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Brain Dead Person
: Human-relationship-oriented Analysis of Brain-death (1989)

Chapter 1
Brain Death as a Form of Human Relationships

Masahiro Morioka

> General information of this book

(Ch.1 Ch.2 Ch.3 Ch.4 Ch.5 Ch.6 Ch.7)

The family members are invited into the ICU,.... At such a moment, the family is not facing the inside of the patient’s brain, or his/her body. What the family is facing is a "person" that has entered the state of brain death.......We, the general public, encounter "brain dead persons" for the first time in the ICU. They might be our parents, children, siblings, relatives, or friends. This is an encounter between people.

"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. What we should consider is "the realm of brain death," or "brain death as a field."

*Translation by Yuko Tamura.
*Page numbers in the original are marked by [(preceding page) / (following page)].

What doctors may not know

    Most of the existing theories on brain death are based on doctors’ perspectives. It is natural for brain surgeons to publish books on brain death, because they are specialists in the brain and the most knowledgeable about its medical state.
    However, this does not necessarily mean that brain surgeons understand the essence of brain death. What surgeons do know well is merely the “medical aspect” of the phenomenon. Doctors may not know how relatives might feel or what they might think when they see a brain dead person. They may not know, as well, what impact it would have on our society and culture to recognize brain death as the death of humans.
    The central issue of brain death lies not in its medical aspect, but in how we should accept brain dead persons in our society. [3/4] The things we are most concerned about as the “general public,” not as medical specialists, are how we should relate to a person who has become brain dead. The medicine of brain death is a secondary matter for us.
    Let me elaborate this point further.
    There is a book titled Theories of Brain Death: the Meaning of Living and Dying (Soshisha, Dec., 1986) written by a brain surgeon, Dr. Hiroshi Mizutani. This is a recommendable book, as it is written from a broad perspective. The first chapter of this book begins as follows:

    Human death, including brain death, is closely connected with the human brain. Before embarking on the subject of death, let me begin by explaining the basic structure of the brain (P.15).

    The book goes on to describe the functions of the limbic system, the brain stem, and the spinal cord. A large cross section of the brain is shown two pages after that. When writing this book, the author begins with the brain functions and the cross section of the brain. Hence, it could be said that Dr. Mizutani’s theory on brain death is written from a doctor’s perspective.
    Let me cite another example. The book Brain Death (Nihon Kirisutokyo Shuppankyoku, April, 1988), consists of a series of dialogues between a medical doctor, Tadao Tsubaki, and a theologian, Masakatsu Seki. This book also begins with the heading “what is the state of brain death” and describes blood pressure and a respirator. The authors explain the functions of the cerebrum and the brain stem, then present the same cross section as in Dr. Mizutani’s book.
    It goes without saying that minimal medical knowledge of brain death is necessary to discuss it. Some critics, such as Takashi Tachibana, say that we should be careful not to go into further discussion before the medical questions are resolved. [4/5] This is one way of thinking, I admit.
    Nevertheless, I look at it this way. When discussing brain death, why do so many authors begin with the cross section of the brain? Do they think readers can fully understand brain death if they know the cross section and functions of the human brain? All that provides is brain death viewed from a doctor’s perspective.
    Is brain death nothing more than a medical state?
    I do not think so. The essence of brain death exists on the other side, the side that cannot be seen from a doctor’s perspective.
    Most of the published arguments on brain death share one common view, a world view, “to know the inside of the brain is to know brain death.” As long as one takes this viewpoint, one will not know the essence of brain death.
    Let us think about this from a different angle.

What is brain death for the family?

