Para bem balizar as ideias, transcrevemos a seguir a importante e esclarecedora entrevista da Prof. Doyen Nguyen (professora na Universidade Pontifícia de S. Tomás de Aquino, em Roma) à revista Radici Cristiane [Raizes Cristãs].
Radici Cristiane (RC): There are people who think that “brain death” is a great deception. Do you agree?
Doyen Nguyen (Nguyen): Yes. “Brain death” has been a medical fiction from its very inception. The evidence for this can be found in the manuscript-drafts of the Ad Hoc Harvard Committee report which introduced “brain death” on August 5, 1968. The Committee, headed by its chairman, Dr. Beecher, worked swiftly on this report from March through June 25, 1968. In the first manuscript-draft, Beecher wrote:
The question before this committee cannot be simply to define brain death. This would not advance the cause of organ transplantation since it would not cope with the essential issue of when the surgical team is authorized—legally, morally, and medically—in removing a vital organ.
In the penultimate manuscript-draft on June 3, 1968, Beecher wrote:
With increased experience and knowledge and development in the field of transplantation, there is great need for the tissues and organs of the hopelessly comatose in order to restore to health those who are still salvageable. (1)
The language in the manuscript-drafts of the Harvard report is thus overtly explicit with regard to the connection between organ donation and the “birth” of “brain death.” In other words, the real reason why the Harvard Committee redefined irreversible coma as death (and gave it a new name, “brain death”) is for a two-fold purpose: (i) to have fresh, viable organs more readily available for the transplantation enterprise, and (ii) at the same time, to avoid any public outcry that transplant surgeons were organ-stealing killers.
In the final draft which became the Harvard report, the explicitly utilitarian language in the earlier drafts was toned down by Ebert (then the dean of the Harvard Medical School), in order to make it seem that transplantation was not the primary cause of the “birth” of “brain death.”
So, in a nutshell, “brain death” is a construct to serve the interest of organ transplantation.
RC: What is the scientific/medical evidence showing that “brain death” is not true human death?
Nguyen: Here I will answer you with a long quote taken from a peer-reviewed article written by Kompanje and De Groot. They are supporters of organ transplantation and therefore, of “brain death.” Yet, because of academic honesty, they have to admit that “brain death” is a construct for the purpose of organ transplantation. They wrote:
Suppose one of your loved ones is admitted to an ICU with a subarachnoid hemorrhage and you are sitting next to her bed, overwhelmed by emotions and holding her hand. She is deeply comatose, connected to a ventilator; intravenous vasopressors are needed to keep her blood pressure stable. You are hoping for the best, but fear the worst. And the worst comes. The intensivist tells you her brain is dead. Then he asks you for permission to take out her organs. You, and your loved one, had never thought about this scenario of dying. You had heard about brain death, but you don’t have a picture of it in your head. You ask the doctor: “when will she die”? He answers: “she is already dead.” You don’t believe him because there are so many signs of life. Her skin is warm, her heart is beating. […] Taking out her organs while her heart is still beating seems like a scene from a cheap horror film. […] We are, as most intensivists, greatly in favor of organ donation for transplantation. The whole concept of organ donation is founded on the concept that the potential organ donor is really dead at the moment that brain death is declared. This is pivotal in order to gain even remote public acceptance of organ donation. They have to be ensured that their loved one is dead before the organs are taken out. But, the bare fact that many brain-dead patients can continue to perform a variety of integrative functions over indefinite time periods, including maintaining body temperature, persistent and adequate hypothalamic hormonal function, regulating salt and water homoeostasis, digesting administered food, healing wounds, increase of infection markers and healing infections, stress responses to bodily interventions such as surgery and gestating fetuses in pregnant brain-dead women, makes some wonder whether a brain-dead patient is as ‘dead’ as the doctors say. Or they mistrust the statement that the patient has been pronounced ‘dead.’ For example, it is very difficult to see a ‘brain-dead’ pregnant woman, in whose womb a fetus grows over a time period for 2–3 months after the determination of brain death, as ‘a cadaver.’ There are just too many signs of life. Declaring these patients ‘dead’ solely on the basis of ‘a definition’ seems to contradict our common sense of what it is to be alive. Brain death is, since the first definitions in the scientific literature in 1968, closely related to organ donation. This is why, some scholars considers equating brain death to death as a moral and legal fiction. […] Without the needs of transplantation medicine, ‘brain death as death’ would not exist at all, but would be seen as […] irreversible […] coma (le coma dépassé). (2)
In fact, the above quote should remind us of the opening statement in the Harvard report which states: “Our primary purpose is to define irreversible coma as a new criterion for death.” Note however, the term “irreversible coma” itself indicates that the patient is alive, for the simple reason that only a living person can become comatose or remain comatose. In other words, it would be an oxymoron to say that a corpse is in coma!
