When Life Ends

Editor's note: The Vatican has said on several occasions that brain death is a legitimate standard for determining death, and that organs can be taken from a brain-dead patient. But what the Vatican means by brain death and what many U.S. hospitals mean are often two different things — there is no national legal standard for what entails brain death.

ROME—Much of the focus of a recent Vatican gathering of physicians was on patients in a “persistent vegetative state” and on Pope John Paul II's insistence that such patients continue to receive the basic necessities of life—hydration and nutrition.

But part of the conference also touched on another controversy. A leading Vatican theologian affirmed that “brain death” is a valid criterion to determine death.

Doctors often declare brain death in order to remove vital organs from an organ donor. But even though the Pope indicated four years ago that the brain-death criterion is acceptable, some Catholic thinkers have resisted it.

Last year, two new Harvard Medical School physicians questioned the validity of brain death. Drs. Robert Truog and Walter Robinson, the authors of a 2003 article in the medical journal Critical Care Medicine, belong to a persistent minority of doctors and philosophers who ask: If a brain-dead person is more like a living person than a dead one—heart beating, warm to the touch, having functioning vital organs and even able to gestate a pregnancy—how can such a person be truly dead?

In an address to the International Congress on Transplants in 2000, John Paul encouraged organ transplants that are performed “in an ethically acceptable manner.”

He reiterated Church teaching that vital organs that occur singly in the body can be removed only “from the body of someone who is certainly dead.”

“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,” the Pope said.

Long History

The Vatican first looked at the Church's role in death determination in 1957. Pope Pius XII stated in “The Prolongation of Life” that the determination of death “does not fall within the competence of the Church” but is left to physicians.

Dr. Paul Byrne, a neonatologist practicing in Ohio and a past president of the Catholic Medical Association, has argued against using the brain-death criterion for years.

He became involved in 1975 after caring for an infant who for two days had a flat brain wave, an indicator of cerebral death. Byrne declined advice to turn off the ventilator and chose to treat the child. His former patient now works as a paramedic.

Byrne believes current practices do not meet the Pope's requirement. “For an organ to be suitable for a transplant, it must be a healthy organ, and the only way you can get a healthy heart is to get it from a living person,” he said. “Brain death doesn't mean you're going to die right away. It becomes the signal to cut out the vital organs.”

But several high-level conferences have taken place at the Vatican recently which have defined just what the Vatican means by brain death.

In 1985, the Pontifical Academy of Sciences concluded that death has occurred when “there has been an irreversible cessation of all brain functions, even if cardiac and respiratory functions that would have ceased have been maintained artificially.”

Brain function “includes every kind of activity by the part of the whole encephalic mass,” said Legion of Christ Father Gonzalo Miranda, dean of the school of bioethics at Rome's Regina Apostolorum Pontifical University. “That means that if there is, for example, blood circulation in the brain, you cannot say the organism is dead.”

Byrne said he doesn't dispute John Paul's teaching but pointed out that the Pope used the language of “complete and irreversible cessation of all brain activity.”

“The only way to have complete and irreversible [cessation of] brain activity is if there is cessation of circulation,” Byrne argued.

But Conventual Franciscan Father Germain Kopaczynski, director of education for the National Catholic Bioethics Center in Boston, said if the Pope had meant to say that cessation of circulation was required for a death determination, he would have said so.

“It seems to me the Holy Father is saying either/or — either total brain death or cardiopulmonary death, and he's very clear on that. This Holy Father certainly could have said … both brain death and heart death — and yet he did say either/or,” Father Kopaczynski said. “He's certainly not unaware of all the ramifications that are there.”

Myriad of Tests

John Haas, director of the National Catholic Bioethics Center, said the assessment of brain death is more sophisticated and in some ways more certain than the traditional heart-death determination.

“The cardiopulmonary criteria are pointing to the fact that eventually you're going to have disintegration of the brain,” he said. “We didn't have a way to measure that in the past. [Now] if it can be determined that the brain stem, cerebral cortex and cerebellum have died and ceased functioning, then the person can be declared dead.”

Part of the confusion is that some organizations use the term “brain death” when they are not referring to the brain stem, cerebral cortex and cerebellum stopping, but only to a flat brain wave.

Regina Apostolorum University's Father Miranda said almost every country has protocols for hospitals to follow before any vital organs are removed from a person. In Italy, the protocols include the absence of consciousness, spontaneous respiration, pupillary reaction and other cranial nerve reflexes (to check mid-brain activity).

“The presence of any of this would imply that the patient is not dead,” Father Miranda said. “This absence ought to be for six hours for an adult, 12 for a child and 24 for an infant, before organs are removed.”

In the United States, the “gold standard” of brain-death protocols is found in a New England Journal of Medicine article by Eelco Wijdicks of the Mayo Clinic in Rochester, Minn., said Edward Furton of the National Catholic Bioethics Center. Furton said some hospitals might follow the criteria laid out by Wijdicks while others might be more lax or stricter.

There is no national legal standard for brain-death protocols. The 1980 Uniform Determination of Death Act, written by a presidential commission, says a determination of death must be made “in accordance with accepted medical standards” but is silent on what diagnostic tests are acceptable.

According to the Wijdicks protocol, only after the patient's CT scan shows conditions such as heavy bleeding inside the head may the physician conduct a neurological examination to determine brain death. Conditions that might lead one to mistake brain death must also be ruled out, Wijdicks cautioned in his 2000 article. In the case of hypothermia, for example, “the diagnosis of brain death cannot be reliably made until the core temperature has reached 32 degrees,” he wrote.

Testing to see if a patient is brain dead must be precise and document absolutes, Wijdicks wrote. One component of the test examines whether the patient is in a coma: There should be no evidence of responsiveness. There should be no eye opening or motor response to voice or pain, for example, from compressing the jaw, he wrote.

Also, the test checks absence of brain-stem reflexes, making sure there is no spontaneous breathing, response to a bright light or grimacing due to pain, for example.

There could be further tests to confirm the determination of death, though the law in the United States does not mandate these confirmatory tests. The tests might include electroencephalography and ultrasound of the brain.

The neurological criterion is the Vatican's standard for brain death.

The U.S. bishops' ethical directives for Catholic hospitals address brain death in general terms, stating in Directive 62 that the “determination of death should be made by the physician or competent medical authority in accordance with responsible and commonly accepted scientific criteria.” Catholic hospitals are advised in Directive 64 that organs for donation “should not be removed until it has been medically determined that the patient has died.”

The Vatican's latest endorsement of the brain-death criterion came at the international physicians congress held in Rome from March 17-20. There, Bishop Elio Sgreccia of the Pontifical Academy for Life stated: “Personally, I am convinced that despite the criticisms levelled against the neurological criterion for the ascertaining of death, if observed scrupulously it merits our trust.”

Ellen Rossini writes from Richardson, Texas.