The Neurologist and the Concept of Brain Death

THE NEUROLOGIST AND THE CONCEPT OF BRAIN DEATH* JAMES F. TOOLE, M.D., L.L.B.] Until recently, all physicians and most laymen have been able to distinguish between life and death oftheir fellow human beings. From time immemorial, everyone has accepted that when the heart stops permanently , life has ceased. Furthermore, we have been trained to believe that until this last cardiac contraction, while there's life, there's hope. All this changed dramatically with the first successful human cardiac transplantation on December 3, 1967. The definition of death—tradition ofmankind for millennia, sanctified by religion, and couched in law—is being challenged and will probably change. Large segments ofthe medical profession are considering the wisdom of adopting the concept of brain death, as evidenced by such articles as, "Death and Heart Transplantation: An Ethical Dilemma?" [1], "Medical Ethics and Morals in a New Age" [2], "When Do We Let the Patient Die?" [3], "Ethical Problems Created by the Hopelessly Unconscious Patient" [4], and many others [5-8]. Titles such as "Public Attitudes in the Diagnosis of Death" [9], "Ethical and Religious Issues in Heart Transplant" [10], and "Life, Death and the Law" [11] demonstrate that the public is keenly aware of the issues involved , and in many cases seems actively to be pushing the medical profession toward the redefinition of death. Sympathetic as I am to the reasons underlying this pressure for change, I have been worried that unanticipated disastrous consequences could follow general acceptance ofthe concept of brain death. For example, most physicians (to say nothing of the nurse or layman) cannot make the diagnosis of brain death with confidence. Even the electroencephalographer is competent only to render his opinion about * Adapted from an address given to Houston Neurologic Society, January 1970. t Teagle Professor of Neurology, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27103. 599 the condition ofbrain waves, not ofthe brain itself, for he makes no direct observation ofthe patient. Consequently, the clinician skilled in neurology or neurosurgery stands alone in judgment of patients considered to be alive by many physicians and dead by others. When forced to make the life-death decision, most neurologists have used as criteria the guidelines published by ad hoc committees of Harvard Medical School [12] and of the American EEG Society [13]. Whenever possible, most neurologists have sidestepped the issue; but now it must be faced squarely, because an amendment to the California Uniform Anatomical Gift Act of 1968 is being prepared which proposes that certification of death of a person by reason of brain death be pronounced only by physicians certified by the American Board ofNeurosurgery or by the American Board ofPsychiatry and Neurology [14]. Even though such a statute would remove legal obstacles for the transplant surgeon, produce an immediate benefit for some patients, and remove from other groups ofphysicians possible guilt feelings engendered by killing patients, it would place the decision-making responsibility upon specialists who only reluctantly accept it. The groups whom he is likely to adjudicate are patients with (1) trauma, which may destroy brain function; (2) intracranial catastrophes, such as hemorrhage; and (3) patients who do not recover consciousness after poisoning, cardiopulmonary resuscitation, following prolonged hypotension or after brain operations. Because the concept of brain death involves social [15, 16], legal [1719 ], and theological issues [20, 21] which physicians have not specifically been trained to consider, some suggest that we trust those who have been to weigh the implications for us. Similar requests were made ofthe physicists who first concerned themselves with the broad implications of nuclear fission. The results have been disastrous. I cannot accept such a restriction [22] and others are of like mind [15]. As Brain [23] wrote in his monograph, Mind, Perception and Science: "Finding that the philosopher provides no answer to most of my questions, I have been compelled to try to answer them myself, well aware of the pitfalls that lie in wait for the amateur, but encouraging myself with the thought that the professionals could hardly disagree with me more than they do among themselves ." Consequently, I present my point of view, first, by considering the requisites for making the diagnosis ofbrain death; second...