20

Robert E Hurley

Similar benefits couldaccrue from adult stem cell and induced pluripotential stem cell research. Recent advances in induced pluripotential stem cell research converting a patients bone marrow stem cells into his own heart cells are promising. This approach would not re uire immunosuppresslon with its adverse side effects.! "either #enotransplantallon nor adult stem cell solutions to donor organ shortages threaten moral integrity$ human dignity$ or civili%ed society.
Conclusion

The medical profession would be well advised to be more resistant to social$ corporate$ and

government pressures to abandon its timetested !first$ do no harm! principle$ which supports the human dignity of every person. &edicine needs to maintain vigilance against temptations to place societal goods ahead of patient goods$ resulting in the ultimate loss of both. 't is

empirically evident from past e#perience$ recent and remote$ that societal good cannot be preserved for long without respect for the sanctity of each human life. 'gnoring human dignity$ for whatever reason$ has to be recogni%ed as a dangerous course to ta(e$ even from a utilitarian perspective$ because it opens the way to tyranny and atrocity$ to which any society$ including our own$ can become inured. 'n closing$ two observations are relevant to contemporary medical ethics and cultural changes$ one by a literary artist and the other by a well-(nown twentieth-century physicist. )lannery *+,onnor has noted that tenderness$ cut off from the -erson of ,hrist$ is wrapped in theory. !.hen tenderness is detached from the source of tenderness$ its logical outcome is terror$ 't ends in forced labor camps and in the

fumes of the gas chamber.!! The second pertinent observation is from the author of the theory of relativity/ !-erfection of tools and confusion of goals are characteristics of our time.!
02 120023/004-56 Richard ". -ierson '''$ !,urrent Status of 7enotransplantation"8&8 400 1200 93/ 9:;. 20. 8lta <ehfar et at$ !=uided Stem ,ell ,ardiopolests/ >iscovery and Translation$+ journal of MolecWar and Cellular Cardiology 520000 22429. 22. )lannery *+,onnor$ !'ntroduction to A Memoir of May Ann," 'n Mystery and Manners: Occasional Prose 1"ew

?or(/ )arrar$ Straus @ =ram 09:93$ 22:-2;.

>. 8lan Shewmon 2 ,ontroversies

surrounding <rain >eath

Basic Medical Facts

<efore discussing some of the current philosophical and ethical controversies surrounding so-called brain death 0400$ let us begin with a basic overview of the medical phenomenon and 'ts pathogenesis. <'3 is best understood as the endpoint of a vicious cycle of brain swelling and decreased blood flow to the brain in response to some inAury 1such as trauma$ hemorrhage$ meningitis$ hypo#iaischemia from cardiac arrest$ and so on3. Bi(e any bodily tissue$ the brain swells when inAured. Cnli(e other organs and tissues$ however$ the brain is

encased in a hard shell$ the s(ull. 8s brain volume increases$ other intracranial components 1namely$ blood and cerebrospinal fluid3 must decrease by the same amount 'f the swelling e#ceeds the capacity of such compensatory changes$ the intracranial pressure will rise rapidly. This$ in turn$ ma(es it more difficult for arterial blood to enter the cranial cavity$ resulting in decreased blood flow to the brain$ further e#acerbating the 'nAury already present. The additional insult causes further swelling$ so that a vicious cycle is established$ the endpoint of which is no blood flow plus massive brain swelling that s uee%es
&any than(s to Steven Densen and the other organi%ers for the invitation to spea( at the important conference concerning organ transplantation$ at the Cniversity of St. Thomas$ Houston$ Te#as.

22 >. 8lan Shewmon

,ontroversies surrounding <rain >eath

neuropathological sense of the term. 'f this were all the term meant$ then a patient with a dead brain would be in an irreversible coma$ Aust as a patient with a dead liver would be in irreversible liver failure. *n the other hand$ Fbrain death! can also be understood as !death of the person by virtue of critical brain pathology.! The -resident+s ,ouncil on <ioethics$ in its recently published !white paper! on the determination of death$ has an e#cellent chapter on terminology$ in which the alternative term !total brain failure! is proposed6 this is a medically descriptive term without the philosophical overtones that burden the term !brain death.! &aybe the terminology will change as a result of the white paper. 'n the meantime !brain death! is so heavily ingrained in our vocabulary$ mine included$ that ' will continue to use it in this essay in the purely neuropathological sense. Brain Death History in a Nutshell ,onsider any radical socio-legal-medical change in a society$ such as a re-conceptuali%ation of death and the corresponding radical revision of the
0. 8rthur Earl .al(er$ !"europathological )indings 'n the <rains of -atients 8dmitted to the ,ollaborative Study$+ in The NE C!" Colla#orati$e "tudy of %rain !eath, ed& '&"&

the lower brainstem out through the bottom of the s(ull into the spinal canal 1brain herniation3. The lac( of blood flow results in total brain infarction$ and conse uently total and irreversible non-function. That is the theory$ anyway. 'n clinical reality$ the brain does not necessarily proceed through this vicious cycle in a homogeneous way$ but some parts may be$ more or less affected than others as the pathogenic spiral progresses. 8utopsy series of clinically diagnosed E> in fact show considerable heterogeneity throughout the brain in terms of degree and stage of evolution of ischemic damage and infarctionE This complicates matters considerably for those who maintain that clinically diagnosed <> reliably fulfills the statutory definition of !irreversible loss of function of the entire brainE 'n any case$ for purposes of this presentation$ ' shall limit consideration to the subset of cases with truly total brain infarction. 'f$ as ' intend to show$ these patients are not dead$ then a fortiori neither are the rest of the cases with only patchy brain infarction. !<rain death! is an unfortunate term because of its semantic ambiguity. *n the one band it can be understood as !death of the brain! 1Aust as any organ can die from lac( of blood flow3. This is a strictly

statutory definition of death. The ideal se uence of events should be as follows. 103 The new concept is introduced$ studied$ and widely agreed upon. 123 Then the concept is applied to biology and medicine 1specifying the general criterion for it3. 143 Then the medical profession establishes reliable diagnostic standards for it 1tests$ algorithms3. 153 Then statutory laws are revised accordingly. 123 )inally$ the new concept is put into practice. .hat has actually happened in the history of <>$ however$ is e#actly the opposite. 103 'n 09:; the practice of unpaired vital organ transplantation began$ with the first heart transplant by ,hristiaan <arnard and the first liver transplant by Thomas Star%l. 2 123 Then$ stimulated by the Harvard committee report of 09:G$4 there was a revision of statutory laws$ beginning in 09;0 in Hansas. >riven by the need to legally Austify the already widespread practice of transplantation$ state after state and country after country revised their statutory definitions of death over the ne#t two decadesE$ 143 'n the meantime$ as laws were being revised$ the medical profession scrambled to come up with diagnostic standards for the newly defined condition. 'n the Cnited States$ the first consensus standard came out in 09G0 with the -resident+s ,ommission reportE The ne#t significant update occurred in 0992 with the 8merican 8cademy of "eurology+s !-ractice -arameters.!: 153 8ll the while$ there was$ and still is$ an incoherent connection between the standard diagnostic algorithms and the biologicallmedical condition which they purportedly diagnose so reliably. 123 )inally$ there was$ and still is$ no general agreement about why total brain destruction 1or !total brain failure!3 should constitute death itself. Thus$ the history of brain death shows how much the practice !cart! has
>epartment of Health and Human Services 1<ethesda$ &d./ C.S. >epartment of Health and Human Services$ 09G03$ 44-;:. Ee(o -. .'ld'c(s and E. 8.frfelfer$ !"europathology of <rain >eath in the &odern Transplant Era$+ Neurology ;0 1200G3/ 0245-4;. 2. adatiaan N& <arnard$ !The *peration. 8 Human ,ardiac Transplant/ 8n 'nterim Report of a Successful *peration -erformed at =roote Schuur Hospital$ ,ape Town$! "outh African Medical (ournal 50 109:;3/ 00;0-;5. Thomas E. StarrI et at$ !*rthotopic Homotransplantation of the Human Biver$! Annals of "urgeryl#) 109:G3i 492-502. 4. Henry H. <eecher et al. !8 >efinition of irreversible ,oma$+ f8&8 202 109:G3/ 44;-50. 5. -resident+s ,ommission for the Study of Ethical -roblems 'n &edicine and <iomedical and <ehavioral Research$ !efining !eath: Medical, *egal, and Ethical ssues in the !etermination of !eath 1.ashington$ >.,./ C.S. =overnment

