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    532 CONTEMPORARY ISSUES IN PRACTICE, EDUCATION, & RESEARCH OPEN ACCESS Revise the Uniform Determination of Death Act to Align the Law With Practice Through Neurorespiratory Criteria Adam Omelianchuk, PhD, James Bernat, MD, Arthur Caplan, PhD, David Greer, MD, Christos Lazaridis, MD, Ariane Lewis, MD, Thaddeus Pope, PhD, Lainie Friedman Ross, PhD, and David Magnus, PhD Neurology 2022;98:532-536. doi:10.1212/WNL.0000000000200024 Abstract Although the Uniform Determination of Death Act (UDDA) has served as a model statute for 40 years, there is a growing recognition that the law must be updated. One issue being considered by the Uniform Law Commission's Drafting Committee to revise the UDDA is whether the text “all functions of the entire brain, including the brainstem” should be changed. Some argue that the absence of diabetes insipidus indicates that some brain functioning continues in many individuals who otherwise meet the "accepted medical standards" like the American Academy of Neurol- ogy's. The concern is that the legal criteria and the medical standards used to determine death by neurologic criteria are not aligned. We argue for the revision of the UDDA to more accurately specify legal criteria that align with the medical standards: brain injury leading to permanent loss of the capacity for consciousness, the ability to breathe spontaneously, and brainstem reflexes. We term these criteria neurorespiratory criteria and show that they are well-supported in the literature for physiologic and social reasons justifying their use in the law. Introduction At the end of the 1970s, neurologic criteria for death were recognized in roughly half of the United States, resulting in a confusing legal landscape. To achieve uniformity across state lines and alignment of the law with medical practice, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavior Research recommended state legislators adopt the Uniform Determination of Death Act (UDDA)¹: An individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brainstem, is dead. A determination of death must be made in accordance with accepted medical standards. 3-5 Although it has served as a model statute for 40 years, and has been embraced in whole or in part throughout the United States, there is a growing recognition that the UDDA must be updated.³ The Uniform Law Commission recently approved a Study Committee's recommendation to form a Drafting Committee that should submit its proposed UDDA revisions by July 2023. Meanwhile, Nevada, Oklahoma, and Texas have already moved to amend their own UDDA statutes (NV. A.B. 424 [2017], Okla. H.B. 1896 [2021], Tex. H.B. 4,329 [2021]). Contentious aspects of the UDDA include interpretation of the phrases "all functions of the entire brain" (vs some specific set of functions) and "accepted medical standards” (should they be specifically named?) and whether accommodations are needed to address religious or principled objections to determining death by neurologic criteria (DNC).6⁹ Here, we propose a solution to the alleged inconsistency between Correspondence Dr. Magnus [email protected] MORE ONLINE Podcast NPub.org/Podcast9813 From the Stanford Center for Biomedical Ethics (A.O., D.M.), CA; Dartmouth Geisel School of Medicine (J.B.), Hanover, NH; NYU Grossman School of Medicine (A.C.), New York; Boston University School of Medicine (D.G.), MA; University of Chicago Medical Center (C.L.), IL; NYU Langone Medical Center (A.L.), New York; Mitchell Hamline School of Law (T.P.), St. Paul, MN; Institute for Translational Medicine (L.F.R.), Chicago; and University of Chicago (L.F.R.), IL. Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. The Article Processing Charge was funded by the authors. See the Highlighted Changes supplement, showing the changes made in this updated version: links.lww.com/WNL/C196. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. Glossary DNC = death by neurologic criteria; UDDA Uniform Determination of Death Act. the meaning of "all functions of the entire brain” and “accepted medical standards" by transitioning from an anatomical ap- proach to DNC to a functional approach, like the approach to death by circulatory criteria. This change will align the law with medical practice, bolster confidence among examiners in the reliability of the currently accepted medical standards, and transparently communicate to the public what the standards are expected to assess. Worldwide Support for The currently accepted medical standards for DNC (published Neurorespiratory Criteria by the American Academy of Neurology in 2010 and the Society