    We can classify those who face brain death in hospitals into the following three categories: doctors who perform the resuscitation of the brain, nurses who care for the patient, and the family that watches the patient from outside the ICU (Intensive Care Unit). The doctors concentrate on the conditions inside the patient’s brain. Unless the doctors understand correctly the location and state of the brain’s damage, they cannot treat it appropriately. [5/6] In this sense, the doctors are facing the “inside of the patient’s brain.”
     On the other hand, the nurses are in a somewhat different position. They concentrate on the body of the comatose patient, watch his/her physical conditions, and see to it that various instruments attached to the patient for measurement and treatment are working properly. They also pay attention to infection control and strictly monitor the body of the patient. In this sense, the nurses in the ICU are facing, first and foremost, the “body of the patient.”
     The family is yet in a different position from the nurses. For nurses, the patient is a stranger, someone they have just met, but for the family, the patient is the irreplaceable person with whom they have lived until recently. The family is allowed to enter the ICU two or three times a day, only for a few minutes each time. During these short visitations, family members face “the person as a patient” with whom they have shared their lives and history.
     Let us suppose the patient has become brain dead, despite all medical efforts. The family members are invited into the ICU, and a doctor pronounces the patient brain dead. The family members gaze at their relative lying on the bed, while listening to the doctor’s explanations. At such a moment, the family is not facing the inside of the patient’s brain, or his/her body. What the family is facing is a “person” who has entered the state of brain death.
     We, general citizens, face brain death only when a relative becomes brain dead in a hospital. In the ICU, we face a “person,” our brain dead relative; in other words, a “brain dead person” and not the inside of a dead brain.
     Put another way, for us, the general citizens, what really matters is not “the existence of a dead brain,” but “the existence of a brain dead person.” [6/7] Hence, discussions on brain death, if intended for the general public, should begin with the issue of the “brain dead person,” rather than the explanation of the dead brain.
     We, the general public, encounter “brain dead persons” for the first time in the ICU. They might be our parents, children, siblings, relatives, or friends. This is an encounter between people, that is to say, an encounter between a person whose heart and brain are functioning, and another person whose brain ceased to work but whose heart is still beating.
    Michi Nakajima depicted this encounter excellently in her famous passage:

    During my five-month visit to the ICU, I felt one thing as most peculiar in the beginning.
    None of the family members would take the hand of the patient, nor shed a single tear at the news that their husband, wife, or a beloved child was brain dead. At first, I thought I accidentally came across people who were cold-hearted or logical-minded. However, I soon understood that no one really felt that the brain dead person was truly dead.
    The family members visit the bedside surrounded by life-monitoring equipment and resuscitation machinery, only for a few minutes, obliged to wear white or blue sterilized caps and outfits, and paper masks. No matter how simply the doctor tried to explain brain death, the family members would only nod absentmindedly, not being able to take their eyes off the working machinery.


    But the same people, without exception, burst into tears or wiped their eyes when the brain dead person’s heart ceased beating and the respirator was removed. [7/8] At this point, they truly realized their relative’s death. (Invisible Death, Bungei Shunju, pp.12-13)

    Some critics say such description shows sentimentalism that cannot bear scientific discussion. Or they say that whatever the emotional response of the family may be, it is not relevant at all to the grave medical fact that the patient is brain dead. I think such criticisms reflect only half of the picture. What the family members encounter and what is most important for them is not the solemn medical fact inside the brain or the scientific debate about the function of the brain. The family members enter the ICU and encounter the “brain dead person” with whom they have lived until only yesterday. When the respirator is removed, the family members say farewell to the “brain dead person” who appeared deep asleep pinned to the bed. The reality of such an encounter and parting between people means something different from scientific data. It is the reality of emotion, feelings, and the denial and acceptance of death.

The “person” whose brain stopped functioning

    In this way, it is the family members who encounter a brain dead person most dramatically. But if you give another thought to the situation, you will see that the nurses who monitor the body of the patient and the doctors attempting to resuscitate the brain have also come face to face with the brain dead person. It is likely, however, that they are less inclined to realize that the patient is a person, since they are concentrating so much on certain parts of the patient’s body. [8/9]
    We can put it as follows. It is the contents of the brain of a person whose brain ceased functioning that was at issue among people concerned. But as I mentioned before, this is nothing but brain death viewed from a doctor’s perspective. It is merely one aspect of the broader concept of “brain death.”
    Let us look at it from a different angle. Suppose there is a “person whose brain ceased functioning” in a room called the ICU in a hospital. The person was surrounded by many people, such as the doctors, the nurses, family members, various persons related to the hospital, as well as local residents. These people hold mutually different human relationships around the “brain dead person.” For instance, the family members solicit the doctors so that they may see the “person whose brain ceased functioning” even for a short time; the doctors are irresolute over whether they are to remove the respirator from the “person whose brain ceased functioning.” The nurses disinfect and clean the patient’s body so that the “person whose brain ceased functioning” does not become infected. Or, perhaps, a transplant surgeon might call, in anticipation of harvesting organs from the “person whose brain ceased functioning.”
    I would like to refer to this situation in which such human relationships develop around the “person whose brain ceased functioning” as “brain death.” “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. What we should consider is “the realm of brain death,” or “brain death as a field.”
    In other words, the essence of “brain death” can be found in the relationship between people. The “brain death” viewed by the doctor, when he/she looks inside the brain of a “person whose brain ceased functioning,” should be no more than one aspect of “brain death.” [9/10]
    If the essence of “brain death” is human relationships, then naturally the question to pose would be how the doctors, nurses, family members, transplant staff, residents, and the general public should relate to one another. This is the ethics of brain death. Because the essence of “brain death” is the relationship between people, there arises the ethical problem of how people should relate to each other. Organ transplant, which I will touch upon later, is exactly the matter of relationship between persons, i.e., the donor, the persons who would give their consent, the recipient, and the mediator.