-rinting *ffice$ 09G0$ appendices , and E$ 009-45$052-2G. S. 'bid.$ appendi# )$ 029-::. :. 8merican 8cademy of "eurologyJKuality Standards Subcommittee$ !-ractice -arameters for >etermining <rain >eath 'n 8dults 1Summary Statement3$! Neurology 52 109923/ 0002-55.

25 >. 8lan Shewmon ,ontroversies surrounding <rain >eath been pulling the conceptual !horse$! rather than the other way around. Boo(ing bac( over the forty-year history of this topic$ we see that <> began as a utilitarian creation and still remains a conclusion in search of a Austification. Four Main Categories of the Concept of Death The various proposed Austifications for e uating <> with death can be grouped into four main categories. *ne is !loss of conferred membership in human society$! This is a sociological$ society-specific concept of death. The 09:G Harvard committee implicitly endorsed this rationale.E Some advocates of so-called higher-brain death appeal to this rationale$ as do some advocates of !whole-brain death! 1the patients are !as good as dead$! so might as well be treated as dead3. The second main category is !loss of essential human properties or personbood.! This is a psychological$ species-specific definition of death$ which 's held by most !higher-brain death! or aneocortical death! advocatesI 't 's also the implicit rationale of many who endorse !whole-brain death.!E The third main category is !loss of somatic integrative unity! or !cessation of the organism as a whole.! This is a biological$ speciesnonspecific concept$ which has been endorsed by mainstream defenders of !whole;. Henry H. <eecher$ +8fter the +>efinition of 'rreversible ,oma$+! Ne+ England (ournal of Medicine 2G0109:93/ 00;0-;0. Henry H. <eecher and Henry 0. >ort$ !The "ew >efinition of >eath. Some *pposing Liews$! nternational (ournal of Clinical Pharmacology 2 109;03/ 020a <. Dohn -. li%%a. Persons& ,umanity, and the !efinition of !eath 1<altimore/ Dohns Hop(ins Cniversity -ress$ 200:36 Robert &. .atch$ !The .hole-<raln*riented ,oncept of >eath/ 8n *utmoded -hilosophical )ormulation$! (ournal of Thanatology 4 109;23/ 04-406 Stuart D. &angum/ and Edward T. <artlett$ !Human >eath and High Technology/ The )ailure of the .hole-<rain )ormulations$! Annals of nternal Medicine 99 109G43/ 222-2G6 Richard 8B >iner$ ed.$ !eath: %eyond Whole-%rain Criteria, -hilosophy and &edicine Series 40 1<oston/ Hluwer$ 09GG3. 9. 8ri R. Doffe and ". 8nton$ !<olin >eath/ Cnderstanding of the ,onceptual <asis by -ediatric 'ntensiv'sts in ,anada$! Archi$es of Pediatrics and Adolescent Medicine 0:0 1200:3/ ;5;-226 8d R. Doffe$ ". 8nton$ and L. &ehra$ !8 Survey to >etermine the Cnderstanding of the ,onceptual <asis and >iagnostic Tests Csed for <rain >eath by "eurosur-

geons 'n ,anada$! Neurosurgery :01200;3/ 0049-52$ discussion 5:-5;6 Stuart D. ?oungner et al.$ !-sychosocial and Ethical 'mplications of *rgan Retrieval$! Ne+ England (ournal of Medicine 404 109G23/ 420-256 Stuart D. ?oungner at aB$ !+<rain >eath+ and *rgan RetrievaB 8 ,ross-Sectional Survey of Hnowledge and ,oncepts among Health )rofessionals.!M8&8 2:0109G93/ 2202-00.

brain death$! such as the 09G0 -resident+s ,ommission$ <ernet and colleagues$! the Swedish ,ommittee on >efining >eath$! and the -ontifical 8cademy of Sciences$02 as well as by apologists for the <ritish notion of !brainstem death$!00 't was the concept of death articulated by the late -ope Dohn -aul 00 in his address to the Transplantation Society$ and ' daresay it is the concept of death most compatible with a traditional Dudeo-,hristian woridview.! This is the concept of death that '$ and presumably most of you$ also hold. 'n what follows ' will argue that total brain destruction does not instantiate this concept. 8 fourth category has Aust recently been proposed by the -resident+s ,ouncil on <ioethics in its white paper$ namely$ !loss of the selfpreserving vital wor( of an organism$! that 's$ the need-driven e#change of substances 1!commerce!3 with the environment necessary for survival.! Time will tell how widely this novel rationale will be accepted. ' find many problems with it$ as detailed in a recently published commentary.! Not a Settled issue 8s mentioned above$ <> is far from a settled issue. *ver the years ' have conducted informal Socratic discussions with colleagues$ and it is rare to come across one who can articulate a coherent defense of the mainstream 00. Dames B. <ernet$ ,harles &. ,ulver$ and <ernard =en$ !*n the >efinition and ,rite$ don of >eath$! Annals of nternal Medicine 95 109G03/ 4G9-95. 00. Swedish ,ommittee on >efining >eath$ The Conce.t of !eath& "ummary 1Stoc(holm/ Swedish &inistry of Health and Social 8ffairs$ 09G53. C. ,. ,hagas$ ed.$ Wor/ing 0rou. on the Artificial Prolongation of *W and the !etermination of the E1act Moment of !eath& Octo#er 23-42,23)5, Scripta Larla :0 1Latican ,ity/ -ontifical 8cademy of Sciences$ 09G:36 Robert D. .hite$ Hein% 8ngstwurm$ and 'gnacio ,. ,arrasco de -aula$ eds.$ Wor/ing 0rou. on the !etermination of %rain !eath and ts 6elationshi. to ,uman !eath& 27-28 !ecem#er, 23)3, Scripta varta G4 1Latican ,ity/ -ontifical 8cademy of Sciences$ 099236 &. Sanche% Sorondo$ ed.$ The "igns of !eath& The Proceedings of the Wor/ing 0rou. -24 "e.tem#er 4779& Scripta Laria 000 1Latican ,ity/ -ontifical 8cademy of Sciences$ 200;3. 04. ,hristopher -ains and >. H. Harley$ A%C of %minstem !eath, 2nd ed. 1Bondon6 <&D -ublishing =roup$ 099:3. 05. Dohn -aul 'B 8ddress of 8ugust 29$2000 to the 0Gth 'nternational ,ongress of the Transplantation Society$ http/MMwynv.vaticatvad%olylatherhohnNpaulAifs-eechesf20 00M 'ulsepfdocumentsMhfAp-'lNspeN20000G29NtransplantsNen.html. 02. -resident+s ,ouncil on <loethics$ Contro$ersies in the !etermination of !eath 1.ashington$ >.,./ -resident+s ,ouncil on <ioethics$ 200G3$ available at

http/fMwww.bioethics .govMreportsideath8nde%.hind. 0:. >. 8lan Shewmon$ F<rain >eath/ ,an 't <e ResuscitatedE! ,astings Center 6e.ort 49 120093/0G-256 reprinted in ssues n *m$ Medicine 22 120093/405.

