Living or Not Living? That Is the Question
COMMENTARY: The debate over brain death has no easy answer but requires astute attentiveness to science, Church teaching and the sanctity of human life.
For more than 50 years — that is, since the so-called Harvard definition in 1968 — whole brain death (BD) has been considered by almost everyone, physician and layperson, to be equivalent to human death.
Since then, BD has become a bit of a strawman. Many proponents of the definition, including Catholics, defend it with a vigor unusual for debated moral issues. This is understandable. What’s at stake with it being correct is significant.
Over the years, tens of thousands of people have become vital organ donors anticipating the possibility of brain injury and death, a scenario in which, they have judged, it would be morally legitimate to donate their vital organs for transplantation. If BD is not equivalent to human death, then ventilated BD bodies are not metaphysically speaking corpses but the bodies of extremely disabled living human beings whose vital organs should neither be donated nor harvested.
Those who have heretofore donated vital organs or been involved with their transplantations sincerely believing that BD is human death have not sinned. They have operated on the presumption that total brain infarction is death and have done so in good faith. The question is not whether they have sinned, but whether their belief is grounded in a true judgment?
This has been the subject of a lively debate in the last 20 years. I intend in this article to introduce readers to the “other side” of the debate and the research that precipitated it. I hope to inform consciences to assist readers to make, perhaps reconsider, their judgment on the question based upon the recent evidence.
I am not proposing what conclusion anyone should reach. The question is very difficult. I have struggled with it for nearly two decades. Anyone who gives you easy answers is not doing it justice.
Full disclosure: I have concluded that there is reasonable doubt that all ventilated BD bodies are dead; where such doubt is present, moral certainty is lacking; in the absence of moral certainty, we ought to treat them as if they were alive unless and until such certainty has been reached.
The fascinating and contentious debate was precipitated by what can only be referred to as astonishing evidence published in 2001 in the Journal of Medicine and Philosophy by D. Alan Shewmon, who at the time was chief of neurology at UCLA Medical Center.
Shewmon’s research demonstrated that the bodies of some who are rightly diagnosed as suffering whole brain death express to a fairly high degree what appear to be “integrative functions.”
Integrative functions are what characterize biological organisms, if human, then living human beings. These functions are expressions of an organism’s overall holistic unity, a unity made up of the internal arrangement of and relation between parts, where each part and its functioning exist for — i.e., are internally directed to — the good of the whole. The contrary of integrative unity is not brokenness or sickness or anything per se empirically observable, but rather the absence of this integrative unity. Whatever biological functioning still takes place in a dead body, it is not the functioning of a unified organism. It is not integrative functioning.
The moment of death, biologically speaking, consists in the irreversible cessation of this arrangement of and relationship between a body’s parts, consists in the loss of integrative unity. Because humans are more than biological organisms, the loss of such unity is not a complete description of death, which consists in the definitive separation of the material body and spiritual soul. But because the soul is immaterial, death per se is not observable. We can only observe its signs, e.g., the ceasing of breathing, no heartbeat and brain activity, the setting-in of rigor mortis, and finally cell necrosis.
So one way to know whether or not a body on life support belongs to a living human being is to determine whether or not the body expresses integrative functions. These, we might say, are empirical (biological) indicators — somatic signposts — that the body-soul unity is still intact and the person still alive.
Brain-dead bodies cannot breathe on their own since the involuntary breathing response is mediated by the brain stem, which, in an individual that’s suffered whole brain death, is destroyed. So brain-dead bodies need ventilator support.
But with it, they have been shown to express bodily functions that appear to many to be truly integrative, appear to be functions of a unified, albeit terribly disabled, living human being.
These bodies sometimes can undergo the exchange of O2 and CO2 at the cellular level; digestion and circulation; fight infection and foreign bodies, which involves interactions between the immune system, lymphatic system, bone marrow and microvasculature; maintain the proper balance of a countless number of chemicals, enzymes and macromolecules, a function called homeostasis; eliminate, detoxify and recycle cell waste throughout the body; maintain body temperature; grow proportionately; heal wounds by mounting an immunological defense of self against foreign invaders; exhibit cardiovascular and hormonal stress responses to noxious stimuli such as incisions; and even gestate a fetus including the gaining of weight, redistribution of blood flow favoring the uterus, and immunologic tolerance toward the fetus.
The question at the center of the BD debate is what are we looking at when we are looking at a ventilated BD body that apparently carries out these functions? Are we looking at a corpse that expresses only a semblance of life, whose bodily functions are activated by no intrinsic principle of unity but rather by the extrinsic motion of the ventilator, or are we looking at a highly disabled living human being?
Some claim that John Paul II authoritatively taught that brain death is coextensive with human death, and so anyone who rejects this conclusion is “dissenting” from Catholic teaching.
Let’s consider the claim. What did the pope say and what level of authority does it possess?