The condition of a “brain dead person”

    I would like to provide a basic explanation of a “brain dead person” located at the center of these human relationships. First of all, let us imagine the following three categories of people:

(1) a person whose heart and brain are functioning
(2) a person whose heart is beating but whose brain is not functioning
(3) a person whose heart and brain ceased functioning.

    The first category signifies a person like us, leading an ordinary life. We can feel the heartbeat through the palm of our hands, and we can feel and think thanks to our brain. The third category, a person whose heart and brain ceased functioning, signifies someone lying cold in a coffin. His/her condition is irreversible. We cannot feel the heartbeat or observe any response. [10/11]
    We are familiar with the “persons” in category (1) and (3), having encountered them in our everyday lives. However, we have begun to come across people in category (2), i.e., people whose hearts are beating but whose brains are not working. They are the “brain dead persons.”
    According to recent statistics, a little less than 1% of the dying people become brain dead in ICUs in large hospitals. Normally, a few days after becoming brain dead, the heart stops beating and the person becomes a cold, dead body.
    While the brain dead condition lingers, the brain dead person is chained to various life-supporting devices such as respirators, monitoring equipment, blood transfusion tubes, and so on. Conversely speaking, a brain dead person can only exist in the ICUs of large hospitals where various medical equipment and adequate technical staff are furnished. I will describe in the next chapter what an ICU looks like.
   The lungs and heart of a brain dead person function because of the respirator, but the brain is not working.
    A brain dead person is in the following condition. First, this person is in a state called a deep coma. This person looks deep asleep and does not respond to pain stimulus. For instance, he/she does not grimace even if picked on the face by a pin. Since he/she cannot breath spontaneously, he/she needs help from the respirator. Once the respirator is removed, breathing stops instantly, and so does the heart. Brain stem reflex is gone, and he/she does not close his eyes even if a cotton bud stimulates the cornea. He/she never responds to stimulation inside the throat and trachea, and never responds if cold water is poured into the ears. [11/12] The pupil remains dilated even though the lights are flashed into his/her eyes. Brain waves cannot be detected by an electroencephalograph. This is considered evidence that the cerebrum, which governs the ability to think and have emotions, is not working. There is no possibility that the condition may improve, and in many cases, the heart stops beating within a week (there are some exceptions. I will elaborate on them in Chapter 4. For readers interested in the detailed standard for the determination of brain death, please refer to Nihon Ishikai Zasshi, Vol. 94, No.11, 1985, which features brain death. The full text of the so-called Takeuchi report was published in it. Please consult the Japan Medical Association or a nearby library. It would further your comprehension to read Brain Death by Takashi Tachibana after that.)
    Blood circulates to every part of the body of the brain dead person, except for the brain. This is made possible by the respirator and drugs for maintaining blood pressure. Because of the circulation, the person perspires and accumulates scurf, which requires that nurses clean the body regularly. The water must be replenished that has escaped as sweat. Moreover, the patient excretes, which needs to be taken care of. Like a bedridden elderly person, the patient may suffer bedsores, so regular change of position is necessary.
    Thus, a brain dead person requires care. In a hospital, much of the care falls to nurses. Tateo Sugimoto, who lost his son after brain death, describes the situation as follows:

