Dear Editor,

Michael Potts emphasized that the social acceptance of BD since the Harvard Report was induced by the longing to find organ for transplants. We agree that the final success of transplants was improved by refining the BD concept. Nonetheless, when in 1959 the first accounts of BD were published, organ transplant surgery was in its first steps.(1)

Potts also argued about accepting BD. Some scholars who were strong defenders of BD are now favoring a circulatory-respiratory view.(2, 3, 3) Shewmon remarked that clinical findings in BD are more attributable to multisystem damage and spinal shock than to brain destruction per se.(3) However, this author accepted that the brain plays a role in integrating functions, using as an example the psychoneuroimmunology. He emphasized that "the brain role is one of modulating, fine-tuning, and enhancing an already established and well functioning immune system". If we accept Shewmon's view, then a specific emotional state could influence the immune system, either diminishing or enhancing the immune response. We can ask ourselves: Can we consider this brain's effect over other systems, of "modulating" or “fine-tuning", the highest level of integration within the organism?(4) Korein and Machado proposed that the critical system of the human being is the brain, which is irreplaceable by an artifice, be it biological, chemical, or electromechanical. This critical system of the brain (CSB) is the minimal irreplaceable anatomical substrate of those functions that are utilized by the organism as a whole towards behavior that will result in decreased entropy production.(5)

The classical definition of cardio-respiratory death, as used in medicine, is incomplete and cannot be applied in many situations. Hence, we defend the concept of BD as death of the individual.(4, 5)

Epstein remarked that we defended that the concept of (brain death) BD evolved independently of social interests. There is a relationship between organ transplants and BD. Nonetheless, during the fist half of the XX century both the development of BD concept and transplantation evolved completely independent.(6) We also agree that BD was canonized by the Harvard Committee,(7) although Dr. Machado demonstrated that the first organ transplant using a brain-dead donor was performed by Alexandre, in 1963. Moreover, at late ‘50s and early ‘60s, surgeons brought a donor into the operating room with the recipient for the removal, stopping the respirator until the donor’s heart ceased to beat. Hence, donors had been declared dead by cardio- respiratory criteria, and technically, those donors were not brain-dead.(8)

Wijdicks recently commented about a widespread apprehension that in the Committee transplant physicians played a main role to delineate BD, to impel organ transplants. Wijdicks remarked: “I am uncertain after reading the documents whether an alleged agenda of facilitating transplantation through a new construct of death existed.” He concluded that neurologists played a major role in the Committee.(7)

Epstein also commented that a cardio-respiratory view of death seems to come back. This is an extremely dangerous precedent. (8) If surgeons declare death within minutes after heart stops, without fulfilling BD criteria, for us these subjects are not dead. What would happen with those cases suffering accidental hypothermia combined with circulatory arrest, who were rewarmed to normothermia by use of extracorporeal circulation, with good outcome in several cases. The neuroprotective effect of hypothermia demonstrates that the brain is the target organ after cardiac arrest. Hence, death occurs after cardiac arrest when ischemia and ischemia is sufficiently prolonged to destroy the brain.(6, 9) .

David W. Evans agreed with us that the concept of BD was certainly built up in separation from organ transplant practice. We also agree with Evans that Barnard’s first successful cardiac transplantation prompted to settle BD diagnostic.(10) Although we have previously remarked on Alexandre’s contribution performing the first even known organ transplant using a brain-dead donor in 1963.(11) Long before modern technology, everyone agreed that death occurred when heartbeat and breathing ceased. Nonetheless, the concept of death evolved as technology progressed, forcing medicine and society to redefine the ancient cardiorespiratory diagnosis to a neurocentric view of death.(12,6) Historically, It is important to remember, the papal allocution of Pope Pius XII in 1957 to a group of Italian anesthesiologists regarding the limitation of resuscitation.(7)

There are still worldwide controversies regarding the concept of death and the putative neurological grounds for diagnosing it. Moreover, a group of scholars who were strong defenders of a brain-based standard of death are now favoring a circulatory-respiratory view. Hence, the debates on human death are far from concluded.(13-15) This has stimulated us to hold Coma and Death Symposia in Cuba since 1992, every 4 years.(16) The 5th International Symposium of the Definition of Death Network will be held in Varadero Beach, Cuba, on May 20-23, 2008.

