Determining Clinical Death:

1. Determining Clinical Death: Some Current and Future Ethical Challenges Elliot D. Cohen, Ph.D.

2. What is Death? The Layperson�s Definition: If it walks like a duck, quacks like a duck, and looks like a duck then it is a duck. Likewise, if a person looks like he�s dead (is non-responsive) and you can�t get a pulse, then he is in fact dead. Case closed! Unfortunately the determination of death is not always so cut and dried.

3. Are these patients really alive or dead? A patient who has intact lower brain-stem functions but no higher cognitive functions. A patient who is still breathing on a respirator but has minimal or no intact upper or lower brain functions. Isolated brain cells that are still alive, or very small electrical charges showing up on an EEG, but no supercellular brain functions.

4. The Determination of Death As Cultural �Human death is understood, defined, and declared in cultural frames with diverse understandings of the value and definition of persons, communities, and transcendent obligations.��Steven Miles, M.D. �The physician can only describe the physiological state which he observes; whether the patient meeting that description is alive or dead; whether the human organism in that physiological state is to be treated as a living person or as a corpse, is an ethical and legal question.��J.D. Bleich, Rabbi

5. So how does the current cultures of law and medicine in the U.S. define death?

6. Total stoppage of the circulation of the blood, and a cessation of the animal and vital functions consequent there on, such as respiration, pulsation, etc. Common Law Definition of Death: Black�s Law Dictionary Definition

7. Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death (1968) �Our primary purpose is to define irreversible coma as a new criterion of death.�

8. Primary Reasons for Redefining Death According to Harvard Committee 1) �Improvements in resuscitative and supportive measures have led to [cases in which an individual�s] heart continues to beat but whose brain is irreversibly damaged. The burden is great on patients who suffer permanent loss of intellect, on their families, on the hospitals, and those in need of hospital beds�� 2) �Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.�

9. How did the old common law standard lead to �controversy� in obtaining organs?

10. �The Controversy� You Had to wait for the donor to stop breathing and then it was only minutes before the organs deteriorated and could no longer be used.

11. Shift from common law definition of death in terms of total loss of cardiopulmonary functions to a whole brain definition. The Harvard Committee�s Solution:

12. Harvard Criteria of Clinical Death: A Permanently Non-Functioning Brain Unreceptivity and unresponsivity�the patient is completely unaware of externally applied stimuli and inner need. He/she does not respond even to intensely painful stimuli. No movements or breathing�the patient shows no sign of spontaneous movements and spontaneous respiration and does not respond to pain, touch, sound, or light. No reflexes�the pupils of the eyes are fixed and dilated. The patient shows no eye movements even when the ear is flushed with ice water or the head is turned. He/she does not react to harmful stimuli and exhibits no tendon reflexes. Flat electroencephalogram (EEG)�this shows lack of electrical activity in the cerebral cortex. 

13. �Get�um While They�re Hot� Harvard criteria permitted donors to be pronounced dead while their hearts continued to beat. This allowed donors� organs to be harvested before they degraded due to lack of oxygenation.

14. But Is it ethical? �The irresistible utilitarian appeal of organ transplantation has us hell bent on increasing the donor pool�these practices will inevitably pit our insatiable longing for better health and longer life against our deep seated notions of sacred and profane.��Arnold and Youngner

15. Do not treat Patients as Mere Objects �[T]he body of the comatose, so long as-even with the help of art-it still breathes, pulses, and functions otherwise, must still be considered a residual continuance of the subject that loved and was loved, and as such is still entitled to some of the sacrosanctity accorded to such a subject by the laws of God and men. That sacrosanctity decrees that it must not be used as a mere means.� �Hans Jonas

16. Uniform Definition of Death Act (1982) � 1. [Determination of Death]. 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. Part (1) codifies the existing common law basis for determining death - total failure of the cardiorespiratory system. Part (2) extends the common law to include the new procedures for determination of death based upon irreversible loss of all brain functions. The overwhelming majority of cases will continue to be determined according to part (1). When artificial means of support preclude a determination under part (1), the Act recognizes that death can be determined by the alternative procedures.