Moreover, both life and death are realities the nature of which is mind-independent. The world is what it is regardless of what anyone says or thinks about it, and that world includes phenomena such as life, death, diseases, and all natural things from inorganic matter to human persons. Such natural entities are not open to revision or stipulation. In other words, death (understood as a biological phenomenon) is not the kind of thing that occurs by fiat like in the case of marriage. When a doctor declares a comatose patient (whose heart is beating, and whose skin is warm and pink) to be dead, that patient does not thereby become dead.
RC: A threefold question regarding John Paul II’s 2000 Address to the 18th International Congress of the Transplantation Society, the problem which this Address has caused, and what should the Catholic faithful do?
Nguyen: For a detailed answer to this question please read my article: 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 Quarterly 84, no. 2 (2017): 155–186. A more expanded treatment of the topic can be found in my book: Doyen Nguyen, The New Definitions of Death for Organ Donation: A Multidisciplinary Analysis from the Perspective of Christian Ethics (Bern: Peter Lang, 2018) on pages 457-483.
In this interview, I can only give you a brief synoptic answer to this very complex question. The bulk of my answer is found in sections 3.2 and 3.3.
3.1 First point: About the hierarchy of the different types of Magisterial teaching
The ordinary teaching of the Church’s Magisterium includes several gradations, from the higher end (e.g., the teaching of an encyclical such as Veritatis Splendor) to the lower end which consist of interventions in the prudential order, in which some Magisterial documents might not be free from all deficiencies since they might not have taken into immediate consideration every aspect or the entire complexity of a particular issue (see Donum Veritatis, no. 24). In addition, the importance of a particular Church’s teaching can also be inferred from the insistence with which it has been repeated.
In this regard, John Paul II’s address to the Transplantation Society in 2000 belongs to the category of interventions of the prudential order. Moreover, the Pope’s statement (contained in that address) with regard to “brain death” has occurred once and only once in the whole of the teaching of the Magisterium. In particular, John Paul II did not even make a reference to that statement in his 2005 address to the participants of the conference “the Signs of Death” (February 2005) sponsored by the Pontifical Academy of Sciences.
3.2 Second point: John Paul II’s statement in his 2000 address
John Paul II’s statement in his 2000 address is as follows:
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. […] 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.
There are several key points in the Pope’s statement:
(a) Death is the separation of the soul from the body. In other words, the Pope’s teaching on death is grounded in Christian anthropology, according to which: (a) man is the substantial unity of body and soul and, (b) the soul is the life principle of the body. In medical/scientific terms, the separation of the soul from the body manifests itself as the loss of somatic integration, i.e., the process of corruption of the material constituents which once composed the living body.
(b) Vital organs can only be removed after death. In this regard, it is necessary to understand that because human beings belong to the same genus of warm blood mammals, the biological manifestations of the death phenomenon in a human being are no different from that observed in other mammals such as a pet dog or a pet cat – no heartbeat, no respiration, no movements, no responses to any stimulation. The temperature of the dead body quickly drops to the same level as the ambient temperature; and livor mortis and rigor mortis set in within a few hours.
(c) 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 “does not seem.” According to the Pope’s statement, in order to be acceptable, the “brain death” criterion must fulfill three requirements:
(i) the loss of somatic integration, i.e., the physical evidence that the soul has left the body;
(ii) a consensus of the parameters that constitute the “brain death” criterion (i.e., in the Pope’s words: “clearly determined parameters commonly held by the international scientific community”). The parameters here refer to the clinical tests used for determining “brain death;” and
(iii) the rigorous application of these parameters.
3.3 Confronting John Paul II’s 2000 statement and the reality of “brain death”
3.3.1 Without going into details, suffice it to mention that even brain-death advocates have to acknowledge that there is no global consensus on the parameters of the “brain death” paradigm, but rather a confusion of practice. 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 of this wide variability is the variability in apnea testing, recognized by Greer and colleagues as “an area with the greatest possibility for inaccuracies.” (3)
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.
3.3.2 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, which clearly provided the evidence that “brain death” is not death. Examples of such literature include:
(i) Shewmon’s 1998 report of a series of chronic “brain death” survivors;
(ii) 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 section;
(iii) 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.” (4)
(iv) The most important publication which the Pope’s 2000 Address should have known about and should have taken into account is the document of the Quality Standards Subcommittee of the American Academy of Neurology published in 1995 to provide the guidelines for determining “brain death.” 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” – is compatible with the diagnosis of brain death.” (5)
A review done by Saposnik in 2009 shows that up to 80% of brain-dead patients can manifest such movements. Although movements in any particular brain-dead patient may be very infrequent, they nevertheless occur.
