Pope John Paul II and the neurological standard for …...2018/05/02 · Article Pope John Paul II and the neurological standard for the determination of death: A critical analysis

ArticlePope John Paul II and the neurologicalstandard for the determination of death:A critical analysis of his address to theTransplantation Society

DOYEN NGUYEN

Pontifical University of St. Thomas Aquinas, Rome, Italy

The introduction of the “brain death” criterion constitutes a significant paradigm shift in the determina-tion of death. The perception of the public at large is that the Catholic Church has formally endorsed thisneurological standard. However, a critical reading of the only magisterial document on this subject, PopeJohn Paul II’s 2000 address, shows that the pope’s acceptance of the neurological criterion is conditionalin that it entails a twofold requirement. It requires that certain medical presuppositions of theneurological standard are fulfilled, and that its philosophical premise coheres with the Church’s teachingon the body-soul union. This article demonstrates that the medical presuppositions are not fulfilled, andthat the doctrine of the brain as the central somatic integrator of the body does not cohere either with thecurrent holistic understanding of the human organism or with the Church’s Thomistic doctrine of the soulas the form of the body.

Summary: The concept of “brain death” (the neurological basis for legally declaring a person dead)has caused much controversy since its inception. In this regard, it has been generally perceivedthat the Catholic Church has officially affirmed the “brain death” criterion. The address of PopeJohn Paul II in 2000 shows, however, that he only gave it a conditional acceptance, one whichrequires that several medical and philosophical presuppositions of the “brain death” standard befulfilled. This article demonstrates, taking into consideration both the empirical evidence and theChurch’s Thomistic anthropology, that the presuppositions have not been fulfilled.

Keywords: Brain death, Papal allocutions, Hylomorphism, Principle of integration, Soul, Anti-entropic principle

INTRODUCTION

Since the 1968 publication of the Harvardreport introducing the “brain death” stan-dard as the new medical definition ofdeath, the controversy over this criterionhas remained unabated despite the inter-vention of state legislatures and authorita-tive bodies to grandfather the “brain

death” paradigm into public acceptanceand to dampen the intensity of the debateat the level of society at large.1 Theongoing case of Jahi McMath has broughtthe controversy to public attention again,however.2

The “brain death” controversy hascaused divisions not only within secularacademia but also among Catholics,

The Linacre Quarterly 84 (2) 2017, 155–186

� Catholic Medical Association 2017 DOI 10.1080/00243639.2017.1307502

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including the ordained, especially thoseholding high ecclesiastical offices. As agroup, Catholics opposing the “braindeath” paradigm are in the minority.3 Incontrast, not a few Catholics supporters of“brain death” occupy prominent positionsin the Church, such that their publica-tions, coming from a level of authority,give the impression that the “brain death”standard has been “given the stamp ofapproval of the Roman Catholic Church”(Lock 2004, 137; see, also, Eberl 2015,235).4 However, these documents do notcontain magisterial authority; they remainonly opinions/suggestions advanced byscholars working with and for the Magis-terium.

The crucial question is thus, “has theCatholic Church indeed formally endorsedbrain death as death?”Themagisterial docu-ment that touches on the neurological stan-dard is the address of the Holy Father JohnPaul II to the 18th International Congress ofthe Transplantation Society in August 2000.It has been hailed by Catholic “brain death”defenders as the indication that the Churchhas “indeed give[n] definitive approval to theuse of neurological criteria for the determi-nation of death” (Furton 2002, 455; see,also, Diamond 2007, 492; Haas 2011, 279;Eberl 2015, 235). However, a critical read-ing of this rather synthetic document shouldtake into account other papal pronounce-ments on the issues of death and organtransplantation, and also the premises (med-ical and philosophical) embedded in thedocument itself. These seem to have beenoverlooked by most commentators as theyfocused mainly on the third paragraph ofarticle 5 of the address.

Thus, in order to answer the aforemen-tioned question, whether indeed theChurch, through her magisterial teaching,has fully endorsed the “brain death” stan-dard, the purpose of this essay is to re-readcritically John Paul II’s August 2000address, unpacking and analyzing the

premises contained therein. In this way,it will be demonstrated that the so-called“definitive approval” is only a conditionalapproval pending the fulfillment of severalspecific presuppositions or conditions. Aswill be shown, these presuppositions havenot been met whether on the empirical-practical level or on the philosophical-anthropological level. Since the pope’saddress was about both organ transplanta-tion and the use of the neurological stan-dard for the determination of death, theessay will begin with a brief account of thegenesis of “brain death” (less known orinaccessible to the public), which shedslight on the motivating reasons for theintroduction of the “brain death”criterion.5 It will become evident that thesame motivations still operate today, andthat they do not necessarily cohere withthe Church’s mission and her precepts.

GENESIS OF THE “BRAIN DEATH”CRITERION

For millennia, the determination of deathhas been (and still is, in the great majorityof cases) based on the cessation of all vitalfunctions. As pointed out by WilliamArnet, prior to the introduction of “braindeath:”

[the] definitions of death found in variousmedical dictionaries and cyclopedias revolvearound one central theme: the cessation ofall vital functions of the human body. Informulating the criteria for determiningdeath, these traditional medical definitionsdo not isolate the function of any one organ;rather, they emphasize the total stoppage ofall vital bodily functions,… as evidenced byabsence of heartbeat and respiration …beyond the possibility of resuscitation.(Arnet 1973, 221–2)

Thus, the traditional conception of deathdoes not attribute primacy to any organ or

156 The Linacre Quarterly 84 (2) 2017

organ system; rather it “place[s] the defini-tion of death on an integrated basis”(Arnet 1973, 222). In medical parlance,this has been referred to as the traditionalcardiopulmonary standard; but this termi-nology does not fully convey the integratedcharacter of the traditional concept ofdeath (a concept that reflects a holisticunderstanding of life). In fact, the deter-mination of death according to the tradi-tional standard includes other signs inaddition to the cessation of heartbeat andrespiration. Regardless of which organ(heart, lungs) or organ system (circulation)stops first, the close link between them issuch that when one stops suddenly (e.g.,loss of circulation caused by a massivehemorrhage due to a gunshot wound tothe abdominal aorta), the other two alsostop quasi-simultaneously with it. This isquickly followed by the cessation of func-tions of other organs, in particular, thebrain.