of Critical Care Medicine, American Academy of Pediatrics, and Child Neurology Society in 2011) ¹0-12 require documentation of an injury that explains the loss of brain function, the exclusion of confounding conditions, and a clinical examination that dem- onstrates unarousable unresponsiveness, brainstem areflexia, and apnea. Some argue that the absence of diabetes insipidus in many 13,14 individuals who meet these standards indicates that some func- tions of the brain continue after pronouncement of death, namely those in the neurosecretory hypothalamus that regulate salt and water balance. With this in mind, a Nature editorial argued, "The time has come for a serious discussion on redrafting laws that push doctors towards a form of deceit.”¹5(p570) To align the law with practice, either the "accepted medical standards” must include a more demanding set of tests that exclude neu- rosecretory functioning or the text requiring cessation of "all functions of the entire brain" must be revised. 16,17 18,19 At some level, the criteria used to determine death must be a matter of convention and consensus. The relevant ques- tion is not whether any brain functions remain, but rather whether those functions contradict a determination of death. Unlike consciousness, responsiveness, or spontaneous re- spiratory effort, outside of a discussion about the phrase "all functions of the entire brain," the presence of neurosecretory functioning is not recognized as a contradiction to de- termination of death.20-25 While we welcome further debate on its significance, we see no reason to reject the recom- mendations of consensus statements like that of the World Brain Death Project²6 that the persistence of neurosecretory function is consistent with DNC. Therefore, we support revision of the UDDA to more ac- curately specify legal criteria that align with the medical standards: brain injury leading to permanent loss of (a) the capacity for consciousness, (b) the ability to breathe spontaneously, and (c) brainstem reflexes. 3,4 We term these amended criteria "neurorespiratory criteria." We recognize that there may be different and competing reasons to be- lieve why neurorespiratory criteria are appropriate, as there is even disagreement about this among ourselves, but we all agree that the law would be more clearly aligned with practice if the phrase "all functions of the entire brain" were replaced with language clearly specifying neurorespiratory criteria. The use of neurorespiratory criteria is well- supported in the literature for physiologic and social rea- sons, justifying its use in the law. Neurology.org/N The motivation to declare DNC arose in the context of the critical care setting in which some ventilator-dependent pa- tients were found to be comatose, lacked the capacity to ini- tiate breathing, and no longer had reflexes that mediate pupillary reaction to bright light, spontaneous eye-tracking of objects when the head is abruptly turned, and cough or gag responses. According to the 1981 President's Commission's report, which articulated justifications for the UDDA, neu- rologic criteria for death, like circulatory criteria, provide sufficient evidence for the death of the patient and are to be used if there is reason to believe circulatory functioning does not reliably indicate the presence of life. Many of the arguments made by the President's Commis- sion in Defining Death¹ are consistent with the neuro- respiratory criterion. The "whole-brain" formulation never meant that every neuron had to fail; rather, it was meant to contrast with the so-called "higher brain” formulation, according to which the permanent loss of consciousness alone is decisive for determining death. “What is missing in the dead," the drafters argued, “is a cluster of attributes, all of which form part of an organism's responsiveness to its in- ternal and external environment." »1(p36) The relevant "cluster of attributes" becomes clearer in their explanation of the language of "all functions of the entire brain, including the brainstem:" This may be thought doubly redundant, but at least it should make plain the intent to exclude any patient who has lost only "higher” brain functions or, conversely, who maintains those functions but has suffered solely a direct injury to the brain stem which interferes with the vegetative functions of the body. (p75, emphasis original) Thus, if one is conscious or spontaneously breathes, one is not dead. While not explicitly stated, the implication is that if the cause of brain injury is known and confounding factors like hypothermia or drug intoxication are excluded, then permanent loss