Special Section to: "Death by Neurologic Criteria 1968 - 2014: Changing Interpretations"History of brain death as death: 1968 to the present
Introduction
It has been more than 40 years since the concept of brain death was introduced; and although it is widely accepted, many of the controversies that surround it have not been settled. Much of the public, and some in the medical profession, still consider brain dead patients to be “for all practical purposes dead” but not really dead. This reflects uncertainties about the boundaries that divide life and death and the relationship between death of the cells and tissues and death of the human being. It may also reflect a misconstruction of history.
Section snippets
The transition from heart to brain
At the end of the last century, a new definition of death was introduced. In the past, the irreversible loss of heart and lung functions had signaled death. The new definition was based on the irreversible loss of brain functions. The transition from heart to brain grew out of several parallel developments that converged in 1968 (Fig. 1.). It began in 1947 when Claude Beck performed the first successful defibrillation of a human heart [1]. Suddenly, death was “reversible.” In 1950, Bower and
1968 — The Harvard Ad Hoc Committee and the new definition
Three months earlier, in September 1967, Henry Beecher, Chair of Anesthesiology at Massachusetts General Hospital, wrote to Robert Ebert, Dean of Harvard Medical School, to call a meeting of the Standing Committee on Human Studies. The reason was to discuss the “ethical problems created by the hopelessly unconscious patient.” Beecher explained,
As I am sure you are aware the developments in resuscitative and supportive therapy have led to many desperate efforts to save the dying patient.
1970s—the aftermath
At the dawn of the new decade, there was growing acceptance of the Harvard definition but also confusion and reticence. In a survey of more than 400 neurologists, 15% were skeptical and insisted on a traditional cardiopulmonary definition for the declaration of death [39]. Others shared this skepticism. “We do not know with certainty the borderline between life and death, and a definition cannot substitute for knowledge,” argued the philosopher Hans Jonas, “In this state of marginal ignorance
1980s—the President’s Commission
In 1979, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research was organized to bring clarity to brain death and other ethical issues that had emerged in the 1950s but were crystallized in the case of Karen Ann Quinlan, a young woman in a persistent vegetative state. Recognizing the need for broader guidelines regarding end-of-life care, Congress passed legislation for the landmark President’s Commission. One overarching goal was for
1990s—American Academy of Neurology Practice Parameters and criticisms
In 1994, the American Academy of Neurology undertook the mission to finally standardize the neurological criteria. Eelco Wijdicks, a neurointensivist, led the mission. Practice Parameters were published the following year [50]. The 3 cardinal findings in brain death were to be “coma or unresponsiveness, absence of brainstem reflexes, and apnea.” A protocol for completing the apnea test was spelled out, and the role of “confirmatory tests” was also clarified: “A confirmatory test is not
2000s—back to the drawing board
In November 2007, another President’s Council on Bioethics was created to address some of these lingering concerns. Their white paper was appropriately called “Controversies in the Determination of Death” [56]. First, it discarded the ambiguous term brain death, replacing it with the philosophically neutral term total brain failure. Second, it challenged the various conceptual arguments for brain death advanced over the years and admitted the limitations of the integrative unity position. It
The present
That the boundary remains shadowy and vague, at least in the public’s mind, was made painfully obvious last year. On December 12, 2013, physicians at Children’s Hospital in Oakland, CA, pronounced 13-year old Jahi McMath brain dead following complications from a tonsillectomy. Her parents refused to accept it and obtained a restraining order to prevent the hospital from disconnecting her from a ventilator. A court-appointed neurologist confirmed brain death according to the neurological
References (81)
- et al.
History of technology in the intensive care unit
Crit Care Clin
(2009) - et al.
A history of ethics and law in the intensive care unit
Crit Care Clin
(2009) Diagnostic e´lectro-sous-cortico-graphique de la mort du syste`me nerveux central au cours de certains comas
Electroencephalogr Clin Neurophysiol
(1959)The respirator brain death syndrome
Hum Pathol
(1973)- et al.
Brain stem reticular formation and activation of the EEG
Electroencephalogr Clin Neurophysiol
(1949) A change of heart and a change of mind? Technology and the redefinition of death in 1968
Soc Sci Med
(1997)- et al.
Human renal transplantation. I. Clinical experiences with six cases of renal homotransplantation
J Urol
(1963) - et al.
Organ transplantation for advanced cardiopulmonary disease
Ann Thorac Surg
(1969) - et al.