The year 1968 witnessed a revolutionaryre-definition of death in biological termsas the Harvard Ad Hoc Committee equa-ted irreversible coma (now known as“brain death”) with death. The openingparagraph of the Harvard Committee’sreport states that the main reason for thenecessity to redefine death is the burdenthat patients, deemed to be in irreversiblecoma, pose to themselves and theirfamilies, and that this concern precedesthe need to free up beds in the intensivecare unit (Harvard Medical School 1968,337). Obtaining transplantable organsappears to be merely a fortuitous benefitand a peripheral concern. According torespectable medical historians, however,there were three key elements in the gen-esis of the Harvard report that suggestotherwise (Pernick 1999, 9–11; Giacomini1997; Rothman 2003, 156–64).

The first was the 1966 internationalsymposium on “Ethics in Medical Pro-gress: With Special Reference to

Transplantation,” sponsored by the CibaFoundation. As “the [then] burgeoningfield of organ transplantation unleasheda strong desire to expand the recipientpool” (Diringer and Wijdicks 2001, 6),there were intense discussions at thesymposium on the need for a new para-digm for death, namely, that severelybrain-injured patients could be used as“heart-lung preparations” or “living cada-vers” to provide more viable kidneys.This idea was enthusiastically supportedby Joseph Murray (future member of theHarvard Committee).6 There wasenough opposition, however, that theconference ended without reaching anyconsensus.7

The movement toward redefining the cri-teria for death, which had begun with theneed for better quality kidneys, took anaccelerated turn with heart transplantation.The second important element was, there-fore, Christiaan Barnard’s first successfulheart transplant in Cape Town on Decem-ber 3, 1967.8 The operation “was hailedthroughout the world as a major medicaltriumph” (Hoffenberg 2001, 1478). Asnoted by Gregory Pence, because of thereality of heart transplants, “medicineneeded a new standard of death, specificallybrain death, to determine when organs couldbe removed from a still-living body” (Pence2004, 44). Thus, shortly after Barnard’s tri-umph (although the recipient only survivedfor 18 days), the Harvard Committee wasformed on January 4, 1968, because of “thenecessity of giving further consideration tothe problem of brain death” (Harvard wasthen a leader in transplantation).9 The com-mittee worked swiftly behind closed doorsfrom March through June;10 and completedits work with the sixth and final draft of itsreport submitted to the dean on June 25,1968 (Giacomini 1997, 1474; Wijdicks2003, 972). The report received immediatepublication on August 5, 1968 (HarvardMedical School 1968, 337).

Nguyen – Pope John Paul II and neurological standard for the determination of death 157

The third element is the language usedin the manuscript drafts of the Harvardreport, explicitly stating the necessity of“brain-death” for the advancement oftransplantation:11

The question before this committee can-not be simply to define brain death. Thiswould not advance the cause of organtransplantation since it would not copewith the essential issue of when the sur-gical team is authorized—legally, morally,and medically—in removing a vitalorgan.12 (Giacomini 1997, 1474)

With increased experience and knowl-edge and development in the field oftransplantation, there is great need forthe tissues and organs of the hopelesslycomatose in order to restore to healththose who are still salvageable.13 (Giaco-mini 1997, 1475)

Thus, both external and internal evidence(including the subsequent remarks of thecommittee’s chairman14) strongly suggestthat the reasons for the Harvard Commit-tee’s re-definition of death were primarilythe pragmatic and utilitarian needs oftransplantation to obtain fresh and viableorgans. Such utilitarian ethics, which con-tinues to be the driving force in the diag-nosis of “brain death” today,15 contradictsthe noble altruistic notion of the “gift oflife.” Moreover, the “brain death” standardwas advanced without any prior rigorousscientific/clinical studies, even though thisis a known requirement in medicine forany procedure prior to its actual applica-tion in clinical practice. For the Church tofully endorse the neurological standard forthe determination of death means that shewould have to reconcile the aforemen-tioned utilitarian ethics and lack of scien-tific validation with her non-utilitarianethos and moral requirement for rigorousand transparent scientific practice. This, initself, is a problematic issue, in addition tothose issues which arise from the

presuppositions and premises containedin John Paul II’s 2000 address, to whichthis essay now turns.

READING JOHN PAUL II’S ADDRESS TO

THE 18TH INTERNATIONAL CONGRESS OF

TRANSPLANTATION

As alluded to in the introduction, the mainreason for reading John Paul II’s 2000address again is to identify the presupposi-tions and premises that formed the basis ofthe pope’s remarks with respect to organtransplantation and the “brain death” stan-dard. Once these presuppositions are iden-tified, an in-depth analysis can be carriedout to determine if they have been fulfilled(both at the empirical and conceptuallevels). Only then can it be said that thepope has given a definitive approval to theuse of the neurological standard for thedetermination of death.In addition, it is also helpful to read

the document from the pope’s perspec-tive. While praising organ transplantationat the start of his address, John Paul IIalso reminds us that: (i) that “donation oforgans [must be] performed in an ethi-cally acceptable manner” (John Paul II2000, no. 1), and (ii) “what is technicallypossible is not for that reason admissible”(John Paul II 2000, no. 2). Hence, farmore important than any scientific pro-gress is the human being; consequently,the one absolute limit which organ trans-plantation cannot and must not trans-gress is the good of the donor, namelyhis or her life and human dignity. Thepope’s opening statements echo thebalanced teaching of the Catechism of theCatholic Church. The Catechism, thoughpraising organ donation as a “noble andmeritorious act … [and] an expression ofgenerous solidarity” (CCC 2003, no.2296), emphasizes that it must conformto the moral law, precisely because “it is


not morally admissible to bring about thedisabling mutilation or death of a humanbeing, even in order to delay the death ofother persons” (CCC 2003, no. 2296).Any method for organ harvesting thatcauses or directly hastens the death ofthe donor violates both the sacrednessof human life and the dignity of thehuman person. Such a method amountsto euthanasia by “putting an end to thelives of handicapped, sick, or dying per-sons” (CCC 2003, no. 2277).

From the very start of his address, JohnPaul II’s approach to organ donation is one ofbalance and prudential wisdom, whichreflects the position of the Church and setsthe tone for the remainder of the address.Such a prudential attitude was also presentin earlier documents. For instance, in his1991 address to the Society for Organ Shar-ing, the pope praised organ transplantation asa new way for man to make a sincere gift ofhimself in service to life through the donationof his organ(s), a newway for him to fulfill his“constitutive calling to love and communion”(John Paul II 1991, no. 3). At the same time,however, the pope, in his wisdom, couldintuit that organ transplantation “is not …without its dark side” (John Paul II 1991, no.2) and that there are serious issues (especiallythose of the ethical order) that need to beconfronted. In this light, it can be said thatthe pope’s insistence in his 2000 address that“vital organs which occur singly in the body canbe removed only after death, that is, from thebody of someone who is certainly dead …[because] to act otherwise wouldmean inten-tionally to cause the death of the donor”(John Paul II 2000, no. 4), was in a way anindirect allusion to the “dark side.”What thatdark side is was previously made explicit inhis prophetic warning in Evangelium Vitae:

