Brain death: Part two

In 1968, the Harvard Committee cleverly manipulated the term “death” to include people who were considered in an irreversible coma by labeling the condition as “brain death” and making it a new definition of death. The previous article of this two-part series explained that “brain death” (i.e., irreversible coma) is not death. Part II of this series will examine St. John Paul II’s words from an address he gave in 2000 and will help us understand what the Church teaches about “brain death” and why this term is not consistent with the Church’s teaching on the human person. 

Why the necessity to analyze John Paul II’s statement on “brain death”?

Life and death are natural, biological phenomena. They are what they are regardless of what we may think or say about them. Put simply, the fact that the Harvard Committee defined “irreversible coma” (the term) as “death” (the word) does not suddenly make irreversible coma (the phenomenon) become death (the phenomenon). Unfortunately, the medicolegal practice of “brain death” has become entrenched worldwide. It is even condoned by many religions, except for a minority of Orthodox Jews. But what is the Catholic Church’s stance on “brain death”? Edward Furton, chief editor of the National Catholic Bioethics Quarterly, wrote in 2002: “John Paul’s August 2000 address did indeed give definitive approval to the use of neurological criteria for the determination of death. That approval was based upon the widespread scientific and medical consensus on the validity of these criteria.”¹  

The phrase “neurological criteria for the determination of death” is synonymous to “brain death.” John Haas of the National Catholic Bioethics Center also affirmed “the legitimacy of the neurological criteria for the determination of death,”² invoking the authority of Pope John Paul II, the Pontifical Academy of Sciences, and some Vatican dicasteries, among others. The Pontifical Academy of Sciences has emphatically declared that “brain death is death.”³ However, it is only a consultative body to the Holy See, and as such, it has no magisterial authority. 

Opinions like those above have led many in the public at large—including many Catholic faithful—to believe that “brain death” has received the blessing of the Church. But if “brain death” is not really death, how could this be? 

This second article on “brain death” will shed light on this issue. While space constraints preclude a detailed discussion of its complexities, an in-depth examination of the problem can be found in the article entitled “Pope John Paul II and the Neurological Standard for the Determination of Death: A Critical Analysis of His Address to the Transplantation Society” in Linacre Quarterly 84, no. 2 (2017) and in pages 457-483 of The New Definitions of Death for Organ Donation: A Multidisciplinary Analysis from the Perspective of Christian Ethics (Bern: Peter Lang, 2018).

The hierarchy of the different types of magisterial teaching

Besides the extraordinary infallible teaching (ex cathedra) to which the faithful are to give the full assent of faith, the bulk of the Magisterium’s teaching consists of ordinary teaching, which includes several gradations—from encyclicals such as Humanae Vitae and Veritatis Splendor to other minor Church documents. The latter group consists of interventions in the prudential order, in which a magisterial document might not be free from all deficiencies since it might not have taken into account some crucial details regarding the issue under examination.⁴ In addition, the importance of a particular Church teaching can also be inferred from the insistence with which it has been repeated. Last but not least, according to the Congregation for the Doctrine of the Faith’s Donum Veritatis: “The weight of the Magisterium’s authority [is] only intelligible in relation to the truth of Christian doctrine.”⁵ The believers’ response to authentic Magisterial teaching (i.e., a teaching in conformity with Catholic doctrine) is that of the “religious submission of will and of mind.”⁶

In this regard, John Paul II’s address to the Transplantation Society in 2000 belongs to the category of interventions of the prudential order. His statement regarding “brain death”—which constitutes the core of that address—has occurred once and only once in the entirety of the Magisterium. John Paul II did not even make a reference to that statement in his 2005 letter to the participants of the “The Signs of Death” conference sponsored by the Pontifical Academy of Sciences in February of that year.⁷

A synoptic analysis of John Paul II’s 2000 address to the Transplantation Society

The pope’s teaching on organ donation in this address begins with a reminder from Donum Vitae that “what is technically possible is not for that reason alone morally admissible.”⁸

The heart of John Paul II’s 2000 address consists of the following words: 