2: >. 8lan Shewmon ,ontroversies surrounding <rain >eath 1integrative unity3 rationale for why total brain destruction 1or irreversible non-function3 should be death. Csually some logical inconsistency emerges 1that is$ a statement implying that they actually thin( a<> patient is not really dead$ but rather !as good as dead! or !might as well be dead!3. Those who are logically coherent almost always endorse the psychological rationale$ that is$ even though there may still be a living human organism$ it is no longer a human person. )ormal surveys of health-care profession/ als$ including those intimately involved in transplantation$ document that some 40 to 20 percent of respondents have an incoherent or anomalous un- derstanding of <>.%% These findings are disturbing enough$ but they were based on codified answers to a few basic uestions. ' suspect that one-on-one$ in-depth Socratic probing would uncover an even higher incidence of conceptual incoherence. *n the international scene$ the touted widespread consensus is also superficial. Dapan+s <> law is relatively recent compared to those in other developed countries. )or the first few years it was incoherent/ if a <> patient is going to become an organ donor$ then he+s legally dead$ but if he+s not going to become an organ donor$ then he+s legally still alive. Recently$ however$ Dapan passed a revised$ more coherent statute defining death neurologically in general$ not Aust in the conte#t of transplantation-00 =erman law permits the e#traction of organs from brain-dead patients$ but the law does not e#plicitly define brain death as death6 it is implied$ but they Aust couldn+t uite bring themselves to declare it. The >anish ,ouncil of Ethics issued a series of statements reiterating its conviction that <> is not death and that organ transplantation needs to be Austified some other wayE+ There has been increasing publication of criti ues of neurological determinations of death. Significantly$ the medical establishment 1that is$ rel22& Ari 6& Doffe and ". 8nton$ !<rain >eath!6 & R. Doffe$ ". 8nton$ and L. &ehta$ !8 Survey!6 Stuart A. ?ottngner et al.$ !-sychosocial and Ethical 'mplications+/ Stuart '. ?oungster et at$ !8 ,ross-Sectional Survey.+ 0G. Special Report/ "o.0/ <rain >eath and Transplantation 'n Aapan Milo:gyring .lifestadies.orgispecialreport*thtml 1accessed "ovember 9$ 20003. 0G. >anish ,ouncil of Ethics$ !>eath ,riteria. )irst 8nnual Report$ 09GG+ 1>enmar(/ The >anish ,ouncil of Ethics$ 09G936 >anish ,ouncil of Ethics$ !4rd ?ear of the >anish

,ouncil of Ethics/ 8nnual Report for 0990! 1>enmar(/ The >anish ,ouncil of Ethics$ 099036 <o 8ndreassen Ri#$ !>anish Ethics ,ouncil ReAects <rain >eath as the ,riterion of >eath$! (ournal of Medical Ethics 0: 109903/ 2-;6 <o 8ndreassen Ri#$ !<rain >eath$ Ethics$ and -olitics in >enmar($! 'n The !efinition of !eath: Contem.orary Contro$ersies&, ed. Stuart D. ?oungner$ Robert &. 8rnold$ and Ren( Schapiro 1<altimore/ Aohns Hop(ins Cniversity -ress$ 09993$ 22;-4G.

evant professional associations li(e the 8merican 8cademy of "eurology$ the 8merican &edical 8ssociation$ and so on3 has ignored the conceptual criti ues and focused only on how to diagnose global brain infarction. There has been a reAection of the mainstream rationale by an increasing number of high-profile e#perts$ particularly advocates of !higher-brain death$! but also people Aumping ship from the biological rationale to the psychological !personhood! rationale. There are also some very interesting )reudian slips by people who$cestainly (now what they+re tal(ing about. *ne article from American Medical Ne+s was entitled !<rain->ead .oman *rdered Hept 8live.!%o 8 more recent article from Neurology Today features an interview with 8llan Hopper$ a well-(nown e#pert in intensive care neurology$ who has published a great deal about brain death. 't states/ !>r. Hopper added that it has been suggested that children who are brain dead can be (ept alive by artificial means for a long period of time.!20 &aybe that was a medical reporter putting words into his mouth$ but here are some of his own words in a recent te#tboo(/ !'n e#ceptional cases Oof <>P$ however$ the provision of ade uate fluid$ vasopressor$ and respiratory support allows preservation of the somatic organism in a comatose state for longer periods.!22 He e#plicitly asserts that such a <> patient is an !organism$! and a living organism at that$ because corpses cannot be described as !comatose.! The following uotation is from a te#tboo( by a neurosurgeon/ !+'ranscranial >oppler findings were obtained in 02 patients who fulfilled the clinical criteria for brain death.... 8ll of the patients died within 25 hours or upon discontinuation of the mechanical ventilation.!4 8n even mote significant e#ample is from a chapter written by )red -lum$ one of the maAor figures in 8merican neurology$ who has written e#tensively about coma and brain deathEQ 'n a table of cases of !prolonged visceral survival after brain death$! there is a column with the heading
205 Everson$ !<rain->ead .oman *rdered Hept 8live. Second Recent ,ase to Save )etus$! American Medical Ne+s, 8ugust 02. 09G:$ 05-02. 20. 8lice =oodman$ !<rain >eath/ 8greement on the ,oncept but "ot the >etermination -rocedures$! Neurology Today 2 120023/0$ :$ ;. 22. 8llan H. Rapper and Robert ''. <rown$ Adams and :ictor;s Princi.les of Neurology, Gth ed. 1"ew ?or(/ &c=raw-Hill$ 20;23$ 9:2. 24. 8lbrecht Harden$ Neurosurgical A..lications of ifrWISCIVITIGi !o..ler "onogra.hy 1"ew ?or(/ Springer-Ledag$ 09G:3$ 002. 25. )red -lum$ !,linical Standards and Technological ,onfirmatory Tests in

>iagnosing <rain >eath$! in ?oungner et al.$ eds.$ The !efinition of !eath: Contem.orary Contro$ersies, 4G.

