Life Studies Blog (Old)

December 18, 2004

Psychological care of the family, and a brain dead person (by M)

The translation of Chapter 2 of Brain Dead Person (1989) was finally finished. Translation was made by Alex Jones, thank you Alex!

Chapter 2 (
translation here) is the most important part of this book. There I introduced the idea "care of the sphere." Sphere means the sphere of human relationships surrounding a brain dead person in a hospital. In the intensive care unit in a hospital the family of a brain dead person try to accept the death of the patient by caring for the patient (at least in Japan where brain death does not necessarily mean death). In some cases they accept, but in other cases they don't accept or refuse the idea of brain death. In this chapter I proposed doctors and nurses to "help the family to attend the brain dead person." Please read the text for details.

This book was published in 1989, and probably this was the first book that stressed the importance of the care for the family who are attending the brain dead person (not for harvesting organs but for the psychological care of the family). Do you know any other materials in English?

Anyway, it was 15 years ago. I was 30 years old when I published this book. Time flies.
Photo: Surutto-chan at Osaka Subway

What's New:
Brain Dead Person Chapter 2.


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2 Comments:

  • I read “Reconsidering Brain Death A Lesson from Japan’s Fifteen Years of Experience“ together with “Brain Dead Person” chp. 1 and 2, and I am confused about the following passage:
    “We must not enlarge death to include persistent vegetative states or anencephaly. Bioethicists in the English speaking world often speak of “cerebral death” as human death. But there are reports of exceptional patients in a persistent vegetative state who recover from it with intensive nursing care, and even become able to write and/or speak. The difference between brain death and a persistent vegetative state is that while the former never recovers, the latter has a slight chance of recovery.”
    How do we separate the two from each other? Does the phrase “never recovers” involve prognosis, under some circumstances? After reading the following statements from International Working Party Report On The Vegetative State – 1996 (http://www.comarecovery.org/artman/publish/ReportOnTheVegetativeState.shtml) and “Brain Death and Disorders of Consciousness” -Proceedings of the Fourth International Symposium on Coma and Death, held March 9-12, 2004, in Havana, Cuba. “Brain Death” Is Not Death by Paul A. Byrne, M.D. and Walt F. Weaver, M.D (), I am not sure if there is a certain way to discern.
    There are intersting pasages in “Brain Death and Disorders of Consciousness”:
    //Brain-related criteria are not based on valid scientific data. The Harvard Criteria were published without any patient data and there were no references to basic science reports. The Minnesota Criteria evolved from a study of 25 patients. Only 9 had an EEG done and of these, 2 had ‘biologic’ activity in their EEG after they had been declared ‘brain dead.’ Their conclusion: No longer is it necessary to do an EEG. It seems scientifically invalid not to use an EEG in the diagnosis of “brain death” if any degree of certainty is to be obtained. The British Criteria do not include the EEG. This was apparently due to the influence of the Minnesota Criteria, which do not require an EEG. The National Institutes of Health Criteria were based on a very limited study and, ’Accordingly, these criteria are recommended for a larger clinical trial.’ This has never been done.”
    By 1978, more than 30 sets of criteria had been published. Many more have appeared subsequently for various reasons and in different countries. In most cases, physicians are free to choose any one of these. Thus, a patient could be determined to be dead by one set, but not by another.
    No matter how seemingly rigid the criteria are, the ease with which they can be bent is manifested in the report by the President’s Commission, where it is written: “An individual with irreversible cessation of all functions of the entire brain, including the brain stem, is dead. The ‘functions of the entire brain’ that are relevant to the diagnosis are those that are clinically ascertainable” In one sentence, whatever stringency there was has been reduced to no more than what can be ‘clinically ascertainable.’ Thankfully, there is more physiology taking place in all of us than what is ‘clinically ascertainable’.
    If one uses the Minnesota Criteria, the British Criteria, or the published Guidelines of the President’s Commission, it is not necessary to include EEG evaluation in determining “brain death.” In which case, if the cortex is still functioning, but is wholly cut off from manifesting its activity clinically by damage elsewhere in the brain–something that does occur and which an EEG can clearly show–then this functioning (which could involve memory, feelings, emotion, language skills, etc.) is suddenly considered irrelevant to the person’s life or death. According to the NIH Study, 8% of those declared dead on the basis of criteria that omit the EEG, still have cortical activity when evaluated by non-clinical means (EEG). Thus, action such as excision of a donor’s beating heart causes death in at least one out of twelve cases under such circumstances. As Dr. Walker (Clinical Neurosciences, 1975) wrote, this represents “…an anomalous and undesirable situation.” The general public might use much stronger words!
    It is worrisome to note that “brain dead” pregnant mothers given modern life support efforts have survived for as long as 107 days until delivery of a normal child.10 Yet, in the usual prospective donors there often seems to be a utilitarian based urgency to declare “brain death” and move ahead with vital organ transplantation. Transplant cardiologists know it is important to protect and preserve the vital organs by this urgency, but one must wonder: could it be that it is also urgent to move ahead before any signs of recovery of brain function would appear and embarrass the physician who had declared death? It is of interest that in “brain dead” victims of homicidal assault, lawyers rarely file charges until the victim is truly and certainly dead. In similar manner, to our knowledge undertakers never embalm until “brain dead” patients are truly and unequivocally dead. Sometimes common sense overrules utilitarian reason!//
    “The utilitarian reason” is the keyword. The utilitarian reasoning in the condition of brain death would be something like this: The care-taking of an individual who is “not likely” to recover completely and immediately and go back to fulfill his/her social functions is a burden. Thinking of the money and the labor, it is a burden for his/her family, the hospital staff, and the whole society. Moreover, if the patient is an organ donor, with the declaration of his/her death the lives of people waiting for organ transplantation will be saved. The declaration by the physicians about brain death of the person in a vegetative state is made under these circumstances. The criteria to declare someone as “brain dead” is relative. 30 different sets of criteria exist in various countries. So it is right to say “’Brain death’ is not found in the brain of a ‘person whose brain ceased functioning,’ but in the realm of human relationships surrounding this person.” This realm is where some kind of reasoning occurs. This reasoning determines our decisions, interpretations about the phenomena we encounter. You can not say, brain death criteria is absolutely not scientific - as said in the Cuban symposium, it is indeed scientific but also it is based on the utilitarian reason. The statements of Dr. Paul Byrne’s in the Cuban symposium are also scientific, but it is based on a different point of view. I do not think that Dr. Paul Byrne’s being the president of the Catholic Medical Association is only a coincidence. Generally, the people with religious concerns doubt the concept of brain death, because they are not easily sold on the ideas like “if something is feasible technologically and economically, there is no obstacle for it to be done.” But, these doubting people are usually accused of being superstitious and backward, though you can not easily find something to be qualified as such even in the words of pope in the “Statement Opposing Brain Death Criteria”. Otherwise, “right of individuals to be properly informed” and make their decisions in a “free and conscientious manner” must be accepted as a superstition.
    I think we have the right to choose another way of reasoning, other than those of the utilitarian rationality and religious rationality, without being qualified as backward and superstitious.

