Intended for healthcare professionals

Letters

Brain death

BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7364.598/a (Published 14 September 2002) Cite this as: BMJ 2002;325:598

Open letter to Professor Eelco F.M. Wijdicks, author of book on brain death

Editorial note

This is an open letter to Professor Wijdicks, which we thought would
be of interest to readers following the debate on brain death.

Dear Professor Wijdicks,

Brain Death

I have just finished reading your anthology(1) which will henceforth
be generally available on the Cambridge University Clinical School Library
shelves. As it seems likely to be oft quoted, and may already be the
standard work of reference on this topic in the United States, I felt I
should write to you in the hope of correcting some misunderstandings which
your work perpetuates - particularly in regard to the U.K. history of
"brain death" but also in respect of persistent claims that one or another
(or even all) of the many different varieties of "brain death" are to be
considered equivalent to death in some contrived sense.

As your book makes clear to the thoughtful reader, there are far too many
inconsistencies for there to be general acceptance of the idea that the
various pre-mortal syndromes called "brain death" constitute a single,
reliably diagnosable, entity. All of them are, of course, very obviously
different from the state universally recognised as death and long attended
by cultural and religious practices of an importance which may well have
been underestimated. It is a pity that Margaret Lock's monograph(2) and
Michael Potts's anthology(3) were not available to you when you compiled
your book. I trust their contributions will have due influence upon
subsequent editions. I offer the following observations, which I will
number for ease of reference, in the spirit of furthering true
understanding and avoiding risk of misleading the less critical by
seemingly authoritative statements which, on rigorous examination, are
found to lack a sound scientific basis. Here in the U.K., that concern is
actively bound up with considerations of informed consent at this time -
particularly with regard to the true state of organ donors with beating
hearts when operated upon for transplant purposes.

1. I think you should be quite clear that there is no officially
sanctioned means of diagnosing brain death in the U.K. these days. It is
therefore misleading to say (page 21) "There is uniform acceptance of
brain death across Europe" and to include the U.K. in Table 1-8 (page 22)
as if there were. Elsewhere you acknowledge that (in 1995) the Conference
of the Medical Royal Colleges replaced "brain death" with "brain stem
death" as the name of the syndrome their criteria diagnosed - although
they do not have the power to diagnose that either, in the de facto
sense(4), as has subsequently been admitted. Just what they are currently
supposed to diagnose is not entirely clear. The best that the Department
of Health's spokesman has come up with so far is "death for transplant
purposes". Be that as it may, use of the term "brain death" is now
officially discouraged - after many years of improper and actively
misleading use in persuading trusting people to allow their relatives to
be used as organ donors. Thankfully, the basis of the certification of
death for those purposes is currently under consideration as part of a
wide review of organ acquisition and related practices by the Department
of Health. It may be that legislation will be required. I expect you know
that there is no legal definition of death in this country, none having
been necessary until the advent of transplant practices requiring removal
of organs before death in the ordinarily accepted sense has occurred.

2. I was interested to read (page 173) that the U.K. concept that
"loss of all brain stem functions alone is sufficient for death" was truly
unique, "all other jurisdictions in the world that accept brain death,
including the United States" espousing the whole-brain concept. I knew, of
course, that it was highly idiosyncratic but had not fully appreciated how
entirely "out on a limb" the likes of Pallis were in that simplistic
notion. Thank you (and Professor Bernat) for that. On that topic, I see
that Jennett's foreword includes the statement that "rigorous but simple
tests are reliable" (for the diagnosis of brain death) "but only if all of
them are always carried out". It doesn't take much imagination to envisage
head trauma of such degree as to make that requirement impossible to meet.
In the U.K., a specific dispensation was granted by Robson, the Conference
Secretary, to omit some of the tests in "circumstances in which it is
impossible or inappropriate to carry out every one", saying that the
published criteria were "recommended guidelines rather than rigid rules
and it is for the doctors at the bedside to decide when the patient is
dead"(5).

3. Even if completely and rigorously carried out, the U.K. tests (and
those prescribed elsewhere for the diagnosis of the brain stem element of
whole brain death) lack the power to establish the irreversible loss of
all brain stem functions. You recognise (page 71) that apnoea testing is
essential to exclude preserved medullary function - and tacitly
acknowledge the dangers of such testing (via hypotensive, acidotic and
hypoxaemic mechanisms) - but fail to point out that none of the prescribed
tests subject the respiratory centre to the ultimate excitatory stimulus
(anoxic drive). It may be that final exposure to that stimulus is
responsible for the agonal gasps seen (more commonly in our younger days)
some time after the ventilator is finally disconnected at the end of the
second series of tests so that death may be allowed to occur, i.e. when
there is no transplant interest involved.

While no apnoea test based solely on induced hypercarbia has the
power to diagnose irreversible loss of respiratory centre function, it is
worth noting that many such tests in use worldwide seem purely notional
while (perhaps because of the perceived risks) apnoea testing is omitted
altogether in many of the 80 nations you surveyed(6).