2G >. 8lan Shewmon ,ontroversies surrounding <rain >eath !&ode of >eath.! The listed modes of death include !spontaneous cardiac arrest! and !respirator discontinued$! so obviously -lum did not consider these patients already dead by virtue of their brain being destroyed. 8t the Third 'nternational Symposium on ,oma and >eath$ in Havana in 2000$ during the uestion-and-answer period after my (eynote address$ -lum publicly e#pressed words to the effect$ !8ll right$ '+ll grant you that they are living human organisms$ but are they human .ersons<" 8nother famous neurologist who has written e#tensively on brain death is the late Ron ,ranford. 'n an article about vegetative state$ be wrote something in passing about brain death that is uite significant/ !'t seems$ then$ that permanently unconscious patients have characteristics of both the living and the dead. 't would be tempting to call them dead and then retrospectively ripply the principles of death$ as society has done with brain death.!22
My Conceptual Itinerary

2;. >. 8lan Shewmon$ =regory B. Holmes$ and -aul 8. <yrne$ !,onsciousness in ,ongenitally >ecorticate ,hildren/ >evelopmental Legetative State as Self)ulfilling -rophecy,"!e$elo.mental Medicine and Child Neurology 50109993/ 4:5;5. 22. >. 8lan Shewmon$ !+<rain >eath+/ 8 Lalid Theme with 'nvalid Lariations$ <lurred by Semantic 8mbiguity$+ in .hite et al.$ eds.. Wor/ing 0rou. on the !etermination of %rain !eath and ts 6elationshi. to ,uman !eath& 27-28 !ecem#er, 23)3, 4=-52&

&y own conceptual itinerary is uite circuitous. 8t one time or another ' have held each of the main positions on <>$ so ' understand all of them uite well. )rom 09G0 to +G9$ ' endorsed the notion of !neocortical death! and published to that effect 2: This view had to be abandoned when ' came across some hydranencephalic children 1with virtually no cerebral corte#3$ who in principle ought to have been in a vegetative state but were clearly conscious.22 So ' adopted a variation on the theme of !whole-brain death$! which ' presented at the -ontifical 8cademy of Sciences in 09G9.25 Then in 0992 0 was consulted on the case of a thirteen-year-old boy$ who had Aumped onto the hood of a slowly moving car$ fallen off$ hit his head against the pavement$ and within four days was <>$ based on serial neurological e#ams and an apnea test. His parents could not accept that this 22. Ronald <. ,ranford and >avid R. Smith$ !,onsciousness/ The &ost ,ritical &oral 1,onstitutional3 Standard for Human -ersonhood$+ American (ournal of *a+ and Medicine 04 109G;3/ 244-5G. 2:. >. &an Shewmon$ +The &etaphysics of <rain >eath$ -ersistent Legetative State$ and >ementia$+ The <Monist 59109G23/ 25-G0.

was death6 they refused organ donation and insisted that intensive care be continued. Since the medical profession at that time !(new for a fact! that with <> cardiac arrest supervenes imminently despite all therapeutic interventions$ the boy+s physicians thought$ !*(ay$ we+ll go along with the parents for a few days6 nature will ta(e its inevitable course and eliminate the need for an ugly confrontation with them.! The parents were deeply religious and insisted on doing what they considered =od+s will. <ut the physicians argued that continued treatment was interfering with =od+s will. .hen it became clear that nature was not +ta(ing its inevitable course$! the theological impasse was finally bro(en by an agreement between physicians and parents to determine =od+s will by withdrawing all support for forty-eight hours e#cept for the ventilator and basic fluids. .hatever the outcome was would be accepted by all as an indication of =od+s will. The doctors were sure the boy would succumb and thought this would be an acceptable way to bring the dispute with parents to closure To their astonishment$ he survived6 now they were in the aw(ward position of having to follow through on their end of the agreement. 8fter another few wee(s they were actually able to find a s(illed nursing facility that accepted transfer of the boy$ despite the official diagnosis of !brain death.! *f course in the state of ,alifornia he was legally dead$ and the personnel at the nursing facility were understandably very confused by the transfer. They had never before received a legal corpse as a patient. This is the reason why ' was consulted. ' reviewed all the records$ e#amined the boy$ and concurred with the diagnosis. 8ma%ingly$ while in the state of <> he began pubertal changes$ with new appearance of early pubic hair. )inally$ after a total of si#ty-three days he succumbed to an untreated infection. This case flew in the face of everything ' had been taught regarding the universality and imminence of somatic demise in brain death. 't forced me to rethin( the whole thing from a fresh perspective$ !outside the bo#! of prevailing concepts. 8round the same time$ the coup de grace struc(/ a physiological comparison with high spinal cord transection$ to be discussed momentarily. The combined clinical e#perience and conceptual insight forced me to reAect a neurological criterion for death altogether. Since 0992 ' have been convinced that human death is not purely neurologicaB Several developments since then have served to reinforce that conviction. ' collected and published a series of cases of prolonged

surviv-

40 >. 8lan Shewmon ,ontroversies surrounding <rain >eath 24 al in the state of 0404. &any of these patients showed evidence of somatic integration and holistic properties. 8lso$ various disconnects between mainstream concepts$ criteria$ and tests for death have become increasingly glaring over the past two decades. The most recent stage in my conceptual itinerary involves insights from linguistics. &y wife is a linguist$ and our professional collaboration produced a couple of publications on the linguistics of death/ specifically$ how the language that we grow up in may influence our conceptual framewor(s$ including death concepts.20 ' will not address these issues in this paper. Bet me now e#plain the spinal cord analogy. .hat occurred to me 'n 0992 was the following. 'f the body needs brain-based integration to be a unified organism$ the somatic effect of loss of that integration should be the same$ regardless whether the loss results from brain destruction or brain disconnection6 either way$ there is no longer any brain-based somatic 'ntegration. ' therefore went to the literature on high spinal cord inAury to see whether the clinical realities of that condition would corroborate this theoretical prediction. ' was ama%ed to discover how closely the somatic pathophysiology of high spinal cord inAury resembles that of brain deathJso much so$ that one could ta(e a chapter on the ',C management of high spinal cord inAury and a chapter on the ',C maintenance of <> organ donors$ interchange the words Fspinal cord inAury! and !brain death.! and the chapters would be virtually identical. The two groups of patients have the same (ind of somatic instabilities$ complications$ and therapeutic re uirements. There are two small flaws in the analogy that are easily fi#ed. )or one$ there is no vagus nerve function in <>$ whereas there normally is in high spinal cord inAury. To tighten the analogy$ we could limit the spinal cord cases to that subset without vagus function 1for e#ample$ sometimes the vagus is pharmacologically suppressed to treat e#cessively slow heartbeat3. 8nother difference between the two conditions is that many <> patients have diabetes insipidus 1e#cess production of dilute urine$ resulting from hypothalamic and posterior pituitary failure3$ whereas spinal inAury victims do not. *n the other hand$ we could limit the comparison to that

29. >. 8lan Sherman$ !,hronic +<rain >eath+/ &eta-8nalysis and ,onceptual ,onse uences$! Neurology 20 1099G3/ 024G-52. 40. >. 8lan Shewmon and Elisabeth Seit% Shewmon$ +The Semiotics of >eath and 'ts &edical 'mplication$! in %rain !eath and !isorders of Consciousness, ed. ,ali#to &achado and >. 8lan Showman 1"ew Tre(/ Hluwer 8cademicM-lenum -ublishers$ 20053$ G9-0056 >. 8lan Shewmon$ +The >ead >onor Ende/ Bessons from Binguistics$! >ennedy nstitute of Ethics (ournal 28 120053/ 2;;-400.

subset of <> cases without diabetes insipidus$ or we could imagine that the spinal inAury victim happened to be an endocrinology patient under chronic treatment for diabetes insipidus. .ith these two twists$ the somatic physiological comparison becomes e#act.40 The comparison forces us to conclude that$ if brain death is death on the basis of loss of integration of the organism as a whole$ then patients with high spinal cord transection cannot be living organisms as a whole either. The only significant difference between the two conditions is the preservation or absence of consciousness. The standard rationale for brain death would have us say that the spinal cord victim is a conscious non-organism$ which doesn+t ma(e a whole lot of sense. ,onvertely$ if we accept that the spinal cord patient is a living organism$ then a <> patient must he regarded as an e ually living organism$ albeit an irreversibly comatose one. .hether that is death or not depends entirely on one+s philosophy of personhood$ not on any biomedical aspects. &oreover$ if E> is death on that basis$ then so are all other forms of permanent unconsciousness.

