Brain dead: Is it the same as 'really dead'?

28 Sep 2003, The Straits Times

Question

Name of the Person: Andy Ho

Senior Writer with The Straits TImes.

Brain dead: Is it the same as 'really dead'?

LUCKILY for Miss Tanya Liu, she was declared dead in a country with an opt-in organ donation programme.

Otherwise she might be buried by now and her organs working away in other people's bodies.

Instead, the Taiwanese newscaster, declared brain dead by London doctors after she was injured severely in a train crash in May last year, was moved at the insistence of her family to a hospital in Beijing.

There, herbal remedies and electrical stimulation of her brain saw her regain consciousness three months later.

It made the news everywhere.

The proposal to make brain death the legal criterion for harvesting organs here has made some people uneasy, especially when stories like Miss Liu's suggest that a person is not necessarily dead when her brain is dead.

But brain death is the legal standard used in most nations for organ transplants.

Japan, for example, adopted it in 1997, and Singapore is considering working it into amendments to the Human Organ Transplant Act.

Now, the Act authorises kidneys to be removed from non-Muslim accident victims who have not opted out.

The proposed amendments are to expand, first, the list of organs to include the liver, heart and corneas and, secondly, the pool of potential donors to people certified as 'brain dead'.

The concept of brain death, while widely used, is not universally accepted.

It was first mooted by the Harvard Medical School in 1968 to enable doctors to harvest organs for transplantation.

If the brain is no longer able to coordinate all the systems in the body, such that the person cannot breathe on his own, maintain the heart beat and blood circulation spontaneously, and remain conscious, can you say he is still alive?

The Harvard doctors listed six criteria to establish brain death but left this question unanswered to this day.

Despite the Minister of State for Health Balaji Sadasivan's reassuring comment made to reporters recently - 'There is very scientific and medical criteria to determine brain death' - the question remains whether people are really dead if they are brain dead.

After all, we are talking about warm, pink bodies in whom hearts continue to beat. In fact, for brain-dead organ donors, the life-support machine is left on so the heart continues to beat and pump blood through organs.

In 1997, the CBS television show, 60 Minutes, aired a story entitled, Not Quite Dead, about how brain-dead persons could be kept alive for surprisingly long periods.

It had been an article of faith that brain death would lead to the heart stopping despite all treatment. In fact, persons declared brain dead are known to have hearts that continue to beat on their own. A study of 155 persons with no electrical activity or blood flow in the brain - whole brain death - revealed that 80 survived two weeks, 44 four weeks, 20 two months, seven six months, and four longer than one year.

The longest-known survivor was declared brain dead at four from meningitis.

Scans show that his brain has liquefied. Today, the 20-year-old American is still comatose but, without question, alive.

That the issue remains unsettled is evident from the fact that in the United States, the whole brain must stop functioning to diagnose brain death whereas, in Britain, brain-stem death is enough. The brain stem is the lower part of the brain that connects the cerebral hemispheres in the skull to the spinal cord in the backbone; it controls breathing, digestion, heart rate, blood pressure and how we stay awake.

The definition of death becomes an issue only because of organ transplantation.

If doctors wait until the heart stops beating before they harvest organs, they must race against the clock to transplant them before they become unviable.

How long to wait after the heart stops before declaring a person truly dead?

There are no answers in medical texts, which never had to deal with this before.

After 60 Minutes aired the episode, the US government asked the Institute of Medicine to look for an answer.

The prestigious non-profit group concluded that it was virtually certain that the heart would not restart on its own after five minutes although there were 'no scientific studies to allow a definite conclusion. (On this, there is a) lack of scientific certainty'.

After all, the ticker can - even after five minutes - be kicked back into life with a defibrillator; the resuscitated person may even come back with some brain function intact.

BETTER GUIDELINE FOR ORGAN REMOVAL?

THERE is no question that transplantations save lives but policy-makers owe it to would-be donors to define death plainly, especially in Singapore's opt-out system.

In opt-in systems where people have to pledge to be donors, many resist signing up precisely because of the uncertainty over brain death.

Plainly, 'as good as dead' isn't quite the same as 'really dead', and we must not sidestep the issue by declaring would-be donors dead too soon.

It may indeed be good policy to permit organ removal after five minutes - or to follow some better guideline - but, first, we must engage in the appropriate debate, not dismiss doubts and fears in a cavalier fashion.

Reply

Name of the Person: Dr Arthur Chern
Director (Health Service Development)
Ministry of Health

STRINGENT SAFEGUARDS IN PLACE ON BRAIN DEAD

The commentary by Andy Ho (ST, 27th Sept) "Brain-dead is dead - but maybe not for loved ones??? raised several interesting points on the issue of brain-dead.

The Ministry agrees that the concerns of loved ones must not be taken lightly when dealing with organ donation.

However, the Ministry would like to clarify that the Human Organ Transplant Act has always applied to brain dead cases since its enactment in 1987 and not as reported in the article that "Prior to 1998, these kidneys could be taken out only when what doctors call cardiac death had occurredandnbsp;- that is when the heart stopped."

In practice, organ retrieval is performed on brain dead persons and very seldom on cardiac dead persons as the organs would have deteriorated very quickly after blood circulation has stopped.

Brain death is accepted as a legal definition of death in Singapore and in many other developed countries. It is determined based on a well-defined standard set of clinical criteria. There are very stringent safeguards and procedures in the certification of brain death, which must be performed by two independent doctors with the required postgraduate qualifications before the retrieval of organs could take place.