“MOSTLY DEAD”

Scene from The Princess Bride:

Inigo: We need a miracle. It’s very important.

Miracle Max: Look, I’m retired. And besides, why would you want someone the king’s stinking son fired? I might kill whoever you wanted me to miracle.

Inigo: He’s already dead.

Miracle Max: He is, huh? I’ll take a look. Bring him in….

(They enter. Westley [the hero] is laid on the table. Max examines him.)

Miracle Max: I’ve seen worse…. He probably owes you money, huh?… Well, I’ll ask him.

Inigo: He’s dead. He can’t talk.

Miracle Max: Hoo hoo hoo! Look who knows so much, heh? Well, it just so happens that your friend here is only mostly dead. There’s a big difference between mostly dead and all dead…. Now, mostly dead is slightly alive. Now, all dead…well, with all dead, there’s usually only one thing you can do.

Inigo: What’s that?

Miracle Max: Go through his clothes and look for loose change.

from The Princess Bride
Director: Rob Reiner
Executive Producer: Norman Lear
Written by: William Goldman
(No copyright infringement is intended: “Fair Use”/not-for-profit/educational)

The following is an abridged version of the article, “Do the ‘brain dead’ merely appear to be alive?”, published in the juried Journal of Medical Ethics, August 28, 2017, under Open Access, as stated below. Stop Hospital Euthanasia (SHE) is grateful for permission to use this study.

DO THE ‘BRAIN DEAD’ MERELY APPEAR TO BE ALIVE?

Michael Nair-Collins and Franklin G Miller

Abstract

The established view regarding ‘brain death’ in medicine and medical ethics is that patients determined to be dead by neurological criteria are dead in terms of a biological conception of death, not a philosophical conception of personhood, a social construction or a legal fiction. Although such individuals show apparent signs of being alive, in reality they are (biologically) dead, though this reality is masked by the intervention of medical technology. In this article, we argue that an appeal to the distinction between appearance and reality fails in defending the view that the ‘brain dead’ are dead. Specifically, this view relies on an inaccurate and overly simplistic account of the role of medical technology in the physiology of a ‘brain dead’ patient. We conclude by offering an explanation of why the conventional view on ‘brain death’, though mistaken, continues to be endorsed in light of its connection to organ transplantation and the dead donor rule. [emphasis ours]

Introduction

With the development of mechanical ventilation, it is possible to ventilate [patients without a functioning respiratory system]… thus allowing the otherwise apnoeic [temporary absence or cessation of breathing] patient to remain alive…

Patients with… irreversible unconsciousness, can be maintained on the ventilator nearly indefinitely… a fundamental philosophical and scientific question still must be addressed: are these most unfortunate patients alive or dead?…

[S]cholars argue that in cases of ‘brain death’, the body or organism remains alive, but the person (as distinct from the organism) has died due to irreversible unconsciousness… ‘alive’ and ‘dead’ in this context are covertly normative, or moral terms…

Another type of view holds that whether such patients are alive or dead is… a social construction, and that there are good social, legal and moral reasons to draw the (somewhat arbitrary) dividing line between life and death in such a way that ‘brain dead’ patients are on the dead side of the line….

Each of the above views approaches the question of ‘brain death’ from a largely non-biological perspective. However, the most influential views, at least in terms of law and policy, have treated death in biological terms. The President’s Council on Bioethics in 2008 reiterated this stance: “[we] reject the idea that death should be treated merely as a legal construct or as a matter of social agreement. Instead, (we) … respect the biological reality of death”.

…[R]esponsible moral and policy deliberation begins with an unbiased assessment of relevant factual questions… the biological question: what is the vital status of this organism?

The established view regarding ‘brain death’ [is that] although such individuals show apparent signs of being alive, in reality they are (biologically) dead….

This view was given a seemingly authoritative articulation in 1981 by the U.S. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, and in 2008 the President’s Council endorsed the view, though offered a new justification for it….

