Brain Dead is Dead?

Sandra Gandarez
Neurobiology and Behavior
February 24, 2009

It is a moral obligation of hospitals protocol and physicians to remove a "brain-dead" individual from life support since they are already technically dead.

Before discussing the moral issues some basic information and view points are necessary to understand certain stances. Brain death is defined in several articles as the complete and irreversible loss of brain stem function. In brain death, all the brain stem functions, including those that maintain breathing, stop working. (1, 2) There is an absence of blood flow to the entire brain which in turn causes the deprivation that enables brain death. (3)

The brain is set up in a way that the unconscious actions that we take for granted (including walking, breathing and balance) are closest to the base of the brain and brain stem. More complex functions (including speech, imagination and language) are positioned closer to the outer and upper surfaces. The entire brain does not always die as a whole because the cerebral cortex (which needs a lot of oxygen and energy to function) can die in a matter of minutes if oxygen is cut off whereas the brain stem can still live. When there is still activity in the brain stem then it is brain damage rather than brain death; even if many functions are lost, such as speech and language skills. Even some "vegetables" are not considered brain dead because they can still breathe on their own and may respond to certain stimuli including pain and noise. The only thing that prolongs the life of a brain dead person is the use of life support machines and there is no chance of recovery. (1) A person can be pronounced legally dead even if the heart continues to beat due to life support measures. (2)

There must be a few critical points that mark a person as brain dead rather than severely brain damaged. Those points are:
 1. There is no question of deep intoxication from drugs, poisons or other chemical agents.
2. The condition is not due to the effects of paralyzing drugs.
3. It is not the result of lowered body temperature (hypothermia).
4. There is no question of any neurological condition that could simulate brain death.
5. There are no spontaneous breathing movements.
6. The pupils are round or oval and dilated 4-6mm.
7. The pupils do not change size when a bright light is projected into them.
8. There are no reflex responses above the neck: no response to corneal contact (touching of the surface of the eye), no gag reflex when the back of the soft palate is touched, no coughing in response to tube suction of the windpipe.
 9. There are no eye movements when the outer ear canal is irrigated with warm or cold water (caloric test).
10. The electroencephalogram shows no sign of electrical activity in the brain, as recorded from a minimum of 8 points. All channels must be flat. (2)

The loss of spontaneous respiration and lack of pupil dilation were the most commonly mentioned in readings as being indicators of brain death. Several physical aspects are also listed such as coexistent coma and apnea and a complete loss of volitional activity and consciousness. (4) Brain-death is often confused with the state of vegetation because it is not a necessity to be brain dead to be a "vegetable". Severely brain damaged individuals can be considered "vegetables" as well which is why the assumption is so misleading. (2) 

Morality of pulling an individual off of life support is still a very controversial issue among religions and political stances. Some of the very definite terminology I found in my research was amazingly blunt, a few are:
1. If the brain is dead there is no chance that the person will recover, and therefore no reason to continue with life support. (1)
2. Thus anencephaly, in which there is no higher brain present, is generally not considered brain death, although it is certainly an irreversible condition in which it may be appropriate to withdraw life support. (2)
3. These professionals agree that the death of the brain is equivalent to the death of the person. The view that brain death signifies the death of the person is an important societal decision that should be endorsed by legislation in the individual states. (3)
4. If someone is brain dead, the person is dead, period. (5)
Most medically minded people believe that once you are declared brain dead then you are gone for good.  The fact is that many families do not grasp the gone for good concept because they see their family member's chest rise and the heart beat and believe that it is still possible for them to wake up and be back to normal.
Another issue with the declaration of brain dead is that most families do not want organs harvested while there is "false hope." (5) The mentality is that why give them away when they are still needed here. The religious and moral decisions tend to clash quite violently when thinking about an individual being brain dead and having to make the decision of what to do. To top it off is the donor decision for that individual. In some countries (Portugal, Poland and Belgium) everyone is automatically a donor, taking a lot of difficult decisions out of people's hands. (2)
Something that should be considered and that has been brought into the limelight in recent years is the manner in which these people should be allowed to die. A well known case of that is Terri Schiavo, who was taken off her feeding tube which subjected her to die of starvation rather than something much quicker and less painful. Death row inmates die within minutes for their capital crimes yet an innocent woman was left to starve to death for almost two weeks. (6) Even dogs are put to sleep in an ethical manner but a human being is not. The matter of moral obligations to these people must be met to prevent this from happening regularly. 

References
1. NHS 24 Health Library http://www.nhs24.com/content/default.asp?page=s5_4&articleID=60&sectionID=1
2. NationMaster - Encyclopedia
http://www.nationmaster.com/encyclopedia/brain-death
3. Crawford, Ronald, and Barbara Patrick. "Confirmatory Tests in the Diagnoses of Brain Death: The Role of the Radioisotope Brain Scan." Bioethics Quarterly 3(1981): 67-72.
4. eMedicine
http://emedicine.medscape.com/article/1177999-overview
5. Brain Dead Means Dead
http://www.wired.com/science/discoveries/news/2001/04/42847
6. CNN
http://www.cnn.com/2005/US/03/31/schiavo/