Jama Intern Med 2014 Aug 174(8) 2 Meaning

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Copyright 2014 American Medical Association. All rig hts reserved.

TheMeaning of Brain Death

A Different View

The recent caseof Jahi McMath, a teenager in Oak-

land, California, was extensively publicized in the news

media and led to prominent commentaries in medical

journals on the meaning of brain death.1,2 McMath is a

14-year-old adolescent who in December 2013 experi-

enced devastating neurologicaldamage following com-

plications froma tonsillectomy. McMathmet criteriafor

thediagnosisof brain death.She continues,however,to

receive mechanical ventilation,tube feedings,and sup-

portive care at an undisclosed location, with her treat-

ment financed by private funds,according to the most

recent reports.

Virtually allof thecommentaryon theMcMath case

has focused on how unreasonable it wasfor her family

to insist on the continued use of life support. One bio-

ethicist was quoted in USA Todayas saying of the un-

named medical facilitywhere McMath was placedon a

ventilator, What could they be thinking? Their think-

ing must bedisordered,froma medical pointof view.

There is a word for this: crazy.3 Another bioethicist in-

sistedthat continued mechanical ventilationwas notlife

support and that the teenager was not a patient be-

causeshe was dead. The bioethicistwas quotedas say-

ing that the newphysicians aretrying to ventilateand

otherwise treat a corpse. She is going to start to

decompose.3

Inourview,theseandothercommentatorshaveig-

nored an important distinction between braindeath as

a biological phenomenon and as a legal status.4,5 For

morethan 200years,the essentialfeaturesof living or-ganisms have been the subject of scientific investiga-

tion. At present, we understand life to be defined in

termsofthecapacityoforganismstouseenergyinmain-

taining a stable homeostatic internal environment and

integratedfunctioning.6Whenanorganismlosesthisca-

pacity, it hasdied. Thisdefinitionappliesacross thebio-

logical spectrum, fromsingle-celled organisms to com-

plex plants and animals.

The history of brain death reveals a persistent and

continuedfailureto connect theconceptof brain death

withthisbiological understanding of lifeand death. The

1968 report from the Ad Hoc Committee of the Har-

vard Medical Schoolto Examine theDefinition of BrainDeath proposed a definition of irreversible coma but

provided no reason to consider patients in this condi-

tion to be actually dead.6

In 1981, the Presidents Commission for the Study

ofEthical Problemsin Medicineand Biomedical andBe-

havioral Researchasserted thatbrain-deadpatients did

in fact fulfill this biological definitionbecause they had

lost the integrated functioning of the organism as a

whole.7(p33)Overthe pastseveraldecades,however, in-

controvertibleevidenceshowsthat thisassertion is false.

Many individuals with a diagnosis of brain death can

maintainintegrated functioning for prolongedperiods,

evenyears.These functionsmay include circulation,di-

gestion,excretionof waste products,temperaturecon-

trol,woundhealing, fightinginfections,growthand de-

velopment, and gestating a fetus.8 We now know that

the integrated functioning of the organism as a whole

is an emergent property of living organisms and is not

dependenton a central organizersuch as thebrain. The

fact that those with a diagnosis of brain death cannot

breathe without being supported by a ventilator does

not make them dead because this is no different from

the situation of patients with high-level spinal cord in-

jury whoare unableto breathespontaneouslybut surely

are alive.

The scientific evidence is clearin many cases,

brain-dead patients are biologically alive. Neverthe-

less, there is good reason to maintain the widely

accepted policy stance that those with a diagnosis of

brain death are legally dead. Prior to the development

of intensive care medicine, when the mind ceased to

function the body also ceased to function. However,

technology such as the mechanical ventilator permits

the body to continue vital functions even when the

patients capacity for mental life has been irreversibly

lost. The unfortunate individual in this condition is

biologically alive but psychologically dead. With no

mental life, there is no value in living. This makes it

reasonable to treat a patient who is brain dead as

legally dead; the patient is as good as dead. Maintain-ing life support can be of no value for a person in an

irreversible coma; nor cansuch a personbe harmed or

wronged by procuring their organs for transplanta-

tion, as long as valid consent has been obtained.

Patients whohave correctlyreceived a diagnosis of

being in a persistent vegetative statealso have perma-

nently lostconsciousness. At present, the clinical crite-

ria for diagnosing the persistent vegetative state are

much less reliable thanthose for braindeath, however.

Thus, it is not prudent to consider a patient in a persis-

tent vegetative state as legally dead.

The legalstatusof braindeathhasanalogiestoother

areas of the law, in which entities may be given a legalstatusthatdiffersfromthenatureoftheentity.Apromi-

nent example is thelegaldoctrine that a corporationis

a person in the eyes of the law. It may serve appropri-

atelegalpurposesinapplyingthelawtocorporationsto

treatthem as persons,even though theyare, of course,

not persons.6Similarly, someindividualsare deemed le-

gally blind despite thefactthatthey retainlimitedeye-

sight.Althoughthosewithadiagnosisofbraindeathare

not biologically dead, they are properly understood as

legally dead.