The appearance/reality distinction in this context is a critical component of the established view, but it has not been carefully analyzed previously… appeal to this distinction fails [emphasis ours] in defending the view that the ‘brain dead’ are biologically dead…. [Public bioethics committees have introduced or repeated overly simplistic distortions or outright falsehoods… erroneous factual claims continue to be repeated in the literature on the determination of death, [W]e conclude by offering an account of why the mistaken, conventional view on ‘brain death’ continues to be endorsed in light of its connection to organ transplantation and the dead donor rule, which prohibits procuring vital organs from a living donor.

Two bioethics committee reports

The President’s Council departed from the President’s Commission in an important respect…. it proposed a new theory of life and death based on ‘the vital work of the organism’. Nonetheless, it repeats the stance that the ‘brain dead’ merely appear to be alive…. Can this stance withstand critical scrutiny?

Appearance and reality

One might defend a claim that appearances are misleading in (at least) two ways. On the one hand, there are perceptual illusions[:]

Müller-Lyer illusion[:] two lines appear to most observers to differ in length, but in reality they are the same. This illusion is readily dispelled by an empirical test, such as placing a ruler next to the two lines;

On the other hand, appeal to background knowledge can explain the reality of what is being perceived along with why the misleading appearance arises in the way that it does… [I]n watching the sun set over the western horizon, it appears as if the sun is moving relative to a stationary Earth, suggesting that the sun revolves around the Earth. But with background knowledge of modern astronomy, we can explain the reality (the Earth is revolving around the sun) as well as why appearances are misleading (our changing perspective from the surface of the Earth yields the appearance that the sun is moving).

[The bioethics committees] do not suggest that some sort of perceptual illusion is in play. It is not as if the heart only appears to be beating when in fact it is not, or that the skin only feels warm when in fact it is cold. Rather, they suggest that, in spite of the beating heart, warm skin and other (real) features of the ‘brain dead’ body, that organism has already died.

Of necessity, the explanatory account relies on a background theory or conceptual framework. The explanation of the setting sun gains no purchase in adjudicating reality or in dispelling illusory appearances unless our background understanding of basic astronomy is correct. Similarly, the explanation of the allegedly illusory appearance of life in ‘brain dead’ patients gains no purchase unless our background understanding of the physiology associated with ‘brain death’ is correct, and the specific biological conception of organismic death to which we appeal is adequate.

The President’s Commission defined death as the irreversible cessation of the integrated functioning of the organism as a whole. By contrast, the 2008 committee acknowledged that ‘brain dead’ patients do not satisfy this conception of biological death.

[I]n order to defend their view, they had to reject the traditional biological conception of death and instead develop a new one. The council argued that a living organism was characterized by its ‘vital work’, the work of interacting with the environment…

We address the council’s newly proposed concept of death below…. We concur with their emphasis on empirically grounding our claims about organismic death in relevant physiology. However, both committee reports rely on overly simplistic distortions regarding the role of medical technology in the physiology of a ‘brain dead’ patient.

‘Brain death’ pathophysiology and the role of medical technology

‘Brain death’ can have a number of [causes], but the basic pathophysiology is a simple matter of fluid dynamics. Any insult, injury or illness that causes intracranial pressure (ICP) to rise precipitously can cause an irreversible coma… If ICP rises high enough that it begins to resist the driving force of blood entering the skull, blood flow to the brain begins to decrease. This results in cell damage, which in turn leads to edema,,, [and] results in a further increase in ICP, leading to a further decrease in cerebral perfusion, more cell damage and edema, and so on in a positive feedback cycle. The outcome [is that] blood can no longer reach the brain, causing global cerebral anoxia and often brain herniation as well….

The accepted procedure for diagnosing ‘brain death’ requires identifying the cause of coma and ruling out confounds such as sedatives, hypothermia and others. Once these prerequisites are met, the tests are clinical, with three cardinal features: unresponsiveness to pain or other stimulation (allowing for spinally mediated reflexes), brainstem areflexia and apnoea….

