What Catholics should know about brain death

On death— described as “the end of man's earthly pilgrimage”— the Church teaches in the Catechism of the Catholic Church that “life is changed, not ended;” that death represents the moment of “the separation of the soul from the body.”

Apr 24, 2021

By  Jonah McKeown
The Catholic Church is clear in its teaching on when life begins: at conception. 

On death— described as “the end of man's earthly pilgrimage”— the Church teaches in the Catechism of the Catholic Church that “life is changed, not ended;” that death represents the moment of “the separation of the soul from the body.”

While the moment of human conception— the beginning of life— is well-understood and observed from a scientific standpoint, the exact moment of death can be harder to pin down.

This is especially true thanks to various forms of modern technology such as ventilators, which make it possible for doctors to declare a patient dead based on the state of their brain, even if their body appears, to the untrained eye, still to be alive. 

Brain death, also called death by neurological criteria, is the practice of declaring a person dead based on the loss of brain function, rather than the stoppage of the heart and breathing.

Brain death is, today, a commonly accepted standard for declaring a person dead. According to the 1981 guidelines of the American Medical Association, brain death entails the “irreversible cessation of all functions of the entire brain.” 

Most people are unlikely to need to think about brain death until it affects a loved one— but on a nationwide scale, the phenomenon is more common than one might think. An estimated 42 people are declared brain dead throughout the U.S. every day. 

The issue is complicated by the reality of organ transplantation. Brain-dead donors are, today, the primary source of organ transplants. 

Organs such as the heart, lungs, and pancreas can be— and are— harvested from brain dead donors as close to the time of death as possible. Donors’ bodies are sometimes given painkillers to stop involuntary movements originating from the spinal cord. 

What Catholics should make of this
The term “brain death” is not found in the Catechism of the Catholic Church. But statements from popes and from the Vatican have made it clear that, if properly diagnosed, the complete and irreversible cessation of all brain function is a valid way to assess with moral certainty that a person has died.

Moral certainty, St. John Paul II has said, “is considered the necessary and sufficient basis for an ethically correct course of action.”

Catholic doctors and ethicists today largely echo the Vatican in stating that brain death, when properly diagnosed, is not a “kind” of death; it is simply death, period. 

However, brain death remains a hotly debated topic among some Catholic medical professionals and ethicists.

One Catholic doctor said he is concerned that proposed changes to U.S. law regarding brain death could make it easier for doctors to diagnose, and thus may remove some of the rigor that the Church requires for moral certainty about brain death.

What brain death is
A Harvard Medical School Ad Hoc Committee introduced the concept of “brain death” in August 1968— less than a year after the first successful heart transplant, performed in South Africa in December 1967.

That document from the Harvard committee introduced the idea that in addition to using “irreversible cessation” of cardiorespiratory function as a criterion for death, doctors also can use irreversible cessation of brain function to determine death. 

While legal standards for determining brain death differ from country to country, in the U.S. the law relevant to brain death is the Uniform Determination of Death Act. 

The UDDA, passed in 1981, states that an individual who has sustained “irreversible cessation of all functions of the entire brain, including the brain stem, is dead.” 

All 50 states have adopted the UDDA into their own laws, with a few variations in the language used. New Jersey allows the family or proxy of a patient declared brain dead to object to the diagnosis on religious grounds. 

The UDDA leaves the “acceptable diagnostic tests and medical procedures” for determining brain death to the “medical profession,” saying doctors remain “free to formulate acceptable medical practices and to utilize new biomedical knowledge, diagnostic tests, and equipment.” 

But above all, the act stipulates that a determination of death “must be made in accordance with accepted medical standards.”

It is worth noting that the “entire  brain” provision of the UDDA differs from the law in some other  countries, such as the UK. 

In an illustrative case in February  2020, four-month-old Midrar Ali  was disconnected from his ventilator after judges agreed with doctors  that the boy’s brain stem was dead.  “Brain stem death” is not accepted  for a diagnosis of death in many parts  of the world, including in the US.

