Brain Death?

A reader writes:

A national Catholic paper recently referred to the Church’s teaching on "brain death." I haven’t seen this in the Catechism. What is the Church’s teaching on "brain death"?

I haven’t seen the paper you refer to (so I deleted the name of it), but it would be misleading to state in a blunt fashion that the Church has a "teaching" on the concept of brain death. This term is not used in magisterial documents, and the key document that delves into this area contain important qualifications that make it possible to say that there is a "teaching" here only in the most tenuous sense.

The situation is analagous to the question of evolution. The Church doesn’t have a "teaching" on evolution per se. Evolution is a scientific hypothesis, and the Church is not in the business of teaching scientific hypotheses. What the Church does teach on is Scripture and the deposit of faith, and in the 1950s Pope Pius XII issued a preliminary finding that certain versions of biological evolution do not appear to conflict with what is found in the sources of revelation. A Catholic is thus morally permitted to believe in those forms of evolution.

Whether any of them are true or not, though, is a matter of science, not of faith, and thus the Church does not teach evolution. It teaches only that certain forms of evolution would not contradict the sources of faith and that a Catholic may accept these forms of evolutionary belief if he feels that the evidence warrantes them.

A similar situation pertains to the subject of "brain death." The Church does not teach, as some individuals hold, that an individual is dead when he is "brain dead." Instead, in the year 2000 Pope John Paul II issued a preliminary finding that certain versions of "brain death" criteria do not appear to conflict with what is found in the sources of faith regarding the human person and that a Catholic is thus morally permitted to act on those versions of brain death criteria.

Here’s what the pope said:

4. [O]ne of the most debated issues in contemporary bioethics, as well as to serious concerns in the minds of ordinary people . . . [is] the problem of ascertaining the fact of death. When can a person be considered dead with complete certainty? . . .

The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly.

Yet human experience shows that once death occurs certain biological signs inevitably follow, which medicine has learnt to recognize with increasing precision. In this sense, the "criteria" for ascertaining death used by medicine today should not be understood as the technical-scientific determination of the exact moment of a person’s death, but as a scientifically secure means of identifying the biological signs that a person has indeed died.

5. It is a well-known fact that for some time certain scientific approaches to ascertaining death have shifted the emphasis from the traditional cardio-respiratory signs to the so-called "neurological" criterion. Specifically, this consists in establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity. 

With regard to the parameters used today for ascertaining death – whether the "encephalic" signs or the more traditional cardio-respiratory signs – the Church does not make technical decisions. She limits herself to the Gospel duty of comparing the data offered by medical science with the Christian understanding of the unity of the person, bringing out the similarities and the possible conflicts capable of endangering respect for human dignity.

Here it can be said that 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 judgement which moral teaching describes as "moral certainty" [SOURCE].

There are a number of important things to note here:

1. The pope indicates that this is one of the most debated areas in bioethics and he is not trying to settle it.
2. This is why he says that the Church "does not make technical decisions" regarding the criteria that are to be used in ascertaining death, whether they are neurological or cardio-respiratory criteria. Both kinds of criteria may thus still be used.
3. What the pope does is give a preliminary finding that, at least certain versions of the neurological criteria <massively important phrase>"do not seem to conflict"</massively important phrase> with what the Church knows of anthropology, or the doctrine of man (human nature).
4. Therefore, a healthcare worker <massively important word>"can"</massively important word> act on those versions of the neurological criteria that do not appear to conflict with sound anthropology.
5. One applying these criteria thus could achieve "moral certainty" that a person is dead, but not the "complete certainty" that the pope refers to earlier.
6. This means that we have a situation very much like evolution: The Church knows certain things about the sources of faith, including Christian anthropology, and it has made a preliminary finding that certain kinds of criteria–whether they be cardio-respiratory or neurological in nature–that do not appear to conflict with Church teaching and that therefore can be used by Catholic individuals assessing whether death has occurred.
7. The pope does not say that they must use these criteria, any more than popes have said Catholic must believe in evolution. The hypothesis that biological evolution happened and the hypothesis that certain criteria are sure signs that death has occurred are both scientific hypotheses subject to further examination and, potentially, falsification.
8. A Catholic is thus at liberty with respect to whether or not to believe in evolution and with respect to what criteria he believes are sure signs of death. As John Paul II put it, "the Church does not make technical decisions" in this area.
9. All it has done is given a tentative finding (note the "seems to" language) that certain kinds of criteria would be permissible for a Catholic to use in assessing death.
10. Those criteria are remarkably strict, as they involve "the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem)." The assessment of these criteria opens a can of worms too complex to continue this numbered list, so let’s go back to paragraphs.

The first problem is measuring the complete cessation of activity in the cerebrum, cerebellum, and brain stem. Even if you’ve got a person hooked up to an EEG, a real question exists about whether these machines are  sensitive enough to make this determination. Can an EEG read individual neurons firing deep within the brain? If not then they are not capable of determinine whether a complete cessation of activity has occurred.

We are thus facing a potential technological limitation in the assessment of this criterion. While it may be true that death has occurred if a complete (and irreversible) cessation of activity has occurred, we simply may not have the tools needed to measure this as yet.