Although state laws in the USA based on the Uniform Determination of Death Act require the irreversible cessation of all functions of the entire brain, patients satisfying the above described diagnostic tests can retain some brain function… Furthermore, the fact that some brain function is commonly preserved in these patients demonstrates that the President’s Council’s preferred terminology — ‘total brain failure’ — is a misnomer…. [emphasis ours]

It is impossible to know how many [patients] could be supported in this way since, once the declaration of ‘brain death’ is made, the patient will almost certainly either have life-sustaining treatment removed or will be an organ donor. However, there are at least 30 known cases of pregnant women having been physiologically supported for up to 107 days to gestate a fetus…

Both committee reports assert that the presence of a beating heart in the patient meeting diagnostic criteria for ‘brain death’ is a function of the ventilator. This claim deserves careful scrutiny.

However, the presence of mechanical ventilation alone is not responsible for the beating heart. Quite the contrary.

All of the roughly 100 trillion cells that compose the human body are surrounded by fluid, known as extracellular fluid…. the extracellular fluid is known as the internal milieu, or internal environment, because it constitutes the environment in which all cells live and function….

Supplementary Material

Supplementary Table 1

… [M]aintaining homeostasis of the extracellular fluid is an active process involving many mutually interdependent physiological functions; it is not a single function that can be anatomically localized to any part of the organism. All of these functions, together with mechanical ventilation and tube feeding, have been involved in keeping [a patient’s] heart beating for the 6 weeks after the diagnosis of ‘brain death’. This information is critical for evaluating the factual basis underlying the two committees’ claims. [emphasis ours]

Evaluating the committees’ claims

The President’s Commission writes, ‘One must be certain that the functions of the entire brain are irreversibly lost and that respiration and circulation are, therefore, solely artifacts of mechanical intervention’ [italics in original article]

If interpreted as meaning that the ventilator is causally sufficient for the heartbeat, this is patently false. An array of conditions is required to preserve the heartbeat, especially the homeostatic maintenance of the extracellular fluid, and this cannot be performed by the ventilator. This is demonstrated by the fact that if one were to intubate and mechanically ventilate an actual corpse, this will not result in a heartbeat or any other sign of life…. [emphasis ours]

These physiological functions throughout the entire organism are thus mutually interdependent. Therefore, in view of human physiology, it is simply false that the ventilator causes the heartbeat and other apparent signs of life because the ventilator is not causally sufficient for the heartbeat [emphasis ours]…. [italics in original article]

[I]f the President’s Commission merely meant to claim that the ventilator is a necessary condition, then it is a misleading distortion to assert that the heart continues to beat solely because of the ventilator….

Despite the benefit of 27 years of clinical experience and scholarly writing about ‘brain death’, the President’s Council makes the same false or misleading claim….

The ventilator alone does not and cannot effect gas exchange. In fact, the reality is precisely the opposite: gas exchange is an achievement of the integrated functioning of the organism as a whole….

The ventilator is capable of blowing air in and out of the bronchial tree; the organism must do the rest. In patients meeting ‘brain death’ criteria, the ventilator provides a necessary condition — air flow — that the organism would not otherwise provide due to brain injury, and therefore the ventilator is life-sustaining technology…. [italics in original article]

In sum, both committee reports rely on erroneous factual claims [emphasis ours]regarding the role of technology in a patient meeting ‘brain death’ criteria. If they meant to assert that the ventilator is causally sufficient for a beating heart or for gas exchange, then this is patently false. If they merely meant to point out that airflow is a necessary condition for the heart to beat, then this is radically incomplete and misleading, resulting in an oversimplified distortion of the physiological reality involved in the preserved heartbeat and other signs of life in a patient meeting ‘brain death’ criteria. Far from offering a ‘detailed picture of the medical facts’, both committees offer a false or oversimplified distortion of the medical facts. Since the proffered explanations for why the ‘brain dead’ merely appear to have vital signs are grounded in and dependent on erroneous claims about physiology, the explanations are undermined and should be rejected accordingly. [emphasis ours]

The vital work theory

The President’s Council acknowledged that ‘brain dead’ patients do not satisfy the traditional view of biological death [emphasis ours]as the irreversible cessation of the integrated functioning of the organism as a whole…. This new conception of death deserves comment, although briefly.

