The Concept of Brain Death and the Tragic Cases of Marlise Munoz and Jahi McMath

This guest post is part of The Bioethics Program’s Online Symposium on the Munoz and McMath cases. To see all symposium contributions, click here.

by Ryan Abbott, M.D., J.D., M.T.O.M.
Associate Professor of Law, Southwestern Law School, and Visiting Assistant Professor of Medicine, David Geffen School of Medicine at UCLA

Historically, death has been a very simple and intuitive thing to understand – it occurs when someone stops breathing and their heart stops. Visually, it is a dramatic change that anyone can comprehend.

However, we now live in an age where machines can keep people breathing, and their hearts beating, when they would otherwise die. These medical advances have been revolutionary, and they are vital to allowing living patients to recover after severe illness or injury. On the other hand, they can make it more difficult for people to accept and understand death, because it can make dead patients “appear” alive.

Brain death refers to the irrevocable loss of all functions of the brain, including the brainsteam. Someone with brain death is just as dead as someone who has stopped breathing and whose heart has stopped. Doctors confirm brain death through a neurological examination, and once diagnosed the patient is dead. That person will never have any brain functioning and will never return to life or “wake up.”

That, of course, is a difficult concept to explain to people without medical training, and who don’t understand how the brain and body work. To family members, a loved one with brain death on life support has some of the features they associate with being alive. For example, a video now circulating online that purports to show Jahi McMath responding to stimulation may simply demonstrate that some reflexes may persist after brain death, such as a Babinski’s reflex that causes the big toe to move upward while the other toes fan out in response to the sole of the foot being firmly stroked. Grieving family members are, understandably, sometimes unable to accept a diagnosis of brain death.

However, as a physician and scientist, I can tell you that there is no murkiness in the concept of brain death. If there is something being learned from these tragic cases, it is that medical professionals sometimes do a poor job with public education and outreach. The scientific community, the media, and politicians should speak with a united voice to explain that when someone is brain dead, there is no hope of them returning to life. Alas, end-of-life issues are not discussed nearly enough, and worst, even when they are some politicians have provided misinformation for political reasons or due to ignorance.

Brain death is universally considered death by the medical profession. However, the issue is not treated uniformly by state laws. Most states have adopted a model law, the Uniform Determination of Death Act (UDDA), which states, “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.” California and Texas have both adopted definitions consistent with the UDDA, as should all states. Universal adoption of the UDDA would be helpful for improving public understanding of death.

As to who decides whether life support should be provided to a brain dead patient, both California and Texas permit physicians to withdraw life support from dead patients, and legally protect doctors from doing so when death has been properly diagnosed. It doesn’t benefit anyone for brain dead patients to be kept on life support indefinitely – not the patients, the families, or society. It should also be recognized that we have limited medical resources, and that the medical care going toward a patient who is already dead could be used to benefit someone with desperate need.

[Cross-posted at Bill of Health.]

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