By Wadud Abbasi
The Oxford Language Dictionary provides that death is “the permanent ending of vital processes in a cell or tissue.” While this simple definition has been upheld prior to the early twentieth century, the development of new medical technologies that can detect and monitor brain activity and other organs prompted its change, specifically coming from Harvard Medical School. After daughter Karen was found not “brain dead” in the seminal New Jersey Supreme Court ruling on Garger v. New Jersey (1976), the Court discussed changing the definition of death. The Court approved standards from the Ad Hoc Committee of the Harvard Medical School in describing brain death as the “absence of response to pain or other stimuli, pupillary reflexes, corneal, pharyngeal and other reflexes.” But the controversy has not finished.
Would you kill someone to save the lives of others? Naturally, we would respond ‘no.’ But how would you know that you did not kill your patient after his organs were removed, or did not announce him dead incorrectly? Of course, to calm controversy surrounding ‘accidentally being buried alive,’ the Uniform Declaration of Death Act (UDDA) proposed measures to clarify the line between life and death.
The UDDA states that:
An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.
The “irreversible cessation of circulatory and respiratory functions,” meaning undoable damage to breathing and pulsing, is deemed as a determining factor for an overwhelming majority of cases. The second part clarifies that the full upper systemic nervous system has to stop working before the declaration of death (often done by a CT scanner). The cerebral hemispheres (upper brain) control memory, consciousness, knowledge, and thought, while the brain stem (lower brain) controls the circulatory system (lungs, heart, blood, etc.). Brain death is often after the onset of strokes or blood clotting in the brain that causes it to swell and push against the skull. This inhibits the flow of necessary oxygenated blood, which can cause neurons to break down and liquefy. To be legally “brain dead,” both the upper and lower brain must cease to function, meaning a person can be permanently unconscious but still perform bodily functions under an artificial ventilator. However, the UDDA still opens the conversation to the states of America.
When the National Conference of Commissioners on Uniform State Laws (NCCUSL) recommended the enactment of the UDDA in all states in 1980, some states added additional regulation. For example, the determination of death in Florida must be performed by two doctors -- the treating physician and a board-eligible neurologist, pediatrician, surgeon, anesthesiologist, or internist. On the other hand, Texas claims that a registered nurse or physician’s assistant alone can declare death (including brain death).
Despite the differences, the significance of the UDDA still remains fundamental to many legal practices. Calling this final decision eliminates the ambiguity and hastens the process when it comes to criminal cases, life insurance, estate laws, and especially organ donation. Actually, ongoing medications, like cyclosporine in 1980, sparked a need for a modified procurement policy, or in other words, the “Dead-Donor-Rule” (DDR). However, the DDR and UDDA are not definitive rubrics to assess for life. A patient can lose the function of its integral brain cells to maintain consciousness but still have living homeostatic ones that control body temperature. In this case, not “all functions of the entire brain” have ceased to work. Questions also arise whether death should be proclaimed by brain death and cardiopulmonary death, death mainly caused by an irreversible sudden cardiac arrest or ventricular fibrillation. In a changing political and biomedical world, modern ethics makes the question of death far from permanent.
Comprehension Questions:
How do modern prerequisites to be declared dead differ from past attempts?
While there exist different regulations following the death of humans, most orthodox beliefs claim that as long as the heart is still beating -- even with the use of an artificial ventilator -- a person is still living. Most scientists believed in resuscitation, where they could summon life from a dead organism by ‘pinching’ specific organs that can stimulate the body. But to this day, physicians and surgeons can identify death by testing for reflexes (e.g. dilated pupils), responses from the central nervous system or the circulatory system. Dyes (angiogram) can be transmitted inside the blood to determine whether blood flow reaches the brain.
How is brain death different from permanent unconsciousness?
Definitions of brain death still have their gray-areas; however, a person who is permanently unconscious but still has blood circulated through his/her body is not considered brain dead, since the brain stem would still be active.
References
Black, P. M. L. (2014, December 19). Three definitions of death. OUP Academic. Retrieved February 13, 2022, from https://academic.oup.com/monist/article-abstract/60/1/136/997314?redirectedFrom=fulltext
Defining death. The Australian Museum. (n.d.). Retrieved February 13, 2022, from https://australian.museum/about/history/exhibitions/death-the-last-taboo/defining-death/
New Jersey Law Revision Commission. (n.d.). Retrieved February 13, 2022, from https://www.njlrc.org/
Sade, R. (2011, August). Brain death, cardiac death, and the dead donor rule. Retrieved February 28, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372912/
What is the Uniform Declaration of Death Act (UDDA)? Findlaw. (2018, June 12). Retrieved February 13, 2022, from https://www.findlaw.com/healthcare/patient-rights/what-is-the-uniform-declaration-of-death-act-or-udda.html
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