April 9, 2007 09:21 AM
UNDERSTANDING BRAIN DEATH DIAGNOSIS
SECOND OF A TWO-PART SERIES
John M. Travaline, M.D., F.A.C.P.
In the second part of his essay, presented here, Dr. Travaline discusses the the determination of death by neurological criteria in the light of Church teaching. The first part, on medical criteria for this diagnosis, appeared in March.—Ed.
In the previous issue of Ethics and Medics, I discussed the diagnosis of death by neurological criteria, commonly known as brain death. In this issue, I offer, as a Catholic critical-care physician, a perspective on brain death in the context of the Church’s views on personhood and death.
Thinking about brain death inevitably raises many questions. There are three critical elements of the diagnosis of brain death that we need to understand if we are to properly position it in the broader domains of moral, ethical, and theological discourse. These key elements are (1) the concept of personhood, (2) the essence of death, and (3) the determination of death.
I will examine these elements that draw upon the teaching of the Church as presented in the Catechism of the Catholic Church and as found in magisterial comments on the human body, resuscitation, and organ transplantation. Regarding the latter sources, it is instructive to recall the thought of two pontiffs in particular—specifically, Pius XII and John Paul II. Each of them, echoing centuries-old Catholic tradition and teaching about personhood, life, and death, illuminate this important clinical diagnosis.
Personhood
The concept of personhood, not the physical body alone, is crucial to an understanding of brain death. The Catechism says, “The human person, created in the image of God, is a being at once corporeal and spiritual.”1 Concerning the spiritual component, or soul, the Catechism says, “In Sacred Scripture the term ‘soul’ often refers to human life or the entire human person. But ‘soul’ also refers to the innermost aspect of man, that which is of greatest value in him, that by which he is most especially in God’s image: ‘soul’ signifies the spiritual principle in man.”2
Regarding the relationship between the body and soul, we read,
The unity of soul and body is so profound that one has to consider the soul to be the “form” of the body; i.e., it is because of its spiritual soul that the body made of matter becomes a living, human body; spirit and matter, in man, are not two natures united, but rather their union forms a single nature.3
This notion derives from Aristotelian thought. For Aristotle, the human being is, in essence, a substantial union of body and soul. The view that the soul unifies and enlivens the body is critical to understanding how a diagnosis of brain death can be compatible with sound moral and theological reasoning.
The relationship between the physical body, maintaining as it does a myriad biological processes (albeit sometimes requiring medications and mechanical devices), and personhood is the fundamental premise on which we must consider the concept of brain death—that is, a situation in which the physical body appears “alive,” in the sense of ongoing biologic processes, yet the “person” is dead. We must characterize this relationship in more detail to appreciate its significance.
Death as Separation of Body and Soul
Conceptually, personhood aligns itself with the notion of the soul. Catholic teaching tells us that the soul, while it has a beginning, is also immortal. In some sense, then, the essence of a person never dies.
Unlike the soul, the body is mortal. When the body dies, the enlivening force in the body is lost. Another way of saying this is that the soul has departed from the body. This process—the separation of the soul from the body— is no less operative in brain death than in death determined by cardiopulmonary criteria.
When an individual suffers a traumatic blow to the head, there is a loss of blood flow within the skull and the physical body can no longer sustain itself biologically. Although mechanical devices may maintain the body’s physiological functions for some time, complete and irreversible loss of brain function is considered by medical science to be a proper criterion of death. The Church accepts this determination of death as a state in which there is no longer a unity of the body and soul. In brain death, the body is no longer able to remain in union with the soul.
In clinical practice, the diagnosis of brain death is often accompanied by discussion about harvesting the person’s organs for transplantation. Organ donation is indeed a charitable act, but it is particularly important in these circumstances for the health-care team to remember that it is never morally permissible to use the body as an object. In doing so, a physician violates human dignity.
We must be careful not to think of the body as in some way inferior to the soul. It is through the body that the person expresses himself. We must appreciate that the body is, in fact, a sacramental expression of the person, speaking its own “language.”4 Further,
by virtue of its substantial union with a spiritual soul, the human body cannot be considered as a mere complex of tissues, organs and functions, nor can it be evaluated in the same way as the body of animals; rather it is a constitutive part of the person who manifests and expresses himself through it. 5
So how do we reconcile the notion of death—something so final—when we have a biologically active body and an immortal soul? We must understand death as separation of the body and the soul rather than as the end of either the body or the soul.
When Does Separation Occur?
The precise moment at which the soul departs from the body is unknowable. Death, however, is an obvious reality and necessitates that someone make a judgment. All cases in which diagnoses of brain death are made occur in a medical setting. Typically, physicians are already involved in the care of the patient and are most appropriately disposed, as medical “experts,” to make a diagnosis of brain death.6
In his 1957 address to the International Congress of Anesthesiologists, Pope Pius XII discusses moral and theological issues surrounding the “resuscitation” of dying patients. He states:
It remains for the doctor, and especially the anesthesiologist, to give a clear and precise definition of “death” and the “moment of death” of a patient who passes away in a state of unconsciousness. Here one can accept the usual concept of complete and final separation of the soul from the body; but in practice one must take into account the lack of precision of the terms “body” and “separation.” 7
This statement preceded the formulation of brain death criteria by many years, but we already see the Church’s deference toward physicians in the determination of death. In 2000, Pope John Paul II reiterates this idea in his address to the Eighteenth International Congress of the Transplantation Society. Here he reminds us that death involves the separation of the soul from the body, and that its determination is best left to the medical community:
In this regard, it is helpful to recall that 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. The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly. … Here 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 judgment which moral teaching describes as “moral certainty.” 8
The diagnosis of brain death is unsettling to some. This is partly because the tangibly present body, with ongoing “life” processes, is so intimately connected to our understanding of what constitutes personhood. It is helpful to know that the Church teaches that the soul is the primary bearer of personhood, and that at death, the soul continues to exist. The Church, in her wisdom, leaves it to medical science to make the determination of brain death, but this does not mean that physicians make theological judgments. Physicans only make a determination of fact. It is for the Church to decide whether that judgment of fact corresponds to a sound anthropology.
John M. Travaline, M.D., F.A.C.P. Associate Professor of Medicine Temple University School of Medicine Philadelphia, Pennsylvania
1 Catechism of the Catholic Church, n. 362.
2 Ibid., n. 363.
3 Ibid., n. 365.
4 John Paul II, “Language of the Body Reread in the Truth,” Man and Woman He Created Them: The Theology of the Body (Boston: Pauline Books & Media, 2006), 538–542; general audience January 19, 1983.
5 Congregation for the Doctrine of the Faith, Donum vitae (February 22, 1987), Introduction, 3, http://www.vatican.va/roman_curia/ congregations/cfaith/documents/rc_con_cfaith _doc_ 19870222_respect- for-human-life_en.html.
6 John M. Travaline, M.D., “Understanding Brain Death Diagnosis,” (part 1), Ethics and Medics 32.3 (March 2007): 1–2.
7 Pius XII, “Prolongation of Life: Allocution to the International Congress of Anesthesiologists” (November 24, 1957), The Pope Speaks 4 (1958): 393–398.
8 John Paul II, “Address to the 18th International Congress of the Transplantation Society” (August 29, 2000), nn. 4–5, http:// www. vatican.va/holy_father/john_paul_ii/speeches/2000/jul-sep/ documents/hf_jp-ii_spe_20000829_transplants_en.html