    9:10 a.m. I heard that a doctor found a bedsore while I was away to the washroom. He left an instruction for us to change our son’s position regularly.
    I checked and found a red bedsore on the backside of his leg. I was ashamed of our poor nursing. We applied a pad on the sore and changed his position every now and then. (Uniform my Son might have Worn, Nami Shobo, Mar., 1986, p.45) [12/13]

The above is the condition of a “brain dead person.”
    A brain dead person is perceived differently by people around him/her, according to their various positions. For instance, to most of the doctors and nurses, a brain dead person is a stranger who was suddenly brought into the ICU. But for the family, the person is someone with whom they shared their lives and history only until recently. On the contrary, for patients waiting to receive organs in distant hospitals, the brain dead person is nothing more than an abstract imagination. I, as an individual, can be said to be a good father to my child, a rather worn out lover to my wife, a serious salaried man to my colleagues, and a merry drunkard to the barkeeper. The same could be said of a brain dead person. Unless we understand the perceived gap between the people around the brain dead person, we cannot see the essence of the issue of brain death.

Are “persons” limited to those who are “alive?”

    I presume many readers may disagree with the use of the words “brain dead person.” In other books, those people are referred to as “the brain dead,” “brain dead bodies” or “patients in the condition of brain death.” But such wordings do not express the “human” aspect of brain death that I am willing to emphasize. [13/14]
    I guess this will induce further objections. That is, the wording, brain dead “person,” is irrational. They are dead at the time they became brain dead, and so it is unscientific and wrong to refer to such bodies as “person.” I will discuss later whether this is unscientific or not, but I want to spare a moment to contemplate, since the objections themselves are significant.
    There are some questions I would like to address to people who raise objections. What will a person become when he/she is dead? They would answer that the person will become a “dead body.” Then, my question goes on, isn’t a dead body a “person”? They would answer, “No.” Then what is a dead body? I assume they would reply, “A dead body is an object/matter. It is not a person.”
    I believe that such a way of thinking is being questioned with the issue of brain death. Let us presuppose that a dead body is an object, then dying would mean a person becomes an object. As long as a person is alive, he is a “person,” but as soon as he dies, he becomes an “object.” In this way of thinking, we regard “being alive” and “being a person” as the same thing. But is this really true?
    There is a phrase, “a person who is dead.” [Note: We have such an expression in Japanese.] What does this mean? According to the idea that a dead body is an object, “a person who is dead” cannot exist in essence, because it is a self-contradicting concept.
    But in our daily lives, we often use the words “a person who is dead.” We do not note a contradiction when we use them. We refer to a dead body as “a person who is dead.” In other words, we regard some dead bodies as dead “persons.” [14/15] This is significant. For us, some dead bodies are “persons.”
    That is to say, when looking at “people” in terms of life and death, they can be divided into two categories, i.e., “person who is alive” and “person who is dead.” The conditions of these two groups of people are totally different, and so are our relationships with them in daily lives. But, nevertheless, we should pay special attention to the fact that both are “persons.”
    By examining the point from another angle, we can categorize “people” in a different way.
    Earlier on, I divided “people” into the following three categories: (1) a person whose heart and brain are functioning; (2) a person whose heart is beating but whose brain is not functioning; and (3) a person whose heart and brain ceased functioning.
    We would say the person of type (1) is a “living person,” including those who are sick. The type (2) is a “brain dead person,” and type (3) a “cardiac dead person.” When we focus on the function of the brain and the heart, we can categorize “people” into these three types. These people each have quite distinctive characters, however, they are the same in that they are all “persons.” [Note: “person who is alive” and “living person” are different concepts. See Figure 1.]
    We often argue whether brain death is human death or not. This problem is, so to say, the question of how to connect the two ways of categorizing “people” in a reasonable way. Figure 1 indicates the fundamental differences between the idea that brain death is equal to human death, and the idea that brain death is not equal to human death.
    The question of whether brain death is human death is not a major ethical problem, although it is a fundamental legal issue in terms of inheritance or the damage to the corpse. [15/16] What matters most ethically is not the question of whether a brain dead person is alive or dead, but how we should relate to the “brain dead person.” (Please see An Invitation to the Study of Life, Keiso Shobo, April, 1988, esp. Chapter 8, “Discourses and Ethics on Brain Death,” which elaborates on brain death, and the life and death of human beings.)



