“Brain-death” is a problematic term, a topic Robert Truog has treated in JAMA (Journal of the American Medical Association) in three pieces (two with colleagues) in the past two years.[1],[2],[3] His thinking continues to evolve about the term’s limitations and problems, but he has not, to date, given up on it. We have, however.[4] At the least, we suggest that the advantages of doing so be given some thought.
“Brain-death,” meaning irreversible coma and apnea, as a new criterion for death first came to world attention in 1968.But the old criterion—possibly as old as language itself—meaning a body is irreversibly cold and pulseless, even now some families, for cultural and religious reasons, can be exceedingly “stubborn” in defending; lawsuits are increasingly filed on, directly or indirectly, its behalf. We clinicians (and ethicists) sometimes become quite bullying in our attempts to bring such families around to our newer persuasion[5]—never a comfortable posture for us and one that’s maddening for those we should be comforting instead.
What irreversible coma does predict with perfect accuracy is the retreat forever from the corporeal world of the personwho once occupied the comatose body. This, we believe, is the point around which our talks with families could be centered. It’s an honest point: it neither claims nor disclaims too much. We do not believe it would incite reluctance about organ-donation. Yes, it presumes irreversible is indeed irreversible—a forecast that might be improved on technically.3 But what is fully secure is that our guidelines for irreversibility predict just that with regard to who once occupied the body in question: she is gone forever from the corporeal world. We believe a shift in language, from death to an irredeemable absence of a person, will help us as clinicians be present with grieving families; it will focus our grieving with them.
Is it practical otherwise? It violates the “dead-donor rule” for transplantation of a vital organ unless each such process is adjusted as it must be for chronic vegetative state. Do we have the will for that? Or to pester state legislatures to redo the law? Did successful passage of the new criterion for “death” into legal reality ruin possibility for amendment now? Or should we accept the solace in a gem Dr. Truog and colleagues place near the end of the second of his recent JAMA pieces: “History is full of ironies…”?2
Robert Arnold Johnson, MD
Thomas Alderson Davis, PhD
[1] Truog RD. Defining death—making sense of the case of Jahi McMath. JAMA. 2018;319(19):1859-1860.
[2] Truog RD, Pope TM, Jones DS. The 50-year legacy of the Harvard report on brain death. JAMA. 2018;320(4):335-336.
[3] Truog RD, Paquette ET, Tasker RC. Understanding brain death. JAMA. 2020;323(21):2139-2140.
[4] Johnson RA, Davis TA. Story by Story: Who I Am, What I Suffer. Cambridge Scholars Publishing; 2019.
[5] Aviv R. The death debate. The New Yorker. February 5, 2018:30-41.