Integrity in the Concept and Determination of Brain Death Recent Challenges in Medicine, Law, and Culture
The recent symposium on brain death organized by The National Catholic Bioethics Center (NCBC), The Center for Law & the Human Person at the Columbus School of Law of The Catholic University of America (CUA), and the Pellegrino Center for Clinical Bioethics at Georgetown University achieved a remarkable success in bringing together a broad spectrum of leaders from Catholic health care, the United States Conference of Catholic Bishops, academics, lawyers, and health care professionals for a robust and productive exchange of views on the many issues raised by the concept and determination of brain death.
Dr. John Brehany, the NCBC’s Executive Vice President & Director of Institutional Relations, deserves great credit for bringing together the many elements needed for a successful symposium. He also served as the moderator for the two days. He commented: “It can be daunting to address complex, contentious issues in bioethics. And so, it was a blessing last week at the symposium to see so many diverse people come together to learn, reflect, and dialogue on how to respond to the challenging issues posed by the breakdown in clinical and legal standards for the determination of death by neurologic criteria. I hope and pray that we can successfully build upon this effort.”
A conscientious attempt was made to achieve fair representation of opposing positions in an atmosphere of a common search for the truth in charity. I have seen how deeply held contradictory beliefs can lead to acrimony and ad hominem exchanges that generate more heat than light. Throughout this symposium the speakers and participants maintained not only civility but a fruitful exchange of views, even when taking different sides of the debated issues. The co-sponsorship by the Center for Theology & Ethics in Catholic Health of the Catholic Health Association, the Catholic Medical Association, Franciscan Health, and OSF Healthcare showed a deep interest in the symposium by major organizations in the US Catholic health care world.
The search for common ground to move forward yielded several results. For example, there was a shared acknowledgment that scientific evidence on key aspects of brain death is lacking and that knowing more would be extremely helpful to medical professionals and the public. Dr. Carlo Tornatore offered to leverage his position as chair of the department of neurology at Georgetown University Medical Center to conduct research on the risk factors for and prevention of brain death. He referred to the currently used clinical examination as a “blunt instrument” that should be replaced by modern diagnostic tools like the four-vessel angiogram. Despite the greater cost of this test, it was seen as the “Gold Standard” towards which medical centers should be striving.
Another Georgetown physician, Dr. Allen H. Roberts, proposed that the apnea test, which plays a key role in the clinical determination of brain death, represents enough risk of harm that it should not be performed without the informed consent of the medical proxies of the patient. This is not the current position of the American Academy of Neurology, but it was agreed by most participants at the symposium.
Among those who accept the concept of brain death, another point of agreement was that medical professionals should receive training and certification in diagnostic procedures for determining brain death rather than the current situation where very little is required of those doing these tests beyond a medical diploma. There seemed to be similar accord that more than 48 hours need to elapse between a traumatic brain injury and an attempt to diagnose brain death.
A significant portion of the symposium was devoted to the adequacy or inadequacy of the American Academy of Neurology’s 2023 guidelines. The question of hypothalamic function in the brain played an important role in this debate. The 2023 guidelines explicitly state that a diagnosis of brain death is compatible with hypothalamic function. Some argued that glandular activity does not add to the life function. This was strongly refuted by the long list of important vital functions of the hypothalamus such as body temperature and blood pressure regulation, and controlling our hunger, thirst and sleep.
Beyond the issue of hypothalamic function, however, Dr. Heidi Klessig pointed out the danger of mistaking global ischemic penumbra for brain death when brain tissue may no longer be functioning due to lack of blood flow but can still revive if oxygenation is restored. Presenting the view that the 2023 guidelines are not valid, she noted that Jahi McMath met all the brain death criteria, including lack of hypothalamic function, but regained hypothalamic function months later.
Perhaps most decisively from my perspective was the reminder of the address from the year 2000 by Pope Saint John Paul II that a minimum definition of brain death that “does not seem to conflict with the essential elements of a sound anthropology” is one where rigorous testing is done to ascertain “the complete and irreversible cessation of all brain activity.” Given the agreement that the hypothalamus is part of the brain, any clinical testing for brain death that formally excludes functioning of the hypothalamus is only determining partial rather than whole brain death.
NCBC President, Dr. John A. Di Camillo, had this to say after the conclusion of the event:
“This successful symposium on the determination of death demonstrates the critical role of The National Catholic Bioethics Center. It is humbling and inspiring to foster personal encounters and intellectual exchange among key stakeholders of differing viewpoints in a constructive manner. Our unity in Christ enables us to advance these conversations even when there are major differences of opinion. Without a doubt, this is a model for future symposia on unsettled issues that profoundly impact real-life decision-making.”
Joseph Meaney received his PhD in bioethics from the Catholic University of the Sacred Heart in Rome. His doctoral program was founded by the late Elio Cardinal Sgreccia and linked to the medical school and Gemelli teaching hospital. His dissertation topic was Conscience and Health Care: A Bioethical Analysis. Dr. Meaney earned his master’s in Latin American studies, focusing on health care in Guatemala, from the University of Texas at Austin. He graduated from the University of Dallas with a BA in history and a concentration in international studies. The Benedict XVI Catholic University in Trujillo, Peru, awarded Dr. Meaney an honorary visiting professorship. The University of Dallas bestowed on him an honorary doctorate in Humane Letters in 2022.