Calixto Machado

President of the National Cuban Commission for the Determination of Death
Institute of Neurology and Neurosurgery

Julius Korein, Yazmina Ferrer, Liana Portela, Maria de la C. Garcia, Jose M. Manero

References:

1. Barnard CN. The operation. A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town. S Afr Med J 1967;41:1271-1274.

2. Machado C. The first organ transplant from a brain-dead donor. Neurology 2005;64:1938-1942.

3. Fischgold H and Mathis P. Obnubilations, comas et stupeurs. Electroenceph.clin.Neurophysiol 1959;Suppl No 11 (Masson et Cie, Paris):126.

4. Korein J. The problem of brain death: development and history. Ann N Y Acad Sci 1978;315:19-38.

5. Pius XII. The prolongation of life (an address of Pope Pius XII to an International Congress of Anesthesiologists. November 24, 1957). The Pope speaks 1958:393-398.

6. Machado C. Consciousness as a definition of death: its appeal and complexity. Clin Electroencephalogr 1999;30: 156-164.

7. Korein J, Machado C. Brain death: updating a valid concept for 2004. Adv Exp Med Biol 2004;550:1-14.

8. Korein J. Ontogenesis of the fetal nervous system: the onset of brain life. Transplant Proc 1990;22: 982-983.

9. Machado C. Havana and the coma and death symposia. N Engl J Med 2004;351(11):1150-1151.

10. Machado C, Korein J, Ferrer Y, Portela L, De la C García M, and Manero JM. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197-200.

11. Potts M. A requiem for whole brain death: a response to D. Alan Shewmon's 'the brain and somatic integration'. J Med Philos 2001;26: 479- 491.

12. Shewmon DA. Spinal shock and brain death': somatic pathophysiological equivalence and implications for the integrative-unity rationale. Spinal Cord 1999;37: 313-324.

13. Machado C, Korein J, Ferrer Y, Portela L, De la C Garcia M, and Manero JM. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197-200.

14. Wijdicks EF. The neurologist and Harvard criteria for brain death. Neurology 2003;61: 970-976.

15. Korein J. Brain states: Death, Vegetation, and life. In: Cotrrell JE, Turndorf H (eds). Anaesthesia and Neurosurgery, 2nd edn. New York: C.V. Mosby Co, 1986: 293-351.

16. Landau WM, Schneider S, Machado C, Longstreth Jr WT, Fahrenbruch CE, Olsufka M, Walsh TR, Copass MK, and Cobb LA. Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac arrest. Neurology 2003;60:1868-1869.

Dear Editor,

Calixto Machado and his colleagues (1) claim that because the development of organ transplantation and brain death originally developed independently, that “the concept of brain death did not evolve to benefit organ transplantation.” This is a classic non sequitur, since it remains possible that the contemporary development of brain death criteria from the Harvard Report (2) on was influenced by the desire to find transplantable organs. The Harvard Ad Hoc Committee Report explicitly states that “Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation” (2), with the obvious implication that such controversy should be avoided. Three years after the publication of the Harvard Committee Report, Beecher and Dorr (3) state that one of the reasons for the Harvard Criteria “was to increase the flow of organs for transplantation,” and they continue, “there is indeed a life -saving potential in the new definition, for, when accepted, it will lead to greater availability than formerly of essential organs in viable condition, for transplantation, and thus countless lives inevitably will be saved.”

Even if Machado et al. were correct in their claim about the development of the brain death concept, brain death criteria themselves have come under increasing criticism (4, 5). The conceptual basis for the U.S. “whole brain” criteria, the belief that whole brain death means the loss of integrated organic unity in a human being, has been subjected to a powerful critique by neurologist Alan Shewmon (6). Some physicians are questioning whether we can be sure the entire brain is really dead in patients declared dead by whole brain (US) or brainstem (UK) criteria (7). This suggests that physicians who support removing organs from “brain dead” individuals should take a second look at the evidence in favor of brain death criteria if they wish to avoid removing organs from patients who may well still be alive.