of the capacities for consciousness and the drive to breathe clinically indicate the permanent loss of the relevant "cluster of attributes" necessary for an organism to live, ¹(p36) Neurology | Volume 98, Number 13 | March 29, 2022 533 534 These attributes are clearly affirmed in the United Kingdom by the Academy of Royal Medical Colleges' A Code of Practice for the Diagnosis and Confirmation of Death 28: "when the brain- stem has been damaged in such a way, and to such a degree, that its integrative functions (which include the neural control of cardiac and pulmonary function and consciousness) are irreversibly destroyed, death of the individual has occur- red."28(p13) As to the definition of death, the Academy of Royal Medical Colleges asserts that: Death entails the irreversible loss of those essential characteristics which are necessary to the existence of a living human person and, thus, the definition of death should be regarded as the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe. ¹(p¹¹) The relationship between the destruction of the brainstem's "integrative functions" and the irreversible loss of the ca- pacities for consciousness and the drive to breathe could not be clearer. Supporters of the brainstem formulation of DNC in the United Kingdom have maintained for decades that neurorespiratory criteria are philosophically and culturally accepted, not only because of their critical importance for continued life, but also because they represent at the neu- rophysiologic level the departure of the "conscious soul" and the "breath of life."29,30 The President's Council on Bioethics' 2008 white paper Con- troversies in the Determination of Death is another landmark document that supports neurorespiratory criteria.³1 After reviewing the criticisms of the 1981 President's Commission's report, the majority view of the President's Council ("Position Two") was that DNC should be accepted as a way to determine the loss of the organism's capacity to perform its “vital work."31(p60) The authors noted that the loss of the organism's capacity to engage in need-driven interaction with its environ- ment, sensing what it needs (oxygen) and acting to meet those needs (striving to take in air), is what marks the end of the organism.³2 This vital activity was explicitly operationalized in terms of neurorespiratory criteria: “If there are no signs of consciousness and if spontaneous breathing is absent and if the best clinical judgment is that these neurophysiologic facts cannot be reversed, Position Two would lead us to conclude that a once- 32 living patient has now died" (emphasis original).32(p64) Like the UK model, Position Two further says, "From a philosophical- biological perspective, it becomes clear that a human being with a destroyed brainstem has lost the functional capacities that define organismic life."32(p66) Although the authors did not recom- mend changing the law to a “brainstem-only” formulation, they did clearly recommend using neurorespiratory criteria to de- termine what they call "total brain failure" (or DNC).33(p¹2) Further support for neurorespiratory criteria can be adduced from 2 other representative professional societies. The Ca- nadian Medical Association's 2006 report on the neurologic determination of death ³4 recommends that the "concept and definition of neurologic death" be defined "as the irreversible loss of the capacity for consciousness combined with the Neurology Volume 98, Number 13 | March 29, 2022 irreversible loss of all brain stem functions [named elsewhere 1134(p3) in the document], including the capacity to breathe." The WHO's 2012 statement on death criteria says, "Death occurs when there is permanent loss of capacity for con- sciousness and loss of all brainstem functions."35 (p31) Al- though the capacity to breathe is not explicitly mentioned, its loss is implied as they recognize that "respiratory arrest" is "secondary to the loss of brainstem function."35(p13) The most recent highly influential publication to acknowledge neurorespiratory criteria is the World Brain Death Project (2020), an international consensus statement endorsed by 5 world federations and numerous medical societies. The members recommended that neurologic criteria for death be defined as "the complete and permanent loss of brain function as defined by an unresponsive coma with loss of capacity for consciousness, brainstem reflexes, and the ability to breathe independently.”26(p1081) The President's Commission, the Royal Medical Colleges, the President's Council, the Canadian Medical Association, the WHO, and the World Brain Death Project all highlighted the importance of brainstem functioning for the capacities of consciousness and spontaneous breathing. The overlap of functions attributable to the brainstem nuclei-emotion, wakefulness and sleep, basic attention, and consciousness itself—are essential for the homeostatic balance of a living organism.