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The grisly question of deciding when somebody has died

A few days ago on Twitter, our Editor here at Gript, John McGuirk questioned the level of training that was necessary for a HSE nurse to make a determination of death.

It was a question that John asked in good faith-since most of us assume that such a determination should be straightforward.

But since this is an area in which I have some small knowledge-at least with respect to the ethical aspects-I thought it might be helpful to show that the criteria we use to determine whether or not death has occurred is actually not half as straight forward as you might think.

Let me stress that what follows is a mere overview

Without being facetious, I also want to make it clear that what I am talking about here is how we determine death in a clinical or health care setting and not in those instances where death is ‘obvious’; such as in a horrendous road traffic accident or in other incidences either accidental or intentional where the physical structure of the human body has been subjected to significant violent trauma such as an explosion.

The first thing to say then is that the medical and legal criteria used to determine death has been through a series of evolving definitions in recent decades.

For instance-the 1968 ad hoc committee at Harvard Medical School, in response to the advances in respiratory technology such as ventilators, highlighted the inadequacy of irreversible cessation of cardiopulmonary function as the legal definition of death.

Merely identifying that the heart had stopped beating and the person had stopped breathing was no longer a credible or ethically acceptable way of determining that a person was in fact ‘dead.’

Then In 1972 Capron and Kass proposed that either the irreversible cessation of spontaneous circulatory and respiratory functions or irreversible cessation of brain functions could be used to determine if death had occurred.

But by 1981, with the majority of legal, medical, and ethical opinion focusing on the concept of brain death, the following definition was inserted into the Uniform Determination of Death Act in the US:

“It is the laws determination that brain death is the legal equivalent of death because the capacity for life is irretrievably lost when the entire brain, including the brain stem, has ceased functioning.”

This understanding was later affirmed by Pope John Paul when he addressed the 18th International Congress of the Transplantation Society  in August 2000:

“The criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology. Therefore, a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgment which moral teaching describes as “moral certainty.”)

There is a qualifier however which it seems both necessary and appropriate to note at this point; this is that the use of ‘brain death’ as a criteria to establish the death of an individual is still the subject of an ongoing and vigorous ethical debate.

A 2012, a frankly quite alarming study by A.R Joffe found that American neurologists “did not have a consistent rationale for accepting Brain Death as death, nor did they have a clear understanding of diagnostic tests that might determine Brain Death.”

Despite these ongoing debates however, there is still a fairly unanimous medical consensus that total brain death (or total brain failure- irreversible loss of brain function, including the brain stem) can in fact be used to determine that death has in fact taken place.

This is just a brief sample of some of the complexity involved in this area.

So much more could be said, especially around the hugely problematic area of how we determine when organs can be taken from a ‘dead’ person for use in organ transplantation.

At present, organ donation typically takes place after a diagnosis of brain death.

But there is another technique, called deceased cardiac donation which allows organ donation after the heart stops beating. This approach is legal in many EU countries. As I understand it up to 40% of all UK donations occur in this way.

This should bring into the stark relief just how important it is that we give serious ethical consideration to how we determine death.

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