Brain-Death: What for?

AT A funeral in my hometown recently, a young executive came to the table I was seated at, and must have had prior knowledge of what I do for a living. He asked me firmly, even if politely, what I thought might have "killed" the 28-year-old who was involved in a "high-velocity vehicular injury", seated next to the driver, twelve weeks earlier.

He said the Medical Officer in attendance, when the victim was delivered at the district hospital, had told the loved ones who accompanied him that "he was gasping on arrival and died shortly thereafter." Don't we forget, the Philosopher and Scientist, Aristotle, [384-322 BC (also teacher of Alexander the Great)], understood the body and soul to function together, and that "both were located in the heart."

Hufeland (1762-1836), Royal Physician in Weimar, Germany, saw the different entities, "breathing" and "heart action," however, as "essential for retention of life," and that both must "cease" when death occurs. Death, as it is understood today, seems to take a slightly different meaning from the way medical men and society understood it in yesteryears, (from Aristotle through Hippocrates, until modern times, altogether some five thousand years).

With death, the individual's life has ended, and no therapeutic consequences could any longer be relevant. Anything that "the particular dead individual" would have been obliged to execute would have to be done on his behalf by an authorised person. Anybody found responsible for the death would usually be made to face the law, with possible consequences, i.e. should the death be deemed "unnatural." As the dimensions regarding law and ethics widen, the more the issue of death is looked at with criticism.

For almost 200 years now, natural Science has given the expression "death" a new momentum. Death in the past meant that the heart had stopped beating. Scientific development, "evolution" in Electricity and the subsequent application thereof in medicine (Electrocardiogram, EKG), encouraged the French Anatomist Bichat to introduce, for the very first time, in the field of medical practice, the expression "Brain-Death" in 1800.

When the heart ceases to beat, it could be brought to re-start beating by employing electrical stimulation. In other words, separation between breathing and the beating of the heart is possible.

Respiratory action was artificially introduced in its primordial, as a "kiss of life", when the person "giving life" to another would breathe "actively" into the lungs of the victim, who is rendered incapable of breathing herself/himself, by disease, or some force, through the mouth.

This could happen anywhere, including in the street. It could be extended further by introducing "an artificial tube", through which air could be made to pass down into the lungs, either by blowing it through the mouth, or through an apparatus named "Ambu-bag."

An extension (improvement) could be achieved through a machine called the mechanical ventilator, or respirator. The respirator is capable of functioning interminably, using a source of electrical power in a closed system.

A state, designated as "Coma depasse," coined by Mollaret & Gullon in 1959, delivers an entity in which "artificial breathing is made possible", "ad infinitum." These data have been subjected to scientific as well as religious and eugenic discussions, especially in the last fifty years, mostly in Christian Europe.

Then, in 1968 the "Committee of Harvard Medical School" organised a meeting, bringing together other than doctors, legal experts, as well as moral philosophers, to determine exactly what kind of criteria to lay down for "brain death" that could not so easily be questioned.

In Europe, Catholic and Protestant Clergymen, (Bishops) had to knock their heads together in order to reach a consensus, which would be acceptable, and this was because organ donation, and transplantation, both as a unit, would soon come to hang like the Sword of Damocles over the heads of communities.

Prolonged discussions had to take place, and Encyclicals from the Vatican were not avoidable. A special entity affecting pregnant women had to be carved out. Situations in which a pregnant woman could sustain any injury that might lead to irreversible shock, and eventually "brain death" all of a sudden, and the babies might not yet be viable, had to be spelled out.

The best solution, after almost interminable discussions, looked like this: Life support should continue until the baby may be deemed viable. Under "life-support" are measures that keep respiration and circulation afloat. Solutions that keep the cells of the subject adequately nourished (calories, electrolytes, oxygen transport, and all such processes that take place in the mitochondria, etc), are also included.

External, as well as internal temperatures need to be regulated. In the situation of a "fetus-carrying-brain-dead-mother", the process of artificially keeping the baby alive until delivery per Caesarean section may electively take place several months later, is the crux of the matter.

Expertise acquired lately by pediatricians of taking care of premature babies, delivered under other circumstances, and "nourishing them into survival" have reduced the extent, and the need of these cutting-edge procedures.

To what avail is the concept of brain-death, and the ballyhoo accompanying it? Simple! It is true that either due to our way of life, or God-ingrained systems, we tend to die, until recently, an awful lot earlier than the "God-promised three-score-and ten" years.

Those who study animals could swear to God on us that lions live exclusively on meat, but the incidence of heart attack, or myocardial infarction killing them is not anywhere near that of ours, as homo sapiens. We store the meat and eat it at leisure, and not only when we are hungry.

One of the many prices we pay is that we lose such organs as the heart, the kidney, and let us stop just here, (there could be many more), prematurely to disease. But, since the last fifty years, we have been clever enough to learn how to explant a useful organ from a brain-dead individual, and implant it in another, with an end-stage sick organ. (commonly the Heart, or Kidney).

Patients have lived three decades with a transplanted heart in South Africa, (transplanted by the late ace and pioneer Cardiac Surgeon, Christian Barnard). Kidneys are routinely transplanted these days, not only in the West, but in the Middle East and India as well.

It has been communicated to the readers of The Chronicle in previous entries, how for the future (into the future), STEM-CELLS should best bail us out. With stem-cells, the hazard of type-incompatibility, and hence organ rejection should no longer be an issue.

When we have reached that far, no longer should the essence of brain death certification be relevant. Not quite. Life-support and intensive care are the extremes of "money-spending" in the practice of medicine to date.

That being the case, it would make sense to be able to scientifically determine and pronounce individuals "brain-dead" when they fulfill all the conditions.

It would in quintessence ease the decision making to halt all measures that cost heaps of money, but are of no avail in the long run.

This may not always be that simple, given the circumstances. On the other side of the coin, let us say that it would not be a bad idea at all, if in our community too, knowledge about the end–debacle of life were free to be shared more openly.

Perhaps, we would learn to preserve life better, so that we may not lose it at times, so carelessly, and so prematurely. The gentleman whose untimely death triggered the discussion in this entry might have been prevented, if the facility he was brought to had the back-up for life-support. Scientific arguments exist that, perhaps, in this century, medical science might add another score to our lifespan to begin with.

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