First, the vital work theory is ad hoc: it has no independent justification but is designed solely for the purpose of concluding that patients meeting ‘brain death’ criteria are biologically dead…. If a new theory of organismic death is to be endorsed, then it should be appraised on the basis of the usual theoretical virtues such as coherence with other well-accepted theories… and it should be shown to be superior to the older view in these regards. But since no reason has been given to justify endorsing a new view of the nature of biological death — other than that it allegedly implies a more palatable conclusion about the ‘brain dead’ — the view should be rejected….

[T]he President’s Council’s insistence that spontaneous breathing counts as ‘vital work’ but the myriad other physiological functions that continue in a patient meeting ‘brain death’ criteria do not is entirely arbitrary from the perspective of physiology….

The strategy of identifying some privileged functions that ‘count’ (ie, perform ‘vital work’) as distinct from those that do not ‘count’ is arbitrary and ad hoc. Necessary conditions are necessary conditions; none are either privileged or discountable.

Integrated functioning and the organism as a whole

Some commentators take the position that in the case of a patient diagnosed as ‘brain dead’ but receiving technological support, parts of the organism remain alive but the patient is dead because the organism as a whole has irreversibly ceased to function.

We show that this view depends on repeating the same erroneous claims about physiology propounded by the two bioethics committee reports.

[Bioestheticist Melissa] Moschella distinguishes the functioning of the organism as a whole from integrated functioning….

The basic idea here is that parts of the organism may remain alive, but the organism as a whole is dead because a special, ontologically privileged organ, the master part, has (mostly) ceased to function. This idea is similar to the President’s Council’s attempt to distinguish the privileged biological functions that ‘count’, or perform ‘vital work’, while discounting the tremendous range of preserved functions that do not count.

Moschella writes, ‘I am not convinced that the functions exhibited by a [“brain dead” body] … indicate that [the body] is itself an organism as a whole rather than an aggregation of organs and tissues inside a bag of skin, maintained in a coordinated relationship with one another through the action of external causes’…. As with the bioethics committee reports, this claim is based on mistaken assumptions about physiology and the causal role of the ventilator. First, the skin is not a ‘bag’; it is a living organ that plays vital roles in maintaining homeostasis via (among other things) contributing to innate immunity and maintenance of body temperature — functions maintained by the ‘brain dead’ body. Like all other organs, the skin both requires and contributes to homeostasis of the extracellular fluid.

Furthermore, the coordinated relationship between the various organs and tissues is not due to the action of external causes. [emphasis ours] The ventilator provides positive pressure and hence airflow through the bronchial tree; the organism must do the rest. [italics in original article]

Moschella argues that the brain is the master part because it controls the functioning of all other parts, directly or indirectly. But all organs and tissues mutually influence each other, and all are mutually interdependent on each other. Hence, they all control each other, directly or indirectly. Nearly all parts are involved in nearly all functions, directly or indirectly, because all cells and organs both require, and contribute to, the maintenance of the internal environment within conditions suitable for life. As [Dr.] John Hall [D.O.]describes it,

Each functional structure [e.g., organ or tissue] contributes its share to the maintenance of homeostatic conditions in the extracellular fluid … As long as normal conditions are maintained in this [extracellular fluid], the cells of the body continue to live and function. [italics in original article]

Thus, Moschella relies on essentially the same mistaken factual claims regarding the role of technology in the physiology of a ‘brain dead’ patient as did the earlier committee reports. The ventilator does not cause the heart to beat. The ventilator does not cause gas exchange. The ventilator does not trigger the actions of the other organs. And the ventilator certainly does not cause the coordination of activity between the different organs. It blows air in and out; the living organism does all the rest. [emphasis ours]

What explains the mistaken understanding of ‘brain death’?