What the Catholic Church has said about brain death
In an Aug. 29, 2000 address to the International Congress of the Transplantation Society, St. John Paul II addressed the concept of brain death. 

The pope said 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.”

In 2008 the Pontifical Academy of Sciences stated that “brain death...'is' death,” and that “something essential distinguishes brain death from all other types of severe brain dysfunction that encompass alterations of consciousness (for example, coma, vegetative state, and minimally conscious state).”

“If the criteria for brain death are not met, the barrier between life and death is not crossed, no matter how severe and irreversible a brain injury may be,” the academy added.

Zalot pointed to a FAQ on brain death
Jozef Zalot, a staff ethicist for the National Catholic Bioethics Center, said that if accepted guidelines for determining brain death are rigorously applied, then it is possible to determine with “moral certainty” that a person has died.

“The Catholic Church looks to the medical community to determine the biological signs that indicate with moral certainty that this event has already occurred. In recent years, medical research has indicated that the irreversible loss of brain function provides a firm indicator that death has already occurred,” the NCBC says. 

The United States Conference of Catholic Bishops, in its 2018 Ethical and Religious Directives for Catholic Healthcare Services, states that the “determination of death should be made by the physician or competent medical authority in accordance with responsible and commonly accepted scientific criteria.” 

Dr. Barbara Golder, a medical doctor and lawyer with the Catholic Medical Association, stressed that Catholics are not obliged to continue futile care. She said that in general, for most situations, a brain death diagnosis is both “reliable and reasonable” when it is used to determine whether to cease care, such as a ventilator, to a patient. 

Golder noted, however, that the realities of a brain death diagnosis can leave doctors, family members, and observers uneasy. 

This is mainly because brain death often does not “look” like death, as a patient declared brain dead may still appear to be breathing, exhibit involuntary functions such as sweating, and may even grow and develop. 

Harvard ethicist Robert Truog, who does not believe that brain death necessarily represents biological death, has noted that “In some cases — particularly involving children and otherwise healthy young adults — patients diagnosed as brain-dead can actually survive biologically many years, provided they receive basic life support like mechanical ventilation and tube feedings.”

The bodies of brain-dead patients are sometimes given anesthetics while their organs are harvested, and may exhibit involuntary movements. 

The Pontifical Academy of Sciences addressed this in its 2008 paper stating that “the ventilator and not the individual, artificially maintains the appearance of vitality of the body. Thus, in a condition of brain death, the so-called life of the parts of the body is ‘artificial life’ and not natural life. In essence, an artificial instrument has become the principal cause of such a non-natural ‘life’. In this way, death is camouflaged or masked by the use of the artificial instrument.”

The NCBC agrees, stating that despite the complete loss of brain function, “artificial support may cause the victim to appear alive visually and to the touch.”

The media, in reporting on brain death cases, often focus on this fact.  

One highly publicized case is that of Jahi McMath, a 13-year old California girl who in December 2013 suffered a brain hemorrhage after complications following routine tonsil surgery. 

Five physicians- two at Children’s Hospital Oakland and three independent doctors requested by the family- declared McMath brain dead based on tests showing no blood flow to her brain and no signs of electrical activity after performing an EEG.

McMath’s family contested the diagnosis, and in January 2014 the hospital released her. The girl’s family took her to an undisclosed location— reportedly in New Jersey— for treatment where, the family claims, McMath continued to live and grow with the help of a feeding tube. Videos posted online show McMath occasionally exhibiting movement, such as twitching her foot. 

In June 2018, McMath’s family said that the teenager had died, citing “complications associated with liver failure.” 

The NCBC has said in the past that in cases where a patient declared brain dead has ultimately recovered or improved indicates an incorrect diagnosis of brain death in the first place.

