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.

Significant passages on suffering

To come to a right perspective on suffering one needs to understand 3 significant passages of Scripture. There may be more but at minimum there are 3 aspects it would do well to fully comprehend. The 3 passages are found in Genesis, Job, and the Gospels.

1. Genesis 1-3 gives us the nature of the created world and the Fall of man.
2. Job discusses the suffering of the righteous.
3. The Gospels, especially the latter aspects of them, teaches us about redemption of suffering.

So the passages cover the:

1. Reason suffering exists;
2. Righteous suffering; and
3. Redemption of suffering.

The 3 passages primarily address each of these, though they also give us insight into the other 2.

Genesis
The world was broken by man when he choose disobedience over life. The world created perfect is now flawed as a result of Adam's sin. The choice to eat what they were forbidden to brought sin, suffering and death into this world. The entire universe suffered as a result of man's disobedience. All suffering came after this event and is caused by it. It is unlikely people can overestimate how great was our fall from grace. It is imperative to grasp that no sadness, pain or death existed in the world before the Fall; and that all suffering resulted from it.

Job
While the suffering of the wicked may appear consistent with justice, the suffering of the righteous seems unfair. And while all men are sinners, including Job, suffering is frequently not the result of personal sin. The innocent frequently suffer because of others. This strikes us as extremely unjust. The story of Job addresses this and teaches us that, contrary Job's friend's advice, the righteous do suffer. There is much to learn from Job including that suffering can do good. Not that suffering is good, rather it can produce good; God brings good out of evil, sometimes greater good than would have been had the evil not occurred, but woe to him who brings about evil (Mar 9:42; Rom 6:1-2).

Gospels
Jesus is the quintessential example of the righteous sufferer. The 3 aspects mentioned above occur in these and other passages. However we also learn about God's redemption of suffering. The death and resurrection of Jesus an enormous good out of such a horrendous evil. And God used it to redeem us. The death and resurrection work against the very core of suffering and removes it. It allows for God to completely do away with suffering. Sin, suffering, evil, sadness, pain and death itself are on their way out and will be no more.

Developing a biblical concept of physical life

In response to my article on the nature of death Jc_Freak asks

First, I have always understood nephesh to mean 'soul', yet you define it here as 'life'. How would you distinguish therefore between the concept of nephesh and the concept of chay?

Second, you mention that this might have implications on how we view euthanasia, abortion, ect... I don't really see how since we already define death in those terms. Within general culture the cessation of the heart is still the prinicple symbol of the moment of death. Thus, I am not sure how challenging this is. Could you elaborate on how you feel this would alter people's perceptions?

Starting with the second question: What I was trying to do here is laying out some ground work for developing a fully fledged biblical concept of physical life. It may not seem that challenging if such a position happens to coincide with secular definitions—for which we should be grateful—but it is important for us to have the right reasons. A libertarian and drunkard may both decry Prohibition, but they do so from different positions. It may be that the secular arguments around death derive, in part, from our Western Christian heritage, though definitions of life are being challenged by medical ethicists in the literature and abortionettes in the culture war.

I have considered this matter for some time, not all my thoughts included in the post; it seems to me that blood is closely tied to life which is what I was establishing in the post.  But because this connection is foundational it is important to maximise certainty before deriving corollaries.

There are arguments around abortion and euthanasia relating to personhood, though personhood may not completely equate to living—animals have the latter, not the former. If the commandments of God (eg. Do not kill) are based on human life—even if the reason for the commandments is the imago Dei—then we need to consider how being alive affects permissible behaviour.

Regarding the first question I am afraid I cannot answer this to any degree of satisfaction. I included the Hebrew words to show which word occurs where, and to emphasise the repetition of the word "blood". I do not read Hebrew so my thoughts are somewhat restricted. I understand about unwarranted expansion of semantic ranges, but I am also cautious about undue restriction based on word use: biblical narrative, and even more so poetry, uses frequent parallelism which relies on the use of synonyms; we should caution against making non-existent distinctions between synonyms.

That said, I understand nephesh to roughly parallel the English "life", or perhaps "soul"? It applies to humans and higher animals, and is related to the concept of breathing. Plants and some creatures classified Animalia are not living in the nephesh sense. So perhaps "soul" is a better translation? We will then need to grant that a cow may have a soul, but in a Hebrew biblical sense, and not necessarily in an English sense? I am uncertain how this relates to chay, though chay as life seems to also contain the meaning (or be metaphorical for) "newness" or "freshness".

Defining death biblically

Modern medicine defines death in several ways. There can be cessation of heart beating, cessation of breathing, or cessation of brain activity. The latter is intended to be defined quite clearly so as to not include people in comas that may potentially wake up.

Heart death is when the heart stops pumping and electrical activity ceases (asystole, flat-lining). A heart may stop beating but the electrical activity continues. This may occur because the heart cannot pump (pulseless electrical activity) such as when there is no blood (bleeding), or nowhere for the blood to go (clot in the lungs), or no space for the heart to contract (blood around the heart). It may also occur when abnormal electrical activity does not cause heart contraction (ventricular fibrillation). Both these situations very rapidly become asystole if not treated, and frequently even if treated, especially when death is expected.

