Maintaining Integrity When Making Medical Decisions
Upholding Authentic and Moral Principles
Brain death cases raise many ethical and moral considerations. If brain death is declared, and the Uniform Determination of Death Act (UDDA) has not been strictly followed, the patient’s life rights are violated. This view was supported by the 2009 President’s Council on Bioethics (PBCE). The PBCE released a statement advocating that “We cannot know with certainty that patients with total brain failure are dead or alive and as a result, such patients should be regarded as living until their heart stops.”
Another aspect to consider is the individual’s and family’s right to medical decisions. Pushing or directing a family to medical termination of life is not morally advisable (for example encouraging a family to sign a Do Not Resituate form). In these medical cases, only integrity and “authentic” moral principles should be upheld whose aim is only to do good to the human person. Authenticity requires true and informed consent. The operant principals of common societal moral action guides used in medical ethics, according to the University of Washington School of Bioethic Tools are:
Four commonly accepted principles of health care ethics, excerpted from Beauchamp and Childress (2008), include the:
- Principle of respect for autonomy,
- Principle of nonmaleficence,
- Principle of beneficence, and
- Principle of justice.
The 2009 President’s Council on Bioethics discuss that moral principal is “the decision to act for the good and the morally optimal way despite persistent certainty about the outcome.”
Prudence requires two principals of moral action when in doubt.
- Actions should avoid the greatest danger known as the precautionary principal.
- The principal of proportionality. It is the balance of benefits and the burdens of treatments.
Actions that veer from that position are akin to driving the getaway car when someone robs the bank.
Without integrity there is guilt by association for all. It is not morally wrong to remove a patient’s life support if the patient is truly dead, meaning cessation of all brain stem functions, or if the patient has signed an organ donor card to be a beating heart donor. It is also not morally wrong for a patient to remain on life support, or extended life support, if that is the wish of the patient and his or her family.
Ultimately the medical decision will boil down to either preserving the life of your loved one, or accepting brain death as true death because of financial concerns.
It can only be one or the other.
If the patient is an organ donor but has not made that choice for themselves, and there is not true death, then “the gift of life” through recycling of the patient’s organs becomes a gift by live dissection. When life ends, it does not belong to objective science as much as it belongs to the principal that each one of us has an individual supreme right to self-determination that cannot be superseded by another.
There are no shades of gray when someone’s life hangs in the balance. The determination of brain death must, according to the law, be “beyond all reasonable doubt.” Once the termination action is done, it can never be undone. It is something that the decision-makers and loved ones must live with every day for a lifetime.
Ultimately, it is about the patient’s values and their concept of quality of life. The outcome of the situation will likely depend on the patient, and the patient’s beliefs about quality of life. These are decisions that only the patient and his or her immediate families can make.
About Futile Care
The coma dépassé, or deep coma (brain dead), patient is now in a state of being, having their personal liberty to self-determination, their life, and personal security placed in the hands of others. Medically, the patient’s life is viewed as what is called a “futile care” issue. Futile care is care that allows the treatment of a patient when there is no “benefit” of a cure. It should be noted that it is misleading to describe patients as truly dead when the prognoses is brain death, as they could be in a state of deep coma, thereby causing reduced consciousness–as long as there is still brain stem function.
According to the UDDA, no patient with an active brain stem should be declared brain dead. The law precisely states that “irreversible cessation of all functions of the entire brain, including the (no longer functioning) brain stem, is dead.” Total death of the brain stem results in the total physiological death of a patient, even while on a ventilator.
In American medicine, there is some acceptance that it is permissible to end a life-sustaining treatment if it is no longer benefiting the patient. This is known as futile care. In an exclusive ethics survey, 37 percent of doctors indicated that they would not recommend or provide futile care. Nearly 46 percent of doctors stated physician-assisted suicide should be legal.
The article states, “Futile care is distinct from euthanasia because euthanasia involves active intervention to end life, while withholding futile medical care does not encourage, nor speed the natural onset of death.” Medically, brain stem function is any primitive functioning of the basic controls of breathing, kidney function, and self-regulating body temperature by the hypothalamic function and functioning cortex where human conscious thought is produced within the locked-in patient.
Redefining Brain Death
Defining brain death is becoming harder as researchers publish more findings of complex signs of brain activity in the hippocampus region of the brain responsible for memory and learning in both animals and human subjects who have flat-lined EEGs.
One study found that a declaration of brain death might not be physiologically accurate in many instances. In fact, the research study concluded that the definition of brain death would now have to be redefined. Adding credence to the scientific evidence based medical research that brain activity is still going on and life is still present even with flat EEG brain waves readings.
The prognosis of brain death is considered when the patient requires mechanical life support through the use of a ventilator to help them breathe, which keeps their heart beating. If the patient is non-responsive to any outside stimulation and there is clear medical and clinical evidence that severe brain injury has occurred, the coma is deemed irreversible.
The second definition of death “that vital external work of an organism is required to be alive, and once an organism no longer interacts with the environment to obtain what it needs to survive, it is dead” is said to alter the 2009 PBCE recommendation when the intent and the interpretation of the UDDA is not carried out, except in the cases of those individuals who are registered organ donors, prior to the traumatic brain injury event by their individual personal choice.
The intent and interpretation of the UDDA remains in agreement with the whole brain death dead donor rule guidelines, which require doctors to determine that the brain cortex—the place of consciousness in humans—has shut down after brain stem functioning is lost.
A determination of death by two doctors is required and must be made in accordance with accepted medical standards. This assures that the brain and brain stem have died beyond all reasonable doubt of biological fact—physiologically and medically.