A brain dead person is legally dead, but whether they may be biologically alive is still up for debate.
It was 1989, and she was still a resident anesthesiologist, Dr. Heidi
Klessig recalled in her book, “The Brain Death Fallacy.”
One day, her attending anesthesiologist told her to prepare a brain-dead
organ donor for organ removal surgery.
Upon examining the patient, Dr. Klessig was surprised to find that the
man looked exactly like every other critically ill, living patient and, in
fact, better than most.
“He was warm, his heart was beating, and his monitors showed stable vital signs,” wrote Dr. Klessig. “Nevertheless, on his bedside exam, he checked all the boxes for brain death, and the neurologist declared him ‘dead.’”
Dr. Klessig’s supervising attending anesthesiologist asked her what anesthesia she was going to give the donor for the operation.
Her answer was a paralyzing agent so the donor would not move during
surgery, as well as some fentanyl to blunt the body’s responses to pain.
The anesthesiologist looked at her and asked, “Well, are you going to give anything to block consciousness?
Dr. Klessig was stunned. Consciousness blockers are given to patients to ensure they are not awake and aware during an operation.
Her education told her that brain-dead patients should not be conscious;
apart from having a biologically active body, their minds were gone.
“I looked at him and said, ‘Why would I do that? Isn’t he dead?’”
Her attending anesthesiologist looked at her, asking, “Why don’t you
give him something to block consciousness—just in case.”
“I get a pit in my stomach every time I remember his face,” Dr. Klessig
told The Epoch Times. “I remember him looking at me over his mask ... It seemed
very confusing.
“I did as I was told, and I’m very grateful [that I did.]”
Is Brain
Dead, Dead?
Once a person is brain dead, they become legally dead, but their bodies
are technically still alive.
The definition of brain death, also known as death by neurological
criteria, is when a person falls into a permanent coma, loses their brainstem
reflexes and consciousness, and cannot breathe without stimulus or support.
Yet a person’s heart can be beating, his or her organs functional, and
he or she can fight off infection, grow, and even carry babies to term.
Though they may exhibit no signs of consciousness, some areas of the
brain may still work. Around 50 percent of brain-death patients retain activity in their hypothalamus,
which coordinates the body’s endocrine system and regulates body temperature.
However, all of this stops if they get taken off life support.
For this reason, physicians hotly contest whether brain death is
synonymous with death.
Dr. James Bernat, a neurologist and professor emeritus at the Dartmouth
Geisel School of Medicine, told The Epoch Times that people who are brain dead
are dead because their bodies “no longer function as an organism as a whole.”
Without the technology to develop these life support machines, these people
would be dead, he said.
Radiologist Dr. Joseph Eble and previous academic hematopathologist Dr.
Doyen Nguyen, on the other hand, wrote in an article that machines
can only sustain life, not generate it—much like how a dead man could not
breathe while on a ventilator.
Another topic regarding brain death is whether a patient can still feel.
Among European anesthesiologists, there is an ongoing debate about
whether brain-dead organ donors should be given consciousness blockers during
organ procurement.
Some argue that they should do so in case patients feel pain. Others
disagree. Surprisingly, the anesthesiologists’ position is “not based on the
claim that patients were incapable of experiencing pain,” but, instead, out of
concern that the public might have doubts about the brain-death diagnosis,
bioethicists Dr. Robert Truog and Franklin Miller (who has a doctorate in
philosophy) wrote in their book, “Death, Dying,
and Organ Transplantation.”
Dr. Ronald Dworkin, a research fellow and anesthesiologist, wrote in an article on organ
procurement that he chose to give consciousness blockers because he thought his
patient “might still be a ‘little alive’, [sic] whatever that means,” he said.
Mr. Miller, who is also a professor of medical ethics in medicine at
Weill Cornell Medical College, said the label of brain death is misleading. He
and Dr. Truog, professor of anesthesiology and director emeritus of the Harvard
Medical School Center for Bioethics, are of the opinion that brain-dead people
are alive but will likely not regain consciousness and recover.
Some say brain-dead patients might actually recover, as in the famous
case of Jahi McMath, a 13-year-old girl who was declared
brain-dead on Dec. 12, 2013. Her mother opposed her brain-death diagnosis and
kept Jahi on life support for four and a half years. Though Jahi could not
speak and never regained full consciousness, two neurologists testified that in
her final days, she was in a “minimally conscious state.”
Jahi would move to instructions, nurses and doctors testified. Later, an electroencephalogram (EEG) detected brain wave signals.
A brain-dead person should have no EEG activity whatsoever.
“Jahi McMath is the sterling example of someone ‘correctly/properly’
diagnosed as being brain dead who subsequently was documented to have recovered
brain function,” Dr. Klessig said. The girl was indisputably diagnosed brain
dead according to the guidelines of her time and would be diagnosed as such
under the new guidelines, she added.