Nor can we remain silent in the face ofother more furtive, but no less serious andreal, forms of euthanasia. These couldoccur for example when, in order to

increase the availability of organs fortransplants, organs are removed withoutrespecting objective and adequate criteriawhich verify the death of the donor.(John Paul II 1995, no. 15)

In his message to the participants of theconference “The Signs of Death” organizedby the Pontifical Academy of Sciences onFebruary 2–3, 2005, John Paul II once againreiterated the balanced position of theChurch, stating: “On the one hand, theChurch has encouraged the free donationof organs, and on the other hand, she hasunderlined the ethical conditions for suchdonation” (John Paul II 2005, no. 2).16

Since the pope consistently maintained abalanced position toward organ transplanta-tion, his address in 2000 on the controversialissue of “brain death” should be read from hisbalanced and prudential perspective.17 As pre-sented in the following section, the centralpart of his discourse (nos. 4 and 5) containsthree important presuppositions.

First presupposition

First, the pope’s teaching on death presup-poses Christian anthropology, accordingto which: (a) the human person is thesubstantial unity of body and soul, and(b) the soul is the life principle (substantialform) of the body. This is the doctrine ofthe Church as taught in the Catechism andformally declared by the Council ofVienne in 1312 (CCC, no. 365). Thus,according to Christian anthropology, “themoment of death for each person consistsin the definitive loss of the constitutiveunity of body and spirit” (John Paul II2005, no. 4). The death-event, the separa-tion of the soul from the body, bringsabout “the total disintegration of [the]unitary and integrated whole” (John PaulII 2005, no. 4) that was the person.While the event of the body-soul

separation cannot be directly identified by


any scientific method, its consequence canbe recognized empirically. The separationsets in motion an unstoppable process ofsomatic disintegration,18 producing “biolo-gical signs that a person has indeed died”(John Paul II 2000, no. 4). In otherwords, as long as somatic integration ofthe human organism as a whole continues,it is indirect evidence that the soul is stillunited to the body.19 The specification ofbiological parameters indicating that deathhas occurred “does not fall within thecompetence of the Church” (Pius XII1957), however.20 Rather, it pertains tothe responsibility and competence of themedical profession to judge and establish,with as much precision as possible, theconstellation of signs which can serve asreliable indicators that death has occurred,such that a declaration of death can bemade with adequate moral certainty.

In view of John Paul II’s first presupposi-tion, the critical question regarding the neu-rological standard for the determination ofdeath is thus twofold: (1) does it agree withthe Church’s anthropology? and (2) can itqualify as an adequately sound method forascertaining that the patient has indeeddied? The first is at the conceptual/philoso-phical level while the second belongs to thelevel of the particular and empirical. JohnPaul II, therefore, did not elaborate on thelatter aspect. In a way, this issue was alreadytouched upon by Pope Pius XII in hisaddress to an international congress ofanesthesiologists in 1957. One of the ques-tions submitted to Pius XII was the follow-ing: when can a comatose, brain-injuredpatient “be considered de facto or even dejure dead” (Pius XII 1957)?

Has death already occurred after gravetrauma of the brain, which has provokeddeep unconsciousness and central breath-ing paralysis, the fatal consequences ofwhich have nevertheless been retarded byartificial respiration? Or does it occur…

only when there is complete arrest ofcirculation despite prolonged artificialrespiration? (Pius XII 1957; emphasisadded)

The aforementioned passage encapsulatesthe kernel of the “brain death” controversy.One of the most frequent arguments madeby “brain death” defenders is that the bodyof a “brain-dead” individual is not “a bodybut a corpse, even when it may seem alivebecause a ventilator masks its death.”21

What “masking death” means has neverbeen explicated, however.22 Since life anddeath are mutually exclusive, and death isthe privation of life and refers to the dis-integration of the organism, then in whatway can death be masked if not by somemeans of production of life? This is why,in the context of the affirmation that“brain death” is death simpliciter (Battroet al. 2007, xxi), the additional claim that“death is camouflaged or masked by theuse of [an] artificial instrument” (Battroet al. 2007, xxix) is a very ambitious asser-tion because it cannot but imply that man-made machinery somehow has the powerof producing life. But this is an impossi-bility because, according to the principle ofproportionate causality, whatever is pre-sent in an effect must also be in someway in its cause. To assert, as Bishop Sor-ondo did during the general discussionsession of the Pontifical Academy ofSciences (PAS) 2006 conference, that“the ventilator is the principal cause todelay the corpse’s inexorable decomposi-tion process” (Sorondo 2007, 274) is tocontradict this very principle, because, aspointed out by Accad (2015, 224), “theventilator, … which only manifests a sim-ple power of insufflation, … has no powerto control homeostasis, circulation, diges-tion, growth, or any other such function,even for a millisecond.” In other words, bythe principle of proportionate causes andeffects, medical technology, however


advanced it might be, cannot generate thevery complex phenomenon of somaticintegration which emerges from thenumerous interrelated activities of life(e.g., circulation, gas exchange, homeosta-sis of various types, and metabolic pro-cesses to keep the body temperatureconstant, among others) that are stillongoing in the body of “brain-dead”patients. What has been commonlyreferred to as the appearance of life(namely, the look and feel of warm andpink flesh) is actually the result of thesenumerous “behind the scene” interrelatedactivities of life. In other words, “appear-ance of life” is life, as there cannot be theappearance of life unless there are activitiesof life ongoing in the subject.

To reiterate, the ventilator cannot maskdeath and produce the appearance of lifein a dead entity because:

1. The ventilator does only two things: (1)expand the lungs in lieu of the intercostalmuscles and the diaphragm, and (2)pump oxygenated air into the lungs. Byvirtue of its design, the ventilator has norole to play in the exchange of oxygenand carbon dioxide (which takes place inthe lungs and in all the organs and tissuesthroughout the body), pushing the bloodthrough the vascular system, or in any ofthe many vegetative activities that are stillongoing in the body of “brain-dead”patients.

2. To claim that the ventilator can maskdeath (to cause the appearance of life) in“brain death,” and that “brain death” isdeath simpliciter, is to claim that the ven-tilator can cause the appearance of life indeath simpliciter. Traditional death (deathas determined by the traditional stan-dard) has been known for millennia asdeath simpliciter. Logically then, if oneconnects the ventilator to the corpse of aperson whose death was determined bythe traditional criteria, then one wouldexpect the ventilator to cause what it is

alleged to be capable of, that is, to givethe appearance of life in a dead entity. Asintuited by common sense, this will nothappen, however.

