The Signs of Death Pontifical Academy of Sciences, Scripta Varia 110, Vatican City 2007 www.pas.va/content/dam/accademia/pdf/sv110/sv110-shewmon.pdf MENTAL DISCONNECT: ‘PHYSIOLOGICAL DECAPITATION’ AS A HEURISTIC FOR UNDERSTANDING ‘BRAIN DEATH’ *,1 D. ALAN SHEWMON 1. STATEMENT OF THE PROBLEM The important task entrusted to this Conference by Popes Benedict XVI and his predecessor John Paul II has been clearly articulated by Bishop Chancellor Sánchez Sorondo: ‘The Academy is thus faced with the task of seeing whether the criterion of brain death (according to its full definition) indicates the biological state of death of an individual …’ (Conference Brochure, p. 4, ‘The Purpose of the Meeting’). It is remarkable that in the last decade or so, the various position state- ments and official commentaries on brain death by neurological and other medical societies have failed to state why brain death should be regarded as death of the individual. The same can be said for many recent books and chapters by neurologists on the subject. The equivalence is simply taken for granted as common knowledge, and the discussions focus rather on such aspects as diagnostic criteria for determining that the brain is dead, con- troversies over how much of the brain must be destroyed for the brain as a whole to be dead, etc. The American Academy of Neurology, for example, in its ‘Practice Parameters for Determining Brain Death in Adults’ (1995), which still remain the gold-standard diagnostic criteria in the United States, did not offer a single reason why it considers death of the brain to be death. Neither did fellow conferee Dr. Eelco Wijdicks in his accompanying commentary on the ‘Practice Parameters’ (Wijdicks, 1995) or in the chapter on brain death in his book on critical care neurology (Wijdicks, 2003, pp. 547-62). Nor, in his recent book on brain death (Wijdicks, 2001a), does he state why he him- * The views expressed with absolute freedom in this paper should be understood as representing the views of the author and not necessarily those of the Pontifical Academy of Sciences. 1 Although not publicly discussed, this paper was added because Professor Shewmon sent it in before the meeting and it was privately viewed and discussed by the participants. MENTAL DISCONNECT 293 self believes brain death to be death; rather, that apologetic task was dele- gated to co-conferee Dr. James Bernat, who has become somewhat of the unofficial brain-death-theory spokesperson for mainstream neurology (not without good reason), in whose chapter only a single paragraph is devoted to answering what he himself characterizes as ‘the most serious challenges thus far to the brain death concept’ (namely my publications as of that time) (Bernat, 2001, p. 180). Neither does fellow conferee Dr. Allan Ropper, in the sections on brain death in his two widely read textbooks, state why he considers brain death to be death (Ropper and Brown, 2005, pp. 306-7, 961-2; Ropper et al., 2004, pp. 157-64). Along similar lines, in their intro- ductory essay for the conference brochure entitled ‘Why the Concept of Brain Death is Still Valid as a Definition of Death’, Dr. Ropper and col- leagues concern themselves with rebutting the weakest arguments against brain death, while ignoring or glibly dismissing the strongest arguments, without in the end offering a single reason ‘why the concept of brain death is still’ – or ever was – ‘valid as a definition of death’. Discussions at this conference regarding the history of brain death, dis- orders that are not brain death, neuroimaging, apnea testing, determina- tion of irreversibility, determination of totality of brain nonfunction or destruction, controversies over what constitutes a ‘critical’ function of the brain, etc., interesting and important though they may be, will not bring the Church any closer to an understanding of whether and why death of the brain, so diagnosed, ‘indicates the biological state of death of an individu- al’. I daresay that doctors in general, and neurologists in particular, have come to an overwhelming consensus that brain death is death, not because they have examined the evidence and concluded it for themselves, but pure- ly and simply from a professional herd mentality. When queried about it, few can give a coherent explanation why brain death is death itself, as opposed to deep coma in a dying patient. In a revealing survey of physicians and nurses involved in transplantation, who surely ought to have a solid understanding of brain death for the sake of their own consciences, 58% did not use a coherent concept of death consistently and 19% held a con- cept of death that would logically classify patients in a persistent vegetative state as dead (Youngner et al., 1989). This is a serious mental disconnect in professionals who should have clear and coherent thoughts on the matter. 