Brain Death is Death

Claiming otherwise leads to serious problems

I wish to note at the outset of this post, valued Value Judgments readers, that when I started this newsletter way back on, uh, Monday, I had no grand anti-Washington Post agenda. But they started it. First, they published a bad article on assisted dying in Canada, which I responded to here. Now they’ve taken a strong and implausible stance on the definition of death. Their position goes against well-established legal, medical, and philosophical norms, and it will lead to confusion about what has actually occurred in the stories they discuss.

So here’s the backstory. The actress Anne Heche was seriously injured in a car crash on August 5th and then died on August 12th. She was dead in the sense that she met the criteria that every U.S. state (and Canada, the U.K., and elsewhere) use to define death: namely, that she experienced the irreversible cessation of all functions of the entire brain, including the brain stem. (There’s no statutory definition in the U.K., but similar criteria are used.)

But there was a wrinkle. Heche had previously expressed a wish to be an organ donor, so, even though she was dead, her body was kept attached to a ventilator. This isn’t unusual. Some organs begin to deteriorate within minutes of being removed from the body, so healthcare teams will sometimes wait in order to assess the organs and until a suitable transplant recipient is ready nearby to maximize the chances of a successful transplant.

It’s worth noting that, unlike in some other cases, there was no disagreement among the family, healthcare providers, or the government about Heche’s death. Her family announced her death on Friday when her brain irreversibly ceased all functioning; her death certificate will also list Friday, August 12th as the day she died.

Nevertheless, since Heche’s body was still attached to a ventilator, some news organizations said that she wasn’t really dead, and chose instead to report her death on Sunday, August 14th. The Washington Post then ran a story explaining this discrepancy and explaining their own policy.

Before digging into that, two points about wording. First, sometimes people use the term ‘brain death’ in place of the ‘irreversible cessation of all brain function’ definition I mentioned above. I and many others dislike the term ‘brain death’ because it suggests that it’s different from other forms of death, so that if someone is brain dead then they aren’t really dead. But, as I mentioned, all the U.S. states recognize brain death as real, actual death, as does the American Medical Association and other groups. Therefore, there isn’t value in saying ‘brain death’. We don’t say ‘heart death’ when someone’s heart stops. They’re just dead. The same should apply to brain death.

The other terminological point concerns a misuse of the term ‘life support’. Now, this term is fine in most cases, since mechanical ventilation, dialysis, and other interventions do actually support life. But it’s confusing if someone says that a dead person, such as Heche, is on life support. To be sure, her body was still attached to machines that previously were helping to sustain her life, but then she died, so ‘life support’ is no longer appropriate. The machines haven’t changed, but a crucial factor about the patient’s clinical situation has.

The Washington Post isn’t buying it. They reason the other way: someone on life support can’t be dead; therefore, Heche wasn’t dead. Here’s Adam Bernstein, the Post’s obituary editor: 

“It’s black and white. There’s no gray area here. If you’re on life support, you’re still alive,” Bernstein said. “Other publications can make their own judgment about when they’re comfortable publishing. I’m comfortable when someone is actually dead.” 

Bernstein doesn’t say why we should reason this way—i.e., why ‘life support’ should still be considered life support in such cases. The result of this approach is sentences like the following: “Variety, which noted that Heche was still technically alive [on Friday], published a statement it attributed to Heche’s ‘family and friends’ on Friday”.

I’m against this approach. It promotes an implausible definition that leads to serious problems.

First, the definition. The brain-cessation view is also called the ‘whole-brain view of death’ or ‘death by neurological criteria’. The basic case for this view is that the brain integrates the body. Without a functioning brain, there can still be active parts of the body, but there’s no organism. So, when we talk about an individual being dead or alive, we mean an integrated organism. We could keep some aspect of a body alive by removing it and keeping it in a lab, but it wouldn’t make sense to say that someone is still alive just because their heart (or whatever) is still pumping with mechanical assistance. Someone attached to a ventilator might look alive, but she lacks bodily integration. Referring to someone as brain dead suggests that, in some more important sense, they’re still alive, but this is false.

This leads to practical issues. If we instead go with the Post’s approach, this significantly, and problematically, changes the analysis of what happened to Heche. According to the Post, Heche’s brain stopped working, then doctors removed her organs, thereby killing her. This mischaracterizes what happened in a way that has significant practical implications, so we should avoid it. 

The more general problem is that using ‘brain death’ causes confusion and distress for families who are making decisions for loved ones. Saying that a patient is brain dead suggests that the patient isn’t fully or actually dead, which can lead families to feel distress about removing mechanical ventilation, since it might feel like giving up or ‘pulling the plug’. In the worst cases, this leads to drawn-out legal battles.

The Post exacerbates the issue with the following sentence: “The Post’s obituaries editor, Adam Bernstein, said the newspaper doesn’t recognize brain death, which is sometimes partial, as a clear marker of death.”

Contrary to this claim, brain death can’t be partial: either death has occurred or it hasn’t. There can be clinical situations where there’s uncertainty about whether death by neurological criteria has occurred, but, as a definitional matter, either the whole brain has irreversibly stopped working or it hasn’t. As we learned in The Princess Bride, “There’s a big difference between ‘mostly dead’ and ‘all dead.’” Someone can be near death or in the dying process, but death itself is binary: either it has happened or it hasn’t.  

In The Wizard of Oz, the coroner presents the death certificate for the wicked witch and declares that “she’s not only merely dead, she’s really most sincerely dead.” People who lack all brain function are really most sincerely dead, and saying otherwise causes unnecessary confusion.