How Is
Brain Death Assessed?
According to the most recent brain-death assessment guidelines,
published by the American Academy of Neurology (AAN)
in 2023, brain death is determined through a bedside assessment.
Before the brain-death assessment is conducted, neuroimaging must be
done to ensure there is damage to the brain.
“If you see a normal CAT scan or a normal MRI, then you need to be very,
very careful and cognizant that you may be going to a false-positive
situation,” Dr. Panayiotis Varelas, one of the co-authors of AAN’s 2010
guidelines and chair of the Department of Neurology at Albany Medical College,
told The Epoch Times.
After brain injury is confirmed, two doctors then complete the
brain-death assessment. The patient is tested twice for their responsiveness to
pain stimulus and brainstem reflexes, with a 24-hour interval between each
test.
If the patient tests positive both times, the doctors will conduct an apnea test—considered the most conclusive—to see if the person has lost breathing reflexes. In children, there are two apnea tests, one after each bedside brain-death assessment.
During the apnea test, the patient is taken off the ventilator for 10 minutes. A tube carrying pure oxygen is inserted into the airways. If the patient does not breathe voluntarily, they are considered brain dead.
The apnea test comes with several risks.
For example, those with respiratory failure may experience
complications, including severe hypotension, hypoxia, and cardiac arrhythmia.
In a patient whose brain is already compromised, an apnea test may
worsen the person’s condition or cause further damage, Dr. Paul Byrne, regarded
as a pioneer in neonatology and involved in treating supposedly brain-dead
neonates, told The Epoch Times. A worse condition can compound a brain-death
diagnosis in individuals who may actually be on track for recovery.
Misdiagnosis could also occur during brain-death assessment.
One example is Zack Dunlap. In November 2007, he got into a traffic accident and was pronounced brain dead at the hospital.ack Dunlap)
Mr. Dunlap told The Epoch Times that he regained consciousness in the
hospital after he was pronounced brain dead and his friends and family were
saying their goodbyes.
He tried to scream and move, but nothing happened. Since he was an organ
donor, he was soon scheduled for organ procurement.
The family prayed for Mr. Dunlap in the hospital. Mr. Dunlap’s cousin, who is a nurse, didn’t believe it was his time
The cousin conducted additional tests on him. When the cousin pressed
under Mr. Dunlap’s thumbnail, Mr. Dunlap pulled his arm to the other side of
the body. This movement revoked the diagnosis.
After a few more days, Mr. Dunlap began breathing on his own. He was
discharged a month later.
Dr. Varelas, who reviewed media reports on Mr. Dunlap, told The Epoch
Times that Mr. Dunlap’s outcomes looked so good that he suspects some steps may
have been missed during the assessment.
If doctors had adequate experience with brain-death assessments and
diligently followed the AAN’s guidelines, false positives would not occur, said
Dr. Varelas.
While his hospital makes 50 to 60 brain-death assessments every year,
smaller community hospitals may make very few. Therefore, doctors at these
hospitals may not have enough experience, miss signs, or carry out the
brain-death assessments out of order, he added.
Dr. Bernat said that the test often performed incorrectly is the apnea
test.
In 2010, neurologists conducted a review for the AAN to evaluate all cases of recovery from
brain death in adults between 1996 and 2009. They determined that there were
“no published reports of recovery” from brain death if patients were diagnosed
correctly using the brain-death diagnostic criteria of the time. Mr. Dunlap’s
case was not assessed.
To further complicate matters, several conditions can mimic brain death.
These must be excluded before starting brain-death assessments.
Deceptive
Death Conditions
The authors of the 2023 AAN guidelines advise that prior to brain-death
assessment, all of the following conditions should be eliminated, including:
- Hypothermia (low body
temperature)
- Autoimmune nervous
system diseases
- Drug overdoses
- Poisoning
Therapeutic hypothermia, a treatment that lowers body temperature, is commonly used in patients who have been resuscitated after a cardiac arrest. Cooling devices are applied to help the body and brain recover and heal. However, hypothermic patients can take up to a week to regain consciousness.Autoimmune conditions like Guillain-Barré syndrome, which damages a person’s nervous system, can also rob someone of their reflexes and consciousness.
Dr. May Kim-Tenser, associate professor of clinical neurology at Keck
School of Medicine at the University of Southern California, reported in 2016 on a case where a
patient with a form of Guillain-Barré syndrome was initially misdiagnosed as
brain dead.
The patient was admitted to the hospital after showing severe symptoms.
Within several days, he became unconscious and unresponsive, lost his brainstem
reflexes, and needed a ventilator to breathe.
