Point of View A brain death: concepts and confusions among medical experts, legal authorities and general public in Sri Lanka Ruwanpura P Rohan Consultant Judicial Medical Officer, Teaching Hospital, Karapitiya, Galle. Introduction Cortical death The concept of brain death exists for over The concept of cortical death 4 evolved from hundred years but has been conceptualized only socio-anthropological definition of death, as a during fifth and sixth decades of the 20 th person with cortical death can no longer be century, especially, after the publication of the recognised as a “social man” 5. It is true that landmark paper by the Ad Hoc Committee of permanent and irrecoverable dysfunction of the the Harvard Medical School 1. This new brain will not allow a patient to be back to scientific definition of brain death 2 replaced standard social life, but one should realise that, then prevailing socio-biological concept based in many social settings, severely disabled on cessation of all the functions of a human unconscious persons and anencephalic body, a somatic or biological death, as a legal newborns were also being treated as "socially death. The concept of brain death has now been dead" before biological death had occurred. accepted as a legal definition of death in many Conversely, a dead body may be treated as alive parts of the world, of course with great for some time after physical death due to variations in diagnostic criteria 3. However, it religious believes of spiritual origin of life. should be realized that a layperson would be Therefore, permanent vegetative state cannot be reluctant to accept someone with a beating equalised to biological death 6, but may be heart, a normal pulse, a normal blood pressure, a considered for euthanasia and organ normal colour and a normal temperature as transplantation in case by case basis. The Sri dead. Hence, socio-anthropological concept of Lankan law does not identify persistent death, permanent cessation of somatic and social vegetative state as a specific entity and medical functions of a human body is most applicable to professional has no option other than treating common public sense. him as a deeply comatose patient. Medico-legal aspects of brain death Brain stem death There are many medico-legal issues pertaining The concept of brain stem death is mainly to determination of the point of death, or brain practiced in United Kingdom 7. The scientific death. This include disconnection of the basis of brain stem death relies upon the artificial respiration, removal of kidneys and traditional belief that the cerebral cortex cannot other organs for transplantation, issuing death be viable over the dead brain stem. Though the certificates, maternal rights and rights of live legal requirement for the diagnosis of brain stem foetus in maternal death, insurance disputes in death is "irreversible cessation of all functions determining whether the death is a result of an of the brain stem”, it is "accepted" that this injury or a natural cause, prosecuting with requirement has been fulfilled by observing murder charges, arranging final religious and absence of breathing (apnea test) and absence of astrological customs. Therefore, it is essential brain-stem reflexes only 8. However, there are for the medical practitioner to clearly multiple functions of the brain stem such as understand medico-legal inferences of this control of body temperature, central nervous concept. system control of blood pressure, neurogenic The brain death may exist in three forms. These control of heart rate, and hypothalamic–pituitary are cortical death better known as permanent control of thyroid and adrenal gland influence vegetative state (PVS), brain stem death and on maintaining temperature, blood pressure, whole brain death concept. electrolyte balance, which are not considered 48 Galle Medical Journal, Vol 13: No. 1, September 2008 Point of View and may be functioning at the time when patient Brain death and organ transplantation is called brain dead. The recent advances of It should be realized that the transplantation neuro-physiological investigations showed the owed its development to advances in surgery presence of cortical electrical activities over the and immunosuppressive treatment. Brain Death irreversibly dysfunctioning brain stem. owed its origin to the development of intensive Furthermore, future advancement of computed care 14 . According to provisions of the neurosurgical technologies would facilitate us to transplantation Act, once brain death is replace brain stem functions with ever- confirmed by physicians who shall be neither increasing success 9, and prolonged survival of a involved nor personally interested in the patient with a mechanical brain stem, but transplantation process, the cadaver may be otherwise intact cognition, would show the considered as a potential organ donor. The main inadequacy of a brain stem definition. The Sri problem here is that many potential healthy Lankan law does not accept the concept of organ donors are victims