Introduction
The diagnosis of death has been full of obscurities since historical times and a man employed many peculiar methods to confirm death. In modern times, this diagnosis has been made even more complex by advances in medical technology. Modern resuscitation and intensive care technology are responsible for the difficulty in defining death since patients with severe and permanent brain damage, who would previously have died from respiratory failure, can now be kept alive by mechanical ventilation (Dubois, 2010). While criteria for determining if one is brain dead have been formulated, there exist some doubts about these criteria which lead to a number of ethical issues on the subject. This paper will set out to discuss the ethical consequence of being declared brain dead. The paper will begin by offering a valid definition of brain death and then proceed to articulate the ethical issues surrounding brain death with a focus on organ donation and the role of family and physicians.
Brain Death: A definition
Many countries have adopted the United States concept of brain death as meaning whole-brain’ where a person loses all brain function. However, not all patients who are diagnosed as dead under whole brain death criteria have “irreversible cessation of all functions of the entire brain”. Miller and Robert (2008) therefore propose that brain death should not necessitate the literal loss of functions of the entire brain but rather, the “loss of those critical brain functions that maintain the integrity of the body as a living organism” (p.39). The UK has accepted a conceptual definition of brainstem death where death entails “the irreversible loss of those essential characteristics which are necessary to the existence of a living person” (Elliot, 2003, p.26). The irreversible damage to the brainstem is, therefore, a critical feature of brain death. Elliot (2003) documents that most cases of brain death are caused by head trauma or spontaneous intracranial hemorrhage. A patient can also progress from a coma into being brain dead. A coma is a state of the persistent state of unconsciousness through which the patient cannot be revived and does not respond to normal stimuli. The major difference between a coma and brain death is that while the coma patient can come out of the coma and regain awareness, the brain-dead patient has no chance of recovering.
Ethical Issues
Part of the ethical problem with brain death is that it first emerged as a result of socio-medico-legal issues. Shewmon (2009) notes that the rationale given for equating irreversible cessation of all brain functions to death by the Harvard Committee of 1968 which reformulated death in terms of brain function was that it would “free up beds in intensive care units and facilitate organ transplantation” (p.3). The Brain-dead category was therefore invented as a utilitarian solution and without any philosophical rationale.
Retrieving vital organs from brain-dead patients is one of the major ethical issues surrounding brain death. Vital organ transplantation requires a dead body and a living body which requires a new body organ. One of the important rules in the organ procurement system is the “dead donor rule” which implies that it is only permissible to retrieve vital organs from dead patients. This rule is based on the principle that it is “wrong to kill or cause the death of an innocent person so as to benefit or save the life of another person” (Truog, 2007, p.277). There is therefore an implicit assumption among medical professionals that vital organs should not be removed from patients who are still alive since this removal would become the cause of their death. The concept of brain death has been essential for organ transplantation to develop and flourish since it makes it possible for the removal of organs from a patient who still has a beating heart without violating the dead donor rule (Truog, 2007). This is because brain-dead patients are defined as dead (even while the heart is beating) before the removal of the vital organs. However, this equating of brain death to death is not unanimously held and some medical professionals argue that the brain death criterion is insufficient to be absolutely sure that “patients are incapable of experiencing pain” (Truog, 2007). As such, the brain death criterion has led to self-delusion by medical professionals who have to continually defend this concept.
Being declared brain dead has numerous psychological repercussions to the family members of the patient. Truog (2007) suggests that most family members do not believe that their brain-dead relations are “really” dead since most brain-dead patients appear physically healthy. This makes it hard for them to start the grieving process as would be the case if the patient was declared dead through the classical heartbeat criterion and their body lacked any signs of life. Informed consent of legal surrogates is necessary for organ procurement and medical research to be practiced on brain-dead individuals. The family members can therefore end up filling guilty if they do not grasp the concept of brain death since they will feel responsible for the “death” of the patient since they gave consent for the removal of vital organs or the removal of the mechanical ventilation that sustains life in the brain-dead patient.
Another ground for opposition to research with brain dead subjects is that it can lead to the indefinite storage of human parts; a prospect that is viewed by many as morally offensive since it is disrespectful both to the deceased ant their survivors (Pentz et al., 2003).
Tests may be required to confirm the brainstem death of a patient and after this, the patient can be declared legally dead. If organ donation is under consideration, the situation is discussed with the family with the core aim of ascertaining the patient’s wishes about donation. This creates an ethical issue especially if the discussion is held before the first set of tests for brainstem death has been completed. Elliot (2003) states that the family may in such a scenario assume that the testing is to be performed mainly with organ procurement in mind.
Truog (2007) notes that some individuals would prefer to donate the organs of a loved one who was severely brain-damaged and surviving through mechanical aid even if he/she was not yet declared brain dead. Some physicians also have this motivation and Truog (2007) reveals that some physicians are at times willing to declare brain death even when a patient does not meet the full criteria for brain death so as to begin the organ procurement process. Such actions would reduce the public trust in the organ procurement system since it could be argued that the physician killed the patient for their organs. This would not only offend the public but also damage trust in the transplantation system.
Summary and Personal Opinion
This paper had shown that a brain-dead person has zero chances of recovering his/her brain functions and requires mechanical ventilation to keep breathing. The ethical issue arises in determining whether the patient who has been declared as “brain dead” actually is dead and can therefore be treated as a breathing corpse. There are batteries of tests that can be used to confirm if a person is brain dead. In my opinion, the declaration of brain death must be unequivocal and independent so as to dispel any concern held by families of donors about their kin’s organs being harvested before the donor is dead. Using a neurologist not involved with either the research or the organ donation of the patient to establish the brain-based determination of death can help to ascertain the independence and validity of the declaration of brain death.
Another issue surrounding brain dead patients is the manner in which their bodies can be used to advance science. As has been noted in this paper, research on brain-dead subjects can decrease the level of public trust in both researchers and physicians. In my opinion, brain-dead bodies can be very valuable test subjects for new medicine and promising research. Their use should therefore be continued but with utmost care so as to ensure that the dignity of the body is upheld at all times.
Death is a distressing experience for the survivors of the patient and they are bound to suffer from grief. The doctors should therefore be very cautious when explaining the concept of brain death to the family and make sure that no false hope is given about the future health of the patient. It is unlikely that the family of the patient will ask for continued treatment once the person has been determined to be brain dead and without any likelihood of recovery. Grief counseling should therefore be offered to such families and their wishes on what should be done with the patient honored.
References
Dubois, J.M. (2010). The Ethics of Creating and Responding to Doubts about Death Criteria. Journal of Medicine and Philosophy, 35(1), 365–380.
Elliot, J.M. (2003). Brain death. Trauma, 5(1), 23-42.
Miller, F.G. & Robert, D. T. (2008). Rethinking the Ethics of Vital Organ Donations.Hastings Center Report, 38(6), 38- 46.
Pentz, R.D., Anne L. F., Renata, P., Christopher J.L. & Wadih, A. (2003). Revisiting Ethical Guidelines for Research with Terminal Wean and Brain Dead Participants. Hastings Center Report, 33(1), 20-26.
Shewmon, A.D. (2009). Brain Death: Can It Be Resuscitated? Issues in Law & Medicine, 25 (1), 3-14.
Truog, R.D. (2007). Brain Death – Too Flawed to Endure, Too Ingrained to Abandon. Journal of Law, Medicine & Ethics. 45(3), 273-281.