2. FOUR CANDIDATE RATIONALES FOR EQUATING BRAIN DEATH WITH DEATH Across the half-century of brain-death history up to the present, the many proposed reasons for equating death of the brain with death of the 294 D. ALAN SHEWMON individual have fallen into four basic categories: (1) because death is not an objective physical state but a relativistic legal definition or custom based on what seems most useful to a given society at a given time (societal relativism); or (2) because the brain is the organ of the mind, which is the essence of the person; therefore, the irreversible cessation of mind is cessation of the person, i.e., ‘death of the individual’ (person/mind reductionism); or (3) because the brain is the central integrating organ of the body, so that without brain function the body ceases to be a unified biological organism and begins the irrevocable process of disintegration, thereby indicating ces- sation of ‘the corporal reality of the person’ (to quote Pope John Paul II, 2000) (somatic integration rationale). (4) because the permanent loss of both mental functions and bodily unity, attendant upon death of the brain, constitutes – again in the words of Pope John Paul II (2000) – ‘the total disintegration of that unitary and integrated whole that is the personal self’ (psychosomatic integration rationale). A fifth rationale is not listed, because it is only a pseudo-rationale, name- ly the ‘fatal lesion fallacy’ (brain death is death because it will imminently lead to death). Remarkably, some experts still offer this as an implicit ration- ale for brain death (e.g., Dr. Wijdicks, 2001b, p. 76): ‘In the United States, pri- mary brainstem death does not fit into the concept of whole brain death, but it has been accepted in the United Kingdom and rightly so, because no sur- vivor has been reported when all brainstem function has been lost’. There are no other broad categories of proposed reasons why death of the brain as an organ should constitute death of the individual person. Let us now examine these four rationales in somewhat greater detail. (1) Societal relativism was the rationale of, among others, Dr. Henry Beecher, chairman of the Harvard Committee, as made clear in some of his commentaries following the revolutionary Harvard Committee report of 1968, which marked the beginning of the general acceptance of brain death as death (Beecher et al., 1968). ‘At whatever level we choose to call death, it is an arbitrary decision. Death of the heart? The hair still grows. Death of the brain? The heart may still beat. The need is to choose an irreversible state where the brain no longer functions. It is best to choose a level where, although the brain is dead, usefulness of other organs is still present (p. 120). … Here we arbitrarily accept as death, destruction of one part of the body; but it is the supreme part, the brain (p. 121). … Can society afford to discard the tissues and organs of the hopelessly unconscious patient so greatly needed for study and experimental trial to help those who can be MENTAL DISCONNECT 295 salvaged? (p. 122)’ (Beecher and Dorr, 1971) (emphasis mine). Needless to say, societal relativism is incompatible with any sort of objective meta- physics of life and death, and as such is incompatible with the fundamen- tal tenets of many of the world’s religions, including Catholicism. (2) Person/mind reductionism declares the person to be dead when there is no longer a personal mind or consciousness, even in potency (e.g., excluding states of sleep or coma from which there is a potential to awak- en; whether human embryos are excluded or not varies across authors). According to this view, truly irreversible coma, as well as permanent vege- tative state (defined according to the American Academy of Neurology and many other professional societies in terms of unawareness of self and envi- ronment – cf. Shewmon, 2004a; Shewmon, 2004b) are therefore death of a person, regardless of the biological life/death status of the (former) person’s body (also prescinding here from the subtle controversies surrounding the terms ‘irreversible’ and ‘permanent’ (Cole, 1992; Lizza, 2005; Lizza, 2006, pp. 102-7; Tomlinson, 1993). This rationale is frequently referred to in the literature as the ‘higher brain’ formulation of brain death. It has had and continues to have many advocates. Such equating of person with mind is patently Platonic/Cartesian and contrary to the Aristotelian/Thomistic notion, which the Church endorses, that the human person is a corpo- ral/mental hybrid, so that the spiritual soul is at once both the center and source of intellectual and volitional powers of the mind, as well as substan- tial form (life-principle) of the body (Council of Vienne [1312], 1957). This psychological rationale was most strikingly articulated by one of the participants of the Pontifical Academy of Sciences’ Second Working Group on Brain Death: ‘[T]he Cartesian ‘cogito ergo sum’ principle is still applicable in our days.