Medical Disagreements


Determining Brain Death: Research from the American Academy of Neurology

The definition and determination of brain death is the subject of controversy and debate. An open inquiry must look at beating heart living organ donations, a medical quality of life measurement of the value of a person’s life. The Glasgow Coma Scale, is the most common scoring measurement to describe traumatic brain injury to a described level of consciousness.  According to this scale, the types of death can be grouped as follows:

A 2011 Canadian study of 500 board-certified American neurologists asked if American neurologists agree with the standard concept of death (irreversible loss of integrative unity of the organism) and whether they understand the state of the brain when brain death is diagnosed. The study found that American neurologists do not have a consistent means of testing for brain death or diagnosing brain death.

The American Academy of Neurology (AAN) uses a 25 step process to determine brain death in patients. Recently, changes were made to the process based on the Canadian study. It was determined that neurologists believe an organism, like the brain, can be alive, even if is not working properly. “Very few neurologists consider the irreversible lack of vital work of an organism as a concept of death that the brain death criterion may satisfy,” the Canadian study found.

The research also indicated that many neurologists feel that the clinical tests that are given to determine if patients are brain dead may produce incorrect results and therefore the incorrect diagnosis of death.

According to the study, most medical professionals consider brain death as death because of the loss of integrative unity of the organism (the brain). It can, however, be argued that even a brain that is not functioning properly is still “whole” enough to be considered alive.

Even though brain dead patients are allowed to die, no one in our society considers them officially dead. Regardless of their quality of life, brain death is a prognosis, indicating that there is a medical issue, but that issue is not necessarily death.

The President’s Council on Bioethics (PBCE) has suggested an unusual concept of death. They state 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. Importantly, simply restating the criterion of brain death does not give any concept of death that brain death satisfies to justify brain death being death.”

According to this research, it is not common for doctors to believe that the loss of function of an organism equates death. “Many confused a restatement of the criterion of brain death as justification that it is death, and a few conflated the prognosis of death with the diagnosis of death. Most consider a higher brain concept of death justified.”

The research concludes that neurologists do not understand if, or disagree whether, the definition of brain death fulfills the concept of death. This research is important because the very medical professionals who were surveyed for these statistics are the specialists declaring patients brain dead in hospitals every day.

The bottom line is that medical professionals differ in their rationale for accepting brain death as death. More than half of the medical professionals surveyed do not consider brain death as the same severity of circulatory death. These results have important ethical implications for the practice of intensive care medicine.

Determining Brain Death

At best, medicine is not an exact science.  It is limited knowledgeable science combined with the human art of exercising trained, but sometimes flawed, judgments that in turn make decisions using population-driven data.

Note that, according to the Uniform Determination of Death Act (UDDA), it is legal in 5,723 registered hospitals in the United States to remove a patient from life support immediately upon determination of brain death by two doctors.  There is no observation waiting period or testing required by law—only the bedside examination. Determination must be made by two independent doctors, and the examinations are often only hours apart.

The two doctors who make the brain death diagnosis should not be involved with organ donation and transplantation. The doctors performing the death determination test, which is usually performed in front of the family to show /prove death, should not know how the patient or family feels about organ donation.

The 25 step examination guidelines can be performed, and brain death declared, even in cases in which  higher doses of therapeutic sedatives, barbiturates and analgesics produce death-like states, such as paralyzation with a possibility of conscious awareness, known as locked in patients. This leads to a misdiagnosis of brain death for reversible transient death-like states.

Neurologists do not agree about the legitimacy of brain death tests. EG activity, evoked potential activity, tracking cerebral blood flow, monitoring pituitary hormones and examining normal brainstem pathology are some of the tests that raise concerns about how accurately they help a doctor to determine brain death.

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