Correlation between people around a brain dead person

    For centuries we have thought about ways to get along with other living people, which has developed into what we call social customs These customs have been handed down through history and have become ingrained in our tradition and culture. For example, when we live with those who are “living,” we act according to basic proprieties. This might sound like exaggeration, but it is common, such as we should avoid using words that hurt others deeply, or we should refrain from suddenly turning up on the doorsteps of other people, or we should accept gifts with pleasure. To recognize one another’s rights to life might be included here. Such accumulation of relationships with the people who surround us form our ethical traditions. And such traditions must have experienced several turns.
    The same thing must be said of the social interaction with “cardiac dead persons.” You might be alarmed by this idea, but, for instance, funerals are one form of that. [16/17] In our society, when a person dies (a cardiac dead person), we hold a ceremony called funerals. At funerals, relatives and acquaintances are invited to offer incense. The wake is performed, and after the final farewell, the coffin is carried away to be incinerated. The ways the ceremonies are performed differ by regions and periods, but it is nonetheless true that social ceremonies surrounding “cardiac dead persons” have been handed down from generation to generation.
    The funeral serves to unite the bereaved relatives and people in the local community. However, the meaning of funerals should not be confined to that. It is a mutual support network created by the surviving people so that the soul of the cardiac dead person may safely reach the next world, and the bereaved family can accept death. (Actually, it involves the interests of undertakers and monks). What it emphasizes is the human relationships surrounding the cardiac dead person. [17/18] Since this is one form of human relationship, there must be a certain customs to follow. For instance, the bodies are to be treated gently, or not to speak ill of the dead, or not to disturb the relatives, or to refrain from a behavior that would disrupt the solemn atmosphere of the funeral. Because of these inherited basic manners, the bereaved are able to gradually accept the death of their kin, and thus it is believed that the soul of the dead is freed to depart to the other horizon.
    As such, our society has created and handed down the minimum proprieties concerning our relationship with “living persons” and with “cardiac dead persons.” And a “brain dead person” is also a “person.” Then, isn’t it necessary to create basic proprieties that must be shared among family members, doctors, nurses and transplant coordinators when we accept brain dead persons in our society, however long it might take? And shouldn’t we hand them down to the next generation? Isn’t this the true “ethics of brain death” that we should think about?
    Shohei Yonemoto stated the following, not only in reference to brain death, but also on a broad issue of bioethics.

    If the form of our culture does not allow intense discussions of ethical issues in advanced medicine as in Europe and the U.S., our objectives for the time being would be to create rules to get along with or to avoid these technologies. (The Revolution in Advanced Medicine, Chuko Shinsho, Apr., 1988, p.181.)

    Yonemoto argues that the ethical discussion in Japan should be such that deepens discussion about the “forms” and “manners” as standards. This perspective is quite similar to that of Tatsuo Inoue, who re-evaluated the theory of justice as the “manner” of co-living. (Manners of Co-living, Sobunsha, Jun., 1986). [18/19] I sympathize with this idea.
    I believe part of the current social confusion regarding brain death and organ transplants is brought about by the fact that the proprieties Yonemoto referred to have not been established in a way that is accepted by all. In other words, our society does not yet share the minimum proprieties regarding human relationships surrounding brain dead persons. And this gives rise to various ethical issues.
    The important point is that a brain dead person is, again, a “person,” and that brain death is nothing but a form of human relationships.
    In other words, the ethical issue of brain death is equivalent to the question of how to establish “co-living” between brain dead persons and us. By achieving this goal, we will be able to “co-live” with “disabled persons” and “senile dementia persons” as well in this society.
    From this viewpoint, for the first time, one can grasp an ethical issue that should be discussed beforehand, prior to the issue of organ transplants. It is the question of how people should relate to one another in the ICUs where brain dead persons spend most of their time. In other words, ethical issues in the ICUs.


(End of Chapter 1)

>> Go to Chapter 2

Commentary on this chapter/book

>> Commentary on "Brain Dead Person" Chapter 1 by Robert D. Truog, MD [Nov.24,2001]

*For more information, visit Brain Death and Organ Transplantation in Japan.