Friday, January 17, 2014

Lights Out: A New Reckoning for Brain Death

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“Brain death” was introduced to the world, in 1968, by a committee at Harvard Medical School. “Responsible medical opinion,” the committee reported, “is ready to adopt new criteria for pronouncing death to have occurred in an individual sustaining irreversible coma as a result of permanent brain damage.” People on ventilators in intensive care units, their brains destroyed by trauma or disease, their hearts still going strong, may have been breathing, taking in nourishment, excreting waste, and healing from infection, but, at least in the opinion of doctors, they were dead—“heart-beating cadavers,” as bioethicists came to call them. Thirteen years later, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research endorsed this opinion, recommending that all states adopt statutes to give doctors the right to pronounce brain-dead people legally deceased. Today, in every state, if your brain, including the brain stem, has been irreversibly and completely destroyed, you are dead.

As I wrote in the magazine, in 2001, death was legally redefined, in large part, to facilitate organ donation, a practice that, because of advances in immunosuppression and surgical technique, was increasingly effective, and, therefore, frequent. People in need of organs were, in the words of Henry Beecher, the Harvard committee member credited with writing the report, “stacked up waiting for suitable donors.” As Beecher knew, patients on life support—a population that was growing, thanks to the increased efficacy of intensive-care units—were the definition of the suitable donor, because their hearts still beat well enough to perfuse the organs with oxygen, keeping them viable. But such people were, according to the laws of the time, still alive. To Beecher, this was an outrage of inefficiency. “Can society afford to discard the tissues and organs of the hopelessly unconscious patient when they could be used to restore the otherwise hopelessly ill, but still salvageable individual?” he asked. If, on the other hand, brain-dead people were legally dead, then the supply problem was solved: transplant doctors could remove a still-beating heart (and a patient’s other organs) without committing murder.

Among the challenges that advocates of the new definition of death faced was explaining to the public why this redefinition was not simply a conceptual gerrymander. Was there some reason, other than “responsible medical opinion,” to move life’s most enduring boundary? In recommending the adoption of brain-death laws, the Presidential bioethics commission provided a rationale: the brain-dead person was dead because the brain was the maestro that conducted the body’s various instruments, and, without it, the body no longer exists as an integrated whole. Indeed, the committee concluded, the reason that cardiac arrest constituted death was that, when the blood stopped flowing, the brain eventually died. Brain death had always been the true death; we just didn’t know it.

For the rest of the story: http://www.newyorker.com/online/blogs/elements/2014/01/lights-out-a-new-reckoning-for-brain-death.html

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