The ventilator and other technologicaltools are instruments of life support, whichmeans that they can only work if there isstill some life present in the individual.Consequently, technological prowess can-not mask death.23 It can only retard themoment of death. Until that very moment,the soul remains united to the body, thatis, the patient remains an integrated wholeeven though deeply comatose and comple-tely unresponsive to stimuli. This is whyPius XII responded to the above questionas follows: “human life continues for aslong as its vital functions … manifestthemselves spontaneously or even withthe help of artificial processes” (Pius XII1957). Pius XII’s answer not only reflectshis deep insight on the matter, but alsosums up the Church’s belief that the soulis the only and sufficient integrator of thebody of the human organism as a whole.The soul manifests itself through multiple,complex, mutually interacting vital func-tions, which are distinct from sensori-motor functions (e.g., brainstem reflexes)and “rational” functions (including con-sciousness). Pius XII’s statement shouldhelp us to understand that, even at theend of life, in dubio pro vita.

Second presupposition

The second important premise in JohnPaul II’s address is that the determinationof biological death pertains to the medicalcommunity, and not the Church. There-fore, his remarks regarding the neurologi-cal standard cannot but rest on thepresupposition that the standard has beenestablished by “clearly determined para-meters commonly held by the internationalscientific community” (John Paul II 2000,


no. 5; emphasis added). In the context ofthe discussion, the parameters referred toare the clinical test-criteria used for deter-mining “brain death.” They can only beclearly determined if they have undergonerigorous validation prior to being intro-duced into clinical practice. This was notperformed by the Harvard Committee,however.24 No other large clinical trialshave been carried out even though thiswas recommended by a collaborativestudy on 503 “brain-dead” patients(National Institutes of Health 1977).With respect to the pope’s requirementthat the parameters be commonly held inthe medical community worldwide, even“brain death” advocates have to admitthat there exists no global consensus (Wij-dicks 2002; Greer et al. 2008, 287),25 butrather a confusion of practice with signifi-cant variability found in all areas, includingapnea testing.26 Added to these proble-matic issues are the many inconsistenciesinherent in the “brain death” paradigmitself. As will be shown in the followingsection, the most notable inconsistenciesare those between the definition of “braindeath” (which requires the irreversible andcomplete loss of all brain functions) andthe empirical evidence, which has repeat-edly shown not only: (1) the presence ofresidual brain functions in “brain dead”individuals, but also (2) that some “braindead” patients can survive for months andyears if they are appropriately supportedbeyond the acute phase of their injuryinstead of being sent to surgery for organharvesting (Halevy and Brody 1993,520–21; Veatch 2005, 356–58; Truogand Miller 2008, 674).

Medicine is not a science of absolutecertainty. Nevertheless, the determinationof death, especially when it is soon followedby the removal of viable organs for trans-plantation, must be as precise as possible.Connected to the aforementioned secondpresupposition is the pope’s requirement

that the neurological standard be “rigor-ously applied” (John Paul II 2000, no. 5),to warrant sufficient moral certainty todeclare a patient dead. Significant variabil-ity in clinical testing for “brain death” isper se contrary to this requirement, how-ever. Furthermore, even if the problem ofvariability could be corrected by educationand training, there would still remain thequestion of whether the battery of clinicaltest-criteria, which is constitutive of the“whole brain death” standard, is adequateto establish “the complete and irreversiblecessation of all brain activity” (John PaulII 2000, no. 5). This medical issue will bediscussed in the next section.

Third presupposition

The third important presupposition inJohn Paul II’s address is contained in thethird paragraph of number 5, the contentof which is connected to that of the firstparagraph of the same article. The respec-tive relevant parts read as follows:

For some time certain scientificapproaches to ascertaining death haveshifted the emphasis from the traditionalcardio-respiratory signs to the so-called“neurological” criterion. Specifically, thisconsists in establishing, according toclearly determined parameters commonlyheld by the international scientific com-munity, the complete and irreversible ces-sation of all brain activity (in thecerebrum, cerebellum, and brain stem).This is then considered [to be] the signthat the individual organism has lost itsintegrative capacity. (John Paul II 2000,no. 5.1)

The criterion adopted in more recenttimes for ascertaining the fact of death,namely the complete and irreversible cessa-tion of all brain activity, if rigorouslyapplied, does not seem to conflict withthe essential elements of a sound anthro-pology. Therefore a health-worker pro-fessionally responsible for ascertaining


death can use these criteria in each indi-vidual case as the basis for arriving at thatdegree of assurance in ethical judgementwhich moral teaching describes as “moralcertainty”. This moral certainty is consid-ered the necessary and sufficient basis foran ethically correct course of action. (JohnPaul II 2000, no. 5.3)

It seems that the conditional phrase “ifrigorously applied” refers only to the clin-ical test-criteria of the “brain death” stan-dard. The articulation of the firststatement of the third paragraph, inwhich this conditional phrase is found, israther ambiguous, however, as it is unclearwhether the term “criterion” refers to: (1)the application of the “brain death” stan-dard, in which case it would refer to theclinical test-criteria, or (2) to the “braindeath” standard itself. The former involvesarguments at the medical-empirical level,whereas the latter involves both philoso-phical and medical arguments. Even withthis ambiguity, it is nevertheless clear thatthe third important presupposition in JohnPaul II’s address is that the “whole braindeath” paradigm coheres with soundanthropology as held and taught by theChurch. This presupposition necessarilyincludes the premise that “brain death”signifies loss of somatic integrity.

As mentioned earlier, the tone of thepope’s address is one of prudential wis-dom. It is therefore notable that JohnPaul II never stated that the neurologicalstandard is “the sign that the individualorganism has lost its integrative capacity”(John Paul II 2000, no. 5), but ratherthat it “is … considered [to be] thesign ….” Readers of the pope’s addresswho are familiar with the history of“brain death” can easily recognize thathere, an implicit reference was beingmade to the medical and legislative com-munities by and through which “braindeath” has been considered to be the

sign that death has occurred. It wasalso with the same prudential wisdomthat John Paul II (2000, no. 5) statedthat “the complete and irreversible cessa-tion of all brain activity, … does not seemto conflict with the essential elements ofa sound anthropology” [emphasis added]instead of simply affirming that it “doesnot conflict with … sound anthropol-ogy.” In other words, the premise, thatthe “whole brain death” paradigm is notinconsistent with the Church’s anthro-pology only seems to be true, accordingto the pope’s judgment based on theknowledge that he had around the timeof his address.27

To recapitulate, the three importantpresuppositions upon which the pope’sapproval of the neurological standardrests, include:

1. Christian anthropology—this is thepope’s foundational starting point.

2. A twofold presupposition regarding theclinical test-criteria: (a) international con-sensus and, (b) rigorous application of theclinical tests, which also presupposes thatthe battery of tests is adequate for deter-mining the irreversible loss of all brainfunctions.

