Academic journal article Ethics & Medicine

The Higher-Brain Concept of Death: A Christian Theological Appraisal

Academic journal article Ethics & Medicine

The Higher-Brain Concept of Death: A Christian Theological Appraisal

Article excerpt

In the practice of Critical Care Medicine, an all-too-frequent scenario involves the care of a patient who is progressing toward a possible state of whole brain death (WBD). Clinical energies which have hitherto been focused on saving life are shifted to confirming what is held to be, by law, a state of actual death, and by law, the regional Organ Procurement Organization (OPO) must be contacted, who will in turn determine the donor-potential of the patient. The OPO is concerned with not just one patient, but hundreds, and many of these will die, should they fail to receive an organ transplant.1 Much, and for many, hangs on the determination of death.

The significant "supply-demand" imbalance for transplantable organs has generated a number of initiatives designed to make available for transplantation an optimum number of maximally viable organs. One such proposal is to broaden the current criteria that establish brain death to include a determination of death based on the loss of so-called "higher-brain" function, whereby a person, typically a patient in persistent vegetative state (PVS) who has permanent loss of consciousness but continues to breathe unassisted, could be pronounced dead and their organs potentially made available.

The purpose of this essay is to explore the higher-brain death (HBD) criterion, to identify arguments supporting and opposing the proposal, and to locate this proposal, broadly speaking, within the contemporary brain death debate. Finally, the essay will engage the question of how the proposal might be viewed in Christian thought, and whether it may be endorsed from a Christian standpoint.

In this endeavor, it is necessary to acknowledge the inevitable inconsistency of terminology among the concepts of "spirit," "soul," and "mind" across philosophical presuppositions and across history. For the purposes of this appraisal, we will employ a concept of "mind" as articulated by J.P. Moreland: "The mind is that faculty of the soul that contains thoughts and beliefs along with the relevant abilities to have them.

. . . The spirit is that faculty of the soul through which the person relates to God."2

Less than a year after the first successful human heart transplant, the medical community foresaw the inevitable need for more organs. In 1968, the Journal of the American Medical Association (JAMA) published the report of the Harvard Ad-Hoc committee on the definition of irreversible coma;3 the stated intent of the report was to make hospital beds available, and to increase the number of organs which might be made available for donation. There followed in 1981 the President's Commission Report on Defining Death, which concluded that death could be established by either a cardio-respiratory or a whole-brain death criterion.4 The Commission's recommendations were codified in the Uniform Definition of Death Act (UDDA); the "dead donor rule" which followed is a philosophical synthesis of the UDDA and homicide law, and establishes that no organ may be procured from anyone who is not dead by one of these criteria.5

In 2009, The President's Council on Bioethics (PCB) issued a White Paper Report on Controversies Surrounding the Determination of Death, which, acknowledging difficulties associated with the concept of WBD, reaffirmed that the diagnosis of death may be made either by WBD, designated by the Council to be "Total Brain Failure" (TBF), or by cardio-respiratory criteria.6 The Council affirmed the essential 'unified organism status' of human life, the biological single-event nature of death, and the inevitability of death.7 This construct is ascendant in philosophy, law, and medical practice, and provides the necessary starting point for this discussion. Current practice is prescribed in the PCB 2009 report.8 The council acknowledged but rejected alternative brain death criteria proposals, including HBD.

To be sure, the WBD/TBF formula is not without controversy. Critical Care practitioner and ethicist Robert Truog summarizes the obvious "questions about whether patients with massive brain injury, apnea, and loss of brain stem reflexes are really dead. …

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