In the absence of such tools, we of course have to make do with what we have, and it would not be immoral for a healthcare worker to use an EEG to arrive at moral certainty that all brain activity has stopped, but moral certainty is not complete certainty. It may be that, as technology develops, we will find out that activity continues in the brain longer and deeper and fainter than what an EEG is capable of detecting, and a healthcare worker might prefer to act on more strict criteria than what an EEG is capable of measuring.

The advancement of technology also impacts the second of the criteria that the pope proposed: the irreversibility of cessation of brain activity. Right now, so far as I know, we don’t have very good ways to restart brain activity when it has stopped. Okay, but a hundred years ago we didn’t have very good ways to restart heart and lung function when they stopped, either.

It may be that in a hundred years (or ten) we will have better ways to reinitiate brain function that has stopped, such as injecting certain chemicals into the brain (the equivalent of injecting adrenalin into the heart), using direct electrical stimulation (the brain equivalent of a heart defibrilator), indirect electrical stimulation through the use of a powerful, focused magnetic field, or the use of nanites (who might be needed also to repair brain damage in the wake of rebooting a patient’s brain).

Right now, we don’t have those techniques (or, at least, we aren’t using them due to the prevailing pro-death mentality in so much of the medical profession), and so for now it is moral to act on the assumption that a presently irreversible cessation of brain activity is a marker of death, just as a hundred years ago it was moral to act on the assumption that a then-irreversible cessation of heart and lung action were markers of death.

But it is also moral to apply a stricter set of criteria and refrain from treating a patient as dead since in the future we may find out that he’s not really dead as what we thought was irreversible turns out not to be.

By way of comparison, before we could re-start hearts, it could have been moral to harvest someone’s liver (an unpaired vital organ) on the assumption that he was dead when his heart stopped. Now that we can re-start hearts in many cases, it isn’t moral to go after people’s livers so quickly. We now know that they’re still alive; we’ve just got better at bringing them back from death’s doorstep.

In the same way, it is moral today for a healtcare worker to refuse to go after someone’s heart just because his cessation of brain activity is presently irrversible and presently appears to be complete. We may get tech in the future that shows he ain’t really dead because he can (with the new tech) be brought back and we can (with the new tech) measure activity an EEG can’t pick up.

I strongly suspect that as medical technology gets better that both the neurological and the cardio-respiratory criteria will be found to be insufficient and that a much more sophisticated set of criteria will have to be used in assessing when death has occurred.

It would therefore be a mistake for people today to commit decisively to either set of criteria, as both are likely to be significantly revised in the future. That’s why the pope didn’t commit to any set of criteria. He simply gave a preliminary finding that certain criteria don’t seem to conflict with Christian anthropology.

And this is treating matters in the abstract, detached from the way medicine is actually practiced. In reality, a vast number of doctors and nurses are a bunch of guh jun duh hwoon dahn who want to declare you dead so they can cut you up for your organs–or at least so they can be rid of you and not have to try to keep you alive anymore.

I know. I witnessed such hwoon dahn behavior when my wife was dying and the doctors and nurses kept trying to push her over the edge of this life so she’d stop taking up bedspace.

The anti-life ethic that is rampant in the medical profession is so strong that the "brain death" criteria in place in many hospitals are so loosey-goosey that they utterly fail to meet the criteria set forth by the pope.

This practical reality has led many respected Catholic leaders to caution that the pope’s statement cannot be read as an endorsement of the "brain death" criteria as actually employed out in the real world.

A statement titled "Brain Death": Enemy of Life and Truth was signed by such notables as Bishop Fabian Bruskewitz, Bishop Robert Vasa, Fr. Benedict Groeschel, Charles Rice, Paul Byrne (past president of the Catholic Medical Assn.), and numerous others. It warned, in part:

The parameters variously set forth for declaring a person "brain dead," however, are neither "clearly determined" nor are they "commonly held" by the scientific community. Rather the myriad permutations of "brain death" criteria introduced since the publication of the revealingly titled "A Definition of Irreversible Coma" in 1968 -more than 30 sets in the first decade alone have grown increasingly permissive.

At the same time, a growing number of members of the scientific community have taken a closer look at "brain death" and are voicing their concerns. To know with moral certainty that "the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum, and brain stem)" has occurred would require the total absence of all circulation and respiration. Confirmation of this absence would necessitate that the cerebrum, cerebellum, and brain stem have been destroyed and the circulatory and respiratory systems as well.

None of the shifting sets of "so-called neurological criterion" for determining death fulfills the Pope’s requirement that they be "rigorously applied" to ascertain "the complete and irreversible cessation of all brain activity." In fact, "brain death" is not death, and death ought not to be declared unless the entire brain and the respiratory and circulatory systems have been destroyed [SOURCE].

It is thus true that the Church has made a preliminary finding that certain very rigorous neurological criteria do not seem to conflict with Christian anthropology and can be acted upon morally in certain select circumstances, it is not the case that the Church teaches that the "brain death" criteria presently in use in the medical profession are adequate markers of death, nor does it teach that these criteria must be used by healthcare workers today in preference to stricter criteria, nor does it teach that the criteria for recognizing death will not need to be revisited in the future, nor–finally–does the Church teach any particular set of criteria for recognizing when death has occurred.

Be wary, therefore, around claims that the Church has a "teaching" on brain death. This proposition is sustainable only in a highly attenuated sense that is very easy to get wrong.