Catholic Health Care Advocates Papers

Reflections on the Status of Brain Death

Edward J. Furton, M.A., Ph.D.

In his 1989 address to the Pontifical Academy of the Sciences, “Determining the Moment when Death Occurs,” Pope John Paul II set out the central dilemma that faces brain death criteria. Imagine, he says, that there are two people in the same hospital room, one in urgent need of an organ transplant and the other who has expressed a willingness to supply it. If there is any doubt about whether the donor is dead, there is danger that the transplant team will attempt to retrieve the organs too soon and thus be the cause of donor’s death. The solution to this dilemma is for the relevant experts to provide an exact determination of what constitutes the moment of death.

For once such a determination has been arrived at, then the apparent conflict between the duty to respect the life of one person and the duty to effect a cure or even save the life of another, disappears. One would be able to know at what moment it would be perfectly permissible to do what had been definitely forbidden previously, namely, the removal of an organ for transplanting, with the best chances of a successful outcome.

 Although cessation of the cardio-pulmonary system clearly constitutes death, the task the Pope set before the Academy was to determine whether brain death is also a proper criterion for the determination of death.

Doubts about Brain Death

The reason why brain death causes doubts among some is not difficult to understand. The brain dead continue to show heartbeat, respiration, growth of tissue, and the full range of autonomic activities associated with live persons. This contrasts with others, also declared dead, who show none of these same signs. How can two individuals, who display such a wide difference in bodily functions, both be declared dead?

In 1981, the Pontifical Council on Health Affairs “Cor Unum” took note of the “increased reticence in the matter of giving permission for the removal of organs for transplant” and reported that certain “authoritative medical groups” had asked the Vatican “to make an official declaration on the validity or non-validity of taking cerebral death, duly established, as the ‘moment of death’ of the human being.” The Council noted, however, that it was not in a position to make such a ruling because determining what constitutes the moment of death is not a theological question but a medical one. “The very most the Church could do,” replied the Council, “would be to reiterate the conditions that would make it legitimate to accept the better judgment of those whose specific competence has been entrusted the determination of the moment of death.“Cor Unum,” therefore, could only take note of the fact that there is “a growing consensus of opinion that considers a human being dead in whom a total and irreversible absence of life activity in the brain has been established.” Various and somewhat different criteria have been drawn up to determine when this state obtains, “but there is sufficient correspondence among them to make up a list of symptoms of death whose accuracy can be taken as very highly probable.” Though it did not offer official approval of the criteria for brain death, the Pontifical Council “Cor Unum” did express its trust in the judgment of the medical professional to arrive at an accurate determination of this matter.

Traditional Teaching

The trust of the Council in the judgment of the medical community reflected a long-standing willingness among Catholics to accept the authoritative judgments of experts in a given field. As early as 1957, in “The Prolongation of Life,” Pope Pius XII had stated in unequivocal terms that the question of determining when a patient had died was the responsibility of the physician. The appropriate theological description of death, he stated, is the separation of the soul from the body, “but in practice one must take into account the lack of precision of the terms ‘body’ and ‘separation’.” Death is a medical fact, Pius stated, not something that can be deduced from religious or moral principle. Those with the appropriate expertise in medicine, therefore, must make the final judgment about the fact of death.

Pius was also specifically asked should a patient who had suffered severe trauma to the brain and breathing paralysis, but who continued to breathe on artificial respiratory support, be considered dead? Or does death occur only with the loss of heartbeat and cessation of the circulation of the blood? Again, Pius XII responded that death in any given case “does not fall within the competence of the Church” but is a question for the physician. However, he noted that in general we may suppose that human life remains “for as long as the vital functions—distinguished from the simple life of the organs—manifest themselves spontaneously or even with the help of artificial processes.” Of course, in cases of “insoluble” doubt we must presume that life remains.

Thus Pius XII gave no definite answer to the question of whether brain death is true death, but he did draw our attention to the fact that human death is not the death of every cell in the body. Obviously, “the simple life of the organs” can continue for some time following the death of the patient, and this fact is the basis of successful organ transplantation. An organ that has suffered irreparable decay cannot be reanimated with the life of the recipient.

Given the respect of the Vatican for the judgment of the physician, the Catholic community has shown a broad acceptance of brain death criteria. Thus, for example, the Committee on Health Affairs of the United States Catholic Conference issued “Guidelines for the Determination of Brain Death” in 1975. While not abandoning the traditional method of determining death by cessation of heartbeat and respiration, the Committee noted that under certain “circumstances an additional set of criteria, which provides a moral certainty of brain death, may be more suitable.” The document then proceeds to describe the use of those criteria as “morally sound and acceptable.”