Put simply, according to the guidelines for the determination of “brain death,” the brain-dead patient can be declared dead even though he or she may have movements from the arms and legs. The obvious question that any average person should ask is: how is it that a corpse can move? And the obvious question which every Christian should ask is: if the soul has left the body, then what is the principle which accounts for the spontaneous movements and reflexes of the arms and legs in the brain-dead patient? 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, and local movement; and likewise of our understanding. (6)
There, without the soul, there can be no movements, no sweating, no blood flow, no heartbeat, etc.
In a nutshell, given that the brain death criterion admits the presence of spontaneous movements and reflexes, then in what way can it be claimed that “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”? (7)
Such a statement can only reflect a gross oversight of the medical, scientific, and bioethical literature publicly available before 2000. For this very reason, such a statement needs to be seriously amended, or better yet, retracted – for the good of the Church and her children, the faithful.
Truth is the conformity of the mind to reality (veritas est adaequatio rei et intellectus). Given that (i) John Paul II’s 2000 address ranks at the lower end of ordinary Magisterial teaching (the kind which may contain inaccuracies), (ii) the teaching was mentioned once and only once in the entire Magisterial teaching of the Church, (iii) John Paul II himself did not even allude to it in his subsequent address in 2005, and (iv) the statement itself contradicts the medical reality of brain-dead patients, then indeed it cannot be said that the teaching in the 2000 address has any binding force on Catholic believers.
RC: About the interests and pressures on the Church and society in general, such “brain death” is universally accepted?
Nguyen: It should be evident to readers by now that “brain death” is a medico-legal fiction, a social construct for utilitarian purposes. It does not take much imagination to figure out that the transplantation enterprise is a multi-billion dollar (or Euro) business. Even the most staunched defender of “brain death,” Bernat, had to admit (albeit very reluctantly) that the concept of “brain death” is incoherent; but, according to him, in the real world of public law and policy, we must compromise so that death can be declared and organs procured. (8)
It is not correct to say that “brain death” is universally accepted. As Brugger points out, doubt about “brain death” has become an international consensus, in the sense that quite a number scholars in medicine, philosophy, and bioethics from countries worldwide have recognized that the “brain death” paradigm is unsound. (9)
It would be more correct to say that “brain death” has been universally imposed by legislation in different countries. The materialistic, utilitarian mindset of a consumerist culture has led to the so-called worldwide acceptance of “brain death.” It is part and parcel with the culture of death. Surprisingly, somehow this mentality has also penetrated into the Church, probably under the guise of charity and solidarity, especially since in the writings of John Paul II, organ donation has been exalted as a new way for man to make a sincere gift of himself and fulfill his constitutive calling to love and communion and, moreover, the gift of vital organs donated after death gives the donors the possibility to project beyond death their vocation to love. (10)
Certainly, as taught in the Catechism no. 2296, the Church encourages organ donation, because it is a noble act of charity and solidarity. But, it is not morally admissible to bring about the death of a human being, not even in order to delay the death of other persons. In a nutshell, it is not morally permissible to do evil to achieve a good. “Brain death” does exactly that: the deeply comatose patient (usually a young patient who has suffered a traumatic brain injury) is declared dead, so that his or her organs can be removed for transplantation purposes.
(1) the drafts of the Harvard report are part of what is known as the “Beecher manuscripts,” preserved at the Francis Countway Library of Medicine at Harvard. They are not accessible to the public, they are made available only to some selected scholars.
(2) the quote is taken from: Erwin J.O. Kompanje and Yorik J. de Groot, Sounding board: is mandatory recovery of organs for transplantation acceptable? Intensive Care Medicine (2015) 41:1836–1837.
(3) data taken from David M. Greer, Panayiotis N. Varelas, Shamael Haque, Eelco F.M. Wijdicks, Variability of brain death determination guidelines in leading US neurologic institutions. Neurology 70, no. 4 (2008): 284–89]. Ironically, the apnea test is a cornerstone bedside clinical test for making the declaration of “brain death.”
(4) quoted from Robert Taylor, “Reexamining the Definition and Criteria of Death,” Seminars in Neurology 17, no. 3 (1997): 265.
(5) this quote is derived from Eelco F. M. Wijdicks, “Determining Brain Death in Adults,” Neurology 45, no. 5 (1995): 1007.
(6) see Thomas Aquinas, Summa Theologiae, I, q.76, a.1.
(7) this is the statement taken from the 2000 Address.
(8) see James L. Bernat, “The Whole-Brain Concept of Death Remains Optimum Public Policy,” Journal of Law, Medicine & Ethics 34, no. 1 (2006): 41
(9) see E. Christian Brugger, “Are Brain Dead Individuals Dead? Grounds for Reasonable Doubt,” Journal of Medicine and Philosophy 41, no. 3 (2016): 355
(10) see John Paul II, “To Participants of the First International Congress of the Society for Organ Sharing (20 June 1991)