Brain Death & Ethical
issues
Dr. Ashraf Hussain
overview





What is death?
History of death
Clinical death, brain death
Islamic perspective of death
Ethical issues


When a human being is dead?
Why it is important?

When the entity that integrates rest of
the organism dies, the organism dies
with it

Advances in medical Sciences
have made the determination of
the time of person’s death less
simple than it used to be
Death is a process not an event
History of death


Before 1816, physicians were not well trusted
in their ability to diagnose death
Fear of being buried alive
In ancient Rome



Call out deceased person’s name 3 times
If no response-- finger amputated
If no bleeding– declared deceased
Fear to be buried alive
In 14th century
 Duke of Lancaster left instructions to keep his
body in bed for 40 days
 If doctors still believed he was dead then to be
buried
Magic words (1790)
“I am dead”
written on mirrors in invisible ink (silver nitrate)
Decomposed body produced hydrogen sulfide, writing
became visible as silver sulfide was produced
Patented Coffin to alert (1897)
If death was misdiagnosed
 If presumed deceased awoke from sleep
beneath the ground
 A device was rigged to light a lantern, raise a
flag and ring a bell
Clawed forceps
By French physician
 Designed to clamp around the nipple of the
presumed corpse to confirm death
 No response---dead
“…I know when one is dead, and when one
lives. She is dead as earth. Lend me a looking
glass. If that her breath will mist or stain the
stone, why then she lives”
King Lear; Act V, Scene III
William Shakespeare


Invention of stethoscope (1816)
Physician were began to be trusted in their
ability to diagnose death
Primary modes of confirming death



Respiration
Heart sound
pulse
Death criteria
In beginning of 20th century
 Cardiorespiratory criteria
Clinical Death

Cessation of blood circulation and breathing
Change



Change started in 1952 with an outbreak of
polio in Copenhagen, 12 year old girl under
went tracheostomy & put on ventilator
Pierre Mollaret (French) in 1957 reported on
patients who had developed brain injury and
were on mechanical ventilation
No brainstem reflexes were present and post
mortem examination revealed brain
liquefaction
A new diagnosis of death




In 1968 Harvard Brain Death Committee
published report on how to diagnose death on
new criteria
Criteria proposed that patient could have no
brainstem or spinal cord reflexes.
A confirmatory test was also required i.e. EEG
In essence, committee said a person is dead if
the brain is dead
Death


Clinical death
Brain death
Clinical Death
Cessation of blood circulation and breathing
 When the heart stops beating in a regular
rhythm. Condition is called cardiac arrest
 The absence of blood circulation and vital
functions related to blood circulation was
considered to be the definition of death

“Clinical death is now seen as a medical
condition that Precedes death rather than
actually being death”

During clinical death, all tissues and organs
in the body steadily accumulate a type of
injury called Ischemic injury
Factors for change


Increasing availability of mechanical
ventilation—legal implications of
disconnection
Rapidly advancing field of organ
transplantation
Death

Permanent and irreversible cessation
of vital functions of heart, brain and
lungs
(C.K. Parikh; Text book of forensic medicine and toxicology)

If we have a human body being ventilated
on a respirator, but in which there is no sign
of brain activity, ought we to regard that
person dead or alive?



How should we regard a person in permanent
coma?
When should we cease to persist with life
prolonging treatment?
Under what circumstances can patients decline
life-saving measures?
TYPES OF BRAIN INJURY





Coma
Brain death
Vegetative state
Locked-in state
Minimally conscious state
Coma

Prolonged state of unconsciousness, in which
patient is alive, but unable to move or respond
to environment.
Coma
Most serious brain injuries begin with a coma
 “Eyes-closed unconsciousness.”
 It is as if the patient is sleeping but cannot be
aroused.
 Coma is usually not permanent.
 Some patients go on to become brain dead;
others enter the vegetative stage, become
“locked in,” or enter the minimally conscious
state; still others recover completely
Brain death
Irreversible loss of the clinical function of the whole
brain:
 The cortex (responsible for motor and cognitive
function)
 The midbrain (which might be thought of as
integrating higher and lower centers in the brain)
 Brain stem (responsible for vegetative functions such
as sleep-wake cycles and breathing).

Brain death is a product of modern
technology, made possible by mechanical
ventilators and cardiopulmonary
resuscitation
Brain death criteria



Absence of eye opening
Absence of verbal or motor response to pain
Loss of brain stem reflexes (such as pupil
response, corneal reflexes, caloric response to
vestibular stimulation, cough reflexes and
hypercapnia)
Brain death criteria cont;

Total unresponsiveness to these tests,
combined with good evidence that it is caused
by irreversible structural damage to the brain
means that person will never regain
consciousness
Vegetative State:


Refers to plant life i.e. without locomotion)
It is a brain injury resulting from Trauma or
Diseases, where higher functions of brain are
lost while the non-cognitive functions, like
breathing and heart beating are retained.
Vegetative state




“Eyes-opened unconsciousness”
There is a disassociation between wakefulness and
awareness.
While patients may appear awake, there is a lack of
evidence that the upper brain receives or projects
information.
The upper brain and the midbrain are not integrated
in function with the brain stem or the rest of the body,
although the brain stem continues to manage the
vegetative functions.
Vegetative state
“Sustained and reproducible voluntary
response” is important in the diagnosis
Prognosis is determined by the
 Cause of the injury
 Length of time the patient has been in the
vegetative state
 Comorbid conditions.

Duration of the vegetative state also
affects nomenclature



A duration >1 month is said to be persistent.
When the cause of the vegetative state is
nontraumatic —such as an anoxic injury after
cardiopulmonary resuscitation a duration >3 months
is said to be permanent
BUT
When the cause of the vegetative state is traumatic a
patient must remain vegetative for >12 months before
the condition is defined as permanent.
Locked-in state

Consciousness is preserved but the patient is
paralyzed except for eye movement and
blinking.
Locked in Syndrome


Paralyzed from head to toe, the patient, his mind
intact, is imprisoned inside his own body, but unable
to move or speak.
“In my case blinking my left eyelid is my only
means of communication….My heel hurt, my head
weighs a ton, and something like a giant invisible
diving-bell holds my hole body prisoner”
Jean-Dominique Bauby describing his experience in The Diving Bell and the
Butterfly, a book dictated entirely by eye movements
Minimally conscious state

Sleep-wake cycles exist, just as in the vegetative state.

Arousal levels range from obtundation to normal arousal.

There is reproducible but inconsistent evidence of
perception, communication ability, and/or purposeful
motor activity.

Visual tracking is often intact but typically inconsistent.

Communication ranges from none to unreliable, with
inconsistent yes-no responses, verbalizations (typically
fewer than six words), and gestures
Can we cease our medical efforts to
keep alive some one who is brain
dead?
Islamic perspective

Unanimous approval of whole brain death
criterion and its permissibility within Islam
(Acdemy of Islamic jurisprudence, Jordan1986}
PAKISTAN


Brain death is widely accepted
Legislation?
Famous cases for legal Battles



Karen Quinlan
Nancy Cruzan
Theresa Schiavo
Readings




Bioethics for clinicians: 24 Brain death by Neil
M. Lazar et al
The final diagnosis of brain death: David C.
Kaufman www.sccm.org
Ethical & social dimensions of brain death.
F.Moazam. Pakistan journal of neurological
sciences
wikipedia.org