A Philosophical Consideration

In addition to deference to the expertise of the medical community, another reason for the acceptance of brain death among Catholics has been the traditional view of death as a separation of the rational soul from the body. The Fourth Lateran Council and the First Vatican Council both affirmed that the human being consists of two essential components—body and soul. The Council of Vienne (1311–1312) held de fide that the rational soul is the essential form of the human body. We know today that our rational power is exercised through the brain which serves as its material basis.

Given this philosophical emphasis on the human soul as a rational soul, it makes sense to say, in light of current medical knowledge, that when the brain has suffered traumatic injury that causes permanent loss of function, it can no longer serve as the basis for that essential unity that constitutes the identity of the person. The remaining life exhibited in the body, therefore, cannot be the life of the rational soul itself, but must be “the simple life of the organs” maintained by mechanical apparatus. To hold that the rational soul can continue to exist in a completely dead brain would appear to contradict the Catholic teaching that we are souls essentially integrated with physical bodies.

When the apparatus that forces air into the lungs of the brain dead is removed, heartbeat always ceases. Each year there are 15,000 cases of brain death, of which about 5,000 become organ donors. In every case, when brain death is properly diagnosed, there has been no “recovery” after the breathing apparatus has been removed. Of course, if there were even a single case to the contrary, this would have great significance for the validity of brain death criteria. Despite anecdotal claims, however, there have been no clear-cut and documented cases of such exceptions.

We must be careful, however, not to identify brain death with loss of the cerebral cortex or the brain stem or some other part of the brain. One should not confuse brain death with other states resulting from chronic brain damage, such as the persistent vegetative state. Brain death must be whole brain death—including loss of the brain stem. This need not include the death of every single neuron, but it must be the complete loss of all organized function within the brain. Thus the anencephalic child, born with nothing more than a minimally functioning brain stem, is a full human being.
State of the Question

When the deliberations of the Pontifical Academy of the Sciences drew to a close in 1989, the members issued a report that came to the same conclusion as had their earlier report in 1985. Death can be declared when “spontaneous cardiac and respiratory functions which would have ceased have been maintained artificially” or when “there has been an irreversible cessation of all brain functions, even if cardiac and respiratory functions which would have ceased have been maintained artificially.”

Moreover, the report held that the second of these two criteria “is the true medical criterion of death.” Loss of heartbeat may be reversed by cardio-pulmonary resuscitation; but when it is not reversed, brain death quickly follows. There is, however, no reversal of brain death. Thus there are not two states of death; there is only cerebral death. In the view of the Academy, “a person is dead when he has irreversibly lost all ability to integrate and coordinate the physical and mental functions of the body.” The inability to support the vital process of breathing, caused by irreversible loss of whole brain function, is clear evidence that the brain dead no longer have the power to integrate and coordinate their vital functions.

Thus, in the view of the Academy, the dilemma presented by Pope John Paul is resolved. Use of artificial respiration to prolong the life of one who is brain dead merely allows the bodily organs to survive until they can be retrieved for transplantation. When there is a true and proper medical diagnosis that reveals whole brain death, the individual may indeed be considered dead.

The 1993 “Charter for Health Care Workers,” issued by the Pontifical Council for Pastoral Assistance, accepted this view when it described the Pontifical Academy of the Sciences’ 1989 deliberations as “an authoritative contribution” to the question of brain death. The conclusions reached in the Academy’s discussions, and expressed in its report, may be accepted by Catholics as a sound judgment about the validity of brain death criteria. “Faith and morals,” the Council stated, “accept these findings of science.”

Although no definitive judgment has been rendered, one may safely conclude that Catholic physicians may, in good conscience, employ brain death criteria in their determination of death. Similarly, Catholic patients may agree to give or accept organ transplants on the basis of these same criteria. If the Vatican should ever express reservations to the use of these criteria, it will likely be preceded by a widespread rejection of brain death by members of the medical community. There are voices calling for a rejection of these criteria today, but they would appear to be in the minority.

Edward J. Furton, M.A., Ph.D. Editor, Ethics & Medics The National Catholic Bioethics Center Boston, Massachusetts

From the:

The National Catholic Bioethics Center 159 Washington St., Boston MA 02135 Phone: 617-787-1900 Fax : 617-787-4900