The medical establishment and medical ethics experts are reluctant to publicly concede that the ‘brain dead’, in reality, remain biologically alive. Given that the practice and policy regarding vital organ transplantation has relied on endorsing the conventional view of ‘brain death’, it is difficult to see how the status quo of organ transplantation, which treats the dead donor rule as axiomatic, can be maintained if the conventional view of ‘brain death’ is jettisoned….

One plausible explanation for why the conventional view continues to be endorsed is that the conception of death that underlies the view is not a biological understanding of organismic death despite insistence to the contrary. … [T]acit appeal to something like a moral or social concept of death may also play a role. For example, some may hold that, while not completely biologically dead, patients meeting ‘brain death’ criteria are as good as dead [emphasis ours] thus [some] believe that they ought to be considered ‘dead’ for social and legal purposes, including especially for the purpose of organ procurement….

Writing in 1970, [Henry] Beecher asserted, ‘there is need to move death to the site of the individual’s consciousness, and if loss of consciousness is permanent, then to declare death’. Perhaps this claim about ‘the need to move death’ reflected a realization by Beecher that the neurological standard for determining death is not consistent with a biological conception of death. [emphasis ours]

Ari Joffe and colleagues recently conducted a series of surveys of Canadian pediatric intensivists, Canadian neurosurgeons and US neurologists… When asked to explain the conceptual rationale for why ‘brain death’ is death, only a minority selected the loss of integration rationaleor loss of the vital work of the organism rationale. Instead, in each case, the majority selected either an irreversible loss of consciousness concept or a prognosis concept, in which the patient was considered ‘dead’ because respondents felt that further treatment was futile or degrading,… was certain to suffer cardiac arrest in hours or days. [emphasis ours]

[R]ecent experimental work suggests that moral evaluations of organ transplantation can influence beliefs about death. Nair-Collins and Mary Gerend report the results of two experiments in which participants, who were members of the general public, were randomized to read a vignette about organ procurement from an unconscious donor that was framed as either morally good or bad. Participants who were randomized to read the morally good version were more likely to believe that the unconscious donor was dead, and less likely to believe that organ removal caused death, as compared with those who read the morally bad version, even though the physiologic condition of the donor was exactly the same in both versions. Furthermore, individual differences in attitudes towards organ transplantation and euthanasia independently predicted participants’ judgments of death, regardless of experimental condition. This suggests that, ‘rather than concluding that organ removal is permissible because the donor is dead, people may believe that the donor is dead because they believe organ removal to be permissible’. [italics in original; bold typeface emphasis ours]

Conclusion

The neurological standard for determining death, which underwrites vital organ transplantation, has continued to be endorsed over the past 50 years. A corollary of this view is the thesis that although the ‘brain dead’ appear to be alive in certain respects, appearances are misleading. In reality, they are biologically dead organisms. This thesis has been defended by two US bioethics committee reports in 1981 and in 2008. Nevertheless, it cannot withstand critical scrutiny. The science underlying the claim that the ‘brain dead’ are biologically dead organisms is weak and fundamentally flawed.Since the accepted ethical rationale for vital organ procurement from ‘brain dead’ patients relies on the validity of the neurological standard for determining death, the accepted ethical rationale is undermined as well. [emphasis ours]… [I]f vital organ procurement is ethically justified, it cannot be on the grounds that the ‘brain dead’ are (biologically) dead, but must be on some other grounds. It remains to be seen whether a new consensus will emerge regarding the ethics of vital organ transplantation, one which is not premised on demonstrably false claims about the vital status of biologically living patients in an irreversible apnoeic coma.

Acknowledgments

The authors gratefully acknowledge Dr Leslie Beitsch for a critical reading of the manuscript and for helpful comments.

For the complete, unabridged article, please go to this link:

http://jme.bmj.com/content/early/2017/08/28/medethics-2016-103867