In the United States, the definitions of death and
brain death have evolved throughout the years. In a 1968 Harvard University
Medical School Conference, argued that people who are declared dead can still
be on ventilation but are still considered dead. Later, the Uniform Declaration
of Death Act of 1981 argues that an individual can be declared dead if they
meet one of two criteria: the cardiopulmonary standard or the neurological
standard. The cardiopulmonary standard argues that the individual is dead if
the individual’s respiratory system irreversibly stops functioning. The
neurological standard argues that an individual is dead if the brain, including
the brain stem, irreversibly stop functioning. This Act is still in use today
and provides major foundation when determining if there is a black and white
definition of brain death.
In his presentation at Loyola University’s
neuroscience seminar, Dr. Joe Vukov of Loyola’s Philosophy department gave a
presentation on the Uniform Declaration of Death Act of 1981, and the criteria
surrounding death and brain death. He said that it is necessary to understand
disorders of consciousness before attempting to understand brain death and its
implications, so he presented terms to ultimately help define brain death. He
stated that the most basic definition of consciousness is arousal. “Arousal” is
a state in which an individual is awake and has spontaneous eye movement. “Awareness”,
then, is the state where an individual looks for responses to external stimuli.
He defined “coma” as a state in which a person is neither aroused nor awake. An
individual in a coma lacks consciousness, according to Dr. Vukov.
Building upon these attributes, Dr. Vukov defined
brain death as a state in which an individual is in an irreversible coma. The
US National Library of Medicine National Institutes of Health defines brain
death as the “irreversible loss of all functions of the brain, including the
brain stem” (Burkle et al). Dr. Vukov stated that this is the official
definition of brain death in the United States. Dr. Vukov differentiated
between the official definition from the legal definition of brain death by
stating that the legal definition of brain death is the absence of spontaneous
respiration. From the legal perspective, according to Dr. Vukov, brain death
occurs when there is no way to restart the heart, so the cardiovascular and
respiratory systems must have permanently stopped functioning. This definition
poses a problem because there is no way to determine when someone’s respiratory
system has stopped irreversibly.
Dr. Vukov then argued the validity of the implications
behind the two standards of death provided by the Uniform Declaration of Death
Act of 1981: the cardiopulmonary standard and the neurological standard. One of
these two criteria must be met for an individual to be dead. However, Dr. Vukov
argued that there are problems with both standards. The cardiopulmonary
standard poses a problem because health care professionals cannot know exactly
when a person’s systems have stopped irreversibly. This is subjective and
depends on the doctors and other medical professionals attending to the
patient. On the other hand, Dr. Vukov said that the problem with the neurological
standard is that physicians cannot know if people have met the criteria for brain
death because parts of the body can continue to function, even when the brain
may not show activity. An example that Dr. Vukov gave was of Jahi McMath, who
was declared brain dead but kept on life support. Though she was considered
brain dead, she was considered not to be legally dead. Her respiratory system
was functioning normally, but her brain did not show any activity. Therefore,
the definition of brain death, not just the black and white difference between
death and brain death, becomes muddled.
In the United States, there is no difference between
brain death and death. Attempting to define brain death in a black and white
manner poses multiple ethical issues, including when determining when the
individual’s organs are to be donated. Doctors do not want to end the
individual’s life for the purpose of organ transplants, but they also do not
want to utilize valuable resources in artificially maintaining an individual’s
life. Another ethical issue is that medical professionals must carefully and
considerately communicate to the patient’s family and caregivers why continuing
medical treatment is not appropriate if an individual has been declared brain
dead. Dr. Vukov concluded that health care professionals should not worry about
the black and white definition of brain death. There may never be a clear-cut difference
between death and brain death, and it might not even be necessary. One step
that hospitals can take, however, is to educate medical professionals on how to
respond to brain death versus death situations, and how to follow protocol when
declaring a patient dead or brain dead.
The article “Why brain death is considered death and
why there should be no confusion” published by the American Institute of
Neurology, presented solutions to the two major ethical issues behind the case
of Jahi McMath, a thirteen-year-old child who was declared dead. The hospital
that declared her dead said that it did not have a moral obligation to provide
medical treatment, even if the family said it did. Jahi had a beating heart
when she was on ventilation, so the family argued that Jahi was not dead, but
brain dead. The family further argued that the hospital ought to continue to
provide ventilation in accordance to their religious principles and in hopes to
revive Jahi. The hospital cited that it could no longer support Jahi because
they did not to utilize these resources to support and individual who was
declared dead. Disagreement between hospital and family let to Jahi’s family
members to take the case to court. The court report did not release details of
Jahi’s medical condition, but it did mention that her brain did not show
activity. Yet, Jahi was supported by artificial means such as nutrition,
oxygen, and medications upon request by family. The major ethical issues
underlying this problem was how the hospital should respond to Jahi’s family
requesting medical support and continue to provide effective care to all patients.
The case concluded when the Medical Ethics Committee
of the hospital cited that continuing to support Jahi, even after she was
determined to be dead, was not appropriate. This conclusion aligns with Dr.
Vukov’s argument of utilizing valuable resources to support an individual in
this irreversible state. Medical professionals must take great care when
explaining to family members about the implications of continuing medical
treatment for an individual who is determined dead and respect their wishes as
well. However, it is also highly important take actions that are medically
appropriate. Such actions utilize resources and medical professionals to
support patients in the recovery process. There may not be a medically
appropriate definition of brain death and death. If, however, medical
professionals act to maximize the number of patients they strive to serve, show
consideration to patients and family members, and utilize resources carefully,
there may not even be a need for a black and white definition of brain death
and death.
Works Cited
Burkle CM, Sharp RR, and Wijdicks EF. “Why Brian Death
is considered death and why there should be no confusion”. US National Library
of Medicine National Institutes of Health. American
Academy of Neurology. Web. 2014.
Golia, Ajay Kumar and Paward Mridula. “The Diagnosis
of Brain Death” Indian Journal of Critical Care Medicine. Jaypee Brothers Medical Publishing (P) Ltd. Web. Jan-Mar 2009.
Powell, Tia. “Brain Death: What Health Professionals
Should Know” American Journal Of Critical
Care, vol. 23, no. 3, May 2014.
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