"Brain Dead" Boy "Dies"

The case of M.B., the 12-year-old boy whose Orthodox Jewish parents sought to have his life support continued after he was declared dead by neurological criteria, is over. From the story:

The boy had already been declared brain dead, but some adherents of Jewish religious law say death occurs only when the heart and lungs stop functioning. The family had asked a judge to prevent further tests for brain activity. The hospital argued that its "scarce resources" were being used "for the preservation of a deceased body."

For the parents and those who do not accept "brain death" it means MB has actually died. For those who accept the concept, it means his body could no longer be kept functioning--which almost (but not) always happens with the bodies of those declared dead by neurological criteria.

After my earlier post about this matter, I received some serious private blowback because I accepted the concept of brain death, assuming proper diagnosis. My critic believes that brain death is a utilitarian fiction designed to permit organ harvesting. Because I deeply respect the blowbacker (if you will), I checked with my medical and ethics sources again about this issue, and found continued support for the concept of brain death. Our private dialogue continues.

We will discuss this issue further because it is becoming a source of renewed controversy. Some of the attacks on brain death are coming from utilitarian bioethicists and organ transplant ethicists--who are saying, in essence, that since we are killing some patients for their organs--the so-called brain dead who they claim are alive--why not also allow access to unquestionably living patients with irreversible catastrophic brain damage? Stopping this agenda remains my prime concern in this area.

But some, who are anything but utilitarian, also believe that these patients are not dead. Rather than allowing patients with lesser brain damage to be organ sources, these advocates argue, such people are not bodies but patients, and as such they should not be used as donors at all until they are declared dead by cardio/pulmonary criteria. If brain dead is not really dead, they are right.

But let's leave the matter be for now. A young boy has died leaving rending grief in the tragedy's wake. Our deepest sympathies to M.B.'s family who unquestionably tried to do right by their boy. May he rest in peace.

A Miracle or a Mistake?

Zack Dunlap was apparently killed in an auto accident and his organs were going to be procured, when he "came back." From the story:

Natalie Morales: What did the doctors tell you at that point?
Pam Dunlap: She just said it wasn't good.
Doug Dunlap: She said brain matter was coming from Zack’s ear.
Pam Dunlap: All I can remember is just being down on my knees saying, you know, "No. No, God, no. This isn't going to happen." Zack was Medivac’ed to a hospital 50 miles away, in Wichita Falls, Texas--one equipped to deal with traumatic brain injury...

Natalie Morales: Were the doctors giving you any sense of hope?
Doug Dunlap: They were already saying he was brain-dead. (Looking at brain scan)
Natalie Morales: So, when you see this, I mean, he was in a permanent vegetative state?
Dr. Mercer: No, he was dead. He meets the legal, medical requirements for declaring a patient brain dead. Tough as it was, the Dunlaps decided against keeping Zack on long-term artificial life support.

The Dunlaps agreed to organ donation. But they also turned to God and prayed for a miracle. That's when Zack's condition appeared to change. A nurse scraped his foot and he reacted. From the story:

Natalie Morales: As a trauma surgeon and seeing this 21-year-old coming back to life, do you have any sort of medical explanation that you know of?
Dr. Mercer: I don't.
Natalie Morales: Were any mistakes made, or was the process rushed along in any way to declare him brain dead because the family made you aware that he was an organ donor?
Dr. Mercer: No. We didn't rush anything along. We certainly don't do that.
Pam Dunlap: We saw the test. We saw it. They followed every procedure. He was gone.
Natalie Morales: So there is no blame?
Pam Dunlap: There's no blame in a miracle. And there never will be for us.

I understand why Pam Dunlap would embrace the miracle, but we should be more skeptical. This much is sure: Either it was a miracle--which raises interesting issues in itself--or Zack wasn't really and truly dead.

Which it is matters a whole lot. Thus, Zack's "miracle" should not be left as a wonderful and heart warming television story. It needs a deep and meticulous investigation to ensure the public that a living man was not prematurely declared dead. Or, if he was legitimately declared dead, we need to be assured that the criteria used were appropriate. If they were appropriate, we also need to know whether they need to be reviewed. For example, was enough time allowed to pass from initial declaration of brain death until a second confirming test? Was there a second test?

In any event, leaving it as a "miracle"--even if it turns out to be true--just won't do. Answers based on the records and the scientific knowledge of this matter are clearly required to make sure that if God was not involved, that what almost happened to Zack doesn't happen again.

The Need for Uniform Criteria to Declare Death by Neurological Criteria

I have written several posts about the need to develop uniform standards of declaring death by neurological criteria--popularly known as "brain death." Now, there's some more information out about that problem. From the story:

Guidelines for determining brain death differ substantially between major U.S. hospitals, a national survey shows, and few stick to parameters established by the American Academy of Neurology.

"There are substantial differences in practice that may have consequences for the determination of death and initiation of transplant procedures," Dr. David M. Greer, at Massachusetts General Hospital in Boston, and colleagues report in the medical journal Neurology.

Greer's team requested guidelines from hospitals named as having the top 50 neurology programs in the nation in 2006 by US News and World Report. Only 42 percent of the hospitals required that a neurologist or neurosurgeon perform the examination for brain death, results showed. Among the 71 percent that stipulated multiple examinations, the time required between examinations varied from 1 to 24 hours. Furthermore, the authors point out, "It was surprising to find that the cause of brain death was not stipulated in a large number (37 percent) of guidelines."

This is a very serious matter. The trust of the American people depends on getting this most fundamental matter right.