Introduction
Defining brain death has continued to be a highly controversial phenomenon in our society today. In fact, it was recently described as being “at once well settled and persistently unresolved” (Truog 273). Traditionally death involves the “permanent stopping of the heart and cessation of breathing” (Fins and Laureys 1). However, with the advent of the artificial ventilator invented by Bjorn Ibsen from Denmark, a patient’s breathing and heartbeat could be continued, even in the absence of brain function (Fins and Laureys 1). Once physicians diagnose a patient as brain dead, the next step is often the procedure of organ transplantation. There is a multiplicity of views on brain death and subsequent organ transplantation, with each culture’s beliefs shaping its own medical practices; these differing stances often lead to ethical debates.
Background
Brain death was first described in the 1950s by two French physicians, Mollart and Goulon, who termed it as “coma depasse,” a state beyond coma and differentiated it from “coma prolonged,” a continual vegetative state (Ganapathi 10). The Harvard Ad Hoc Committee later reported two definitions of death: the “traditional” cardio-pulmonary death and “brain death” (Lock 138). In 1981, the Report of the Medical Consultants on the Diagnosis of Death to the US President's Commission reevaluated death, advocating that the diagnosis of brain death should not be distinguished from the death of “the organism as a whole” (Death, dying and donation 9). Over the years, medical personnel have come to view brain death as the death of the brain stem, and diagnose it by examining the function of nerves that originate in the brain stem (Death, dying and donation 10). Further, there is no “golden rule” regarding confirmatory and clinical tests on brain dead patients, but tests such as electroencephalogram (EEG), cerebral angiography, and nucleotide radiography have been extensively investigated, even though they are generally not required in adults (Death, dying and donation 10). During ancient times, it was widely agreed that death occurred when a person stopped breathing and his heartbeat ceased. Ancient Greeks believed the heart was the center of life, while ancient Hebrews and Christians considered the breath to be the center of life (Farrell and Levin 3) In the 12th century, the ancient philosopher Maimonides denoted that the loss of the head resulted in the loss of central guidance for the soul (Farrell and Levin 3). Physicians neither diagnosed nor certified death. During the Enlightenment, thinkers questioned the necessity of heartbeat and breath, as well as the definition of life, which led to questioning regarding the definition of death (Farrell and Levin 3).
From its introduction, organ transplantation has been primarily influenced by the major ethical requirement known as the dead donor rule. According to Ascension Health, America’s largest nonprofit health system, “the dead-donor rule refers to two widely accepted ethical norms that govern practices of organ procurement for transplantation. First, vital organs should only be taken from dead patients, and second, living patients should not be killed for or by organ procurement” (Ascension Health 1). For thousands of lifesaving donations and transplantations, the notion of brain death has provided an ethical and legal rationale. Nonetheless, questions as to whether patients with massive brain injury, apnea, and loss of brain-stem reflexes are actually dead have arisen (Truog and Miller 3).
Common causes of brain death include head trauma, Intracranial Hemorrhage, Anoxic Encephalopathy, Subarachnoid Hemorrhage, Cerebral Hemorrhage, and Meningitis (Cohen 13-17). Traumatic brain injury, one of the leading causes of brain death, is physical injury to brain tissue that temporarily or permanently impairs brain function. In the US, as in much of the world, traumatic brain injury (TBI) is a common cause of death and disability. TBI of any sort can produce cerebral edema and decrease brain blood flow.
Perspectives of Brain Death in the United States Typically in the United Sates, patients with massive brain injury are usually placed in an intensive care unit on mechanical ventilation when diagnosed as brain dead. Physicians perform a series of clinical tests for neurological function. Before a physician can diagnose a patient as brain dead, the patient must be in a coma and demonstrate no response to battery tests that have been preformed twice every six to twelve hours (Truog 273). If the results these tests continue to be constant, and all other possible causes for lack of brain function have been ruled out, the patient is diagnosed as dead, and the death certificate cites the time of death with the completion of the final examination (Truog 273). According to David Lamb, the author of Death, Brain Death and Ethics, “the concept of death cannot be exclusively determined by medical criteria… because it is related to general philosophical beliefs concerning the meaning of death” (9). Despite the influence of physicians personal beliefs concerning the meaning of death, the Uniform Determination of Death Act in the United States mandates irreversible cessation of all functions of the entire brain and brainstem (Wijdicks 12). In the majority of deaths after brain death, the physician, in the act of removing the ventilator, is the primary cause of the patient’s death. Because this act is performed with the consent of the patient and the physician is in a role that is sanctioned by society, the physician is not considered a murderer (Truog 279). The majority of physicians agree that there is an “absence of the person” in brain dead patients, because the diagnosis of brain death in itself confirms an irreversible loss of brain function and a permanent loss of consciousness (Lock 141). Moreover, in the United States, the diagnosis of brain death is often taken as the “default definition of death” (Morioka 9), which leads into the topic of organ transplantation. With regard to organ donation, the patient and his family have the right to allow or refuse organ transplantation. If the patient is a suitable candidate, he is left on ventilation while taken to the operating room in order to procure his organs. If the patient is not an organ donor, he will be taken off mechanical ventilation within a short period of time. In America, organ donation is generally seen as a socially acceptable and altruistic act. Moreover, the majority of Americans practice Christianity, which promotes organ and tissue donation. The Church states that “we were created for God's glory and for sharing God's love” (UNOS 9). According to Margaret Lock, “an hegemony is evident, in that organ procurement and donation is unreservedly promoted in North America as the right thing to do” (138).