of violence and road brain stem death, though many practitioners, trauma, where release of the bodies are being influenced by an English concept subjected to an inquest followed by autopsy moderated by Dr Christopher Pallis 10 , continue examination, under the provisions of criminal to diagnose death by clinical signs of the brain procedure code. The provisions of the criminal stem dysfunction. procedure code cannot be overruled by the transplantation Act. Whole brain concept However, there is no legal bar for consented It has been highlighted that only the whole-brain removal of the organs once the corpse is concept, that is the irreversible loss of all released after the autopsy, as practiced in functions of the entire brain, is consistent with corneal, knee joint or skin graft transplant. If the death of a man 11 . The concept of whole organ removal has to be done from a beating brain death as definition of death of the heart cadaver, who is a victim of violence, a individual is accepted in majority of European magisterial permission seems to be necessary countries, while the clinical examination and for the removal of organs and may be obtained documentation of the clinical signs of brain by forwarding a “B” report to the courts through death are very uniform, there are significant the investigating police officer or a lawyer of differences in the guidelines for using technical the transplantation team. This specific situation confirmatory tests to corroborate the clinical is not addressed in the Sri Lankan law. There signs 12 . The definition of death in Sri Lanka is are no procedures laid down in criminal and given in the Transplantation Act No. 48 of transplant laws to overcome such situations in 1987, which states that irreversible cessation the Sri Lankan low. Therefore, the medical of all functions of the entire brain, including community, admiring immense benefits to the the brain stem, is death 13 . A diagnosis of patient by transplantation surgery, could death shall be determined by standard means of tactically overcome such legal inconsistencies current medical practice, which may include by mutual understanding between the transplant clinical signs of prolonged absence of team and the JMO, who may personally witness respiratory and circulatory functions, reflexes, the organ removal and incorporate an additional supported by ancillary tests; EEG, Doppler’s report from transplant surgeon stating that sonography, carotid angiography, CT scan or organs removed are healthy and free of any future advancement of brain function tests significant pathological changes contributory to as appropriate. In this context, our stand on death. The organs removed for transplantation brain death is wide open to accommodate new are essentially of healthy nature and argument technical advancements, and in par with modern by some JMOO that they cannot determine the concepts practiced in many European countries cause of death without that particular organ, and USA. may be a lung, liver or a heart, then becomes invalid. Galle Medical Journal, Vol 13: No. 1, September 2008 49 Point of View Furtherance 3. Wijdicks EF. Brain death worldwide: accepted fact but no global consensus in diagnostic criteria. It is worth to outline that, all concepts of the Neurology. 2002; 58 (1): 20-5. brain death are based on irreversibility of 4. Jannet B, Plum F. Persistent vegetative state after 15 functions of the brain and not on the extent of brain damage. Lancet 1972; 1: 734. actual pathological damages to the neural 5. Brody B. Ethical Questions Raised by the Persistent tissues, whereas, the pathophysiological basis of Vegetative State. Hastings Centre Report 1988; 33-7. brain death refers to permanent and total 6. McMahan J. The Metaphysics of Brain Death. cessation of cerebral circulation. Interestingly, Bioethics 1995; 9: 91-35. many studies conducted on histopathological examination of brains revealed minimal 7. Conference of Medical Royal Colleges and their 16 faculties in the United Kingdom. Diagnosis of Brain anatomical changes of the cerebral tissues , Death. Brit Med J 1976; 2: 1187. though they were clinically confirmed as dead 8. The President’s Commission for the Study of Ethical brains. Problems in Medicine and Biomedical and The discovery of the special malleability of Behavioural Research. Defining Death: A Report on the Medical, Legal and Ethical Issues in the foetal brain tissue, and the ability to stimulate Determination of Death. Washington, DC: US neural cell growth and division with Government Printing Office; 1981. neurotrophic chemicals or gene therapy, raises 9. Stuart Y, Bartlett E. Human death and high the possibility that patients with extensive brain technology: the failure of whole-brain formulations. damage, sufficient to currently be considered Annals of Internal Medicine 1983; 99: 252-8. dead, at least by higher-brain standards, may be 10. Pallis C. Brain stem death- the evolution of a concept. able to return to some degree of function by The Medicolegal Journal 1987; 55 (2): 85-120.