Sunday, 9 July 2017

Brain death

In an earlier post some years back Blair D raised the question of brain death. He mentioned those who are considered brain dead
I have never known of a person diagnosed as brain dead to breathe, in a manner consistent with life sustaining way, for very long. In other words the brain dead person has commenced the process of dying.
and those in a persistent vegetative state
To the clinicians and she was as good as dead in that she was deemed to have none of the higher brain functions remaining intact and therefore was described as a "living brain stem" but no more. No ability to perceive, experience (to give meaning to) and or communicate in any way.
One needs to be careful how death, including brain death, is defined, this should not be happening,
Stephen Thorpe, then 17, was placed in a medically-induced coma following a multi-car pileup....

Although a team of four physicians insisted that his son was “brain-dead” following the wreck, Thorpe’s father enlisted the help of a general practitioner and a neurologist, who demonstrated that his son still had brain wave activity.  The doctors agreed to bring him out of the coma, and five weeks later Thorpe left the hospital, having almost completely recovered.

Today, the 21-year-old with “brain damage” is studying accounting at a local university.
Now many people whose brains are non-functional following trauma never recover, they fail to wake up ever. However because some do wake up, perhaps brain death may not be the best way to define death. This position is consistent with what I understand the biblical definition of death to be. If we are going to have "brain death" then we need to have absent brain function. If there is no brain function then such a person will stop breathing because breathing is controlled by the brain. (The heart is affected by the brain but can continue to function without brain input.) Heart cessation will occur shortly following breathing cessation.

Then why not call brain death a form of death when there is no brain activity in the region that causes respiration? Perhaps medically this could be a definition. However the situation could arise where the breathing centre of the brain has some damage (temporary or permanent) but the person retains higher cognitive functions. He will then be aware that his breathing is being maintained artificially (similar to high neck injuries). So for brain death we need evidence of minimal brain activity, no awareness, and lack of respiratory effort. Even with all these we cannot be certain of irreversibility and people can be maintained in this situation for years. Contra cardiac cessation which is permanent after several minutes (somewhat depending on the temperature).

If we accept that death is cardiac (plus or minus respiratory), where does that leave us with those who are considered brain dead or others who are in a persistent vegetative state?

This is actually a different question to whether or not brain death is death. I would phrase the question: Can we withhold medical treatment from a minimally conscious person who is unlikely to recover?

Which raises another question: What is medical treatment?

The answer to the first question is a guarded yes. If a person is thought to be permanently brain damaged and is in an induced coma the least one should do is "wake" him up. Assessment of response to stimuli should involve significant stimuli in the absence of sedation. But if there is strong evidence for irreversible brain damage and no response to stimuli (without sedation) and the person is without consciousness, then I see no ethical command to maintain life using ongoing medical treatment. This is not to say that  providing such medical treatment is necessarily immoral, rather that there is not an automatic moral responsibility to maintain life artificially indefinitely.

Which leads to the second question: What is medical treatment? If a person is unable to breathe then the removal of ventilation will lead to cessation of respiration followed shortly by cardiac arrest and death. If a person is able to breathe then they may continue to live for several days but die from kidney failure without fluid. The provision of air via an artificial respirator is considered medical treatment because it is a high-tech intervention. The provision of water and food via a feeding tube is not considered high-tech and it is often assumed that this is not a medical intervention but providing the essentials of life. However the respirator is also providing an essential of life: oxygen. That a respirator happens to be more complex than a tube is morally irrelevant. What is relevant is that we are providing air or water or food for the patient. That the person cannot breathe for themselves or swallow for themselves means that we are providing not just vitals for life but the mechanism of receiving vitals.

Brain death may not be the best definition of death. There is no moral duty to maintain medical treatment for someone who is brain dead. Medical treatment is providing the mechanism of receiving the vitals of life regardless of how high-tech that mechanism is.

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