17. Still Not Enough Vital Organs: The Use of Controlled Non-Heart Beating Donors (NHBD)

18. �To provide an ethically justifiable and auditable policy that respects the rights of patients [and their families] to have life support removed and to donate organs if they wish to do so.� Non-Heart-Beating Cadaver Donors: The University of Pittsburgh Protocol (1992)

19. The Pittsburgh Protocol Transplantation does not have to await whole brain death. Instead, patients who are not brain dead (on the Harvard standards) can be removed from life support and their organs harvested. Death is defined as �irreversible cessation of circulatory and respiratory functions� (pursuant to Uniform Definition of Death, Part1) Must wait two minutes from the time heart stops beating before pronouncing death. If a patient�s heart does not stop beating after one hour, then he/she is rendered unsuitable for organ transplants.

20. Pittsburgh Protocol Ethical Guidelines Health care providers cannot initiate discussion with patients and families regarding becoming a NHBD. The physician who cares for the patient, weans patient from respirator and pronounces death cannot be affiliated with the transplant service. Transplant surgeons must not be involved with management of potential donors before their death. Narcotics and sedatives used to manage pain must not be used in �preserving a more usable transplant or in regulating the time of death.�

21. Ethical Questions Raised by NHBD Protocol Does NHBD make doctors willing accomplices to seeking the death of their patients for reasons other than their patients� own good? Granted that the NHBD protocol attempts to draw a line between the team treating the patient and the procurement team, is it reasonable to expect that healthcare providers will not allow their interest in making transplantable organs available to influence the quality of care they give to patients?

22. Two Fundamental Moral Rules Governing Organ Procurement Dead Donor Rule: Vital organs should only be taken from dead patients, and living patients must not be killed by organ retrieval. Living Patient Care Rule: Living patients must never be compromised in favor of potential organ recipients.

23. Ruben Navarro Case (February 26, 2006) 25 year old patient with adrenoleukodystrophy,� celebral palsy, and a seizure disorder, who had suffered a heart attack and was on life support. �Transplant nurse administered 20 mg morphine in ICU.� No evidence of distress� Patient moved to operating room where life support was removed. Over one hour an additional 180 mg morphine and 80 mg Ativan administered by nurse on orders from transplant surgeon, Dr. Hootan Roozrokh. At one point Roozrokh ordered betadine infusion via feeding tube. Roozrokh took Navarro�s pulse and suggested that electronic monitors may have been showing pulseless electronic activity� � But nurse said she saw Navarro�s heart beating and heard it when she examined him. �Patient returned to ICU where expired after approx. seven hours.� Organs were not harvested.

24. Redefining Death in an Age of Stem Cell Research and Cloning

25. Regenerating Brain Cells Researchers have already isolated a particular gene that directs certain stem cells to turn into cerebral cortex cells, the upper part of the brain largely responsible for cognition. Researchers have also been able to �reawaken� the generative powers of stem cells that lie dormant in the brain stem, the lower part of the brain that controls autonomic functions such as breathing and heart rate. They have also begun to transplant stem cells into the brains of stroke victims. These and other breakthroughs of the past year alone point to the imminent possibility of being able to regenerate the cerebral cortex or brain stem of a human brain that has become nonfunctional due to trauma, diseases such as Parkinson�s and Alzheimer�s, or even old age. Predictably, this progress will raise serious ethical challenges.

26. Some Implications for The Definition of Death Current standards of death are rendered obsolete because brain damage is no longer irreversible as required by these standards. No longer necessary to make determination of clinical death dependent on organ procurement. Problem of personal identity raised because regeneration of cerebral cortex would not restore past memories.

27. Just for the Memories �Had we no memory we never shou�d have any notion of causation, nor consequently of that chain of causes and effects, which constitute our self or person.�--David Hume In other words, the sequence of all of our life experiences that make us who we are would be lost.

28. The Problem of Personal Identity Raised by Brain Cell Regeneration Would a patient be considered dead if all his past memories were irreversibly destroyed even though his (upper and lower) brain were restored to functionality and all other bodily functions remained intact?

29. Let�s Speculate:What would the definition of clinical death look like in an age of organ cloning? Shift away from whole brain definition to a partial brain definition in terms of cerebral cortical function. Shift away from a definition purely in terms of brain functionality to one based on brain (memory) content.

30. Do You have an Updated backup copy? Clinical Death = destruction of higher brain functionality with total and irreversible loss of memory.