References:

1. Machado et al. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197-200

2. Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:85-88.

3. Beecher HK, Dorr HI. The new definition of death: some opposing views. Int. J. Clin. Pharmacol. 1971;5:120-124.

4. Potts M, Byrne PA, Nilges RG (eds.). Beyond Brain Death: The Case Against Brain Based Criteria for Human Death. Dordrecht, The Netherlands: Kluwer Academic Publishers, 2000.

5. de Mattei R (ed). Finis vitae - is brain death still life? National Research Council of Italy, Rubbettino Editore, 88049 Soveria Mannelli (Catanzaro), 2006.

6. Shewmon DA. Chronic ‘brain death’: meta-analysis and conceptual consequences. Neurology 1998;51:1538-1545.

7. Evans DW. What is brain death: a British physician’s view. In de Mattei R (ed). Finis vitae - is brain death still life? pp. 99-105. National Research Council of Italy, Rubbettino Editore, 88049 Soveria Mannelli (Catanzaro), 2006.

Dear Editor,

Machado and colleagues rightly argue that the concept of brain death evolved independently of any social interests(1). However, they ignore the fact that its social reception has indeed depended, and continues to depend, on such interests.

The concept of brain death was canonised soon after the publication of the report of the Harvard Committee in 1968(2). The committee, on which two transplant surgeons sat, made no serious attempt to justify its concept. For example, it made no reference to any neurological research(3). That said, the opening remarks of its report were very clear about the interests underlying its endorsement of the concept — meeting the increasing demand for organ transplants (particularly hearts), and containing the financial crisis in intensive-care following the introduction of the ventilator. This point was later on made even more explicit by the creator of the committee himself, the famous Dr. Henry Beecher(4).

The concept of brain death is currently in no danger, but the definition of death as cardiac arrest seems to be making an ironical comeback, albeit through the back door. The Washington Post recently reported that doctors are increasingly declaring patients dead within minutes after their heart stops beating and without any evidence of brain death, so that surgeons could remove their organs(5). The great seventeenth century British philosopher Thomas Hobbes was apparently right: we tailor our philosophy according to our interests, not the other way around(6).

References:

1. Machado et al. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197-200.

2. 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;205:337-40.

3. Jonsen, A. R. The Birth of Bioethics. Oxford: Oxford University Press. 1998: 238-244.

4. Beecher, H. Scarce resources and medical advancement: ethical aspects of experimentation with human subjects. Daedalus 98. 1969;2:275- 313.

5. Stein, R. New trend in organ donation raises questions. Washington Post 18 March, 2007: A03. Available at http://www.washingtonpost.com/wp- dyn/content/article/2007/03/17/AR2007031700963_pf.html. Accessed 16 April, 2007.

6. Hobbes, T. 1996 [1651]. Leviathan. Oxford: Oxford University Press. I.11.21

Dear Editor,

As Machado and colleagues point out(1), the idea that death of the brain, while the body remains alive, might be considered the death of the person did, indeed, develop in isolation from the practice of organ transplantation. But there was no attempt to define brain death and establish formal clinical testing for its diagnosis as a basis for the certification of death(2,3) until that became necessary for the legal practice of human cardiac transplantation in 1967.

The concept remains the subject of vigorous philosophical debate(4). The simplistic UK concept - irreversible loss of the capacity for consciousness and spontaneous breathing alone - has never been universally accepted. The purely bedside tests which are supposed to diagnose that state are clearly inadequate for the purpose and are currently under yet further review by a Working Group of the Academy of Medical Royal Colleges(5) which was set up in 2004.

References:

1. Machado et al. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197-200

2. 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;205:337-40

3. Conference of Medical Royal Colleges and their Faculties in the UK. Diagnosis of brain death. BMJ 1976 (2):1187-88

4. Finis Vitae - is Brain Death Still Life? National Research Council of Italy. Ed. de Mattei R. Rubbettino Editore,2006

5. Simpson P. Working Group on brain stem death. Academy of Medical Royal Colleges,UK