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• The return to the heart definition of death
  Celio Levyman
  Published on: 18 May 2017
• Response to C. Levyman
  Nereo Zamperetti
  Published on: 18 May 2017

• Published on: 18 May 2017

  The return to the heart definition of death

  • Celio Levyman, MD, ScM, Clinical Neurologist

  Dear Editor

  Since the 50s,with the work of Guillan and Mollaret, there has been a preoccupation with the point of no return in brain activity; these French authors choose the expression “coma depassé”. After the first and ethical heart transplantation in South Africa, performed by the Barnard brothers, the medical world was suddenly thrown into a debate about the definition of death. The Harvard ad hoc Committee was...

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  Dear Editor

  Since the 50s,with the work of Guillan and Mollaret, there has been a preoccupation with the point of no return in brain activity; these French authors choose the expression “coma depassé”. After the first and ethical heart transplantation in South Africa, performed by the Barnard brothers, the medical world was suddenly thrown into a debate about the definition of death. The Harvard ad hoc Committee was the first to put the neurological and ethical issues in a more traditional way, considering the definition of brain death as death itself. At present, we have a lot of protocols to determine brain death, and many ancillary examinations to confirm the clinical diagnosis, from the old EEG criteria of the Harvard committee to the up-to-date flow and metabolic analyses existing today, such as transcranial Doppler examination, evoked potentials, SPECT, angio-MR, and so. There is strong evidence in the medical literature to support the definition of brain death as the death itself, using the protocols for both transplanted and non-transplanted cases. Of course, we have an ethical problem at this point, but to use only heart criteria to indicate death is to refuse to acknowledge the lack of activity in the central nervous system as the mark of death. The initial definition of brain death is modified to brainstem death by Christopher Pallis and, more recently, to the concept of whole brain death, as pointed out by Calixto Machado. With appropriate measures and trained professionals, brain death criteria vary little throughout the world, as a recent paper by Eeelco Widjics shows. All of the research that has been carried out by neurologists, intensivists, anaesthetists, and participants in organ transplantation teams, should make us certain that lack of brain function is the point of no return. Reintroducing the heart into the definition of death is regressive, provides no more ethical standard than the brain criteria, and could promote (again) interminable discussions of death, with no practical and bioethical advantage. This would be regressive thinking and could overshadow more than 30 years of research by groups throughout the world in this field.

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  Conflict of Interest:
  None declared.

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• Published on: 18 May 2017

  Response to C. Levyman

  • Nereo Zamperetti, Intensivist
  • Other Contributors:
    • Rinaldo Bellomo and Claudio Ronco

  Dear Editor

  the concept of brain death (BD) refers to two different but strictly related conditions: the death of the brain ("the irreversible cessation of all functions of the entire brain, including the brain stem"[1]) and the patient's death certified by neurological criteria.

  In his letter, C. Levyman strongly supports both aspects of the concept. Actually, even if nobody challenges the fact the BD i...

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  Dear Editor

  the concept of brain death (BD) refers to two different but strictly related conditions: the death of the brain ("the irreversible cessation of all functions of the entire brain, including the brain stem"[1]) and the patient's death certified by neurological criteria.

  In his letter, C. Levyman strongly supports both aspects of the concept. Actually, even if nobody challenges the fact the BD is a point of no return, many authors have questioned that BD identifies the loss of all intracranial functions [2-10] and also the equivalence between BD and the patients biological death has been called into question [6,8,10-17]. The debate is very fascinating and intriguing. We believe that labeling either position as regressive/progressive does not help in the discussion, which should be open and respectful.

  On the other hand, this problem is totally unrelated to our paper, which dealt with the problem of defining the vital status of non-heart- beating organ donors (NHBD). We argued that, given current protocols (which are clearly different from the protocols for brain-dead patients), at the time of organ retrieval it is impossible to define the death of NHBD on either neurological [18] or cardio/respiratory criteria.

  References

  (1) The Uniform Determination of Death Act (UDDA), as expressed by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioural Research (1981) Defining death: a report on the medical, legal, and ethical issues in the determination of death. Washington, D.C.: U.S. Government Printing Office.

  (2) Evans DW, Hill DJ (1989) The brainstem of organ donors are not dead. Catholic Medical Quarterly. 40: 113-121.

  (3) Truog RD, Fackler JC (1992) Rethinking brain death. Crit Care Med 20:1705-1713.

  (4) Veatch RM (1993) The impending collapse of the whole-brain death definition of death. Hasting Center Report 23(4):18-24.

  (5) Halevy A, Brody B (1993) Brain death: reconciling definitions, criteria and tests. Ann Intern Med 119: 519-525.

  (6) Singer P (1994) How death was redefined. In: Singer P Rethinking life and death. The collapse of our traditional ethics. St. Martin's Press, New York, pp 20-37.

  (7) Truog RD (1997) Is it time to abandon brain death? Hasting Center Report 21:29-37

  (8) Kerridge IH, Saul P, Lowe M, McPhee J, Williams D (2002) Death, dying and donation: organ transplantation and the diagnosis of death. J Med Ethics 28: 89-94.

  (9) Facco E, Munari M, Gallo F, Volpin SM, Behr AU, Baratto F, Giron GP (2002) Role of short latency evoked potentials in the diagnosis of brain death. Clinical Neurophysiology 113: 1855-1866.

  (10) Truog RD, Robinson MR (2003) Role of brain death and the dead-donor rule in the ethics of organ transplantation. Crit Care Med, 31(9):2391- 2396.

  (11) Danish Council of Ethics (1988). Death Criteria: a report. The Danish Council of Ethics, Denmark.

  (12) Arnold RM, Youngner SJ (1993) The dead donor rule: should we stretch it, bend it or abandon it? Kennedy Inst Ethics J 3: 263-278

  (13) Shewmon DA (1997) Recovery from "brain death": A neurologist's Apologia. Linacre Quarterly 64:30-96.

  (14) Shewmon DA (1998) Chronic “brain death”: meta-analysis and conceptual consequences. Neurology 51:1538-45.

  (15) Shewmon DA (1998) "Brain-stem death", "brain death" and death: a critical re-evaluation of the purported evidence. Issues Law Med 14: 125- 45.

  (16) Shewmon DA (1999) Spinal shock and 'brain death': somatic pathophysiological equivalence and implications for the integrative-unity rationale. Spinal Cord 37:313-24.

  (17) Shewmon DA (2001) The brain and somatic integration: insights into the standard biological rationale for equating "brain death" with death. J Med Philos. 26(5): 457-78.

  (18) The Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine (2001) Recommendations for non-heart- beating organ donation. A position paper. Crit Care Med 29(9): 1826-1831.

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  Conflict of Interest:
  None declared.

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