3. Congruity of the “whole brain death”paradigm with Christian anthropology.

Evidently, both presuppositions (2) and(3) must hold true or be fulfilled if theconclusion is to follow, whether on theindividual or general level. On the indivi-dual level, the conclusion is about suffi-cient moral certainty with which aphysician could declare a patient dead onthe basis of the “brain death standard”; onthe general level, the conclusion has to dowith the question of the magisterium’sdefinitive endorsement of “whole braindeath.”With regard to the third premise, the

“whole brain death” concept is a twofoldthesis: (1) death is “the permanent


cessation of functioning of the organism asa whole” (Bernat, Culver, and Gert 1981,390), that is, the organism is no longer anintegrative unity because “the highly com-plex interaction of its organ subsystems”comes to an end at death (Bernat, Culver,and Gert 1981, 390); and (2) in the case ofhumans, the brain is the principle of inte-gration (also known as central somaticintegrator in the biophilosophical andmedical jargons) “responsible for … theintegration of organ and tissue subsystemsby neural and neuroendocrine control oftemperature, fluids and electrolytes, nutri-tion, breathing, circulation, [and] appro-priate responses to danger, among others”(Bernat 1984, 48). The first arm of thetwofold premise indeed coheres with theChurch’s doctrine that the soul is the sub-stantial form of the body, “the spiritualprinciple which ensures the unity of theindividual” (John Paul II 1989, no. 4),such that at death, the soulless body, leftto itself, disintegrates. The critical ques-tion, then, is: does the second arm of thepremise, the absolute supremacy of thebrain as the principle of integration, alsocohere with Christian anthropology, andconcomitantly does it correspond to biolo-gical reality?

A BRIEF CONSIDERATION OF THE

EMPIRICAL MEDICAL EVIDENCE

John Paul II’s discourse thus leads to twomain questions upon which depends hisconditional acceptance of the neurologicalstandard. The first question has to do withthe adequacy of the clinical test-criteria toestablish complete loss of all brain func-tion; the second concerns the practical andconceptual soundness of the rationale ofthe brain as the principle of integration,which undergirds the “whole brain death”paradigm. In what follows, the discussionwill be first on the empirical aspect, and

then on the question of the conceptualsoundness.

Are the clinical tests adequate for thedetermination of “brain death”?

According to the Uniform Determinationof Death Act, the legal declaration ofdeath using the “brain-death” standardrequires the “irreversible cessation of allfunctions of the entire brain, includingthe brainstem” (President’s Commission1981, 2). Currently, the American Asso-ciation of Neurology guidelines are theaccepted medical standard for the determi-nation of “brain death” (Wijdicks et al.2010). The guidelines are essentially thesame as those in the Harvard report (Har-vard Medical School 1968, 337–38), withthe difference that the American Associa-tion of Neurology considers the electroen-cephalogram (EEG) as an ancillary testand not as a requirement.28 The requiredtesting consists solely of bedside clinicaltests targeting brainstem function.29 Theissue of the adequacy of the clinical testscan be addressed in one of two ways: (1)considering only the required tests, or (2)considering both the required and ancillarytests.Using the first approach, it is self-evident

that the required clinical test-criteria areinadequate to establish the “complete andirreversible cessation of all brain activity (inthe cerebrum, cerebellum, and brainstem)”(John Paul II 2000, no. 5), since they areonly concerned with brainstem reflexes.Hence, there have been repeated reportsof “brain-dead” patients with demonstrablegenuine electroencephalographic (EEG)activity. In 1971, the Minnesota study ontwenty-five cases of “brain death” reportedEEG activity in two of nine “brain-dead”patients on whom EEG was performed.The authors of the study simply discardedthe evidence by concluding that EEG test-ing is not needed for establishing “brain


death” (Mohandas and Chou 1971). Simi-larly, in another study of fifty-six cases of“brain death,” of which eleven had EEGtesting, three patients demonstrated persis-tent EEG activity (Grigg et al. 1987).Furthermore, as pointed out by Halevyand Brody (1993, 521) in their review,there have been reported cases of “brain-dead” patients in whom evoked potentialsdemonstrated “the functional integrity ofthe auditory and visual pathways,” indica-tive of the presence of brainstem function.

It may be argued that the routineinclusion of ancillary tests to detectbrain electrical activity or cerebral bloodflow would correct the aforedescribedinadequacy. Some basic notions of thepathophysiology of brain injury willexplain why such will not be the case,however.30 First is the self-protectivemechanism of any injured organ (thebrain included) to shut down itsfunction. Second is the conditionknown as global ischemic penumbra dur-ing the acute period of severe braininjury, when cerebral blood flow hasdropped to 50–80% lower than normal,but still remains above the threshold atwhich neuronal injury becomes irreversi-ble (Coimbra 2009, 132). Consequently,brain functions are suppressed but theorganic vitality of the brain is not yetlost because the level of energy (andthus of oxygen) required for sustainingthe vitality of an organ is much lowerthan that needed for maintaining itsfunction (Astrup, Siesjö, and Symon1981). The severely depressed brainfunctions during the penumbra explainEEG isoelectricity and the lack ofresponse to clinical bedside tests.31 Simi-larly, the penumbra-level of cerebralblood flow can fall below the detectionthreshold of the current available testsfor intracranial circulation. Thus, duringthe acute period of severe brain injury,the lack of brainstem reflexes, even if

accompanied by a flat EEG and absenceof intracranial circulation, do not neces-sarily indicate “brain death.”32 It cannotbe excluded that the victim is in fact inthe penumbra condition when neurologi-cal functions (deemed to be lost) remainrecoverable, and the patient’s clinicalcourse remains unpredictable. The “pre-sence of viable brain tissue in thepenumbra also explains why the acuteclinical presentation of stroke [or otherkinds of severe brain injury] is a ratherpoor predictor of outcome” (Astrup,Siesjö, and Symon 1981, 725). Notably,the penumbra is a precious time-windowwhen prompt aggressive neuro-intensiveintervention can significantly improvethe outcome of severe brain injury.Furthermore, there are brain functions not

detectable by any of the current tests for“brain death,” namely, the activity of thehypothalamus-pituitary axis that affectsother endocrine organs of the body. Persis-tent neuroendocrine regulation (whichaccounts for sexual maturation) and secretionof antidiuretic hormone have been reportedin patients who met all the criteria of “braindeath” (Halevy and Brody 1993, 520; Shew-mon 2001, 468).Faced with the irrefutable evidence

of EEG activity, evoked potentials, orneuroendocrine function reported in“brain-dead” patients, Bernat’s school ofthought has simply “discard[ed] certainfunctions of the brain as unimportant orinsignificant” (Veatch 2005, 357). Thus,antidiuretic hormone secretion is classi-fied as a non-critical function, and resi-dual EEG activity as coming from someinsignificant nests of cortical neurons(Bernat 1992, 25). Such a selective dis-carding, distinguishing significant frominsignificant brain functions is ratherarbitrary, however, especially since theconcept of “whole brain death” has beendefined as the complete and irreversibleloss of all brain functions.