³0 The principal nuclei involved in modulating cor- tical activation lie in the upper pons and midbrain, but lower brainstem structures have been also implicated. Detailed ex- amination of the functions of all clinically accessible brainstem nuclei increases certainty that the functions of consciousness and spontaneous breathing have been permanently lost. 36 Advantages of Neurorespiratory Criteria We recognize that there can be varying philosophical, re- ligious, cultural, metaphysical, or biological views on when death occurs, but it is necessary for the law to clearly stipulate legal criteria for determining death and for these criteria to align with medical standards.° As we have demonstrated, neurorespiratory criteria, which have the advantage of basing the determination of death on the loss of key vital functioning rather than anatomical mortality (e.g., “whole-brain death,” "brainstem death," "cardiac death") or the presence of cellular electrical activity, are widely accepted and should be in- corporated into the UDDA. When the neurorespiratory criteria are satisfied, they afford just as bright a line between life and death as the accepted medical standards for circulatory criteria. Although this "bright line" is constructed for important social purposes (determining when the grieving process begins, when a marriage ends, when life insurance pays out, when constitutional rights no longer apply, when multiple vital organs can be procured, when requests for Neurology.org/N autopsy are initiated, and when plans for burial begin³⁹), it is rooted in observable facts, enabling confidence in the de- termination and the ability to make the distinction between life and death in a timely and efficient manner. 34 Although additional revisions to the UDDA are necessary to address other concerns, such as whether the law should specify the medical standards themselves rather than loosely referring to "accepted medical standards," or whether ac- commodations are needed to address religious or principled objections to DNC, we recommend that the first sentence of the UDDA be revised to reference cessation of neuro- respiratory functions to bring the law in alignment with practice. Rather than require “irreversible cessation of all functions of the entire brain, including the brainstem," the UDDA should instead require "brain injury leading to per- manent loss of (a) the capacity for consciousness, (b) the ability to breathe spontaneously, and (c) brainstem reflexes." Study Funding The authors report no targeted funding. Disclosure All authors except Dr. Lazaridis are observers participating in drafting of the revision of the Uniform Declaration of Death Act by the Uniform Law Commission. Go to Neurology.org/ N for full disclosures. Publication History Received by Neurology October 25, 2021. Accepted in final form January 6, 2022. Appendix Authors Location Adam Stanford Center for Omelianchuk, Biomedical Ethic Name PhD James Bernat, MD Arthur Caplan, NYU Grossman School PhD of Medicine David Greer, MD Dartmouth Geisel School of Medicine Christos Lazaridis, MD Boston University School of Medicine University of Chicago Medical Center Neurology.org/N Contribution Drafting/revision of the manuscript for content, including medical writing for content; study concept or design Drafting/revision of the manuscript for content, including medical writing for content; study concept or design Drafting/revision of the manuscript for content, including medical writing for content; study concept or design Drafting/revision of the manuscript for content, including medical writing for content; study concept or design Drafting/revision of the manuscript for content, including medical writing for content; study concept or design Appendix (continued) Location Name Ariane Lewis, MD Thaddeus Pope, PhD Lainie Friedman Ross, PhD 1. David Magnus, Stanford Center for PhD Biomedical Ethics 2. 3. 4. 5. 6. 7. References President's Commission for the Study of Ethical Problems in Medicine and Bio- medical and Behavioral Research. Defining death: medical, legal and ethical issues in the determination of death. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research; 1981. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. NYU Langone Medical Center 21. 