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. 2002 Sep 14;325(7364):598. doi: 10.1136/bmj.325.7364.598/a

Brain death

Brain death is a recent invention

David W Evans 1
PMCID: PMC1124114  PMID: 12228146

Editor—Your explicit recognition that “brain death” is a recent invention for transplant purposes is most welcome and should do much to expose the fallacies and fudgings associated with this supposed new form of death, which have been hidden from public and professional view for far too long.1 As one of those described as campaigning tirelessly against the concept and the bad science underpinning its diagnosis, I am grateful for your journal's support. I query your statement, however, that most doctors in Britain are comfortable with the concept of brain death. Is that statement evidence based? Or is it more likely that most doctors have no need to think deeply about this matter—and choose not to do so?

The review to which you refer notes the cultural emphasis of Margaret Lock's study.2 More detailed consideration of the philosophical and scientific aspects will be found in the anthology by Potts et al, which was not available to Lock when she was writing.3 Since then, thanks to the excellent rapid response facility provided by bmj.com, the most significant development has been the wide dissemination of knowledge about the dangers of the apnoea test (which is a crucial element in the schedule of tests laid down by the Department of Health for the diagnosis of “brain stem death” or “death for transplant purposes”). Thanks, particularly, to the work of Coimbra, it is now clear that apnoea testing may exacerbate the brain damage and even prove lethal.4 That being so, and bearing in mind that the test can be of no possible therapeutic benefit to the patient so tested, its use is clearly unethical.

How long, therefore, now that this risk is generally known, can the Department of Health go on encouraging use of this damaging diagnostic procedure—which may have ensured the fulfilment of the allegedly invariably fatal prognosis attached to the diagnosis of “brain stem death” in at least some cases in the past?

References

  • 1. Editor's choice. Deep fears. BMJ 2002;324(7348). (8 June.)
  • 2.Gray C. “Twice dead: organ transplants and the reinvention of death” by Margaret Lock [reviewed] BMJ. 2002;324:1401. [Google Scholar]
  • 3.Potts M, Byrne PA, Nilges R, editors. Beyond brain death—the case against brain based criteria for human death. Dordrecht: Kluwer; 2000. [Google Scholar]
  • 4.Coimbra CG. Implications of ischemic penumbra for the diagnosis of brain death. Braz J Med Biol Res. 1999;32:1479–1487. doi: 10.1590/s0100-879x1999001200005. [DOI] [PubMed] [Google Scholar]
BMJ. 2002 Sep 14;325(7364):598.

Fear has basis in reason

Michael Potts 1

Editor—A deep seated fear may yet be rational. The fear of being declared dead while still alive, in the case of “brain dead” patients, is a fear with a basis in reason.1-1 If such patients are not dead, they certainly will be after unpaired vital organs are removed for transplantation. Rather than being “settled,” the acceptability of criteria for brain death is the subject of intense international debate.

As early as 1974, the philosopher Hans Jonas wrote in opposition to brain death criteria1-2; a lengthy article by Byrne et al followed nine years later (reprinted in an anthology by Potts et al1-3). More recently, the neurologist Alan Shewmon reversed his previous support for brain death criteria.1-4 In 2000, the anthology Beyond Brain Death was published, with contributors from the United States, the United Kingdom, Japan, and Liechtenstein.1-3

There are many reasons for this growing opposition. Shewmon's accounts of long term survivors of whole brain death empirically falsify the claim that whole brain death marks the end of a unified human organism.1-4 Even if Shewmon's claims are unfounded, a prognosis that brain death will lead to immanent somatic death (in the sense of the loss of a unified functioning organism) is not the same thing as a diagnosis that somatic death has occurred (Byrne et al1-3). Evans, among others, discusses the mounting evidence that brain activity persists in a number of patients declared brain dead.1-3 Coimbra identifies the dangers in a key test used to diagnose brain death, the apnoea test.1-5 Philosophers, such as Hans Jonas and Josef Seifert, have attacked the dualism of brain and body (Jonas' term) that is inherent in criteria for brain death.1-3,1-4

This debate should raise serious doubts concerning whether brain dead people are dead and lead to a rethinking of the entire enterprise of removing vital organs from such patients. A fundamental goal of medicine is to do no harm (non-maleficence). Any action that directly causes the death of a patient, even if it is for the good of others, opposes the goal of medicine not to harm that individual patient. Any attempt to downplay the importance of the brain death debate in the interests of organ transplantation is therefore fundamentally wrong. It is precisely whether transplantation kills the donor that is the key issue that cuts to the heart of the goals of medicine.

References

  • 1-1. Editor's choice. Deep fears. BMJ 2002;324(7348). (8 June.)
  • 1-2.Jonas H. Philosophical essays: from ancient creed to technological man. Englewood Cliffs, NJ: Prentice-Hall; 1974. Against the stream. [Google Scholar]
  • 1-3.Potts M, Byrne PA, Nilges RG, editors. Beyond brain death: the case against brain based criteria for human death. Dordrecht: Kluwer; 2000. [Google Scholar]
  • 1-4.Shewmon DA. “Brain stem death,” “brain death” and death: a critical reevaluation of the purported evidence. Issues Law Med. 1998;14:125–145. [PubMed] [Google Scholar]
  • 1-5.Coimbra CG. Implications of ischemic penumbra for the diagnosis of brain death. Braz J Med Bio Res. 1999;32:1479–1487. doi: 10.1590/s0100-879x1999001200005. [DOI] [PubMed] [Google Scholar]

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