Vital organs which occur singly in the body can be removed only after death, that is from the body of someone who is certainly dead. . . . To act otherwise would mean intentionally to cause the death of the donor. . . . The death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person. . . . For some time certain scientific approaches to ascertaining death have shifted the emphasis from the traditional cardio-respiratory signs to the so-called “neurological” criterion. Specifically, this consists in establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity. . . . It can be said that the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology. Therefore a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgement which moral teaching describes as “moral certainty.” . . . Only where such certainty exists, and where informed consent has already been given . . . is it morally right to initiate the technical procedures required for the removal of organs for transplant (italics original, bold added).⁹

We must pay attention to several key points in the pope’s statement. First, his teaching that death is the separation of the soul from the body is firmly grounded in the Church’s anthropology (i.e., the Church’s teaching on the human person) according to which man is the substantial unity of both body and soul—with the soul being the life principle of the body. In scientific terms, the separation of the soul from the body manifests itself as the loss of somatic integration (a concept in contemporary biophilosophy), also referred to as total disintegration—where the body undergoes putrefaction and eventually turns to dust. 

Second, vital organs can only be removed from someone who is truly dead. Here, it helps to remember that, because human beings belong to the genus of warm-blooded mammals, the biological manifestations of death in a human being are no different from those observed in other mammals such as a pet dog or a pet cat. At death, the temperature of the dead body quickly drops to the same level as the ambient (or surrounding) temperature, and livor mortis and rigor mortis set in within a few hours.¹⁰  

Third, and most important, the pope’s endorsement of the neurological criterion for the determination of death (i.e., “brain death”) is a conditional endorsement, clearly indicated by the conjunction “if” and the verb “seem.” According to the pope’s statement, in order to be accepted by the Church, the “brain death” criterion must fulfill the following three conditions: 1) the loss of somatic (bodily) integration which manifests that the soul has left the body; 2) a consensus of the parameters (the clinical tests used for determining “brain death”) that constitute the “brain death” criterion (i.e., in the pope’s words: “clearly determined parameters commonly held by the international scientific community”); and 3) the rigorous application of these parameters.

The discussion below shows that the definition of “brain death” does not meet any of the three requirements. If the conditions are not fulfilled, then the conclusion (i.e., the approval of “brain death” by the Church) cannot follow.

Confronting John Paul II’s 2000 statement with the reality of “brain death”

Even the most vocal defenders of “brain death” must acknowledge that, not only is there no global consensus in the diagnostic criteria of “brain death,” but there is also a confusion of practice.¹¹ For instance, in a well-known study by Greer and colleagues, within the United States alone, there is wide variability in the practice and determination of “brain death” among the top 50 institutions for neurology and neurosurgery. The most worrisome aspect is the variability in apnea testing (a test to determine brain stem functioning), recognized by Greer and colleagues as “an area with the greatest possibility for inaccuracies.”¹² Ironically, the apnea test is a cornerstone bedside clinical test for making the declaration of “brain death.” If there is no consensus in the diagnostic criteria of “brain death,” then in what way can one even speak about the pope’s requirement that the “brain death” standard be “rigorously applied”?

Moreover, the parameters can only be “clearly determined” if they have undergone rigorous validation prior to being introduced into clinical practice. Such a validation process was never done prior to the introduction of “brain death” by the Harvard Committee. No validation study has been performed since that time either.¹³  

Perhaps the most grievous aspect regarding John Paul II’s 2000 address is the fact that it did not take into account the wealth of peer-reviewed literature, published prior to 2000, that clearly provided evidence that “brain death” is not death. Examples of such literature include: 