So much for the medullary control of respiratory function. It is its
control of blood pressure that - where alleged loss of brain stem function
is concerned - has always stuck in my craw. Your book ackowledges (pages
6,61,122,176) the fact that hypotension is an essential feature of what
might properly be called brain stem death. Profound hypotension -
circulatory collapse - immediately following upon discontinuation of the
noradrenaline infusion (page3) was, of course, a quintessential feature of
the pre-mortal syndrome described by Mollaret and Goulon of which your
book makes much (vide infra). And yet there is no requirement for the
documentation of such failure of the medullary cardiovascular "centres" in
the U.K. (or most other?) diagnostic protocols. Indeed, preservation of an
adequate blood pressure, without pharmacological support, has been
specifically mentioned in reports of series of patients pronounced "brain
stem dead" or "brain dead" (7,8). Those patients clearly retained brain
stem function - of which there were other indications in the Wetzel series
particularly, and in others reported subsequently.

4. I wonder if Mollaret and Goulon might be a little unhappy to see
that you say (page 3) "they presented a well-documented description of
what is now called brain death" and that (page 6) they "defined death
based on neurologic criteria". In their seminal article(9) they were at
pains to avoid any such interpretation of the terminal syndrome they so
carefully described. They called it "a fourth degree of coma" from which
recovery could not be expected. There was discussion of the frontier
between life and death and the propriety of discontinuing "reanimation"
efforts on the basis of these prognostic criteria. The fact that
superficially similar criteria - actually much less stringent - were
subsequently hi-jacked and used as criteria for the diagnosis of death is
surely no fault of those properly scientific Frenchmen. I think that, in
the interests of their scientific integrity, they would like that to be
made crystal clear.

5. I am not happy, as you may imagine, about your assertion (page5)
that "little, if any, controversy has persisted among physicians". I have
opposed the use of "brain death" criteria for the certification of death
from the first, being associated with several others whose views were, for
various reasons, not made widely known. A case in point is the letter(10)
which three fellows of the Royal College of Physicians of London sent to
the College journal (confidential to Fellows in those days) in 1981. One
of the three was the senior neurologist at Addenbrooke's Hospital in
Cambridge who opposed "brain death" on the grounds that "there are just
too many anomalies". In our letter we objected to the use of the
potentially manipulative term "brain death" to describe clinical states in
which the brain is so badly damaged that the prognosis is hopeless. We
pointed out that "brainstem death" is also a misnomer and suggested use of
the term "mortal brain damage" as a possible alternative.

On other occasions I wrote, alone or with others, to Presidents of
that College, as did the senior neurosurgeon at the London Hospital. You
could not have known about these protests, of course, nor about the
climate of secrecy and concealment of opposition which prevailed in this
country at that time. In the U.S.A. did not Byrne, Nilges and others try
very hard too - and, like me and my friends, continue to do so?

6. With others, I am concerned that the seemingly complex and co-
ordinated movements sometimes seen in those diagnosed "brain dead", e.g.
"reproducible eye opening …. in response to twisting of a nipple" (page
66) and the body movements which "puzzle the mind" and "frighten family
members" (pages73&74) and physicians(11), may be too readily dismissed
as representing "only spinal activity". The fact that EEG and CBF
examinations have proved negative is surely not sufficient to rule out the
possibility of persisting function (in extremis) in cerebellar and other
intracerebral pathways. Rather, it should be seen as evidence that those
techniques lack the sensitivity to diagnose irreversible loss of all brain
function. Might it be possible to look into these phenomena, where they
are reproducible, by means of somatosensory evoked potential studies?

7. I say this diffidently, but dare to say it. I believe you have
misinterpreted the Pope's position on "brain death" as a basis for the
diagnosis of death. In his superficially apparent endorsement (page142),
he specifically states that "the complete and irreversible cessation of
all brain activity (in the cerebrum, cerebellum and brain stem)" must be
established if the "neurological criterion" is to be used. From what you
and I and many others have said, that is clearly not the case where
current "brain death" diagnoses are concerned.

I hope the above may prove to be of some interest and assistance.
With seasonal good wishes,

yours sincerely,

David Evans

References

1. Brain Death. Ed. Wijdicks E. Lippincott, Williams & Wilkins,
2001. [ISBN 0-7817-3020-1]

2. Twice Dead - Organ Transplants and the Reinvention of Death. Lock
M. Univ. California Press, 2002. [ISBN 0-520-22605-4]

3. Beyond Brain Death - the Case Against Brain Based Criteria for
Human Death. Eds. Potts M, Byrne P, Nilges R. Kluwer Academic Publishers,
2000. [ISBN 0-7923-6578-X]

4. Evans DW, Hill DJ. The brain stems of organ donors are not dead.
Catholic Medical Quarterly 1989; 40: 113-121

5. Brain death - Addendum to 1979 Memorandum, para (3). Robson JG -
in February 1983 edition of the UK Health Departments' 'Cadaveric organs
for transplantation - a code of practice including the diagnosis of brain
death', page 39

6. Wijdicks E. Brain death worldwide. Neurology 2002; 58: 20-25

7. Hall GM et al. Lancet 1980; 2: 1259

8. Wetzel RC et al. Anesthesia and Analgesia 1985; 64: 125-8

9. Mollaret P, Goulon M. Le coma dépassé. Revue Neurologique 1959;
101: 3-15

10. Evans D, Lum C, Yealland M. College Commentary, July 1981

11. Sellers W. BMJ 11 Nov 1989 (vol

Competing interests:  
None declared

Competing interests: No competing interests

11 December 2002
David W Evans
retired physician
Cambridge CB3 9LN