>eath+ with >eath$+ (ournal of Medicine and Philoso.hy 2: 120003/ 52;-;G.

Three Extraordinary Cases

8s though the case of the thirteen-year-old boy above were not instructive enough$ '+ll now present three even more e#traordinary cases. Two are from my published series.42 The third is from Dapan6 ' had the opportunity to e#amine the patient personally in 2002 and have subse uently (ept in touch with his family and doctor there. ,ase 0 The first case is the world-record survivor in the state of <>$ identified in earlier publications as !T',!44 He was a previously normal boy$ who at age 40. >. 8lan Shewmon$ !Spinal Shoc( and +<rain >eath+/ Somatic -athophyslologlcal E uivalence and 'mplications for the 'ntegrative-Cnity Rationale$! ".inal Cord 4; 109993/ 404-256 >. 8lan Shewmcm$ !The +,ritical *rgan+ for the *rganism as a .hole/ Bessons from the Bowly Spinal ,ord$! in &achado and Shewmon$ eds.$ %rain !eath and !isorders of Consciousness, 24-50. 42. Shewmon$ !,hronic +<rain >eath.+! 44. Shewmon$ !,hronic +<rain >eath+!6 >. 8lan Shewmon$ !+<rainstem >eath/ +<rain >eath+ and >eath/ 8 ,ritical Re-evaluation of the -urported E uivalence$! ssues in *a+ &edicine 05 1099G3/ 022-526 >. 8lan Shewmon$ +The <rain and Somatic 'ntegration/ 'nsights into the Standard <iological Rationale for E uating +<rain

42 >. 8lan Shewmon ,ontroversies surrounding <rain >eath four and a half contracted Haemophilus influen%ae meningitis. He had such a rapid downhill course that by the second hospital day he had lost all brain function and was ventilator-dependent. 8 neurology consultant opined that he was clinically dead. 8 formal apnea test was not done$ because the case occurred prior to the e#istence of diagnostic standards for pediatric brain death 1the standard at the time was that of the 09G0 -resident+s ,ommission$ which specifically cautioned against applying its diagnostic criteria to children under age fiveJand he was Aust under that cutoff3.! )or this reason nobody gave him a formal diagnosis of E>$ even though they all considered the diagnosis to be dear. 1"either was he given that diagnosis after turning five$ because according to the common wisdom of the time$ <> patients universally succumb to cardiac arrest within a few days6 therefore$ his physicians concluded that he couldn+t possibly be <>.3 ' want to dwell briefly on the evidence for <> in this case$ because one of the criticisms of my wor( has been that such cases are misdiagnoses$! and ' want to assure you that there was superabundant evidence of the correctness of diagnosis here. )or the rest of TH+s life he e#hibited no cranial nerve refle#es and no spontaneous respirations$ including off of the ventilator for up to two minutes for purposes of changing his tracheostomy. *n day 2 there was sudden onset of both profound hypothermia and diabetes insipidus. <oth of these are fre uent clinical concomitants of brain death$ and there was no other e#planation for those symptoms that day.! He had four electroencephalograms 1EE=s3/ on what ' call !brain death day! 0 1that is$ the day of onset of <>3$ again on day 0$ and again on days G50 and 5$202. 8ll four EE=s were flat at ma#imal sensitivity. 8 computed tomography 1,T3 scan on day 9 showed e#tensive subarachnoid hemorrhage and severe cerebral edema with obliteration of the ventricles and basal cisterns. The intracranial pressure was so high that the already fused bones of his s(ull actually split apart. &ultiple independent neurology consultations reconfirmed the lac( of brain function$ including my own e#amination on day 5$9:9$ which ' videotaped with his mother+s permission. 8 few months later$ thirteen and a half years into the state of <>$ an &R' scan showed an incredibly thic(ened s(ull containing no iden-

8nalysis and ,onceptual ,onse uences! OletterP$ Neurology 24 109993/ 04:9-;0. 45. <eim E .itilicics et al.$ !-ronouncing <rain >eath/ ,ontemporary -ractice and Safety of the 8pnea Test$! Neurology 71(2008): 0250-55.

45. -resident+s ,ommission$ 0::. 42. -i(F -. &. .ddic(s and lames B. <ernet$ !,hronic +<rain >eath+/ &ete-

tifiable brain structure$ Aust a collection of disorgani%ed fluids$ membranes$ and calcifications. 8n &R anglogram showed no intracranial blood flow$ and multi-modality evo(ed potentials 1auditory$ visual$ and somatosensoR ry3 showed no function above the spinal cord. )inally$ if anyone still doubted the diagnosis$ TH passed away a few years ago$ and a brain-only autopsy was performed$ which revealed the outer aspect of the brain to be totally calcified6 inside was a brownish$ gritty material with much calcification.! &icroscopic evaluation of representative sections revealed no neurons$ So there is no uestion that this child was <>. lie was transferred from the ',C to a regular pediatric ward on <> day 205. 8fter seven and a half years in this condition he was finally discharged to a rehab facility and then to home. Subse uently he had seven brief hospitali%ations$ totaling si#ty-five days. T', finally e#pired after twenty and a half years in the state of <>. Thirty-eight percent of that time was spent in the hospital$ 22 percent at home$ and 00 percent in a rehab or s(illed nursing facility. Tles body demonstrated a number of holistic properties. )irst of all$ there was spontaneous homeostasis$ fluid and electrolyte balanre$ energy balance$ and so on$ without fre uent monitoring of blood tests and corresponding adAustments of food and fluids. He was simply given gastrostomy-tube feedings and hydration day after day$ and his body maintained its own homeostasis. *f course all <> patients tend to have subnormal temperatures$ but with a few e#tra blan(ets TH maintained his temperature Aust fine. *ver the years he grew proportionally$ not in a disorgani%ed fashion li(e a cancer. He e#hibited teleological wound healing after surgical procedures or minor abrasions. He recovered from infections. Regarding cardiovascular and autonomic regulation$ TH$ li(e most <> patients$ was very unstable in the beginning. He initially re uired pressor medications but soon maintained a stable blood pressure on his own. He could tolerate a sitting position$ indicating some degree of autonomic control of blood pressure 1that is$ his blood pressure didn+t plummet from blood pooling in his legs upon sitting3. There was a coordinated response to physiological stress$ in terms of blood pressure$ heart rate$ and capillary s(in changes. He had a febrile response to infections. 8nd$ very importantly$ he recovered from a variety of medical crises$ including congestive heart failure$ hypotensive shoc($ and various serious infections 1for

45. Susan Repertinger at al.$ !Bong Survival following <acterial &eningitis8ssociated <rain >estruction$!&untal of Child Neurology 20 1200:3/290-92.

