Copyright 2014 American Medical Association. All rights reserved.

The Meaning of Brain Death

A Different View
The recent case of Jahi McMath, a teenager in Oak-
land, California, was extensively publicized in the news
media and led to prominent commentaries in medical
journals on the meaning of brain death.
1,2
McMath is a
14-year-old adolescent who in December 2013 experi-
enceddevastatingneurological damagefollowingcom-
plications fromatonsillectomy. McMathmet criteriafor
thediagnosis of braindeath. Shecontinues, however, to
receivemechanical ventilation, tubefeedings, andsup-
portive care at an undisclosed location, with her treat-
ment financed by private funds, according to the most
recent reports.
Virtuallyall of thecommentaryontheMcMathcase
has focused on howunreasonable it was for her family
to insist on the continued use of life support. One bio-
ethicist was quoted in USA Today as saying of the un-
named medical facility where McMath was placed on a
ventilator, What could they be thinking? Their think-
ing must be disordered, froma medical point of view.
There is a word for this: crazy.
3
Another bioethicist in-
sistedthat continuedmechanical ventilationwas not life
support and that the teenager was not a patient be-
cause she was dead. The bioethicist was quoted as say-
ing that the newphysicians are trying to ventilate and
otherwise treat a corpse. She is going to start to
decompose.
3
Inour view, theseandother commentators haveig-
nored an important distinction between brain death as
a biological phenomenon and as a legal status.
4,5
For
morethan200years, theessential features of livingor-
ganisms have been the subject of scientific investiga-
tion. At present, we understand life to be defined in
termsof thecapacityof organismstouseenergyinmain-
taining a stable homeostatic internal environment and
integratedfunctioning.
6
Whenanorganismlosesthisca-
pacity, it has died. This definitionapplies across thebio-
logical spectrum, fromsingle-celled organisms to com-
plex plants and animals.
The history of brain death reveals a persistent and
continuedfailuretoconnect theconcept of braindeath
withthis biological understandingof lifeanddeath. The
1968 report from the Ad Hoc Committee of the Har-
vard Medical School to Examine the Definition of Brain
Death proposed a definition of irreversible coma but
provided no reason to consider patients in this condi-
tion to be actually dead.
6
In 1981, the Presidents Commission for the Study
of Ethical Problems inMedicineandBiomedical andBe-
havioral Researchassertedthat brain-deadpatients did
in fact fulfill this biological definition because they had
lost the integrated functioning of the organism as a
whole.
7(p33)
Over thepast several decades, however, in-
controvertibleevidenceshowsthat thisassertionisfalse.
Many individuals with a diagnosis of brain death can
maintainintegratedfunctioning for prolongedperiods,
evenyears. Thesefunctions mayincludecirculation, di-
gestion, excretionof wasteproducts, temperaturecon-
trol, woundhealing, fightinginfections, growthandde-
velopment, and gestating a fetus.
8
We now know that
the integrated functioning of the organism as a whole
is an emergent property of living organisms and is not
dependent ona central organizer suchas thebrain. The
fact that those with a diagnosis of brain death cannot
breathe without being supported by a ventilator does
not make them dead because this is no different from
the situation of patients with high-level spinal cord in-
jurywhoareunabletobreathespontaneouslybut surely
are alive.
The scientific evidence is clearin many cases,
brain-dead patients are biologically alive. Neverthe-
less, there is good reason to maintain the widely
accepted policy stance that those with a diagnosis of
brain death are legally dead. Prior to the development
of intensive care medicine, when the mind ceased to
function the body also ceased to function. However,
technology such as the mechanical ventilator permits
the body to continue vital functions even when the
patients capacity for mental life has been irreversibly
lost. The unfortunate individual in this condition is
biologically alive but psychologically dead. With no
mental life, there is no value in living. This makes it
reasonable to treat a patient who is brain dead as
legally dead; the patient is as good as dead. Maintain-
ing life support can be of no value for a person in an
irreversible coma; nor can such a person be harmed or
wronged by procuring their organs for transplanta-
tion, as long as valid consent has been obtained.
Patients whohavecorrectlyreceiveda diagnosis of
being in a persistent vegetative state also have perma-
nently lost consciousness. At present, the clinical crite-
ria for diagnosing the persistent vegetative state are
much less reliable than those for brain death, however.
Thus, it is not prudent to consider a patient in a persis-
tent vegetative state as legally dead.
