LETTERS in RESPONSE to a 2009 ARTICLE on BRAIN DEATH

The Journal of the American Medical Association (JAMA)
 July 22/29, 2009—Vol 302, No. 4 381

Controversies About Brain Death

To the Editor: The 1968 JAMA article¹ presenting criteria for brain death justly deserves to be considered a classic. However, while the article provided criteria for the diagnosis of irreversible coma, it did not offer a rationale for why these criteria should be diagnostic of the death of a human being.

The commentary by Dr Rosenberg² did not mention the controversy over the status of patients diagnosed as brain dead, which has intensified over the last 20 years. Reflecting this controversy, the President’s Council on Bioethics recently issued a white paper, “Controversies in the Determination of Death.”³ Patients with brain death maintained on mechanical ventilation retain an array of vital functioning that makes it very difficult to give a coherent account of why they are dead.⁴

Forty years after the publication of the classic article, the consensus that brain death constitutes death of a human being has eroded. Although the 1968 JAMA article was instrumental in legitimating the practice of vital organ donation from heart-beating donors, it is no longer credible to base this practice on the proposition that these donors are dead at the time of organ procurement. While patients who meet the diagnostic criteria of brain death are still alive, it has been argued that vital organ donation from these patients remains ethical, but for reasons that derive from a different set of premises.⁵

1. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA. 1968; 205(6):337-340.

2. Rosenberg RN. Consciousness, coma, and brain death: 2009. JAMA. 2009; 301(11):1172-1174.

3. Controversies in the determination of death: a white paper by the President’s Council on Bioethics. http://www.bioethics.gov/reports/death /determination_of_death_report.pdf. Accessed March 22, 2009.

4. Truog RD. Brain death: too flawed to endure, too ingrained to abandon. J Law Med Ethics. 2007;35(2):273-281.

5. Miller FG, Truog RD. Rethinking the ethics of vital organ donation. Hastings Cent Rep. 2008;38(6):38-46.

To the Editor: The review by Dr Rosenberg¹ of the JAMA Classics article on the definition of brain death contains a number of sentences that I find unclear. He states, “Coma refers to the clinical state in which a patient is unarousable and does not respond to stimuli.” In both coma and persistent vegetative state (PVS), the patient is unarousable, and in both there is usually reflex response to some stimuli. It is the presence of periods of wakefulness that distinguishes the 2 syndromes. He also states that “a meaningful and functional return to consciousness occurs with regularity from PVS. . . . “ However, the Multi-Society Task Force reported that at 1 year only 7% of patients with traumatic causes and 1% of patients with nontraumatic causes of PVS had good recovery.²

Rosenberg takes functional neuroimaging of activity in the supplementary motor area and parahippocampal gyrus, parietal lobe, and lateral premotor cortex to show that “a patient in PVS who appears unaware of the environment and commands actually may be fully aware and cognitively intact but unable to show any response to stimuli.” I think that awareness is too hard to investigate for neuroimaging to confirm its presence. What kind of study could confirm this inference?

Thomas E. Finucane, MD

tfinucan@jhmi.edu

Division of Geriatric Medicine and Gerontology Johns Hopkins Bayview Medical Center

Baltimore, Maryland

Financial Disclosures: None reported.

1. Rosenberg RN. Consciousness, coma, and brain death: 2009. JAMA. 2009; 301(11):1172-1174.

2. The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state. N Engl J Med. 1994;330(22):1572-1579.

To the Editor: I believe that in his commentary on the JAMA Classics article on brain death, Dr Rosenberg¹ erred in approvingly commenting on Crick’s book The Astonishing Hypothesis.² Rosenberg summarized the book’s point as “there is no separate mind from the brain, the mind is the brain. Cartesian logic of a separate mind and brain is an archaic philosophical concept displaced by current functional magnetic resonance imaging, DBS [deep brain stimulation] studies, years of meticulous clinical-neuropathologic studies, and experimental neurophysiological animal studies that have proven that consciousness and mind are embedded into specific neuroanatomical arousal and behavioral circuits.”

Cartesian dualism—one of multiple mind-brain dualistic hypotheses—is an interactionist hypothesis that is not only consistent with the studies Rosenberg cites. It predicts an embedded relationship between mind and brain insofar as Cartesian dualistic interactionism posits a (causal) change in the (material) brain for each and every change in the (immaterial) mind.³ Far from being an archaic philosophical concept, Cartesian dualism, in the professional philosophy literature and among a significant number of prominent scientists, is undergoing a renaissance.^4,5

Avak Albert Howsepian, MD, PhD avak.howsepian@va.gov

University of California, San Francisco Fresno Medical Education Program Fresno

1.               Rosenberg RN. Consciousness, coma, and brain death: 2009. JAMA. 2009; 301(11):1172-1174.

2.               Crick HF. The Astonishing Hypothesis. New York, NY: Charles Scribner’s Sons; 1994.

3.               Dilley F. Taking consciousness seriously: a defense of Cartesian dualism. Int J Philos Relig. 2004;55(3):135-153.

4.               Libet B, Freeman A, Sutherland K, eds. The Volitional Brain: Toward a Neuroscience of Free Will. Exeter, UK: Imprint Academic; 1999.

5.               Eccles J, Popper K. The Self and Its Brain. New York, NY: Springer Verlag; 2002.

In Reply: Drs Miller and Truog argue that the determination of brain death is not equivalent to death of a person. Their position is both a philosophical and religious one to which they are entitled. Determination of brain death as de-fined in my Commentary implies that the patient’s coma-tose state is irreversible. The patient will never regain consciousness, never again be able to express human qualities, having lost all neurological ability to express his or her identity, memories, and cognitive functions. These facts indicate that from any practical perspective the patient has died. I leave it to others to debate the nonscientific issues.

Dr Finucane asks how it is possible to measure awareness in a patient in PVS who does not show any response to stimuli on neurological examination. In my Commentary, I pointed out that by measuring the functional magnetic resonance imaging response of a patient in PVS to specific auditory commandsandshowingthatitisidenticaltotheresponseinhealthy controls, it is possible to demonstrate that the patient heard the command and is cognitively responding to it with accu-racy and specificity compared with other audible commands. This paradigm of testing is accurate, specific, and convincing that the patient is aware of the environment and language and able to process information.

Dr Howsepian is a modern-day Cartesian who describes his support of a renaissance of Cartesian dualism that is still alive and well in a new form of an “interactionist hypothesis.” In my Commentary, I presented the view that mind is embedded in brain and is not separate but is the product of neurological codes expressed through neural activity and directed synaptic protein synthesis. I believe that the mathematical equations that define the emergence of mind from neural pathways will be found and will become defined electrical circuits analogous to the circuits of semiconductors and transistors that produce the image on a television screen. Einstein displaced the ether in the universe; Mendel showed that inherited traits follow precise laws independent of social conventions; and Darwin was right about natural selection as the engine of evolution, contrary to religious views. Mind-brain dualism is a concept that has philosophical sup-port, but, operationally, thinking is a direct product of neural activity and will remain so, in my neurological opinion.

Roger N. Rosenberg, MD

roger.rosenberg@utsouthwestern.edu

Department of Neurology

University of Texas Southwestern Medical Center Dallas

Financial Disclosures: None reported.

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