45 >. 8lan Shewmon ,ontroversies surrounding <rain >eath e#ample$ pneumonias$ urinary tract infections$ and sinusitis3 with the help of standard antibiotics. ' consider many of the above properties to be holistic$ because they are attributable not to any one organ or organ system but to the organism as a whole. ,ase 2 8nother ama%ing case was a girl with a malignant brain tumor diagnosed at age twelve$ which progressed relentlessly despite surgery$ radiation$ and chemotherapy. 8t age fifteen she became moribund and was hospitali%ed. She was found to be apneic$ re uiring mechanical ventilation$ and had almost no brain function. Some physicians thought she might be <>$ so they did an apnea test$ which confirmed lac( of respiratory drive. "evertheless$ she could not be declared <> because of a right corneal refle# and a wea( cough to tracheal suctioning6 these were the only brain-stem functions she had. Since her parents adamantly refused to discontinue support$ the girl was discharged bac( home on the ventilator. .hile at home she probably became <03 on what '+m calling <> day !minus 2G! 1that is$ twenty-eight days before her official diagnosis upon readmission3. Suddenly that day her temperature$ heart rate$ and blood pressure all simultaneously plummeted. "o one (nows for sure whether her residual corneal and cough refle#es disappeared then as well6 most li(ely they did. 8 crisis due to obstruction of the ventilator tubing occasioned a trip to the emergency room and readmission$ whereupon she was formally diagnosed as <>. )or the sa(e of conservatism$ ' count this as <> day 0. She had no brainstem refle#es$ a repeat apnea test again showed no respiratory drive$ an EE= was flat at ma#imal sensitivity$ and there was no intracranial blood flow on radionuclide scan. Her parents could not accept that she was dead and insisted that she continue to be given full support. Rather than engage in a hostile confrontation and legal battle$ the physicians discharged her bac( home on the ventilator$ sure that she would very soon succumb anyway. She surprised everyone$ however$ by stabili%ing off pressor medications and continuing at home in this condition for over a year. *n day 402 a neurosurgeon reconfirmed <> 1although he did not repeat the

apnea test3$ and an EE= was again flat. 8 ,T scan of the head showed total disintegration of the brain. There were residual islands of some (ind of tissue under the s(ull$ e#tensive calcifications$ and an epi

ducal residual of her malignant tumor$ which had grown through a surgical s(ull defect into an e#crescence on her forehead. She e#pired on day 500 of official <>$ which was probably 54G days into actual <>6 9G percent of that time she was at home and only 2 percent in the hospital. Bi(e T',$ this girl e#hibited many holistic properties while <>/ homeostasis$ temperature maintenance$ teleological wound healing$ cardiovascular and autonomic regulation. She had a relative paucity of complications$ including one pneumonia$ which resolved at home with enteral antibiotics. *f great interest is a comparison of the disorgani%ed growth of the residual tumor with the teleologically ordered multiplication and turnover of her own cells throughout her body. ,ase 4 The third case is a Dapanese boy who became <> at age thirteen months from a necroti%ing encephalopathy of presumed viral etiology. 8t the time this paper was first presented$ he had been brain dead for seven and a half years$ G0 percent of which was in the hospital and 20 percent at home. Three EE=s 1on <> days 0$ 29:$ and 0$:0:3 were all isoelectric. )our brainstem auditory evo(ed responses 1days 404$ :2G$ 920$ and 2$44:3 showed no response. Radionuclide and single-photonemission-computed-tomography scans on day 2$0:; both showed no intmcranial blood flow. He has had a total of five ,T scans and four &R' scans$ which revealed progressive disintegration of the brain to disorgani%ed fluids and membranes without identifiable internal structures. Bi(e the other cases$ he demonstrates homeostasis$ temperature maintenance$ teleological wound healing$ cardiovascular autonomic regulation$ and recovery from various medical crises. 8nd$ li(e T?$ he has undergone proportional growth. 'f any biologist$ not primed about possible relevance to the <> debate$ were as(ed to e#amine this boy and tell us whether he is a living organism or not$ the biologist would surely conclude$ !*f course this is a living organism6 it is a comatose$ apneic$ living organism.!
Further Considerations

accepted as reliable in some of the e#traordinary cases in my series$ because an apnea test was not performed 1for e#ample$ +'R and the Dapanese boy3. lb

,ertain of my critics have obAected that the diagnosis of <> cannot be

4: >. 8lan Shewmon ,ontroversies surrounding <rain >eath this$ ' would reply that in others an apnea test was performed 1for e#ample$ the boy who led to my rethin(ing the issue in 0992$ the girl with the brain tumor3$ and their holistic properties suffice to prove the point. &oreover$ it is commonly accepted that if an apnea test cannot be performed because of some medical contraindication$ <> can still be diagnosed by means of one or more confirmatory tests 1which TH and the Dapanese boy had in superabundance3. )inally$ in light of the late &R' and ,T scans showing no brain$ including no brainstem$ the apnea test is a moot point/ if there is no brainstem$ there can+t be any brainstem function$ 'ncluding respiration. 8nother obAection is that such cases are so rare6 therefore$ they 1supposedly3 have little relevance regarding the nature of <> in general. ' would ma(e several points in reply. )irst$ the motivation to continue treatment in the conte#t of <> is itself e#ceedingly rare/ in nearly all cases$ once the diagnosis is made$ either organs are harvested or life support is turned off. Therefore$ the rarity of prolonged survivals in the state of <> implies nothing about the degree of innate sur$i$al .otential in that state. .hen$ e#ceptionally$ there is a motive to continue support 1for e#ample$ to bring the fetus in a brain-dead pregnant woman to viability$ or for religious or cultural considerations3$ prolonged survival is actually not so unusual. Second$ the somatic instability 1particularly of blood pressure3 is greatest in the first several days of <>$ but this is due mainly to non-brain factors 1as will be e#plained below3. Therefore$ this cause of early demise cannot be held up as evidence that the #rain is the body+s central integrating organ. Some patients with supracritical multisystem inAury$ including the brain$ no doubt already lac( somatic integrative unity and are dead6 therefore$ their vital functions spiral rapidly downhill to asystole despite all intensive treatment. This does not prove that the brain alone is the critical integrating organ. Those patients who do ma(e it beyond the initial critical period$ in those rare instances when there is motivation to continue support$ tend to stabili%e and demonstrate surprising survival potential. )inally$ so what if tong survivors are rareE Dust one e#ception disproves a universal rule$ and many e#ceptions to this supposed rule have been well documented. 8llow me to elaborate on an aspect of my position that typically receives little attention/ namely$ that some <> patients are indeed dead$ but not #ecause their brains are dead. Rather$ it is because of su.racritical multiorgan damage, including the brain. Such damage can result directly from the pri-

mary etiology of the <> 1for e#ample$ massive trauma$ cardiac arrest3$ or secondarily from the process of brain herniation 1for e#ample$ !sympathet