Is the theory of the brain as the principleof integration supported by empirical

evidence?

According to the rationale of the brain asthe principle of integration, it has beenasserted that, since “only the brain candirect the entire organism” (President’sCommission 1981, 34), then once apatient is “brain dead,” “even with extra-ordinary medical care, [somatic] functionscannot be sustained indefinitely – typically,no longer than several days” (President’sCommission 1981, 35), because imminent“cardiac arrest usually occurs within forty-eight to seventy-two hours of brain deathin adults” (Soifer and Gelb 1989, 816).33

There is truth in the aforementionedassertions, in the sense that, since nomachine can produce life in a truly deadorganism, technological life-support onlyworks if there is still some life (howeverminimal that may be) in the human organ-ism. Once true death occurs, the process ofincreasing entropy becomes unstoppable,and no technological intervention canreverse it.34 Thus, if “brain death” isindeed death simpliciter, then no amountof technological life support can give theappearance of life, especially not for days,weeks, and months (see the aforemen-tioned discussion on the argument of“masking death”). Medical empirical evi-dence on “brain-dead” survivors who didnot undergo organ harvesting but whoinstead continued to receive life support,has confirmed neither the purportedequivalence of “brain death” as death northe theory that the brain is the principle ofintegration, however.

The most persuasive and irrefutable evi-dence comes from Shewmon’s collectionof 175 “brain-dead” patients who survivedbeyond the aforementioned maximumpossible few days (Shewmon 1998a, 135).These cases cannot be dismissed merely asmisdiagnoses, for that would imply the

unreliability of “brain-death” declarations(Shewmon 1998b, 1542), or the incompe-tence of neurologists/neurosurgeonsinvolved in those cases. It would be alsounscientific to disregard such survivors as“cell cultures.”35 Admittedly, the numberof “chronic brain-death” survivors is small,but the reason for this is because the greatmajority of “brain-dead” individuals areeither quickly taken for organ harvestingor removed from life support. In thatsense, the diagnosis of “brain death” hasthe mark of a self-fulfilling prophecy(Truog and Robinson 2003, 2392). Amajor textbook of neurology warns againstsuch a self-fulfilling prophecy as follows:

death … most often is the consequence ofdecisions to limit life support because poorfunctional recovery is anticipated. It isincreasingly recognized, however, thatcaregivers [i.e., doctors, nurses, and health-care professionals] tend to underestimatethe capacity for recovery from severe braininjury and some fatal outcomes may be theresult of self-fulfilling prophecy. (Mayerand Badjatia 2010, 491)

The most important point derived fromShewmon’s data is that “most somaticintegrative functions are not brainmediated” (Shewmon 1998a, 138).36 Ber-nat’s theory of the brain as the principle ofintegration asserts that the brain controlsthree categories of critical functions. Oneof these consists of “integrating functionsthat assure homeostasis of the organism,including the appropriate physiologicresponses to baroreceptors, chemorecep-tors, neuroendocrine feedback loops, andsimilar control systems” (Bernat 1998, 17).These are exactly the properties exhibitedby “chronic brain-death” survivorsreported by Shewmon and other authors.For example, these patients retained thecapacity to develop inflammatory reactionsagainst infections, maintain body tempera-ture, absorb nutrients, get rid of cellular


waste, and undergo sexual maturation.Such diverse activities necessarily involve“homeostasis of a countless variety ofmutually interacting … physiological para-meters” between organ systems (Shewmon2001, 467).37 To date, “brain-death”defenders have not been able to refuteShewmon’s study in a convincing and logi-cal manner.38

For the “brain-death” standard to berelied upon as a sound criterion for thedetermination of death, the theory of thebrain as the principle of integration mustcorrespond to biological reality. Theempirical evidence has shown that it doesnot. This does not mean that the brain hasno role to play, however. Its role is “topromote the continued health and functionof the body” (Condic 2014, cited in Eberl2015, 238). Such a function necessarily pre-supposes an already existing organismicunity, that is, a living organism. In otherwords, the role of the brain is not so muchthat of a principle of integration “conferringunity upon the body… [but, rather that] ofenhancing and preserving a somatic unityalready presupposed” (Shewmon 2001, 464).It is a task somewhat analogous to thesupervisory task of the state (or ruler) inthe governance of a nation, or the domin-ion-role which God has conferred to man-kind over His creation,39 promoting andharmonizing the various systems or bodiesof lower order, but without imperiouslycontrolling or taking over their functions.

In summary, somatic integrative unitydoes not result from the brain controllingother organs and “micromanaging” themin a top-down fashion; rather, it is a non-localized holistic emergent phenomenonarising from the complex, mutual, andmulti-leveled interactions among all theparts of the body. This understandingcoheres with the current philosophicaland biological understanding about lifeand organisms (Maturana, Varela, andBeer 1980; Varela 1979; Aguilar 2006).

IS THE RATIONALE OF “THE BRAIN AS

PRINCIPLE OF INTEGRATION”CONCEPTUALLY SOUND?

Which of the aforementioned two con-cepts: (1) the brain as the master organof somatic integration, or (2) somatic inte-gration as a non-localized emergent phe-nomenon, coheres with Christiananthropology? The anthropology taughtby the Church is grounded in the Aristo-telian-Thomistic doctrine of hylomorph-ism, according to which a living humanperson is the substantial unity of bodyand soul. This means that the humansoul, which is subsistent, is united to thematerial body not as its motor (its mover)but as its substantial form (Aquinas 2010,I, q. 76, a. 1).40 As Thomas explains, inthe substantial unity of matter and form,the form is the cause of union and causesmatter to be in act because the form isitself essentially an act. As such, in thebody-soul union, it is the subsistenthuman soul that communicates esse to thebody, and therefore, “makes [it] to exist inactuality” (Aquinas 2010, I, q. 76, a. 7). Innon-technical language, this means thatthe soul makes the body what the bodyis, holding it together and keeping italive. This rich notion of the soul as sub-stantial form conveys several significantimplications, including the following:

1. Precisely because the soul is not united tothe body as its motor—which it would bein a Platonic conception of the soul—it isimpossible for the unity of body and soulto be mediated by any accidental disposi-tion, because matter (the body) has toreceive first the esse from the form (itsexistence actualized by the form) beforeit can acquire its proper accidental dispo-sitions (Aquinas 2010, I. q. 76, a. 6).Likewise, it is impossible for the body-soul union to be mediated by some inter-mediate corporeal thing (Aquinas 2010,I, q. 76, a. 7).


