"Brainstem Death," "Brain Death" and Death: A Critical Re-Evaluation of the Purported Equivalence

ABSTRACT: The author challenges brain-based diagnoses of death by re-examining the concept of death, its definition, the anatomical criterion, and the clinical signs or tests. Dr. Shewmon challenges the fundamental assumptions underlying brain death: (1) that the brain is the body's "critical system"; and (2) that the body even has a localized "critical system." He does not redefine death, but shifts the anatomical criterion from a single focus (the brain) to the entire body. The clinical tests correspondingly shift from those implying loss of brain function to those implying thermodynamically supracritical microstructural damage diffusely throughout the body. He concludes that the notion of "brain death" as bodily death is logically and physiologically incoherent, and that its replacement by something scientifically more credible would promote not only the sanctity of life, but ironically even transplantation as well. Introduction Statement of the Problem Brain-based diagnoses of death are now legally recognized in most developed countries of the world. This widespread consensus is split into two basic camps, following either the U.S. "whole brain" or the British "brainstem" formulation of so-called "brain death." As nicely summarized by Pallis and Harley,(1) the essential points of the disagreement over detail are twofold: (1) What is "the critical system of the body's critical system"? (That is, what part of the brain is to the brain as the brain is to the body?)--and (2) Can physicians identify the death of the brainstem by exclusively clinical (non-instrumental) methods? It may come as a surprise to some readers that I shall not be arguing here the United States' side of that debate. Rather, my goal is much more radical: to challenge certain fundamental assumptions common to both sides, specifically that: (1) the body's "critical system" is the brain, and (2) the body even has a localized "critical system." Background First some background. As a neurologist in a major academic transplant center, I have extensive clinical experience with "brain death." And as a convert from atheism to theism, I have a particular interest in the relationships among brain, mind, body, and soul. In the early and mid-1980s I was a strong proponent of the notion that human death was essentially neurological in nature, that death of the entire brain was death of the person, and that the most convincing rationale for that equivalence also happened to imply that "neocortical death" was equally death.(2) This opinion evolved to a modified version of "whole brain death," which I presented in 1989 at the Pontifical Academy of Sciences.(3) Since then, I have come to reject all brain-based formulations of death.(4) Thus, I am thoroughly conversant first-hand with the arguments on all sides of the debate. Until the turn of the decade, most people thought that "brain death" was a settled issue; it no longer is. An increasing number of experts have begun to re-examine critically and to reject various key underlying assumptions.(5) Of particular interest is the recent public debate in Germany over incorporating "brain death" into statutory law.(6) A surprising number of intellectuals have argued against it, not the least of whom is the archbishop of Cologne, Joachim Cardinal Meisner, who stated officially that "the identification of brain death with death of the person is from a Christian point of view no longer justifiable."(7) As a testimony to the intensity of the controversy, the finally adopted law merely specified "brain death" as a legal requirement for organ harvesting without actually declaring it to be death.(8) The position against "brain death" that will be advanced here must not be misconstrued as necessarily anti-transplantation.(9) The equating of "brain death" with death was in retrospect quite unnecessary, even for the utilitarian purposes which historically inspired it. …