Friday, October 3, 2008

Brain death 40 years on

My leading candidate for headline of the decade is "Are You Brain Dead? Depends on the Hospital." It is from a news article reporting on a study in Neurology (one of the few studies in the entire medical oeuve of 2008 that we have not blogged on). The study authors surveyed the "Top 50" neurology centers in the United States, as ranked by US News & World Reports, on their institutional guidelines for establishing brain death. Three of the 41 responding institutions do not have guidelines. Of the 38 that do, there was considerable variation in the criteria for determining brain death and more-than-expected variance from the guidelines established by the American Academy of Neurology in 1995 and reaffirmed as recently as 2007. It should be noted that 2008 is the 40th anniversary of the recommendation & criteria for using brain death in potential organ donor situations.

The reason I am bringing this up is that I ran across another headline, this time in the online version of the Times of London: "Vatican called on to re-open debate on brain death as end of life." It seems that, despite the Vatican having accepted the concept of brain death decades ago, there are those inside the Vatican who are now questioning the concept.

Joining the conversation is with "O death, when is thy sting?" The tab label on the web page asks provocatively, 'When, exactly, are you dead?' They point out that in the UK the emphasis is on loss of brainstem function, while in the US whole-brain function is evaluated. The fact that death is defined in varying ways is not new. In serious trauma, on the battlefield, and in expected deaths from advanced disease there is nothing obsolete about using the cessation of heartbeat and respirations as the determinant of deadness.

But variations in the definitions and use of "brain death" in an era of increasing demands for organ donation raise important ethical, legal, and practical questions. Last year Christian briefly blogged on organ donation after cardiac death. According to the article, cardiac-dead donors is the fastest growing proportion of donors. Somewhat odd terminology, but they point out that there were none 10 years ago and 7% in 2006. In August there was a Perspective article in NEJM discussing the 'dead donor rule' and its current applicability/appropriateness given current technology and the growing re-emphasis on cardiac death. The authors appear to be proponents of using cardiac criteria in potential donor situations, but also of calling a spade a spade. They point out that the heart that has arrested in one patient, when transplanted to another and induced to pump on its own, cannot be convincingly said to have been taken from a dead donor. I'm no ethicist, but I think that there are some legitimate "slippery slope" concerns in this conversation. There are plenty of nuances and competing good intentions that are a lot more than philosophical hair-splitting. These are literal matters of life and death that for many people will go beyond ethics and questions of social good, encompassing morality and, potentially, religious dogma.


Greer DM, Varelas PN, Haque S, Wijdicks EF. Variability of brain death determination guidelines in leading US neurologic institutions. Neurology. 2008 Jan 22;70(4):284-9.
Wijdicks EF. Determining brain death in adults. Neurology. 1995 May;45(5):1003-11.
Truog RD, Miller FG. The dead donor rule and organ transplantation. N Engl J Med. 2008 Aug 14;359(7):674-5.

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