Cessation of breathing, eg. blocked airway or drowning, leads to a rise in carbon dioxide in the blood and decreasing oxygen. Increased carbon dioxide quickly leads to unconscious and acidification of the blood. The heart stops after a few minutes (unless there is severe hypothermia) for various reasons.

Brain death is defined as no electrical activity of the brain, no brain reflexes, no response to a stimulus. The person cannot breathe independently, and sometimes cannot maintain a heart beat; thus such a definition exist because of advances in medicine allowing prolonged mechanical ventilation.

These definitions of death are somewhat reasonable. Nevertheless we need to consider what Scripture may say to the issue and whether that modifies our thinking around physical death.

The Bible has several references to various organs of the body. Kidneys, intestines, eyes, liver, skin, blood, bone, heart. Several of the occurrences are literal when describing sacrifice: what to do with the kidneys or liver when offering sacrifices to God. Several are metaphorical, though different to the metaphors we use in English. Thus translators may use English metaphors, though some have become English metaphors from the Hebrew via the English Bible.

"Kidney" (kilyah) may represent emotion. Consider Jeremiah 17:10a

“I the LORD search the heart (leb)
and test the mind (kilyah), (ESV)

I, the Lord, probe into people’s minds (leb).
I examine people’s hearts (kilyah). (NET)

"Kidney" appears on the second line, translated "mind" in the ESV and "heart" in the NET. "Heart" (leb, lebab) in the Hebrew apears in the first line. The ESV retains heart whereas in the NET it is translated as "mind". The NET's translation of "heart" as "mind" is not without justification as "heart" often carries the connotation of "will" in Hebrew, whereas it tends to reflect "emotion" in English.

me`ah means intestines or other internal organs such as stomach or uterus (also beten). Literally Psalm 22:14 reads:

I am poured out like water,
and all my bones are separated;
my heart is like wax;
it is melted within my intestines (insides);

The relevance of this to our discussion relates to the word "blood". Blood represents life in Hebrew. The question is whether this is primarily metaphorical, or symbolic, or whether blood is perceived as the source of life. "Blood" (dam) occurs over 300 times in the Old Testament. It is clearly used at times when "life" (nephesh) is meant. As such it has a figurative use. Though I am inclined to think that this is because the association with life is meant to be a literal one. After the Flood God instructs Noah concerning food and death:

But you shall not eat flesh with its life (nephesh), that is, its blood (dam). And for your lifeblood (dam nephesh) I will require a reckoning: from every beast I will require it and from man. From his fellow man I will require a reckoning for the life (nephesh) of man.

“Whoever sheds the blood (dam) of man,
by man shall his blood (dam) be shed,
for God made man in his own image. (Genesis 9:4-6)

God tells Noah that meat has to be drained of blood because the blood is life. In verse 4 blood is identified with life in a definitional manner:

• Life is blood.

"Life" and "blood" are also juxtaposed in verse 5 which is translated by the English word "lifeblood", or alternatively "blood of your life".

Another consideration in understanding death is the word breath. Breath (neshama) and breathe (naphach) are used in the creation account.

then the LORD God formed the man of dust from the ground and breathed (naphach) into his nostrils the breath (neshama) of life (chay), and the man became a living (chay) creature (nephesh). (Genesis 2:7)

Though there is a connection between breath and life here, it does not seem to be as strong. The breath (spirit) of God is required and it is the breath of life, ie the breath that causes life, but it is not definitional. The breath itself is not identified as the life itself (even though it is the source or cause). An argument can be made for an association between breath and life, though I think it less convincing than blood.

The association of blood with life in Scripture provides us with material to deduce a biblical definition of death. If we accept that blood represents life, or is life, then the complete loss of blood or the cessation of blood flow is a coherent biblical definition of death. How does this correspond to current medical views? We know that cessation of blood flow is due the heart ceasing its function as a pump. Therefore a medical definition of cardiac death as asystole is equivalent the biblical definition of death. The Bible would also allow the loss of significant blood from bleeding, pulseless electrical activity, and ventricular fibrillation as definitions of death, though without medical intervention these situations very rapidly become asystole.

Biblically, death is the loss of blood flow, that is the non-perfusion of (all) organs with blood, this is usually due to the cessation of cardiac function.

If we were to argue that breath also relates to life, a secondary biblical definition of death is cessation of breathing, which incidentally leads quickly to cessation of blood flow, our primary definition.

Brain death is not primarily a biblical definition of death of itself, other than that it involves lack of ability to breath spontaneously.

This leads to some interesting conclusions. It should influence how we think about sentience and life. It may have implications concerning euthanasia, abortion, organ donation, mechanical ventilation and other supportive therapies.

Death of a daughter

I only became aware of this recently. Steven Curtis Chapman, Christian singer, lost his daughter in a car accident in May. Extremely sad. Steven and his wife Mary Beth talked about their loss on Good Morning America.