• Shewmon’s 1998 report of a series of chronic “brain death” survivors¹⁴ 
• Many reports since the 1980s on “brain-dead” pregnant mothers who, with aggressive life support, were able to carry their pregnancy until the time when their babies could be safely delivered by Cesarean section¹⁵ 
• Many critiques of “brain death” authored by scholars who supported organ transplantation, but who, in conformity to academic honesty and scientific realism, publicly acknowledged that “brain death is a social construct created for utilitarian purposes, primarily to permit organ transplantation”¹⁶ 
• A publication by the Quality Standards Subcommittee of the American Academy of Neurology published in 1995 to provide the guidelines for determining “brain death” that John Paul II’s 2000 address should have known about and taken into account. According to the guidelines, the presence of spontaneous movements of the limbs and reflexes of the limbs (e.g., rapid flexion in arms, raising of all limbs off the bed, grasping movements, spontaneous jerking of one leg, etc.) as well as responses such as profuse sweating, blushing, tachycardia, and sudden increases in blood pressure are compatible with the diagnosis of “brain death.”¹⁷ 

A review done by Saposnik in 2009 shows that up to 80 percent of “brain-dead” patients can manifest such movements.¹⁸ Although movements in any particular “brain-dead” patient may be very infrequent, they nevertheless occur. Thus, according to the guidelines for the determination of “brain death,” the “brain-dead” patient can be declared dead even though he may have movements of his arms and legs. 

The obvious question that any average person should ask is: How is it that a corpse can move? And the obvious questions that every Christian should ask are: 1) If the soul has left the body, then what accounts for the spontaneous movements and reflexes of the arms and legs in the “brain-dead” patient? and 2) What accounts for the continuing heartbeat, circulation, and the excretion of waste, among others? 

According to the sound tenets of the Church’s anthropology, the soul is the principle by which the body lives and the principle of our nourishment, sensation, local movement, and of our understanding.¹⁹ Hence, without the soul, there can be no movements, no sweating, no blood flow, no heartbeat, no excretion of waste, etc. If “brain death” is death, and yet at the same time the alleged cadaver can exhibit movements and a whole host of vegetative activities, then in what way can it be claimed that “brain death” “does not seem to conflict with the essential elements of a sound anthropology”?²⁰ 

The “brain death” paradigm does not meet any of the three conditions required by John Paul II’s conditional approval. The most serious aspect is that “brain death” contradicts the sound tenets of the Church’s teaching on the human person. Hence, we cannot interpret the pope’s 2000 address as the Church giving its approval of “brain death.” 

Further evidence

Two additional pieces of evidence show that the Church has not spoken definitively regarding “brain death.” First, if John Paul II had given his definite approval of “brain death,” then why did he request the Pontifical Academy of Sciences to organize a “brain death” conference, which was held in February 2005? As stated above, his letter to the participants of that conference made no reference to his conditional approval of “brain death” made in 2000.

Second, in a 2008 address to the participants attending a conference organized by the Pontifical Academy for Life, Pope Benedict XVI made no reference to the 2000 document. Rather, Benedict XVI reiterated emphatically that “individual vital organs cannot be extracted except ex cadavere.”²¹ As a non-medical person, the pope could only use the term cadavere (cadaver, corpse) in the traditional sense and not in the oxymoronic sense of “heart-beating cadavers” (another name for “brain-dead” donors). Pope Benedict XVI’s thought about “brain death” is better revealed in the following statement made in 1991 when he was still Cardinal Ratzinger: “We are witnessing today a genuine war of the powerful against the weak, a war that seeks to eliminate the handicapped . . . and the ‘useless’ at any moment of their existence. With the complicity of the State, colossal measures are being used against human persons at the dawn of their lives, or when their life becomes vulnerable because of illness and when it is close to the end. . . . Those who, because of illness or accident, fall into ‘irreversible’ coma, will often be put to death to meet the demand for organ transplants . . . (‘warm corpses’)” [author’s translation].²²

Conclusion

The discussion within this two-part article on “brain death” has provided ample evidence that “brain death” is not death and that the Church has not made any definitive pronouncement on this controversial topic. What would be most helpful is if the Magisterium could rectify the serious inaccuracy contained in John Paul II’s 2000 Address to the Transplantation Society. Such a rectification would be for the true good of the whole Church and her children—the Catholic faithful. In the meantime, it is hoped that these two articles will help Catholics make an intelligent decision regarding organ donation and transplantation taken from “brain-dead” donors, namely that one cannot do evil to achieve good (Romans 3:8).