An apnea test was not conducted. Had the patient been tested in such a
way, he would have failed because he would have been too weak to breathe, said
Dr. Kim-Tenser.
The patient was then transferred to Dr. Kim-Tenser’s hospital, where he
was prescribed autoimmune disease medication. Later, he regained consciousness
and some function of his limbs.
Drug overdoses from opioids and cocaine can also cause signs of brain
death. An overdose on the muscle relaxant baclofen, for instance, has been
known to mimic brain death.
“The brain death guidelines talk about what the mimickers are but not
necessarily ways to exclude them. A neurologist should be able to exclude them
with testing,” said Dr. Kim-Tenser.
Conflicts
of Interest
“There is an intense interest in [brain death] by [organ-procurement
organizations], the transplantation community, and patients on organ-waiting
lists,” Dr. Varelas wrote in a 2016 article on brain death.
Around 90 percent of all organ donors are brain-dead people. This is
because the brain-death definition allows surgeons to procure healthy organs
without invoking the “dead-donor rule.”
According to the dead-donor rule, an ethical norm, organ donors must be
declared dead before organ procurement, and organ procurement must not cause
the donor’s death.
Organs cannot be transplanted from people who are biologically dead,
which occurs after a person’s heart stops and he or she cannot be resuscitated.
“When you’re biologically dead, the loss of oxygen to your vital organs causes them to decompose so quickly that you cannot donate an organ,” said Dr. Klessig.
That said, tissues like cornea, cartilage, bone, and skin can come from dead donors. Live-organ donation can also be done to transplant the lobe of a lung, liver, or kidney.
Doctors who make brain-death assessments must not be involved in the
organ procurement process.
“We try to disassociate ourselves from the organ-donation process,” Dr.
Varelas said. “In my mind, we try to save the patient’s life, and that’s the
goal because the Hippocratic Oath is to do no harm.”
Nevertheless, conflicts of interest exist. Forty-nine percent of the
authors of the AAN’s 2023 guidelines on brain-death assessment reported
conflicts of interest related to organ procurement.
Synonymizing brain death with death is an issue of non-transparency, Mr.
Miller said. However, he said he would not consider organ procurement unethical
as long as the donor is well informed.
In the United States, many people sign up to become organ donors when
they apply for a driver’s license, and most of them assume that their organs
will only be removed in the case of their death, Dr. Klessig said.
“They think, ‘If I’m as good as done, might as well take my organs
anyway,’” Dr. Byrne said.
The reality is that their donor status can result in their organs being
procured if they become “brain dead,” with their family members unable to
override donor status.
Still a
Mystery
The concept of brain death started half a century ago, a few years after
the first organ transplant was successfully performed.
Organ procurement from comatose people started in the late 1950s.
However, this was rare and not practiced under any guidelines. During the same
era came a shift in the definition of death.
In 1959, French doctors Pierre Mollaret and Maurice Goulon coined the
term “le coma dépassé,“ meaning ”beyond
coma“ or ”irreversible coma,“ as a condition synonymous with death. Gradually,
brain death, also called ”death of the nervous system,” became a new
definition, and organs could, therefore, be procured from such patients.
On Dec. 3, 1967, the world was astounded by the first report of a
successful human heart transplantation performed by Dr. Christiaan Barnard in
Cape Town, South Africa. The heart was procured from a trauma victim with
massive head injuries. The donor had no brain activity detected on EEG scans
and lacked brainstem reflexes. However, her heart continued to beat with life
support.
The heart recipient survived for 18 days before succumbing to pneumonia,
but his heart functioned properly until his death. This success initiated the
practice of heart transplantation.
A month after Dr. Barnard’s monumental surgery, Dr. Norman Shumway
performed the first human heart transplant in the
United States at Stanford Hospital, removing the heart from a brain-dead donor.
The chief resident assisting him asked, “Do you think this is really
legal?”
“I guess we'll see,” Dr. Shumway said.
In August of 1968, the Ad Hoc Committee of Harvard Medical School
published “A Definition of Irreversible Coma”
in the Journal of the American Medical Association (JAMA).
They defined irreversible coma as a “new criterion for death,” which has
become a foundational cornerstone to the brain-death definition.
Despite this, scientists are still uncertain whether the definition or
the consequent assessment is perfect.
Regarding Mr. Dunlap’s recovery, Dr. Varelas said, “I am glad this young
man survived.” He believes the family’s prayers for Mr. Dunlap could have
contributed to his outcome.
“There are powers much higher than our medical knowledge—or the lack
thereof,” he said.
“The secret of life—including the definition of life—still remains the
deepest and most mysterious one,” said Dr. Dworkins.
Nature may never “permit anyone to know the exact point where brain
death becomes real death,” he added.