Thelegal statusof braindeathhasanalogiestoother
areas of the law, in which entities may be given a legal
status that differs fromthenatureof theentity. Apromi-
nent example is the legal doctrine that a corporation is
a person in the eyes of the law. It may serve appropri-
atelegal purposes inapplyingthelawtocorporations to
treat themas persons, eventhoughthey are, of course,
not persons.
6
Similarly, someindividuals aredeemedle-
gally blind despite the fact that they retain limited eye-
sight. Althoughthosewithadiagnosis of braindeathare
not biologically dead, they are properly understood as
legally dead.
VIEWPOINT
Robert D. Truog, MD
Division of Critical Care
Medicine, Boston
Childrens Hospital,
Boston, Massachusetts,
and Division of Medical
Ethics, Harvard Medical
School, Boston,
Massachusetts.
FranklinG. Miller, PhD
Department of
Bioethics, National
Institutes of Health,
Bethesda, Maryland.
Corresponding
Author: Robert D.
Truog, MD, Division of
Critical Care Medicine,
Boston Childrens
Hospital, 300
Longwood Ave, Bader
621, Boston, MA 02115
(robert.truog
@childrens.harvard
.edu).
Opinion
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Most families have no interest in continuing life support once
they come tounderstandthat their lovedone is irreversibly uncon-
scious. But howshould we respond to families like McMaths, who
wish to maintain life support for a family member who is in an irre-
versible coma and legally dead? To insist that such families are ob-
viously mistaken or in denial is not helpful because from a biologi-
cal perspectivetheymaywell becorrect that their lovedoneremains
alive. Continuing life support in the intensive care unit of a hospital
is not an appropriate use of this expensive and scarce resource be-
cause such care can offer no medical benefit. As a matter of re-
spect, however, for those fewfamilies who insist on continued life
support, clinicians shouldbepreparedtofacilitatetransfer toalong-
term care institution that is willing to maintain such patients. In-
deed, NewJersey legally requires this approach.
6(p55)
Who should pay for this continued treatment? On one hand, it
seems reasonable to say that traditional third-party payers should
not fundthecontinuedcareof patients deemedlegallydead. Onthe
other hand, third-party payers routinely pay for continued life sup-
port for patientsinapersistent vegetativestatepatientswho, if cor-
rectlydiagnosed, arealsoirreversiblyunconscious withnohopefor
a meaningful life. Evenif thedifferenceinlegal status is clear, it may
seem ethically arbitrary to provide financial support in one situa-
tion and not the other. Veatch
9
has therefore argued that all states
shouldfollowNewJerseys example, which is to allowpatients and
families to opt out of accepting brain death and to choose to have
death determined by biological criteria.
It might seemthat allowingpatients andfamilies tochoosetheir
definition of death would have many practical problems, but in-
deedit seemstohaveworkedwell inNewJersey. Familiesrarelywant
to continue the biological existence of a patient who is irreversibly
comatose. Respecting defensible minority views that do not im-
posesubstantial burdens onothers is reasonableandinaccordwith
the ideals of a liberal society.
Facing the reality of brain death raises important questions
about the role of physicians in helping to resolve complex issues
in law, medicine, and public policy. We should provide the public
with the best scientific data and thinking available and allow soci-
ety through the democratic process to use those data in deter-
mining the best policy. In our view, the medical profession, by
insisting that brain death has a biological status even though this
status is unfounded, has not upheld this obligation. Trust and the
public interest would be best served by a more honest discussion
about the meaning of brain death. We owe the public and our
patients no less.
ARTICLE INFORMATION
Published Online: June 9, 2014.
doi:10.1001/jamainternmed.2014.2272.
Conflict of Interest Disclosures: None reported.
Disclaimer: The opinions expressed are the views
of the authors and do not necessarily reflect the
policy of the National Institutes of Health, the
Public Health Service, or the US Department of
Health and Human Services.
REFERENCES
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//www.usatoday.com/story/news/nation/2014/01
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Intensive Care Med. In press.
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Transplantation. NewYork, NY: Oxford University
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7. Presidents Commission for the Study of Ethical
Problems in Medicine and Biomedical and
Behavioral Research. Defining Death: A Report on
the Medical, Legal, and Ethical Issues in the
Determination of Death. Washington, DC:
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8. Shewmon DA. Chronic brain death:
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9. Veatch R. Let parents decide if teen is dead.
CNN.com. January 2, 2014. http://www.cnn.com
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Accessed April 24, 2014.
Opinion Viewpoint
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