The evil absurdity of “brain death”

I was invited to participate in a debate on “brain death” at the annual meeting of the Catholic Medical Association in Orlando this past week. The question was: “Are neurological criteria for the determination of death acceptable in Catholic health care?”

On my side was my friend Pete Colosi, and we argued the negative (i.e., that brain death is not true death, and harvesting organs from people who have been declared brain dead is homicide).

This topic is very dear to me. I have published 2 scholarly papers on brain death, refuting some of the more salient philosophical arguments that have been advanced to push the idea that brain death is true biological death. The most accessible of the 2 can be found here.

Below is my opening statement for the debate. I didn’t know if the audience would be familiar with the topic, so I tried to give a simple overview. I am adding a couple of footnotes here to expound on some key points.

I would like to thank the CMA and the organizers of this event for inviting me and my esteemed friend Professor Pete Colosi to participate in a debate on this most vital question of brain death. 

This is literally a question of life and death, probably one of the most important questions that should preoccupy the medical community. Yet it’s a question that is rarely debated in academic medical circles or even acknowledged to exist.  

We are grateful for the opportunity to present our conviction that the concept of “brain death,” namely, the idea that we can use neurological criteria to declare that a patient with a beating heart is in fact dead, is morally unacceptable.

To introduce my segment of remarks, I would like to offer an imaginary dialogue between Jocelyn, a nurse working in the trauma center of a tertiary care hospital in New York, and her attending physician, Dr. Harvey. 

Jocelyn recently arrived from the Philippines. (She was flown in in response to the vaccine mandate shortages.) She is a very competent nurse, but she has never encountered brain death before. 

On her first day at work, she is asked to take care of Jeremiah, a 24-year-old victim of a motorcycle accident who sustained severe head trauma and was just declared “brain dead” according to the established procedure.  He is now being readied to have his organs, including his heart, harvested for transplantation.

Here is the dialogue:

—Dr. Harvey: Nurse, I’m going to write the death note in Epic. Make sure you watch his vital signs and let me know if he becomes unstable before he is taken to the OR.

—Jocelyn (after a few seconds of hesitation): Yes, doctor, but excuse me for asking. If he is dead, how come he has vital signs and how could he become unstable?

—Dr. Harvey: Excellent question, Jocelyn! You are right that he looks alive and not dead. But he is ‘brain dead.’  Brain dead people are dead even though there is a beating heart and measurable vital signs. You see, the heart is beating but the body is not alive. The organs are kept alive by the ventilator but they are not really integrated into a body because there is no brain function. If the organs are not integrated then what you have is really a disintegrated corpse.

—Jocelyn (after another moment of hesitation): Thank you doctor, but if this is a disintegrated corpse, how come the blood counts, the chemistry panel, and the other lab results are all normal?  Doesn’t that suggest that the organs are integrated? Also, I read in the chart that the wounds that he sustained during the accident are all healing well. 

—Dr. Harvey: Another excellent question, Jocelyn! Well, I was giving you a short and simple answer because that’s how we were initially told to think about brain death back in the 1970s. But your remark is spot on. Now, we are not too sure about whether brain dead bodies are integrated or not. 

In fact, there have been dozens, if not hundreds, of documented cases of patients who received the diagnosis of brain death and remained quite integrated for weeks, months, and some even for years.  One young boy diagnosed with brain death at age 4 survived for another 20 years!  Oops, I shouldn’t say “survived,” because I believe he was already dead at age 4, but nevertheless, his body went on for another 20 years during which time it grew and demonstrated all sorts of integrative functions.

There have been cases of pregnant women diagnosed with brain death who were kept alive–Oops again!–I should say, whose bodies were kept alive for weeks or months, in order to allow the baby to come to maturity. So. the notion that brain dead bodies are only “collections of organs,” seems pretty hard to justify. 

But the question of bodily integrity is now a side issue because even if brain dead bodies are integrated, we now believe that they are not human bodies.

—Jocelyn: “Not human bodies? What kind of bodies are they?”

—Dr. Harvey: Well, that’s a difficult question to answer, but some philosophers—some Catholic philosophers in particular—have argued that when the brain function is completely and irreversibly lacking, then the body cannot be united to a rational soul because the brain is necessary for rational activities and human souls are by definition rational souls.  

Now, I don’t know about that argument because I’m not Catholic, but other philosophers have proposed that when a body is permanently unable to engage in a work of…uhh…they call it…uhh… “commerce,” or…uhh… “self-preserving commerce”…, that’s right. When a body cannot engage in “self-preserving commerce” of exchanging input and outputs with the outside world, then it is not properly a whole body, or a live body, even if it is integrated, and even if its parts are alive.

I know all this is complicated, and I’m not sure I understand it myself, but from my perspective, none of this matters because look at this patient here: permanently unconscious, permanently attached to the ventilator and connected to a feeding tube: Who would want to live like this anyways?”