is storm$! neurogenic pulmonary edema$ subendocardial microinfarcts$ fluid and electrolyte imbalances from diabetes insipidus$ complications of hypotensive shoc($ secondary hypothyroidism$ and adrenal insufficiency3. The importance of non-brain factors in the survival potential of <> patients was demonstrated in a meta-analysis that ' carried out in the late 0990s. 40 The Haplan-&eter survival curve for the subset with multisystem etiologies was statistically significantly shorter than that for the subset with primary brain pathology 1for e#ample$ gunshot wound to the head$ brain tumor$ ruptured cerebral aneurysm$ and so on3. Cnfortunately for clinicians$ the !dead! subset of <> patients can be distinguished from the !live! subset only in retrospect$ after their rapid downhill spiral to asystole despite all intensive care measures 1the first stage of their !dis-integration!3. 8lthough the notion of !integrative functions! is central to the conceptual debate on <>$ the literature reveals a subtle e uivocation surrounding this term. *n the one hand$ most #rain-mediated integrative functions 1for e#ample$ sensorimotor integration$ cognition$ language$ emotions$ and so on3 are not somatically integrating& *n the other hand$ most somatically integrating functions and phenomena 1for e#ample$ homeostasis$ wound healing$ orderly turnover of cells throughout the body$ proportional growth3 are not #rain-mediated& The mainstream rationale of integrative unity also does not Aibe with the mainstream diagnostic criteria for <>. 'f loss of integration were really the reason why <> is death$ why do the official diagnostic guidelines not re uire absence of a single somatically integrating brain functionE 8nd why do they e#plicitly allow preservation of some somatically integrating functions 1for e#ample$ hypothalamic-posterior pituitary function$ cardiovascular stability$ autonomic and endocrine stress response to incision for organ retrieval3E &oreover$ why should brain-mediated integration count 000 percent and spinal-cord-mediated integration count 0 percentE "ot all centralnervoussystem integration is in the brain. ,ord-based integration is typically not e$ident in the acute stage of <> because of spinal shoc(6 it does come into play$ however$ after several wee(s. The brain and the spinal cord are separate entities only in diagrams$ not in reality. There is nothing special about the cervico-medullary Aunction or the foramen magnum that determines the difference between life and death.
4G. Shewmon$ !,hronic +<rain >eath.J

4G >. 8lan Shewmon

depends on recogni%ing the persistence 49. 50.

-resident+s council on <ioethics$ 2;$ n. 0;. 'bid.$ 22. 50. ibid.$ :0.

,ontroversies surrounding <rain >eath ,ompare the following two cases$ and decide whether this state of affairs is coherent ,ase 8 has no brain function e#cept a sluggish gag refle# and is unstable in the ',C$ with multisystem failure$ hypotension$ diabetes insipidus$ and a losing-battle! downhill course. This patient is$ according to all standard medical and legal criteria$ alive. <y contrast$ ,ase < has no brain function at all and is stable at home on a ventilator$ with gastrostomy-tube feedings and routine nursing care. This patient$ according to those same medical and legal criteria$ is dead. The physiological lesson taught by the e#traordinary cases of prolonged survival is that the brain+s role vis-a-vis somatic integration is that of modulator$ fine-tuner$ optimi%er$ enhancer$ and protector of an implicitly already e#isting$ intrinsically mediated somatic unity. 'ntegration does not re uire an integrator$ as plants and embryos amply demonstrate. Somatic integrative unity is not a top-down imposition from a !central integrator on an otherwise unintegrated collection of organs. Rather$ it is a non-locali%ed emergent property from the mutual interaction among all the parts of the body. The -resident+s ,ouncil on <ioethics The -resident+s ,ouncil on <ioethics$ in its recently released white paper on the determination of death$ essentially agreed with the above criti ues of the traditional integrative-unity rationale.49 8fter reviewing and reAecting all previously proposed rationales$ the ,ouncil felt compelled to choose between two alternative positions. !-osition *ne! is simply to con-dude that !there is no sound biological Austification for today+s neurological standard.!50 !-osition Two! is to posit a novel$ !more compelling account of wholeness that would support the intuition that after total brain failure the body is no longer an organismic whole and hence no longer alive.!R 4 'n the ,ouncil+s own words/ >eath remains a condition of the organism as a whole and does not$ therefore$ merely signal the irreversible loss of so-called higher mental functions. <ut reliance on the concept of !integration! is abandoned and with it the false assumption that the brain is the !'ntegrator! of vital functions. >etermining whether an organism remains a whole

or cessation of the fundamental vital +or/ of a living organismJthe wor( of self-preservation$ achieved through the organism+s need-driven commerce with the surrounding world.52 Two forms of environmental commerce are singled out as the only conceptually important ones/ breathing and consciousness. 8ccording to -osition Two$ at least one of these is necessary for a higher organism to be a living whole6 conversely$ the irreversible loss of both suffices to constitute cessation of the organism as a whole. The ,ouncil is to be lauded ffir its creativity in coming up with the first new conceptual rationale for <> in many years. 't remains to be seen how -osition Two$ will fare in the ongoing debate over the ne#t few years. &y own criti ue has already been pub'fthed.54 'n a nutshell/ 0. There is terminologic confusion regarding the notion of +wholeness.! a3 The ,ouncil admits that some <> bodies are organismic !unities! but maintains that they lac( !wholeness.! How can a !unity! not be a !whole!E b3 !.holeness! is defined idiosyncratically in terms of e#ternal wor(. c3 .hy should e#ternally directed self-preserving wor( count for !wholeness$! but immanent$ self-preserving wor( should notE 2. -osition Two conflates physical necessity for staying alive 1in the wild3 with logical necessity for #eing alive 1ontologically3. 4. -osition Two conflates necessity with sufficiency 1of irreversible loss of both consciousness and breathing3 for death. 5. There is ambiguity concerning whether the critical !vital wor(s! are actual e#change with the environment or an inner drive toward such e#change. 2. There is at least one countere#ample/ the embryo or fetus in utero neither breathes nor engages in conscious interaction.ith the environment$ yet is nevertheless clearly alive on the basis of its own internal holistic dynamics. 't is Aust as dependent for survival on support via a !tube! connecting to a maternal !',C! as a <> patient is dependent on support via !tubes! in a medical ',C. :. There is a logical disconnect between apneic coma as the conceptual essence of <> and the diagnostic re uirement of total brain failure.

50 'bid. 54. Sbewmon$ +<rain >eath/ ,an 't <e ResuscitatedE!

50 >. 8lan Shewmon ,ontroversies surrounding <rain >eath A Valid Criterion for Death 'f <> 1or !total brain failure$! if you prefer3 is not death$ then what isE ' maintain that what has always been considered a reliable criterion for death is indeed so$ namely the irreversible cessation of circulation and respiration$ without which consciousness is also irreversibly lost and there is no possibility for the parts of the body to mutually interact to counteract entropy and maintain organismic wholeness. "otice that ' intentionally phrase this criterion in terms of !circulation and respiration$! not !heart and lung function$! because circulation of o#ygenated blood and respire-Hon 1e#change of gases3 can be maintained technologically in the absence of heart and lung function 1for e#ample$ during open-heart surgery with a bypass machine3$ and the patient is still perfectly alive. Global ischemic -enumbra and the Apnea Test "ot only are there serious problems with the theoretical foundations of <>$ but recently a new mon(ey wrench has been thrown into the clinical pra#is as well. This is the phenomenon of !global ischemic penumbra! proposed by the <ra%ilian neurologist ,icero ,oimbra. 55 The concept of !ischemic penumbra! originated in the stro(e field. .ith an ischemlc stro(e$ due to sudden bloc(age of a maAor blood vessel in the brain$ there is a central core of irreversible necrosis where blood flow is inade uate for cellular viability. <etween this core and the unaffected brain areas is a concentric region where blood now is Aust enough to prevent necrosis but not enough to sustain function$ called the ischemic penumbra. The goal of acute stro(e therapy 's to salvage the area of ischemic penumbra. "ow apply the concept of tschemic penumbra to the entire brain. Recall the vicious cycle of brain swelling and decreased blood Row$ discussed at the beginning of this essay. 8t some stage between normal blood flow and %ero blood flow$ it is a mathematical necessity that the entire brain
55. ,icero =alli ,oimbra$ !'mplications of 'schernic -enumbra for the >iagnosis of