“Stories of people continuing on a ventilator for months or years after being declared brain dead typically indicate a failure to apply the tests and criteria for determination of brain death with proper attentiveness and rigor,” said Fr. Tad Pacholczyk, director of education for the center, in a 2005 information sheet.

“In other words, somebody is likely to have cut some corners in carrying out the testing and diagnosis.”

Why Catholics should care about the proposed UDDA changes
Josef Zalot, a  staff ethicist  for the National Catholic Bioethics Centre (NCBC),  said while in  principle having uniform  guidelines is a good thing, it is  worth asking whether the American Association of Neurology  (AAN) guidelines, as proposed by  the authors of the revisions, are  the best guidelines to use.

The proposed changes to the  Uniform Determination of Death  Act (UDDA) seem, Zalot said, to  militate against moral certitude  that a person is dead by making  certain confirmatory tests unnecessary. 

“It certainly gives the appearance of cutting corners,” he said. 

Joseph Eble, a private practice doctor and  president of the  Tulsa Guild of  the Catholic  Medical Association, said he  worries that a  shift away from  anything less  than the most rigorous standards  for diagnosing brain death could  make it harder for Catholics to be  morally certain that a person has  in fact died. 

While the AAN guidelines do  acknowledge that brain death diagnoses are complex and ought  only be done by a doctor with  considerable skill and experience,  the guidelines also state that tests  such as an EEG are not required  for pronouncing brain death. 

“The AAN Guidelines require  only clinical testing at the patient’s bedside for a declaration of  BD, even though more advanced  testing could reveal persistent  brain function which bedside testing could miss,” Eble said. 

Eble says he worries that making such tests optional under law  will make it easier for doctors to  diagnose brain death in patients  who have a chance of recovery if  their organs were not harvested  and they were given additional  time. 

In his 2000 address, St John  Paul II stressed the importance of  only removing organs from people  who have definitively died. 

The Pope’s speech built upon  his writing in the 1995 encyclical Evangelium Vitae, in which  he decried any practice whereby  “organs are removed without respecting objective and adequate  criteria which verify the death of  the donor,” calling such a practice  a form of “furtive...euthanasia.”

Once again, the issue of organ  transplantation, which is a lucrative  business, complicates the matter. 

According to the US House  Committee on Oversight and  Reform, which launched an investigation into corruption in  the organ transplant industry in  December 2020, many of the nation’s 58 organ procurement organisations have exhibited problems such as waste, “exorbitant  executive pay,” and lobbying  against reforms. 

While organ donation and acceptance is allowed and even  laudable for Catholics, care must  be taken to ensure that the patient  is in fact dead. 

The NCBC states that it is acceptable for Catholics to receive  transplanted organs from brain  dead donors, as long as there is  moral certainty that the diagnosis  has been made with “rigor.”

‘It’s really important’
Eble said he hopes Catholics will  carefully consider the topic of  brain death.

“It would be most helpful if the  United States Conference of Catholic Bishops, and ultimately the  Magisterium, could issue a clarification of that Address based on  a careful study of the medical aspects of brain death (in particular  the AAN guidelines) in light of the  essential elements of the Church’s  anthropology. Such a clarification  would help to dispel the confusion among Catholics with respect to brain death,” Eble wrote  along with Dr Doyen Nguyen in  a March article for the Homiletic  and Pastoral Review. 

Golder noted that making the  decision to discontinue treatment  and let an illness run its natural  course — whether the patient has  been declared brain dead or not—  is never easy, and should be done  in close collaboration with a trusted doctor, she said. 

“Don’t be shy about asking for  someone to help guide and interpret. It’s really important,” she  said. 

“Ask the doctor to explain how  the process [of declaring brain  death] works, as different places  have different protocols. There are  no ‘silly’ questions — ask whatever comes to mind.”

Catholic families should understand that most doctors are doing  the best they can when it comes  to diagnosing death. The rest, she  says, is in God’s hands. ––CNA