At this point Jocelyn kept quiet and had no further questions to ask. But she pondered about the sequence of arguments she was presented with: first, that a body is not alive because it is really only a collection of living tissue, next that it may be a living body, but is not really human, and finally, it may be human, but not really worth a human life. That sequence of arguments  seemed dreadfully familiar.

Now, this imaginary dialogue is, of course, imaginary.  But it is not unrealistic. It actually summarizes the main arguments that have been brought forth to defend the concept of brain death.  I will now briefly examine these arguments and provide some objections:

First is the argument from integration: Without the brain and its complex and pervasive influence on many living processes, the argument goes, the body is no longer a body but only a disintegrated collection of organs. A necessary secondary argument is that the intensive care, the ventilator in particular, temporarily “masks” the fact of disintegration so that the body appears integrated when it really is disintegrated and decomposing. 

But that argument is false and untenable on 2 major grounds. 

First is the large empirical evidence that brain dead bodies can survive a firm diagnosis of brain death¹ and, when they do, they show incontrovertible signs of being integrated and resistant to decomposition until they really die of a cardiac arrest.

Second is the philosophical argument that a part cannot integrate a whole. The brain is a part of the body and therefore depends on the body. That which depends on the body cannot be the cause of its integration as a body. Otherwise, the effect would depend on the cause, which is absurd. 

Besides, if the brain integrates the many parts of the body, what is integrating the many parts of the brain? This is a very important question because brain death advocates keep changing the definition of what the brain is. It used to be that everyone agreed that the hypothalamus and pituitary glands were part of the brain. Now brain death advocates wish to redefine the boundaries of the brain and exclude certain structures they find inconvenient to their hypothesis.²

Furthermore, the body is not a mechanical assemblage of parts. The body is an integrated being from the moment of conception when it is a single cell, and it develops into parts from within. What controls the development and the integrity of the body is, of course, the soul, not the brain. It is the absence of the soul–its separation from the body–that defines death, not the absence or separation of the brain.

Moreover, the argument that the ventilator “masks” the disintegration of the body caused by the absence of the brain makes no sense. Are we to believe that an instrument as rudimentary as the ventilator–essentially a plastic tube connected to mechanical bellows–masks the work of an organ as complex and powerful as the brain? Are we to believe that basic insufflation is enough to fool us into thinking that the dead are alive?

Now, most defenders of brain death have actually abandoned the claim that the brain is the integrator of the body. Instead, many now claim that the brain dead body is integrated and alive but it is no longer human or no longer a person.

Some Catholic philosophers hold that view. They hold that the brain dead body is no longer human because they believe that the humanity of a body depends on the possibility of exercising rational functions. Once the brain is destroyed and there is no possibility for rational activity, they argue, the rational soul must have departed that body. 

But that is a gratuitous and dangerous assertion that is begging the question. It may be clear that the brain dead body will never engage in rational acts and be forever in a dependent, vegetative state. But that does not mean that its human nature has vanished, nor that the person with his or her full dignity has vanished.  

And those who argue that the brain dead body is not human or not a person have to answer Jocelyn’s question and tell us what kind of body is it? Is it a plant? But it has kidneys and a beating heart! Is it a monster, half-plant, half animal? And who created it if it is not the same body that existed before the injury?  

All this is clearly untenable.

Footnotes:

1. A declaration of “brain death” is typically a self-fulfilling prophecy since, as a consequence of receiving this “diagnosis,” a person is either taken off the ventilator and then dies a natural death, or is taken to the operating to have his or her organs harvested and then dies an unnatural (and rather violent) death.  In the late 1990s a pediatric neurologist from UCLA, Dr. Alan Shewmon, published a large series of cases of brain death where, for one reason or another, the ventilator was not discontinued yet the patient survived, belying the argument that the ventilator “masks” the true death of brain dead patients. In the 1970s, brain death advocates were asserting that after a diagnosis of brain death the bodies would shows signs of decomposition within days, and it was better to act quickly in order to spare family members and hospital staff the distress of witnessing the process of putrefaction.

2. The statutory definition of brain death is “irreversible cessation of all functions of the entire brain, including the brain stem.”  But many patients who meet the neurological criteria for brain death (obtained from a series of tests and provocative maneuvers performed at the bedside), continue to show evidence of hypothalamic and pituitary function.  In order to avoid a flagrant contradiction, brain death proponents now want to argue either that the pituitary and hypothalamus are not really part of the brain, or that their function is not a “critical” function, which is really begging the question.

The refutation of the various arguments for brain death takes a lot of work. The above is just a superficial sketch of only a few aspects of the arguments on both sides. Dr. Doyen Nguyen has recently published a magnificent treatise in which she carefully and systematically demolishes all the claims for brain death. Her book is a real tour de force.

Brain death is a grave social evil but it is  also a fascinating multidimensional topic. I plan to write more about it in the weeks to come.