<rain >eath$! %ra?ilian (ournal of Medical and %iological 6esearch 42 109993/ 05;9-G;6 ,icero =alli ,oimbra$ !The 8pnea Test-a <edside Bethal +>isaster+ to 8void a Begal +>isaster in the *perating Room$! in @lnis :itae& s %rain !eath "till *ie< ed& Roberto de &attel 1soveria &annelli$ 'taly/ Rubbettino @&ore6 "ationale delle R(erche$ 200:3$ 004526 ,icero =alli ,oimbra$ !The 8pnea Test-a <edside Bethal +>isaster+ to 8void a Begal +>isaster+ in the *perating Room$! in Pirtis :itae: "%rain !eath; s Not mm !eath, eds. Roberto de &attel and -aul <yrne 1*regon$ *hio/ .e =uardian -oundation3$029-:0.

will pass through a period of penumbra-range flow 1perhaps not uniformly and simultaneously but in a patchwor( fashion at different rates$ eventually affecting all parts of the brain3. This stage of the pathological process will be characteri%ed by total lac( of brain function$ but with some parts of the brain 1or even the entire brain3 still viable and in principle recoverable6 the lac( of function is not yet truly irreversible. 8utopsy studies of <> patients in fact often do not show total brain infarction6 in many cases there are patchy areas of necrosis intermingled with relatively preserved areas. 52 Such findings do not prove ,oimbra+s thesis of global ischemie penumbra$ but they lend strong support to it Suppose that clinicians perform an apnea test on a patient whose lac( of brain function is due to ischemic penumbra rather than total brain infarction. The apnea test itself will tend to worsen the brain swelling by dilating the arterioles 1the mirror image of why mechanical hyperventilation is used as a treatment for brain swelling36 moreover$ hypotension and acidosis$ which are common complications of apnea testing$ will further compromise any areas of lust barely viable brain tissue/la Thus$ the apnea test$ rather than merely diagnosing the already reached endpoint of the vicious cycle$ can actually push the process over the edge and become the cou. de grdre that #rings a#out that end.oint& ' have therefore come to agree with ,oimbra and others who conclude that the apnea testJconsidered an essential element of all official diagnostic protocolsJis an inherently unethical procedureI+ 't entails substantial ris(s to the patient$ including the ris( of converting !almost <>! into true$ total brain infarction6 yet it offers no potential benefit to the patient. The entire purpose of the test is to benefit someone else 1organ recipients$ by being able to declare the patient legally dead3. 'nformed consent is re uired for all ris(y procedures carried +out on patients$ yet it is never sought or obtained for apnea tests. The irony is that$ even according to current diagnostic protocols$ the apnea test is not even an absolute reuirement. Sometimes it cannot be performed or must be abandoned before completion6 in such cases$ 0403 can still be diagnosed$ if a blood flow study confirms no blood flow to the entire brain.-la 52. .al(er$ !"europathological )indings!6 .ildic(s and -feifer$ !"europathology.! 5:. =ustavo Saposni( et al.$ !-roblems 8ssociated with the 8pnea Test in the
>iagnosis of <rain >eath$! Neurology ndia 22 120053/ 452-52. 5;. ,oimbra$ !The 8pnea Test$! 200:6 ,oimbra$ !The 8pnea Test$! 2009. 5G. .hether standard blood <ow tests have the sensitivity to distinguish between

20

Robert E. Hurley

Similar benefits could. accrue from adult stem call and induced pluripotential stem cell research. Recent advances in induced pluripotential stem cell research converting a patient+s bone marrow stem cells into his own heart cells are promising. This approach would not re uire immunosuppression with its adverse side effects.! "either #enotransplantation nor adult stem cell solutions to donor organ shortages threaten moral integrity$ human dignity$ or civili%ed society.

Conclusion

The medical profession would be well advised to be more resistant to social$ corporate$ and government pressures to abandon its timetested !first$ do no harm! principle$ which supports the human dignity of every person. &edicine needs to maintain vigilance against temptations to place societal goods ahead of patient goods$ resulting in the ultimate loss of both. 't is empirically evident from past e#perience$ recent and remote$ that societal good cannot be preserved for long without respect for the sanctity of each human life. 'gnoring human dignity$ for whatever reason$ has to be recogni%ed as a dangerous course to ta(e$ even from a utilitarian perspective$ because 't opens the way to tyranny and atrocity$ to which any society$ including our own$ can become inured. 'n closing$ two observations are relevant to contemporary medical ethics and cultural changes$ one by a literary artist and the other by a well-(nown twentieth-century physicist. )lannery *+,onnor has noted that tenderness$ cut off from the -erson of ,hrist$ is wrapped in theory. .hen tenderness is detached from the source of tenderness$ its logical outcome is terror. 't ends in forced labor camps and in the fumes of the gas chamber.! 22 The second pertinent observation is from the author of the theory of relativity: !-erfection of tools and confusion of goals are characteristics of our time.+
12(2005 110!-": #ichard $% &ierson '''( )C*rrent +tat*s of ,enotransplaritation-..A !01 (200/ 1 /01% 20. Atta 2elder et al%( -G*ided +tern Cell Cardiopoiests: Discovery and Translation(3 lawnal of Molecular and Cellular Cardiology/0(2000523-2 22. 4lannery 5)Connor( 3'ntrod*ction to ! Me"oir of Mary !nn# in My$%ery and Manner$# &cca$ional 'ro$e ($e6 7or8: 4arrar( +tra*s 9 Giro*:( 1/0/1% 220-11%

>. 8lan Shewmon

21

2 ,ontroversies

surrounding <rain >eath

Bask Medical Facts

<efore discussing some of the current philosophical and ethical controversies surrounding so-called brain death 1<>3$ let us begin with a basic overview of the medical phenomenon and its pathogenesis. <> is best understood as the endpoint of a vicious cycle of brain swelling and decreased blood flow to the brain in response to some inAury 1such as trauma$ hemorrhage$ meningitis$ hypo#ia-ischemia from cardiac arrest$ and so on3. Bi(e any bodily tissue$ the brain swells when inAured. Cnli(e other organs and tissues$ however$ the brain is encased in a hard shell$ the s(ull. 8s brain volume increases$ other intracranial components 1namely$ blood and cerebrospinal fluid3 must decrease by the same amount. 'f the swelling e#ceeds the capacity of such compensatory changes$ the intracranial pressure will rise rapidly. This$ in turn$ ma(es it more difficult for arterial blood to enter the cranial cavity$ resulting in decreased blood flow to the brain$ further e#acerbating the inAury already present. The additional insult causes further swelling$ so that a vicious cycle is established$ the endpoint of which is no blood flow plus massive brain swelling that s uee%es
.any than8s to +teven ;ensen and the other oaten hers for the invitation to spea8 at the '<portant conference concernin= or=an transplantation( at the >niversity of +t% Tho<as( 2o*ston( Te:as%