22. Institute for Translational Medicine; University of Chicago Contribution Mitchell Hamline School Drafting/revision of the of Law Drafting/revision of the manuscript for content, including medical writing for content; study concept or design manuscript for content, including medical writing for content; study concept or design Drafting/revision of the manuscript for content, including medical writing for content; study concept or design Drafting/revision of the manuscript for content, including medical writing for content; study concept or design Lewis A, Cahn-Fuller K, Caplan A. Shouldn't dead be dead? The search for a uniform definition of death. J L Med Ethics. 2017;45:112-128. Lewis A, Bonnie RJ, Pope T, et al. Determination of death by neurologic criteria in the United States: the case for revising the Uniform Determination of Death Act. JL Med Ethics. 2019;47(4_suppl):9-24. Lewis A, Bonnie RJ, Pope T. It's time to revise the Uniform Determination of Death Act. Ann Intern Med. 2020;172:143-144. Shewmon DA. Statement in support of revising the Uniform Determination of Death Act and in opposition to a proposed revision. J Med Philos. Epub 2021 May 14. Pope T. Brain death and the law: hard cases and legal challenges. Hastings Cent Rep. 2018;48(suppl 4):S46-S48. Lewis A, Greer D. Current controversies in brain death determination. Nat Rev Neurol. 2017;13(8):505-509. Olick RS. Brain death, religious freedom, and public policy: New Jersey's landmark legislative initiative. Kennedy Inst Ethics J. 1991;1(4):275-292. Johnson LSM. The case for reasonable accommodation of conscientious objections to declarations of brain death. Bioethical Inq. 2016;13:105-115. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: determining brain death in adults: report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2010;74(23):1911-1918. Nakagawa TA, Ashwal S, Mathur M, et al. Guidelines for the determination of brain death in infants and children: an update of the 1987 Task Force recommendations. Crit Care Med. 2011;39(9):2139-2155. Lewis A, Bernat JL, Blosser S, et al. An interdisciplinary response to contemporary concerns about brain death determination. Neurology. 2018;90(9):423-426. Nair-Collins M, Northrup J, Olcese J. Hypothalamic-pituitary function in brain death: a review. J Intens Care Med. 2014;31:41-50. Halevy A, Brody B. Brain death: reconciling definitions, criteria, and tests. Ann Intern Med. 1993;119(6):519-525. Delimiting death. Nature. 2009;461:570. Bernat JL, Dalle Ave AL. Aligning the criterion and tests for brain death. Camb Q Healthc Ethics. 2019;28(4):635-641. Dalle Ave AL, Bernat JL. Inconsistencies between the criterion and tests for brain death. J Intens Care Med. 2020;35:772-780. Capron AM, Kass LR. Statutory definition of the standards for determining human death: an appraisal and a proposal. U Penn Law Rev. 1972;121:87. Capron AM. Death, Definition and Determination of: II: Legal Issues in Pronouncing Death. In: Post SG, ed. Encyclopedia of Bioethics, 3rd ed. Macmillan Reference; 2004: 608-615. Schrader H, Krogness K, Aakvaag A, Sortland O, Purvis K. Changes of pituitary hormones in brain death. Acta Neurochir. 1980;52(3-4):239-248. Outwater KM, Rockoff MA. Diabetes insipidus accompanying brain death in children. Neurology. 1984;34(9):1243-1246. Fiser DH, Jimenez JF, Wrape V, Woody R. Diabetes insipidus in children with brain death. Crit Care Med. 1987;15(6):551-553. Neurology | Volume 98, Number 13 | March 29, 2022 535 536 23. 24. 25. 26. 27. 28. Arita K, Uozumi T, Oki S, Ohtani M, Taguchi H, Morio M. Hypothalamic pituitary function in brain death patients from blood pituitary hormones and hypothalamic hormones. No Shinkei Geka. 1988;16:1163-1171. Sugimoto T, Sakano T, Kinoshita Y, Masui M, Yoshioka T. Morphological and functional alterations of the hypothalamic-pituitary system in brain death with long- term bodily living. Acta Neurochir. 1992;115(1-2):31-36. Brandt SA, Angstwurm H. The relevance of irreversible loss of brain function as a reliable sign of death. Dtsch Arztebl Int. 2018;115(41):675-681. Greer DM, Shemie SD, Lewis A, et al. Determination of brain death/death by neurologic criteria: the World Brain Death Project. JAMA. 2020;324(11): 1078-1097. Pallis C. On the brainstem criterion of death. In: Youngner SJ, Arnold RM, Schapiro R, eds. The Definition of Death. John Hopkins University Press; 1999:93-100. President's Council on Bioethics. Controversies in the determination of death: a white paper of the President's Council on Bioethics. President's Council on Bioethics; 2008. 32. Rubenstein A. What and when is death? The New Atlantis. 2009;29-45. 33. Wijdicks EF. The transatlantic divide over brain death determination and the debate. Brain. 