    By Blogger icono-clast, at 3:03 AM, December 30, 2004  

  • Thank you icono-clast. Let me comment on some of the points you made. Clinically speaking, most vegitative state patients still have a potential to respond to some stimulations, such as touching the surface of the eyes, etc., but on the contrary a brain dead person does not respond to such stimuli. But at the same time, it may be hard to discern the deepest & worst vegitative state patient from a brain dead patient, hence we need reliable "brain dead ctiteria." Specialists say that they have never experienced a patient who recovered from the state of brain death, but as you say this is an empirical statement, not a logical one. So, yes, there is a philosophical problem here, that is, the problem of identification of "brain death".

    Japanese criteria require "brain wave test" as a necessary condition of determination of brain death, hence, some brain dead patients in the US or other countries would never be brain dead if diagnosed in Japan.

    As far as I know there has not been a case in which a person who was diagnosed as brain dead recovered from brain death and became able to move or speak again. In the case of vegitative state, some patients began speaking and/or reading again, so this seems to imply that vagitative state patients are basically different from brain dead patients.

    But of course, the existing brain death criteria are not perfect, for example, in many cases the functions of brain cells are found in the brain of a brain dead patient, hence, it might occur that a patient who are diagnosed as brain dead will recover from it in the future.

    The utilitarian reason is the keyword as you pointed out. We need another type of reasoning, different from utilitarianism, or value system free from religious dogma (but of course I don't want to deny religion or religious wisdom. I think there are lots of things to learn from it).

    By Blogger Masahiro_Morioka, at 3:08 AM, December 31, 2004  

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