Academic journal article The Hastings Center Report

Is It Time to Abandon Brain Death?

Academic journal article The Hastings Center Report

Is It Time to Abandon Brain Death?

Article excerpt

Despite its familiarity and widespread acceptance, the concept of "brain death" remains incoherent in theory and confused in practice. Moreover, the only purpose served by the concept is to facilitate the procurement of transplantable organs. By abandoning the concept of brain death and adopting different criteria for organ procurement, we may be able to increase both the supply of transplantable organs and clarity in our understanding of death.

Over the past several decades, the concept of brain death has become well entrenched within the practice of medicine. At a practical level, this concept has been successful in delineating widely accepted ethical and legal boundaries for the procurement of vital organs for transplantation. Despite this success, however, there have been persistent concerns over whether the concept is theoretically coherent and internally consistent.[1] Indeed, some have concluded that the concept is fundamentally flawed, and that it represents only a "superficial and fragile consensus."[2] In this analysis I will identify the sources of these inconsistencies, and suggest that the best resolution to these issues may be to abandon the concept of brain death altogether.

Definitions, Concepts, and Tests

In its seminal work "Defining Death," the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research articulated a formulation of brain death that has come to be known as the "whole-brain standard."[3] In the Uniform Determination of Death Act, the President's Commission specified two criteria for determining death: (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brainstem."

Neurologist James Bernat has been influential in defending and refining this standard. Along with others, he has recognized that analysis of the concept of brain death must begin by differentiating between three distinct levels. At the most general level, the concept must involve a definition. Next, criteria must be specified to determine when the definition has been fulfilled. Finally, tests must be available for evaluating whether the criteria have been satisfied.4 As clarified by Bernat and colleagues, therefore, the concept of death under the whole-brain formulation can be outlined as follows:[5]

Definition of Death: The "permanent

cessation of functioning of

the organism as a whole."

Criterion for Death: The "permanent

cessation of functioning of

the entire brain."

Tests for death: Two distinct sets of

tests are available and acceptable

for determining that the

criterion is fulfilled:

(1) The cardiorespiratory standard

is the traditional approach

for determining death and relies

upon documenting the pro-longed

absence of circulation or

respiration. These tests fulfill the

criterion, according to Bernat,

since the prolonged absence of

these vital signs is diagnostic for

the permanent loss of all brain


(2) The neurological standard

consists of a battery of tests and

procedures, including establishment

of an etiology sufficient

to account for the loss of all brain

functions, diagnosing the presence

of coma, documenting apnea

and the absence of brainstem

reflexes, excluding reversible

conditions, and showing the

persistence of these findings over

a sufficient period of time.[6]

Critique of the Current Formulation of Brain Death

Is this a coherent account of the concept of brain death? To answer this question, one must determine whether each level of analysis is consistent with the others. …

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