If you missed it, be sure to check out Part I of this series in the Spring 2019 issue of Celebrate Life Magazine.

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1. Edward J. Furton, “Brain Death, the Soul, and Organic Life,” National Catholic Bioethics Quarterly2, no. 3 (2002).
2. See John M. Haas, “Catholic Teaching Regarding the Legitimacy of Neurological Criteria for the Determination of Death,” National Catholic Bioethics Quarterly11, no. 2 (2011).
3. Antonio Battro et al., “Why the Concept of Brain Death Is Valid as a Definition of Death: Statement by Neurologists and Others,” in The Signs of Death: The Proceedings of the Working Group,September 11-12, 2006, ed. Marcelo Sánchez Sorondo (Vatican City: Pontifical Academy of Sciences, 2007).
4. See Congregation for the Doctrine of the Faith, Donum Veritatis(May 24, 1990).
5. Ibid., no. 4.
6. 6.Second Vatican Council, Lumen Gentium (Dogmatic Constitution on the Church, November 21, 1964).
7. See John Paul II, “To the Pontifical Academy of Sciences” (Letter, February 1, 2005).
8. John Paul II, “Address to the 18th International Congress of the Transplantation Society” (August 29, 2000).
9. Ibid., nos. 4-5.
10. For further details about the changes taking place in a cadaver, see Norman L. Cantor, After We Die: The Life and Times of the Human Cadaver(Washington, DC: Georgetown University Press, 2010), 76-77.
11. See Eelco F. M. Wijdicks, “Brain Death Worldwide: Accepted Fact but No Global Consensus in Diagnostic Criteria,” Neurology58, no. 1 (2002).
12. David M. Greer et al., “Variability of Brain Death Determination Guidelines in Leading US Neurologic Institutions,” Neurology70, no. 4 (2008): 288.
13. See Doyen Nguyen, “Pope John Paul II and the Neurological Standard for the Determination of Death: A Critical Analysis of His Address to the Transplantation Society,” Linacre Quarterly84, no. 2 (2017): 162, 178 (note 24).
14. See D. Alan Shewmon, “Chronic ‘Brain Death’: Meta-Analysis and Conceptual Consequences,” Neurology51, no. 6 (1998).
15. See, for instance, J. E. Heikkinen et al., “Life Support for 10 Weeks with Successful Fetal Outcome after Fatal Maternal Brain Damage,” British Medical Journal290, no. 6477 (1985); I. M. Bernstein et al., “Maternal Brain Death and Prolonged Fetal Survival,” Obstetrics & Gynecology74, no. 3 (1989).
16. Robert Taylor, “Reexamining the Definition and Criteria of Death,” Seminars in Neurology17, no. 3 (1997): 265.
17. See Eelco F. M. Wijdicks, “Determining Brain Death in Adults,” Neurology45, no. 5 (1995): 1007.
18. See Gustavo Saposnik, Vincenzo S. Basile, and G. Bryan Young, “Movements in Brain Death: A Systematic Review,” Canadian Journal of Neurological Sciences36, no. 2 (2009).
19. Thomas Aquinas, Summa Theologiae, trans., Fathers of the English Dominican Province (New York: Benziger Bros., 1947), I, q. 76, a. 1.
20. See the block quote corresponding to footnote 8.
21. Benedict XVI, “Address to Participants at an International Congress Organized by the Pontifical Academy for Life, November 7, 2008.”
22. The original text in Italian reads: Siamo oggi testimoni di un’autentica guerra dei potenti contro i deboli, una guerra che mira all’eliminazione degli handicappati […] e “inutili” in tutti i momenti della loro esistenza. Con la complicità degli Stati, mezzi colossali sono impiegati contro le persone, all’alba della loro vita, oppure quando la loro vita e resa vulnerabile da una malattia e quando essa e prossima a spegnersi. […] Quelli che la malattia o un incidente faranno cadere in un coma ‘irreversibile,’ saranno spesso messi a morte per rispondere alle domande di trapianti d’organo […] (“cadaveri caldi”). L’Osservatore Romano, venerdì 14 Aprile 1991, 4.