In a 2000 address, the pope stated that when “rigorously applied” the neurological criterion “does not seem to conflict with the essential elements of a sound anthropology”; and goes on to say: “therefore a health-worker professionally responsible for ascertaining death can use these criteria [i.e., both cardio-respiratory and neurological] in each individual case as the basis for arriving at … ‘moral certainty’” (No. 5). So reliably diagnosing that an individual has suffered whole brain death can be the basis of moral certainty that the person has died.
Does he authoritatively teach that whole brain death constitutes human death? No. He teaches that the neurological criterion “does not seem to conflict with” sound anthropology.
“With regard to the parameters used today for ascertaining death … the Church does not make technical decisions. She limits herself to the Gospel duty of comparing the data offered by medical science with the Christian understanding of the unity of the person, bringing out the similarities and the possible conflicts capable of endangering respect for human dignity” (5, emphasis added).
The Church is authoritative in understanding human dignity; and science (or the scientist) is competent to generate and interpret “data” about human health. Both are necessary to arrive at moral certainty that someone has died.
The pope’s statement implies that the Church is competent to understand the dignity of the human person; and also implies that the scientific data and scientific consensus is reliable.
What premise from the data does his judgment specifically rely upon? He tells us:
“The complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem) … is then considered the sign that the individual organism has lost its integrative capacity” (5).
So this is the salient scientific conclusion: that when the human brain is destroyed, the individual loses its “integrative capacity”, which means, it loses its ability to unify the body’s somatic functions and direct them to the good of the whole. When the brain is destroyed, the body literally dis-integrates.
In 2011, I published the following in a Culture of Life ethics brief:
Now the judgment that death is coextensive with an “individual organism [losing] its integrative capacity” is certainly grounded in a sound conception of the human person as rooted in Catholic tradition. But — and this is very important — the judgment that the neurological standard is a reliable sign that [such disintegration] has occurred rests on the credibility of the scientific interpretation. Notice the pope says, “considered the sign”. “Considered” by whom? By the scientific community, not by the Gospel, the teachings of the apostles, or the authoritative tradition of the Church.
Now if evidence emerged from further research contradicting certain putatively accepted interpretations of the scientific data, then there would be no conflict with Catholic faith or morals, or with the obedience due to the teaching of the Magisterium, in raising questions regarding the soundness of the original standard.
Such evidence was adduced by Shewmon at least as early as 2001.
Since then, scholars from all over the philosophical spectrum, those who both defend and criticize the Christian conception of death, are united in thinking unsound the common rationale that when the brain is destroyed the body loses its capacity to self-integrate.
These includes thinkers as diverse as Nicanor Austriaco, Joseph Seifert, Edmund Pellegrino, Alfonso Gómez-Lobo, D. Alan Shewmon, Robert Spaemann, David S. Oderberg, Germain Grisez, Henry Veatch and the members of the 2008 US President’s Council on Bioethics.
Many of these, including Catholic scholars, have gone on to conclude that ventilated BD bodies are in fact living human beings, or at least they deny that they are obviously dead bodies.
Three examples of secular scholars concluding as much include:
B. Andrew Lustig, editor of a 2001 issue of the Journal of Medicine and Philosophy dedicated to BD, after reading Shewmon’s evidence, writes: “Equating brain death with loss of somatic integrative function, while useful for clinical, transplant, and policy purposes, is physiologically inaccurate and theoretically incoherent” (2001, p. 448).
Likewise, John Lizza, defender of a “higher brain death” notion of human death (according to which patients in a persistent vegetative state are “dead”), in response to Shewmon’s research, writes: “At bottom, individuals who have lost all brain function but continue to function in such biologically integrated ways for such lengthy timeframes are integrated organisms of some sort and cannot be classified as corpses or dead organisms” (The Conceptual Basis for Brain Death Revisited, 2004, p. 52).
Additionally, Harvard’s foremost BD expert, Robert D. Truog, stated in a piece in the New England Journal of Medicine: “Patients meeting criteria for brain death were originally considered to be dead because they had lost ‘the integrated functioning of the organism as a ‘whole’… Over the past several decades, however, it has become clear that patients diagnosed as brain dead have not lost this homeostatic balance but can maintain extensive integrated functioning for years.” (Truog, et al., 2013, p. 1288).
If the bodies of BD individuals do not in fact lose their integrative capacity, then they are still living human bodies.
Is this the case with some ventilated BD bodies? As I have said, this is the central point of contention in the debate.
It should be clear now that because the specific scientific claim grounding the papal conclusion (that BD bodies lose their integrative capacity when the brain is destroyed) is hotly disputed, the papal assertion may need reformulation.
Editor's Note: Anyone interested in reading further on this question should at least read Shewmon’s seminal 2001 essay and the essays by Catholic scholars on both sides of the question in this 2016 special edition of the Journal of Medicine and Philosophy.