The Illusion of “Brain Death”

Are “brain-dead” patients truly dead or, rather, severely disabled but living human persons? This distinction is literally a matter of life or death, and it is a matter of practical significance for every American who has a driver’s license.

Since its introduction by the Harvard Medical School Ad Hoc Committee in 1968, “brain death” has been a subject of controversy, including among Catholics. The critical issue is whether “brain-dead” patients are truly dead or, rather, severely disabled but living human persons.

This distinction is literally a matter of life or death, and it is a matter of practical significance for every American who has a driver’s license. If you chose to become an organ donor on your driver’s license, you can be declared dead using “brain death” criteria prior to your organs being harvested for transplantation. If “brain-dead” patients are alive, the act of organ harvesting would be the cause of your death and, as such, violate your inherent dignity, that dignity which forms the principle and basis for all of Catholic social teaching.

The validity of “brain death” has been argued, at times fiercely, for decades among Catholic physicians and scholars. Catholic lay persons, as well as priests and bishops, may ask themselves: How can I possibly know what to believe? The task of ascertaining the truth seems daunting, if not impossible, for a nonexpert.

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Some think it best to safely assert that “brain death” is contentious, that differing opinions exist among faithful Catholics, and that the issue should not be publicly discussed lest people’s consciences be unnecessarily troubled. However, by not challenging the existing paradigm, this “neutral” approach effectively endorses the status quo which sanctions organ harvesting from “brain-dead” patients.

Perhaps an easier and more pragmatic question to ask for those seeking to inform their consciences on the issue of “brain death” is: Should I support the utilization of “brain death” criteria in clinical practice? While this question is related to whether “brain death” is valid, they are not identical. The question of whether “brain death” is valid need not be definitively answered in order to answer the question of whether it should be utilized in clinical practice.

The degree of certainty needed before making a decision is predicated on the consequences of being wrong. In the case of “brain death,” if “brain-dead” patients are alive, then the act of organ harvesting is the cause of their lives ending. Because the stakes are so high, for Catholics to utilize the notion of “brain death” in clinical practice requires us to possess the highest degree of moral certainty.

Pope Benedict XVI articulated this approach in this way in his 2008 “Address to Participants at an International Congress organized by the Pontifical Academy for Life”:

In an area such as this [the determination of death], in fact, there cannot be the slightest suspicion of arbitra[riness] and where certainty has not been attained the principle of precaution must prevail…. The principal criteria of respect for the life of the donator [donor] must always prevail so that the extraction of organs be performed only in the case of his/her true death. (Emphasis added.)

In other words, if any reasonable doubt exists whether “brain-dead” patients are actually dead, we should err on the safe side and respect the life of the donor. Does reasonable doubt exist? It unequivocally does. There is a large body of literature arguing about the validity of brain death, and a substantial amount has been penned by Catholics on both sides of the issue. Moreover, new medical evidence is regularly published which casts further doubt on our ability to accurately determine when death has occurred.

Before looking at two recent scientific research studies, let’s recall that death is defined as the moment when the soul, the substantial form of the body, ceases to inform and enliven the body. This moment cannot be directly determined because the soul is immaterial. So, we must look for indirect evidence that the soul is no longer present, namely that the body begins to disintegrate (to decompose) because its principle of integration, the soul, has left.

In August 2022, an article was published in Nature magazine describing the revival of “dead pigs.” The story was covered by The New York Times, Scientific American, CNN, NBC, and many other news outlets. Researchers anesthetized pigs and placed them on ventilators. Researchers then applied a battery to the pigs’ heart walls to cause an abnormal heart rhythm called ventricular fibrillation, which induced cardiac arrest (their hearts stopped). This resulted in cessation of the pigs’ blood circulation. After cardiac arrest, the ventilators were turned off. The result was that the pigs’ organs, tissues, and cells stopped receiving a fresh supply of oxygen.

The pigs were then divided into five groups. Three of these groups received no additional treatment, which allowed researchers to evaluate the degree of cellular injury at various time points: immediately after the ventilators were turned off and at one and seven hours after the ventilators were turned off. In a fourth group, the ventilators were restarted after one hour and the pigs received advanced medical care with an extracorporeal membrane oxygenation (ECMO) machine.

All the pigs receiving no treatment or ECMO subsequently showed signs of death: their bodies stiffened (rigor mortis), and the blood drained from their surface capillaries into the deep veins, resulting in purple spots on their backs where the blood pooled (livor mortis).

In a fifth group of pigs, the ventilators were restarted after one hour and the pigs received treatment with OrganEx, a proprietary combination blood substitute and delivery system which pumped solution through the pigs’ bodies. Afterward, the pigs were monitored for six hours. The hearts of these pigs began to beat again, albeit irregularly. They demonstrated “preserved tissue integrity, decreased cell death and restored selected molecular and cellular processes across multiple vital organs.” Cells in the heart, liver, kidneys, and brain began to function again. The pigs even demonstrated complex movements of the head and body when contrast material was injected into the carotid artery, the major blood vessel bringing blood to the brain.

