When Does Someone Become Brain-Dead?

Larry A. Law

When a person is biologically dead, their organs cannot be used in a transplant. The reason is because the loss of oxygen causes organs to decay quickly. However, tissue like cornea, cartilage, skin, and even bone can be used. Only individuals declared brain-dead (no electroencephalogram (EEG) activity—no brain waves) can have their organs harvested and used in a transplant if their body is kept alive. While brain-dead means they are legally dead, their bodies are technically still alive. This can create some confusion about whether brain-dead is really dead. In today's world of social incentives for organ donations and fiscal motivations for illegal organ harvesting, this can lead to a situation fraught with moral and ethical conflicts of interest.

Heart Transplants

On December 3, 1967, the first successful human heart transplant was performed by Dr. Christiaan Barnard in Cape Town, South Africa. The replacement heart came from a female trauma victim with massive head injuries. Her heart continued to beat on life support, but there was no brain activity detected on EEG scans and she lacked any brainstem reflexes. The heart recipient survived for 18 days before succumbing to pneumonia, but his heart never stopped beating. A month later, Dr. Norman Shumway performed the first heart transplant in the United States. In an effort to provide guidance to this new surgical option, Harvard Medical School published "A Definition of Irreversible Coma" in the Journal of the American Medical Association (JAMA). They defined irreversible coma as the new criterion for death. 

Procedure for Determining Brain-Death

Today, the American Academy of Neurology (AAN) publishes guidelines for determining whether someone is brain-dead. Brain imaging by CAT scan or MRI must be conducted to ensure damage to the brain exists. Then, two doctors test the patient twice for responsiveness to pain stimulus and brainstem reflexes with a 24-hour interval between the tests. If there is no response, then an apnea test is administered which consists of taking the patient off the ventilator for 10 minutes. A tube carrying pure oxygen is inserted into their airways. If the patient does not begin breathing voluntarily, they are considered brain-dead.

Mistakes Can Happen

Unfortunately, it is not always so clear cut. False indications can result in the following conditions. 1) Hypothermia where the patient experiences low body temperature. This is common in patients resuscitated after cardiac arrest, because of the cooling devices applied to assist in recovery; 2) Autoimmune nervous system diseases like Guillain-Barre Syndrome where a person's nervous system can be robbed of reflexes and consciousness; 3) Drug overdoses; 4) Poisoning.

Zack Dunlap was pronounced brain-dead after a traffic accident in November 2007. He later stated that he regained consciousness after the pronouncement while friends and family were saying their goodbyes. He tried to scream and move, but nothing happened. He was an organ donor and was scheduled for surgery. But after family prayer his cousin, who was a nurse, felt it wasn't his time and conducted additional tests. When she pressed under his thumbnail, he pulled his arm to the other side of his body. The movement immediately revoked the diagnosis. After a few more days, he began breathing on his own and a month later was discharged from the hospital. I imagine he adores his cousin for saving his life!

Can Brain-Dead Donors Still Feel?

There is an ongoing debate whether brain-dead organ donors should be given consciousness blockers during organ procurement. Many doctors argue that while brain-dead people will likely never regain consciousness and recover, they are still alive and who really knows if they can still be aware and experience some level of internal pain. A famous case involved Jahi McMath, a 13-year-old girl who was declared brain-dead on December 12, 2013. However, her mother opposed the diagnosis and kept Jahi on life support for four and a half years. Though she could not speak and never regained full consiousness, two neurologists testified that in her final days she was "minimally conscious." Jahi would move to instructions and her EEG detected brain wave signals. This is impossible for someone brain-dead. So, Jahi recovered brain activity after being declared brain-dead. All of this goes to show that medical determinations do not always get it right. 

Here is a link to a doctor who seriously affirms (and makes a strong case) that there is no such things as being brain-dead.