VIEWPOINT

Robert D.Truog,MD

Division of Critical Care

Medicine,Boston

Childrens Hospital,

Boston, Massachusetts,

andDivisionof Medical

Ethics, Harvard Medical

School, Boston,

Massachusetts.

FranklinG. Miller,PhD

Departmentof

Bioethics, National

Institutesof Health,

Bethesda, Maryland.

Corresponding

Author: RobertD.

Truog, MD,Division of

Critical Care Medicine,

Boston Childrens

Hospital, 300

Longwood Ave, Bader

621, Boston, MA02115

(robert.truog

@childrens.harvard

.edu).

Opinion

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Most families have no interest in continuing life support once

theycome to understandthat their loved one is irreversibly uncon-

scious. Buthow should we respond to families like McMaths, who

wish to maintain life support fora family member whois in an irre-

versible coma andlegally dead? To insistthat such families are ob-

viously mistaken or in denial is not helpful because from a biologi-

calperspectivetheymay wellbe correctthattheir lovedone remains

alive.Continuing life support in the intensive care unit of a hospitalis not anappropriate useof this expensiveand scarceresourcebe-

cause such care can offer no medical benefit. As a matter of re-

spect, however, for thosefew families whoinsist on continued life

support,clinicians shouldbe preparedto facilitatetransferto a long-

term care institution that is willing to maintain such patients. In-

deed, New Jerseylegally requires this approach.6(p55)

Whoshould payfor this continuedtreatment? On onehand, it

seems reasonable to say that traditional third-party payers should

notfundthe continued careof patientsdeemed legallydead.On the

other hand, third-party payers routinelypay for continuedlife sup-

portforpatientsinapersistentvegetativestatepatientswho,ifcor-

rectly diagnosed, arealso irreversibly unconsciouswith nohope for

a meaningful life.Evenif thedifference in legal status is clear, it may

seem ethically arbitrary to provide financial support in one situa-

tion and notthe other. Veatch9 has thereforeargued thatall states

should follow New Jerseysexample,which is to allow patientsand

families to opt out of accepting brain death and to choose to have

deathdetermined by biological criteria.

Itmightseem that allowingpatientsand families tochoose their

definition of death would have many practical problems, but in-

deeditseemstohaveworkedwellinNewJersey.Familiesrarelywant

to continue thebiological existenceof a patient whois irreversiblycomatose. Respecting defensible minority views that do not im-

posesubstantial burdens onothersis reasonableand in accord with

theideals of a liberal society.

Facing the reality of brain death raises important questions

about the role of physicians in helping to resolve complex issues

in law, medicine, and public policy. We should provide the public

with the best scientific data and thinking available and allow soci-

ety through the democratic process to use those data in deter-

mining the best policy. In our view, the medical profession, by

insisting that brain death has a biological status even though this

status is unfounded, has not upheld this obligation. Trust and the

public interest would be best served by a more honest discussion

about the meaning of brain death. We owe the public and our

patients no less.

ARTICLE INFORMATION

Published Online: June9, 2014.

doi:10.1001/jamainternmed.2014.2272.

Conflict of Interest Disclosures: Nonereported.

Disclaimer: Theopinionsexpressed arethe views

of theauthorsand do notnecessarilyreflect the

policy of theNational Institutes of Health, the

PublicHealth Service,or theUS Departmentof

Health and HumanServices.

REFERENCES

1. GostinLO. Legaland ethical responsibilities

following braindeath: the McMath and Muozcases.JAMA. 2014;311(9):903-904.

2. MagnusDC, Wilfond BS,Caplan AL.Accepting

braindeath. N EnglJ Med. 2014;370(10):891-894.

3. SzaboL. Ethicistscriticizetreatmentof teen,

Texas patient. USA Today. January 10,2014. http:

//www.usatoday.com/story/news/nation/2014/01

/09/ethicists-criticize-treatment-brain

-deadpatients/4394173/.Accessed April 24,2014.

4. Truog RD,Miller FG. Changing theconversation

aboutbrain death.Am J Bioeth. Inpress.

5. TruogRD,Miller FG.Definingdeath: the

importanceof scientific candorand transparency.

IntensiveCare Med. Inpress.

6. MillerFG, TruogRD. Death, Dying,and OrganTransplantation. NewYork, NY: Oxford University

Press;2012.

7. Presidents Commission for theStudy of Ethical

Problems in Medicine and Biomedical and

Behavioral Research. Defining Death:A Reporton

theMedical,Legal, andEthical Issuesin the

Determinationof Death. Washington, DC:

Government Printing Office; 1981.

8. Shewmon DA. Chronic braindeath:

meta-analysis and conceptualconsequences.

Neurology. 1998;51(6):1538-1545.

9. Veatch R. Letparentsdecide if teen is dead.

CNN.com. January 2, 2014. http://www.cnn.com

/2014/01/02/opinion/veatch-defining-death.

Accessed April 24,2014.

Opinion Viewpoint

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Jama Intern Med 2014 Aug 174(8) 2 Meaning