While there was no coordinated activity in the pigs’ brains, such activity was inhibited by multiple factors. These include that the OrganEx solution was introduced at a temperature below body temperature and that anesthetic compounds and agents hampering neuron activity were present in the solution. Absent these factors, would the pigs’ brains have regained function? If the brains had regained function, would the pigs have regained consciousness? This same research group performed an experiment in 2019 in which the function of pig brain cells was restored up to four hours after death by a system similar to OrganEx, called BrainEx.

Recall that animals, like human persons, possess souls (albeit not rational souls) which animate and integrate their bodies. The findings in this experiment raise the question—were the pigs treated with OrganEx still alive? Were their bodies still integrated? Based on this experiment, it’s impossible to know, for evaluation for integration was not the intent of the researchers. But the results raise the possibility that the pigs’ souls were still present one hour after clinical death and, given the right type of medical support, could once again exert integration over their physical bodies.

Such speculation is not irresponsible. For generations, Catholic moral theology manuals have taught that the soul may remain within the body for some time after clinical death and that the sacraments can still be administered using a conditional formulation. A representative statement on this teaching is found in The Administration of the Sacraments, written by Nicholas Halligan, O.P. While reading this passage, remember that the pigs experienced a “sudden death” from induced cardiac arrest:

Extreme Unction cannot be given to one who is certainly dead. However, in a particular case death may be only apparent and not real, the only certain signs of the latter being rigor mortis and putrefaction. In the absence of these signs which lend certitude, the period between the apparent death and the actual cessation of all vital functions cannot be determined beyond reasonable doubt….

a) In cases of sudden death, such as from epilepsy, apoplexy, suffocation, drowning, electrocution, and similar violent deaths, it is likely that life lingers for some time after the apparent death of the person. Thus, in these circumstances a person may be anointed conditionally within an hour after apparent death, and even within two or three hours, especially if the person was in full vigor at the time of his demise. (In practice one may conditionally anoint the head of the decapitated.)….

b) Where a lingering illness has gradually consumed the person, it is considered that real death occurs shortly after all signs of life have ceased. Extreme Unction may thus be conferred within a half-hour of apparent death. (p. 350)

This is important to understand for all those involved in pastoral care in hospitals. It has been known to occur that pastoral staff will decline to administer the sacraments immediately after a doctor has declared “death.” But the doctor has no greater insight into when the soul has left the body than any other person. It is for this reason that priests have the ability (and possibly the duty) to administer the sacrament of Extreme Unction a half hour or even up to two or three hours after clinical death, using the conditional formulation, “If you are alive, I anoint you… I absolve you….” A similar conditional formulation can be used by laypersons and clergy for the sacrament of Baptism.

Another recent research article that made headlines and received widespread news coverage, including by The New York Times, NPR, and Forbes, was that surgeons attached kidneys from genetically modified pigs to two “brain-dead” patients in 2021. After harvesting the kidney from the pig, the kidney was attached to the blood vessels of the “brain-dead” patient. It was left outside the patient’s body, on top of the thigh, for ease of monitoring. Leaving aside moral questions related to transplantation between nonhuman animals and humans (xenotransplantation), let us consider what this experiment tells us about “brain death.”

The purpose of the surgeries was to determine whether a genetically modified pig kidney would be safe and functional if transplanted into a patient. The kidneys attached to these “brain-dead” patients functioned normally as late as 54 hours after surgery (the latest time monitored), and the results were hailed as a success.

The obvious question arises: how could a kidney function normally if the “brain-dead” patient were dead? Were a pig kidney attached to a corpse it would certainly not function. The common-sense answer to this question is that the kidney functioned normally because “brain-dead” patients are alive. If “brain-dead” patients were not alive, how could they effectively serve to test the safety and function of pig kidneys in living patients? For this experiment to make logical sense, the “brain-dead” patient must be alive.

At this point the reader is rightly questioning our ability to pinpoint the exact moment when death occurs. But remember—in order to ethically harvest organs from “brain-dead” patients, we must possess the highest degree of moral certainty that they are dead. We have nowhere near the necessary degree of moral certainty.

We must remain very, very humble before the mystery of the human person, and we must be very, very cautious in speculating on the moment of death. We must be willing to reevaluate medical and legal norms in light of new scientific evidence—and always in light of the Gospel of Jesus Christ.

When certainty has not been achieved that a person is dead—and medical evidence continues to accumulate which should make us all increasingly uncertain that we can pinpoint the exact moment of death—we cannot risk ending a patient’s life by harvesting their organs. Therefore, following the sound advice of Pope Benedict XVI on the principle of precaution, we Catholics should oppose organ harvesting from “brain-dead” patients.

[Image Credit: Unsplash]

  • Joseph M. Eble, MD

    Joseph M. Eble, MD, is President of the Tulsa Guild of the Catholic Medical Association and a Managing Partner of Fidelis Radiology. Subjects about which he is passionate include brain death, adoption, and building bridges between persons of different ethnicity. His publications include “Brain Death: Let us remain faithful to the principle of precaution”, co-authored with Bishop Joseph E. Strickland, and his interviews include with Fr. Mitch Pacwa on EWTN Live. He may be reached at [email protected]

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