On the subject of Brain Death [January 28]
Dickens has been invoked, and as usual has something to say about everything. Mr. Gradgrind raises his head to remind us about "the facts" in this reply to a discussion characterized by unphilosophical, ad hominem arguments and faulty logic, emotional buzzwords and imaginary bogeymen.
Father Quay knows where he wants his argument to lead and is willing to get it there by any route. First, he "doubt[s] that brain death is the same thing as death." Fine! Next, he "doubt[s] that physicians have good criteria for determining when someone is brain dead." But in fact, physicians have excellent criteria, based on a bedside examination of the patient, for so-called brain death. If certain brainstem reflexes are gone, if the person does not breathe when tested in a very specific fashion, it has been found that such a person never recovers function but instead completes dying within a day or two. That is, the blood pressure drops and the heart stops. No one satisfying the usual current clinical criteria for "brain death" has had any other outcome. Careful examination of all claims to the contrary have been found not to satisfy currently accepted criteria.
It is not true that medical ethicists and practitioners rarely address Father Quay et al's criticism because "the subject is inconvenient." If we do not routinely involve Father Quay and his allies in lively debate, it is because his views do not represent mainstream Judeo-Christian thinking on the issue; most Catholic, Protestant, and Jewish thinkers who have reflected on the issue accept or at least do not reject the concept of "brain death" as the death of the person (Journal of the American Medical Association, October 10, 1977).
To turn to his most sensational allegation, let us examine the facts of the "disturbing . . . experiments on brain-dead people" to which he alludes in the cited Neurology article. In fact, this study was not some Mengele-like assault on the comatose: its aim was to determine a way to trigger respiration in a comatose person without making him/her hypoxic (short of oxygen). Simply to turn off the ventilator and wait for the individual to breathe subjects the person to hypoxia. The study documented a method to test for apnea (lack of spontaneous breathing) while maintaining a safe blood oxygen level; the method is routinely used today. The three patients (out of ten tested) who are triumphantly cited by Father Quay as proven not to be brain-dead after all were no surprise to the study's authors. Their technique was designed precisely to reveal which patients were not brain dead because when safely tested they breathed on their own. Yet Father Quay accuses the researchers of having misdiagnosed three out of ten patients as brain dead and further berates them for having "[gone] ahead and carried out their tests [unspecified] on the other seven."
Brain death as a concept arose not because of the "new tool" of organ transplantation, but because of the "new tools" of modern methods of resuscitation and technology which can maintain ventilation, heartbeat, and blood pressure during and after such procedures. These helpful technologies, which can extend our capacity to return individuals to their families and loved ones, are designed for viable lives, for rescuable lives, for beneficial procedures which could not otherwise be carried out at all. Problems of ethical decision making arise when they are, quite properly and quite morally, extended to cases in which survival, outcome, life cannot be predicted but an effort must be made. Rarely (in cases which trouble us all) our new tools find themselves applied to bodies which in any prior human era would have become apneic in seconds, pulseless in minutes, rigid in hours, and putrid in days; and which would be so today, if nature had her way, that is, if the machines were turned off.
It is natural for humans to try to understand, to come to terms with and to name their creations. Can we call this condition of suspended animation, of sustained vital function "life"? How else but as death, brain death if you like, can we describe the artificially induced state we have created, when consciousness is irrevocably lost, breathing will never again occur spontaneously, and final heart stoppage is imminent? If the identification of this state occasionally permits the transfer of healthy organs to desperately sick people, can this be denied on the incongruous and self-indulgent grounds of defending the "truth"?
"Bad faith," "malicious" (some doctors), "suspicious" (Father Quay), "something fishy" (brain death), "refined murders"--this is philosophy? Come on, Reader, if you want a serious discussion about a dead-serious topic, you can do better than this.
Donna Bergen, MD
Rush-Presbyterian-Saint Luke's Medical Center
Cook County Hospital
Harold Henderson replies:
I think you're right about the Neurology article. I apologize for letting that mistake get into print. But those two paragraphs aside, I don't think you've laid a glove on the main point of the story. If you find Father Quay too old, too Catholic, or too far from the mainstream to take seriously, then I urge you to consult the brief and readable article by mainstream medical ethicists Robert Arnold and Stuart Youngner, first published in the June issue of the Kennedy Institute of Ethics Journal and reprinted in the December issue of Harper's. They do not reach Father Quay's conclusions. But their anguished reflections on the fact that "the irresistible utilitarian appeal of organ transplantation has us hell-bent on increasing the donor pool" powerfully suggests that the intellectual foundations of "brain death" are--as Father Quay explains better than I--rotten.