I began my academic career, 1981, witnessed the publication of the milestone monograph on “brain death” by the President’s Commission, which endorsed the biological rationale of the brain as central integrator of the body. This explanation impressed me, but I was also impressed by a parallel line of reasoning that the brain, specifically its neocortex, is necessary for awareness and thought, so that without neocortical function, there is no longer a human mind, regardless of the biological status of the body.

In 1985 I published a lengthy article in The Thomist, proposing a thought experiment that I considered the strongest reason for equating “brain death” with death. An extension of the thought experiment implied that patients with intact brainstems but extensive destruction of the neocortex (clinically in a “permanent vegetative state”) were also dead, by virtue of an Aristotelian substantial change to a subhuman form of living organism. A few years later, an encounter with congenitally decorticate children who were clearly conscious forced me to reject the “cortex-consciousness connection” and that extension of the thought experiment. Thus, at the 1989 Pontifical Academy of Sciences’ Working Group on “brain death,” to which I had been invited, I proposed a modified version of the thought experiment that I believed accounted for both loss of human personhood and cessation of the organism as a whole.

I then became concerned about the possibility of “conceptual false positive error”: if I (and official neurology) had been wrong about something so fundamental as the “cortex-consciousness connection,” how could I be sure that I was not also wrong about “brain death” being death? An epiphany came in 1992, when it occurred to me that patients with functional or structural disconnection of the brain (physiologically identical to destruction of the brain from the body’s perspective) were not just conscious bags of loosely interacting organs and tissues, but living though disabled “organisms as a whole.” The body has no “central integrator” organ after all. Later that year I encountered clinical confirmation of that realization: a 14-year-old boy diagnosed “brain dead,” who had not “dis-integrated” but was stable at a long-term-care facility and even began puberty while “brain dead.”

For the next several years I lay low on the topic, while playing a merciless devil’s advocate with myself. By 1996 I was prepared to publicly renounce my previously published convictions through the “Apologia.” Since then, much “brain death” water has passed under the bridge, and my insights from 1992 have matured.

There has been recent interest in having the “Apologia” reprinted and more readily available. With permission from Sage Publications, I created a pdf version formatted with the same pagination but with typesetting errors corrected. Where an update or clarification was appropriate, an endnote was inserted. This corrected and updated version is now freely available here.

Larger Work

Linacre Quarterly

Pages

Vol. 64.1 pp. 30-96

Publisher & Date

The Catholic Medical Association (Sage Publications), February 1997 (rev. March 2024)

Summary

Beneath the nearly unanimous acceptance of the “brain death” concept lies widespread confusion surrounding both the precise signification of “brain death” and the rationale for its purported equivalence with death. As a neurologist with a keen interest in philosophy and bioethics, the author has striven over the years to articulate a coherent concept of human death, integrating clinical neurology with Aristotelian-Thomistic philosophy. This paper chronicles his gradual pendulum swing from “higher-brain” to “whole-brain” formulations, and most recently to a rejection of all purely brain-based diagnoses of death.

His earlier efforts to justify a neurological essence of human death were based on a seemingly incontrovertible thought experiment which supported the notion not only of “whole-brain death” but also of “neocortical death.” Subsequent clinical experience, however, with hydranencephalic children who were nevertheless conscious required abandoning the neocortical extension of the thought experiment and critically re-examining the prevailing neurologic dogmas concerning the vegetative state. His defense of “whole-brain death” culminated in participation in the 1989 Working Group of the Pontifical Academy of Sciences, which endorsed the concept in a consensus statement. Three years later, however, further considerations and a striking clinical case forced abandonment of the axiom that the brain is the “central integrating organ” of the body and consequent abandonment of even whole-brain formulations of death.

According to this revised view, death occurs when failure of multiple vital systems and bodily processes (including the brain) progresses beyond a systems-dynamical point-of-no-return, ordinarily (in the absence of protective therapies) presumably some 20-30 minutes or so after normothermic circulatory arrest. Although some “brain-dead” patients may be truly dead, it is not because their brains are dead but rather because of supra-critical multi-system damage; the remaining subset of “pure brain-dead” patients (with intact other organ systems) are not yet dead but are rather fatally injured and in a deep coma.

This view of death carries profound implications for transplantation ethics, but it does not necessarily preclude (at least in principle) licit harvesting of even unpaired organs of non-heart-beating donors, provided that asystole has persisted long enough for moral certainty that heartbeat and circulation will not spontaneously resume. Organ removal under such circumstances would neither cause nor hasten death, nor alter the functional integrity of the dying person’s body; thus, its moral species seems equivalent to that of removing a single kidney or part of a liver from a living donor. This approach to transplantation deserves further study by moralists.

Historically, the reasons for introducing the “brain-death” concept in the late 1960s were pragmatic and twofold: legitimizing the discontinuation of ventilators and the transplantation of unpaired vital organs. In retrospect, neither reason really required such a radical redefinition of death. Since the “central-integrator-of-the-body” rationale does not withstand careful logical and physiological scrutiny, the only remaining coherent rationale for equating “brain death” with death is the purported loss of “personhood” in a biologically live body, a rationale which entails a radical reconceptualization of “person” and which law and official medicine rightly reject but which many advocates of “brain death” implicitly or explicitly accept. History has amply demonstrated where a conceptual dissociation of personhood from biological human life tends to lead, and we would do well to reconsider whether “brain death” is any longer conceptually viable or even pragmatically necessary.

PDF file containing the entire updated article


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