Perspectives of Brain Death in Japan In Japan, culture greatly influences ideals of brain death and organ transplantation. Japan’s Organ Transplantation Law allows its citizens to choose between traditional death and brain death. Based on the law, a patient is considered “dead” if he is lacking brain function, carriers a donor card, and his family does not object to the legal brain death diagnosis; however, a patient would still be considered “alive” if he does not carry a donor card or the family refuses to accept the brain death diagnosis (Morioka 14). Japan’s concern with violating newly dead bodies is based on the “disruption of family obligations and sensibilities” (Lock 138). These understandings “take precedence over the ‘western’ practice of routine organ procurement” (Lock 138).
The Japanese traditionally do not view a patient with brain death as having an “absence of person” primarily because Japanese indigenous medical knowledge holds that life is diffused throughout the body in the substance of “ki” and most Japanese citizens do not agree that permanent loss of consciousness is synonymous to death (Lock 148). The prevailing perspective in Japan regards the traditional cardio-pulmonary death as the “default death” (Morioka 9) and thus there are less organ transplantations in Japan as compared to other nations, even though Japan has equally advanced technologically (Lock 150). Shinto, the predominant religion throughout Japan, regards a dead body as impure and dangerous, and thus quite powerful (UNOS 25). According to E. Namihira in his article, Shinto Concept Concerning the Dead Human Body, “injuring a dead body is a serious crime…it is difficult to obtain consent from bereaved families for organ donation or dissection for medical education or pathological anatomy…the Japanese regard them all in the sense of injuring a dead body" (UNOS 25).
Perspectives of Brain Death in India
In India irreversible damage of the brainstem is authorization for death. The Transplantation of Human Organs Act states that 'brain-stem death' is the stage at which all functions of the brain stem have permanently and irreversibly ceased. After the initial diagnosis of brain death by authorized medical personnel using pre-specified criteria, a patient who is brain dead can be taken for organ transplantation provided that there is legal consent (Pandya 4-5). Further, the Transplantation of Human Organs Act expounds that all medical care can be terminated after the diagnosis of brain death, and the only justified reason for preserving the patient’s body on a ventilator is to maintain the patient’s organs for later organ transplantation (Pandya 6).
India’s two major religions are Hinduism and Islam, both of which significantly influence the country’s culture. Both Hinduism and Islam believe that it is acceptable to donate one’s organs in order to better the life of another. In fact, stories from Hindu mythology describe events in which parts of the human body have been used to benefit other humans and society as a whole. The Hindu religions states nothing explicitly prohibiting the use of body parts, dead or alive, to alleviate the sufferings of others (UNOS 13). A. Sachedina, in Transplantation Proceedings, Islamic Views on Organ Transplantation states that, "the majority of the Muslim scholars belonging to various schools of Islamic law have invoked the principle of priority of saving human life and have permitted the organ transplant as a necessity to procure that noble end” (UNOS 15). The Islamic law is very supportive of people who donate their organs because it is seen as noble act. In India there is minimal conflict between cultural ideals and medical practices.
Prespectives of Brain Death in Denmark Denmark is the last country in Western Europe to accept brain death as the death of a human being. The debate in Denmark over the definition of death was highly political, and first began in the 1970s, when a group a physicians argued that brain death should serve as ample criteria for the death of a human being (Rix 227). These physicians wanted to increase the quality of cadavers available for kidney transplantation, as they previously had to wait for the heart to stop before the kidneys could be removed (Rix 228). One of the main problems relating to the controversy over brain death in Demark was the public’s lack of knowledge. Therefore, the Council of Ethics distributed over 14,000 reports across the country and used its $300,000 budget for a variety of public education activities (Rix 231). Its numerous booklets and brochures explained both the technical aspects of brain death and the ethical concerns surrounding brain death. Politicians feared public misunderstanding of brain death and organ transplantation would lead to public mistrust in the medical profession as a whole (Rix 237). When the law establishing the new brain death criterion was passed in 1900, various newspapers and journals published editorials on the issue, greatly influencing public opinion (Rix 232). Denmark’s acceptance of brain death as death of a human being was the outcome of its structural institutions shaping public knowledge and agency. Conclusion What is death? Is it when the brain ceases to function or is it when the body enters cardio-pulmonary arrest? The answer to these questions depends on ethnicity, religion, and community ideals – in essence, culture. There is no universal definition of death. Individual cultures shape their country’s medical perspective on brain death differently, and though the official view may not be a unanimous decision, it is the general consensus. Many ethical debates focus not only on the issue of brain death, but also on the subsequent transplantation of organs after death. While some cultures perceive organ donation as a generous act that saved another person’s life, others believe it is family tradition and responsibility to preserve the body. Perhaps a collective meaning of brain death will remain a “persistently unresolved” concept in modern science and society.