2. It follows from the aforementioned thatthe soul cannot be located “just in the onepart of the body by which it moves [andcontrols] the other parts, … [but rather],it must exist in the whole body and ineach part of the body, … [because thesoul is] the form and actuality not onlyof the whole [body] but also of each part”(Aquinas 2010, I, q. 76, a. 8).41 Conse-quently, when the soul leaves the bodyupon death, “no part of the body retainsits proper function” (Aquinas 2010, I, q.76, a. 8). In modern scientific language,this means that the organs and parts ofthe “body” (now a corpse), though theymay still retain some viability for a shortwhile (numbered in hours), can no longerfunction in an integrated manner withone another as they once did in the livingbody. In other words, the soulless body isunable to hold itself together and suc-cumbs to the unstoppable process ofdisintegration.42

3. As the substantial form communicatingits esse to the body, the soul is also thefirst principle of life of the body, that is,

that by which the body is first andforemost alive. And since life is mademanifest by different operations withinthe different grades of living things, thesoul is that by which we perform each ofthese vital works. … The soul is that bywhich we first and foremost assimilatenourishment [nutrimur] have sensorycognition [sentimus], and move fromplace to place [movemur secundumlocum]; and, similarly, the soul is that bywhich we first and foremost have intel-lective understanding [intelligimus].(Aquinas 2010 I, q. 76, a. 1)

The human soul is referred to as the intel-lective or rational soul, but it “has within itspower whatever the sentient soul of bruteanimals has and whatever the nutritive soulof plants has” (Aquinas 2010, I, q. 76, a. 3).Consequently, although the soul is incor-poreal and thus invisible, its presence can

be deduced from the diverse operationssynoptically mentioned in the aforemen-tioned passage—operations which reflectthe various powers of the human soul,namely “the vegetative, the sensitive, theappetitive, the locomotion, and the intellec-tual“ (Aquinas 2010, I, q. 78, a. 1). It is thehuman soul alone, and not any corporealpart (whether the brain, the heart, or anyother bodily organ or part), that is the prin-ciple and cause of all these powers (Aquinas2010, I, q. 77, a. 6). Since the actual opera-tions of the powers of the soul involve cor-poreal organs, it is the human being (thecomposite body-soul unity) rather than thesoul alone, who performs the operationspertaining to each power (Aquinas 2010, I,q. 77, a. 5). Despite the rudimentary biolo-gical knowledge of his time, Aquinas recog-nizes that: (1) the vegetative powers are priorby way of generation to the sensitive powers,and the latter, prior to the intellectualpowers (Aquinas 2010, I, q. 77, a. 4); (2)there are three types of vegetative powers:“generative” (to produce offsprings), “aug-mentative” (growth), and “nutritive,” whichmaintain the human organism in existence(Aquinas 2010, I, q. 78, a. 2); and (3) vege-tative operations involve heat.43 In modernscientific understanding, the “nutritive”power encompasses a whole host of meta-bolic activities and complex homeostasis ofdifferent kinds.In our day, the notion of soul has fallen

by the wayside in the fields of biology andmedicine. In order to convey the timelesstruth of Aquinas’s teaching on the body-soul hylomorphism mentioned above, it isnecessary to “translate” this teaching intoconcepts familiar to the contemporaryscientific/medical mind which understandslife in thermodynamic terms. In thisthinking, life is the continuous anti-entropic activity maintaining the integra-tive unity of the organism. Using thismodern conception, the very same teach-ing of Aquinas on hylomorphism can be


paraphrased and reformulated as follows:in addition to its spiritual dimension, thesoul, as the substantial form of the bodyand its first principle of life, must also bethe anti-entropic organizing principle of thebody, organizing and directing all the dif-ferent parts and organ systems (includingtheir functions and mutual interactions atall levels, that is, from the molecular/microscopic to the macroscopic level) intoone single, complex, dynamic, and unifiedwhole that is the body, which grows andchanges over the course of the person’slifetime. A similar understanding isexpressed by Austriaco from a systems per-spective, namely that

the body is a dynamic, complex, andseamlessly integrated network, not oforgans nor of cells, but of molecules,including DNA, RNA, lipids, and pro-teins, connected by reaction pathwaysthat generate shape, mass, energy, andinformation transfer over the course of ahuman lifetime.… [It is a] process thathas both spatial and temporal manifesta-tions. From the systems perspective, thisparticular pattern, this organization of themolecules of the human being, would bea manifestation of his immaterial soul.(Austriaco 2003, 304)

The aforementioned passage impliesthat the anti-entropic organizing principleof the body is present in the whole of thebody and in each part of the body (insofaras the part remains part of the whole);44 itspresence is thus non-localized. This is whyAquinas insisted that the union of the soulto the body is not mediated by any organin particular. In other words, the soul doesnot reside in any specific organ, nor is anyorgan its “vicar” or “stand-in.”45 As will bediscussed in the following section, organsare only the soul’s instruments to “move”the body (the word “organ” comes fromthe Greek word “organon” which means atool or instrument); but it is the soul (the

substantial form) itself that directlyinforms the body. How exactly the anti-entropic organizing principle of the bodyworks remains a mystery beyond the graspof the human intellect, simply because thisprinciple (which is none other than thesoul) is immaterial; whereas, all humanknowledge necessarily begins with sensoryperception, followed by abstraction andthe formation of concepts. What can beobserved, however, are the numerousemergent holistic properties at every level,working together in concert to maintainorganismic integrative unity. Such proper-ties range from the multiple anti-entropicsomatic integrative functions (such asblood gas exchange at the cellular level,digestion, and complex homeostasis of dif-ferent kinds) to consciousness.46 To put itdifferently, the non-localized phenomenonof somatic integration is indirect evidenceof the non-localized presence and activityof the soul in the body, and therefore, theindirect evidence of its substantial union tothe body. To speak of the anti-entropicprinciple of the body is to speak of itsintegrative principle; they are two facetsof one and the same entity which is thesoul. In sum, the sole principle of integra-tion of the body is its substantial form, thesoul, and not any corporeal thing. It maybe said that the scholastic terminology “toinform the body” corresponds to our mod-ern scientific terminology “to integrate thebody.”As mentioned in the previous para-

graph, the operations of the soul necessa-rily involve a corporeal substrate (Aquinas2010, I, q. 77, a. 5). Organs and bodyparts are thus employed by the soul as itsinstruments to “move” the body, that is, toperform diverse functions flowing from thepowers of the soul—functions and activ-ities which provide life-energy to thehuman organism, and which make it pos-sible for the organism to interact with andrespond to the external world. Since the


soul is itself the integrator of the body, ithas no need for any instrument of integra-tion. The interdependence between thepowers of the soul is reflected in the com-plex interrelationships among the organsand organ systems.