Ventricular fibrillation of long duration abolished by electric shock
J Am Med Assoc
(1947) - et al.
Investigation on the care and treatment of poliomyelitis patients
Ann West Med Surg
(1950)
Brain death and the historical understanding of bioethics
J Hist Med Allied Sci
Diagnosis of death of the nervous system in comas with respiratory arrest treated by artificial respiration
Presse Med
The depassed coma (preliminary memoir)
Rev Neurol (Paris)
EEG as an aid to determinng death in the presence of cardiac activity (ethical, legal and medical aspects)
Electroencephalogr Clin Neurophysiol
Irreversible coma: a clinical, electroencephalographic and neuropathological study
Trans Am Neurol Assoc
Contribution to the knowledge of acute brain death
Trans Am Neurol Assoc
Massive necrosis of the central nervous system in a subject kept alive artificially
Rev Neurol (Paris)
A way of dying
Atl Mon
Life-in-death
N Engl J Med
The hopeless case. Medical and moral considerations
JAMA
Life or death by EEG
JAMA
Successful homotransplantation of the human kidney between identical twins
J Am Med Assoc
Successful transplantation of kidney from a human cadaver
JAMA
Homotransplantation of the liver in humans
Surg Gynecol Obstet
Lung homotransplantation in man
JAMA
Surgery of the soul: reflections on a curious career
Organ transplantation: the practical possibilities
Transplantation: existing legal constraints
The operation. A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town
S Afr Med J
The neurologist and Harvard criteria for brain death
Neurology
Ethics and clinical research
N Engl J Med
Death before dying: history, medicine, and brain death
The waking brain
Mechanisms of nervous integration and conscious experience
Ethical problems created by the hopelessly unconscious patient
N Engl J Med
A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death
JAMA
Philosophical debates about the definition of death: who cares?
J Med Philos
Brain death: welcome definition—or dangerous judgement?
Hastings Cent Rep
Brain death and organ transplantation
J Forensic Med
Twenty-second world medical assembly
Br Med J
Cited by (37)
Moral equivalence theory in neonatology
2022, Seminars in PerinatologyCitation Excerpt :Ethical questions related to WWLST can be traced to the development of life-sustaining treatments (LST). The first modern intensive care units for adults in the United States were established during the late 1950s, following advances in cardiac resuscitation, respiratory support, and organ transplantation – with pediatric and neonatal intensive care units following in the subsequent decades.23,24 Throughout the 1950-60s, decisions to WWLST for patients were at the discretion of physicians in the private domain of intensive care units.25
Public opinion and legislations related to brain death, circulatory death and organ donation
2020, Journal of the Neurological SciencesCitation Excerpt :Before this time, organs for transplantation were typically obtained from non-heart beating donors (NHBD). The introduction of neurological criteria for death made donation after brain death the main source for organs [3,4]. Yet when it became clear that patients waiting for organs outnumbered donors and transplants, additional methods were being looked for to increase the rate of organ donations [5].
Ethical Issues in Organ Transplantation at End of Life: Defining Death
2020, Anesthesiology ClinicsCitation Excerpt :Testing had to be completed by a physician in the absence of central nervous depressants and hypothermia. On the day of publication of the Harvard Criteria, the World Medical Association also declared that death, “is a gradual biological process at the cellular level with tissues varying in their ability to withstand deprivation of oxygen,” stating that “clinical interest lies not in the state of preservation of isolated cells, but in the fate of a person.”14,15 However, BD was met with a reticence on the part of many physicians, philosophers, and the lay public that continues to this day.16
Knowledge and Attitude Toward Brain Death and Organ Donation Among Anesthesiology and Reanimation Professionals
2019, Transplantation ProceedingsBrain Death: Diagnosis and Imaging Techniques
2018, Seminars in Ultrasound, CT and MRICitation Excerpt :In conclusion, the commission stated that the “definition is based on general physiological standards rather than medical criteria and tests which change over time due to refinements in knowledge and techniques.” In the same year, in an attempt to achieve uniform law on “brain death” throughout the nation, the National Conference of Commissioners on Uniform State Laws drafted the landmark “Uniform Determination of Death Act” (UDDA), which was approved by the American Medical Association and American Bar Association.6 The act is a nonbinding statute aimed to serve as guide for state lawmakers.
Milestones in the history of neurocritical care
2023, Neurological Research and Practice