Lecture at the Faculty of Medicine King Saud University, Riyadh on
March 12, 2014 by Dr Omar Hasan Kasule MB ChB (MUK), MPH
(Harvard), DrPH (Harvard) Faculty of Medicine King Fahad Medical City
Riyadh omarkasule@yahoo.com.
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A 60-year old comatose accident victim suffering from severe multi-organ
traumatic injury and with a signed organ donation card was evaluated in the
ER of a remote rural hospital. There was no other plausible cause of
reversible coma or of brain death.
Clinically: no pupillary reflexes, fixedly-dilated pupils, no corneal reflex, no
eye movements, no blink reflex, no vestibule-ocular reflex, no cranial
reflexes, and no gag reflex. Findings were equivocal regarding the apnea
test, cephalic reflexes, and motor response to pain.
Investigations: jugular vein partial oxygen pressure could not be determined.
The EEG was isoelectric. Bedside trans-cranial Doppler showed no cerebral
circulation.
Family members with the exception of the mother were certain of death and
asked the physician not to institute any life support and to call the organ
harvesting team. The doctor was not sure what to do he however convinced
the family to start life support to keep the organs viable until the transplant
team arrived by helicopter.
While walking along the corridor, a nurse overheard members of the family
talking about a 15-year old cousin of the victim lying in a hospital in the
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A 40-year old billionaire stage 4 cancer victim with multi organ
failure in ICU and on artificial life support
Determined clinically dead on the basis of clinical signs repeated
after 6 hours (pupillary reflexes –ve, fixedly-dilated pupils,
corneal reflex –ve, eye movements –ve, blink reflex –ve, cold
water test –ve, cranial reflexes –ve, apnea test –ve, cephalic
reflexes –ve, motor response to pain –ve, gag reflex –ve).
All confirmatory tests were also negative (jugular oxygen partial
pressure -ve, EEG=0, CT angiography).
Family members begged the physicians not to withdraw life
support and not declare death until his beloved last daughter
arrives from London. She might die from shock if she does not
see him alive before death. They were willing to pay for the extra
days of ICU stay.
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A 90-year old deeply comatose man with
multiple organ failure was admitted to the last
available ICU bed and was put on artificial life
support minutes when the family refused a DNR
order.
A few minutes later ambulances started bringing
in over 100 casualties from an air crash site. The
head of the ICU carried out a rapid assessment of
the comatose man showed equivocal clinical
signs of brain death; some indicating death and
others not. None of the confirmatory tests was
positive
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Ethical issues relating to brain death are
analyzable according to the purposes of the
Law, maqasid al shari’at, and principles of the
law, qawa’id al fiqh, to reach conclusions of
practical importance.
Motivation to declare death earlier: the need
to harvest viable organs earlier, save
intensive care resources, and obtaining
tissues for research before deterioration.
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Violation of the principle of intention, qa’idat
al qasd, which requires that actions be
judged by underlying intentions and that the
end does not justify the means.
In this case the nobility of the ends and their
public interest are motivating factors.
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The requirement, by the principle of certainty,
qa’idat al yaqeen, of evidence-based proof of
death are partially fulfilled by brain death
criteria, tests, and examinations.
There is consensus on clinical tests in
determining brain stem death but no such
consensus exists for confirmatory
instrumental tests.
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The principle of custom, qa’idat al ‘aadat, is
partially fulfilled because there is no universal
consensus on criteria of brain deat
Brain death criteria vary by country, by
institution, and over time.
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Do we do brain death testing routinely or are
we selective?
Is repetition of the testing needed after 6, or
24 hours?
How soon shall we act after brain stem death
is confirmed clinically?
Relevance of cerebral death vs brain stem
death difference?
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Feasible?(a) other causes of reversible coma
(b) plausible cause of brain death
Protection of life, maqsad hifdh al nafs, vs
and mistakes in death determination
protecting resources, maqsad hifdh al mal, vs
delayed death determination
Pressure for organ donation: specific
individual vs. general public
Near death vs dead
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The criteria and determination of brain death do not fully
conform to principles of intention, certainty, and custom.
Considerations of organ harvesting, ICU costs, and
research have been a driving force behind development of
brain death criteria.
These criteria have been changing with development of
knowledge and technology and have not reached the level
of universal consensus having variation by country and by
institution.
There is consensus about the reliability of clinical tests of
brain stem death
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Brain stem death, determined by clinical examination
with or without instrumental confirmation, should
remain the mainstay of death definition
The public interest in organ harvesting and saving
ICU resources overrides the doubts that we may have
about clinical criteria of brain death
Legal rulings, fatwa, on brain death should be
reviewed every 3 years to take into consideration new
developments in medical knowledge and technology.