2012;135 (Pt 4):1321-1331. Shemie SD, Doig C, Dickens B, et al. Severe brain injury to neurological determination of death: Canadian forum recommendations. CMAJ. 2006;174(6):S1-S13. World Health Organization. International Guidelines for the Determination of Death: Phase I [online]. Canadian Blood Services; 2012. Accessed June 7, 2021. who.int/ patientsafety/montreal-forum-report.pdf Parvizi J, Damasio A. Consciousness and the brainstem. Cognition. 2001;79(1-2): 135-160. of the case of Jahi Mcmath. JAMA. 2018; 37. Truog RD. Defining death: making 319:1859-1860. Khushf G. A matter of respect: a defense of the dead donor rule and of a "whole-brain" criterion for determination of death. J Med Philos. 2010;35:330-364. Magnus D. A defense of the dead donor rule. Hastings Cent Rep. 2018;48:S36-S38. 30. 31. 34. 35. Beecher HK, Adams RD, Barger AC. A definition of irreversible coma: report of the ad hoc committee of the Harvard Medical School to examine the definition of brain death. JAMA. 1968;205:337-340. Academy of Royal Medical Colleges. A Code of Practice for the Diagnosis and Confir- mation of Death [online]. Academy of Royal Medical Colleges; 2008:1-42. Accessed June 4, 2021. aomrc.org.uk/reports-guidance/ukdec-reports-and-guidance/code- 38. 36. practice-diagnosis-confirmation-death/ 29. Pallis C, Harley DH. ABC of Brainstem Death, 2nd ed. BMJ Publishing Group; 1996. 39. Announcing... Child Neurology: A Case-Based Approach Cases From the Neurology Resident & Fellow Section Neurology Volume 98, Number 13 | March 29, 2022 This collaboration between the American Academy of Neurology (AAN) and the Child Neurology Society (CNS) represents a collection of reprinted cases from the past 15 years from the Neurology Resident & Fellow Section. An invaluable resource for both adult and pediatric neurologists and trainees! FREE download: NPub.org/cnbook Share Your Artistic Expressions in Neurology 'Visions' AAN members are urged to submit medically or scientifically related artistic images, such as photographs, photomicrographs, and paintings, to the "Visions" section of Neurology. These images are creative in nature, rather than the medically instructive images published in the NeuroImages section. The image or series of up to six images may be black and white or color and must fit into one published journal page. Accompanying description should be 100 words or less; the title should be a maximum of 140 characters including spaces and punctuation. Please access the Author Center at NPub.org/authors for full submission information. The Neurology® Null Hypothesis Online Collection... Contributing to a transparent research reporting culture! The Neurology journals have partnered with the Center for Biomedical Research Transparency (CBMRT) to promote and facilitate transparent reporting of biomedical research by ensuring that all biomedical results including negative and inconclusive results-are accessible to researchers and clinicians in the interests of full transparency and research efficiency. Ho Neurology's Null Hypothesis Collection is a dedicated online section for well conducted negative, inconclusive, or replication studies. View the collection at: NPub.org/NullHypothesis Neurology.org/N

  • Losing our Dignity: How Secularized Medicine Is Undermining Fundamental Human Equality
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    An Urgent and Timely Release from Charles Camosy, the award-winning author of Resisting Throwaway Culture There is perhaps no more important value than fundamental human equality. And yet, despite large percentages of people affirming the value, the resources available to explain and defend the basis for such equality are few and far between. In his newest book Charles Camosy provides a thoughtful defense of human dignity. Telling personal stories like those of Jahi McMath, Terri Schiavo, and Alfie Evans, Camosy, a noted bioethicist and theologian, uses an engaging style to show how the influence of secularized medicine is undermining fundamental human equality in the broader culture. And in a disturbing final chapter, Camosy sounds the alarm about the next population to fall if we stay on our current trajectory: dozens of millions of human beings with dementia. Heeding this alarm, Camosy argues, means doing two things. First, making urgent and genuine attempts to dialogue with a secularized culture which cannot see how it is undermining one of its most foundational values. Second, religious communities which hold the Imago Dei sacred must mobilize their existing institutions (and create new ones) to care for a new set of human beings our throwaway culture may deem non-persons.

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    We've detected unusual activity from your computer network To continue, please click the box below to let us know you're not a robot. Why did this happen? Please make sure your browser supports JavaScript and cookies and that you are not blocking them from loading. For more information you can review our Terms of Service and Cookie Policy. Need Help? For inquiries related to this message please contact our support team and provide the reference ID below. Block reference ID:

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    In recent years the question of whether the cessation of brain activity is sufficient to determine the death of the human person has provoked sharp debate among Catholic moral philosophers and scientists. The editors of Communio hope to advance the discussion with the following collection of articles. Brain Death: Part I Is Brain Death the Death of a Human Person? Robert Spaemann “The identification of ‘brain death’ and the death of the human being can be maintained only if the personality of man is disconnected from being a human in the biological sense. . . . To do this by appealing to the doctrine of St. Thomas is absurd.” Read More You Only Die Twice: Augustine, Aquinas, the Council of Vienne, and Death by the Brain Criterion Nicholas Tonti-Filippini "The Church holds that death can be diagnosed on the basis of evidence that shows a complete loss of brain function, but may not be diagnosed if there is still some function of the brain." Read More Brain Death: Part II You Only Die Once: Why Brain Death is Not the Death of a Human Being; A Reply to Nicholas Tonti-Filippini D. Alan Shewmon "[The] accusation that I am in conflict with Church teaching about death relies . . . not only on a mischaracterization of my position, but also on a mischaracterization of Church teaching itself. In point of fact, the Magisterium does not formally oblige us to hold that the brain is the master organ of somatic integration, or that its death is therefore the death of the human being as such. Nor does the hylemorphism espoused by Boethius, Aquinas, and the Council of Vienne entail any such claim." Read More “Bodily Integration”: A Response to Robert Spaemann Nicholas Tonti-Filippini “The medical question for us now is whether the irreversible loss of all brain function is accompanied by the disintegration and loss of unity to which the Pope refers.” Read More Brain Death: Continuing Online Discussion Death by the Brain Criterion: A Response to Shewmon Nicholas Tonti-Filippini Read More

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    Brain Death: A Podcast

    In 1968 a committee at Harvard Medical School met to lay down the groundwork for a new definition of death, one that was no longer confined to the irreversible cessation of cardiopulmonary function but a new concept based on neurological criteria. Over the next 50 years, the debate over the concept of brain death has never really gone away. Rather cases like Jahi McMath have raised issues of the legitimacy of the neurologic criteria. On today's podcast, we talk with one of the leading international thought leaders on Brain Death, Dr. Robert Truog. Robert is the Glessner Lee Professor of Medical Ethics, Anaesthesiology & Pediatrics and Director of the Center for Bioethics at Harvard Medical School. He has also authored multiple articles on this topic including the Hastings Center Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts and these from JAMA: - The 50-Year Legacy of the Harvard Report on Brain Death - Understanding Brain Death - Brain Death—Moving Beyond Consistency in the Diagnostic Criteria In addition to talking about how Robert got interested in the topic of brain death, we discuss the history of the concept of brain death, how we diagnose it and the variability we see around this, the recent JAMA publication from the World Brain Death Project, why brain death is not biologic death (and what is it then) and what the future is for the concept of brain death.

  • Determination of Brain Death/Death by Neurologic Criteria

    The World Brain Death Project was undertaken to establish minimum standards for diagnosing brain death/death by neurologic criteria (BD/DNC) in children and adults across a broad range of settings and clinical circumstances. In this Q&A, senior authors of the 2020 project report join an editorialist and bioethicist to discuss the project. Featuring interviews with Gene Sung, MD, MPH, of the University of Southern California; Ariane Lewis, MD, of NYU Langone Medical Center; Robert Tasker, MD, of the University of Cambridge; and Robert D. Truog, MD, MA, of Harvard University. Click https://ja.ma/3k7mZau to read the full report. Topics discussed in this interview: 0:00 Introduction 1:32 Background on the World Brain Death Project 3:26 Initial impressions of the manuscript 6:40 Supplements 8:33 Takeaways for clinicians about Brain Death/Death By Neurologic Criteria 11:08 The history of brain death determination in the US 13:26 Determination of brain death in the US versus the UK 16:13 The complexity of the brain death determination process 19:41 Irreversible apneic unconsciousness 24:11 The apnea test and diagnosis of brain death 26:16 Reaching consensus with many international societies 27:40 Communicating the idea of brain death with families and loved ones 29:53 Clarity around BD/DNC definitions 32:36 How do neurologists, critical care physicians, and clinicians use this manuscript?