Empirically, it can be intuited that thereexists some sort of hierarchy among thedifferent organ systems in that someorgans are more vital (and thus also morevulnerable) than others; what that hierar-chy is exactly cannot be easily determined,however. At first and for many centuries,primacy was ascribed to the heart: it washeld that “the first motion of the animal[the organism] is the motion of the heart”because “once it stops, the animal dies”(Aquinas De motu cordis; emphasisadded). In other words, the heart was con-sidered to be “the prime instrumentthrough which the soul’s powers were dif-fused in the body to move it” (Boyle 2013,277). Some other authors (e.g., Aristotle,St. Albert the Great, Avicenna) evenexalted the primacy of the heart to thepoint of seeing it as the seat of the soul,or at least as its “deputized organ” (Boyle2013, 276), that is, its “vicar” or “stand-in.”Aquinas did not fall into the error ofexalting any organ (whether heart, lung,or brain), however. This is evident in thefollowing explanatory statement whichAquinas made, when pointing out that thesoul-body union is not mediated by anycorporeal thing:

The reason why the union of the soul tothe body ceases when breath ceases is notthat breath is a mediator, but that thedisposition by which the body is disposedtoward such a union is destroyed. Still,breath is a mediator in effecting move-ment as the first instrument of motion.47

(Aquinas 2010, I, q. 76, a. 7, ad 2)

It is clear from the aforementioned passagethat the role of an organ and its functionsis strictly that of an “instrument of

motion;” it is not that of a mediator ofthe soul-body union, and therefore notthat of an instrument of integration.In the earlier writing, De Motu Cordis,

the heart seems to be the first instrumentby which the soul “moves” the body; here,in the Summa Theologiae, the lungs(breath) seem to be the first instrumentinstead. It is thus apparent that: (1) ourintellect can recognize that certain organs(corporeal instruments of motion) are ofspecial importance because they “serve todispose the union of body and soul”(Accad 2016, 2); but (2) we do not knowwhether or not there exists a rankingamong them, and if there were, we donot know which instrument is the first.For centuries, up until the radical para-digm shift to the “brain-death” standard,it was recognized that “three organs—theheart, lungs, and brain—assume specialsignificance” (President’s Commission1981, 33). Finally, the brain is exalted tothe apex of this very same triangle (Pre-sident’s Commission 1981, 33). But whatabout the case of a young individual, inwhom the brain, heart, and lungs are inperfect working condition, but who suffersa sudden bout of massive uncontrolledhemorrhage (e.g., from a gunshot woundto the abdominal aorta)? Here, the flawedinstrument that impedes the operation ofthe soul is neither the brain, heart, nor thelungs, but instead the blood/circulatorysystem. In other words, empirical evidencedoes not support the thesis of a primaryorgan.Rather, the evidence suggests that: (1)

the soul employs several instrumentswhich, in working closely together andquasi-simultaneously, “serve to disposethe union of body and soul” (Accad2016, 2); and (2) there is more than onecategory of instruments. In simple terms,it may be said that there are two broadcategories of instruments according totheir respective predominant focus, ad


intra or ad extra. Instruments of the soulwith a predominant ad intra focus arethose concerned with maintaining theinternal environment of the humanorganism in a dynamic homeostatic con-dition, whereas those with apredominant ad extra focus are concernedwith the organism’s interaction with theexternal world, which in turn involvessensorimotor and cognitive functions. Atthe macroscopic level, the heart, lungs,and circulatory system are the mostobvious examples of the first category ofinstruments of the soul, whereas the cen-tral nervous system, together with itsassociated sensory and motor parts ofthe body, belongs to the second category.But, at a deeper level there are numerousother operations of the soul withoutwhich the organism would succumb tobiological decay – operations which man-ifest as complex life processes at the non-macroscopic level, and which keep theorganism as an integrative unity, that is,“in a dynamic state of endogenous activeopposition to the tendency to increasingentropy” (Shewmon 2012b, 436). This“infrastructure” of invisible operations,together with those macroscopic instru-ments of the first category, correspondsto what is referred to as the vegetativefunction of the rational human soul.Vegetative operations are intrinsic to life,and without them, neither sensorimotornor cognitive function can take place.This was already recognized by Aquinasand his predecessors, that in the order ofgeneration, vegetative powers come first(Aquinas 2010, I, q. 77, a. 4). In otherwords, the most fundamental organismicintegration is integration at the vegetativelevel. In this regard, only a small part of thebrain is involved in the regulation of theorganism’s internal environment, namelythe neuroendocrine system, and thoseparts of the sympathetic and

parasympathetic systems found in thebrainstem (Shewmon 2012b, 447–48).48

The battery of clinical tests for “braindeath” do not evaluate any of the functionsof these systems, however; they only evalu-ate the patient’s (reflex) motor response tovarious external stimuli. It is thus safe to saythat the brain is not the critical instrumentemployed by the soul for the operations ofits vegetative powers—operations that arenecessary for maintaining the organismalive. Rather, the brain is the prime instru-ment for the soul to manifest its higherfaculties. In sum, even if the brain is con-sidered as the top organ in the hierarchy oforgan systems because of its involvement inthe operations of the soul’s intellectualpowers, its role is not and cannot be thatof the principle of integration. That rolepertains to the soul alone.But, according to the philosophical

rationale (advanced by Bernat in 1981and promoted by the 1981 President’sCommission) that undergirds the conceptof “whole brain death,”

The brain is necessary for the functioningof the organism as a whole. It integrates,generates, interrelates, and controls com-plex bodily activities. (Bernat, Culver, andGert 1981, 391; emphasis added)

It is primarily the brain that is responsiblefor the functioning of the organism as awhole: the integration of organs and tissuesubsystems by neural and neuroendocrinecontrol of temperature, fluids and electro-lytes, nutrition, breathing, circulation,[and] appropriate responses to danger,among others. (Bernat 1984, 48; empha-sis added)

[The brain] is the irreplaceable, indispen-sable, complex, structural-functionalcontrol system that maintains the healthand life of the organism, without whichthe organism no longer can function as awhole. … With the loss of the criticalsystem, the organism loses its life-


characterizing processes, especially itsanti-entropic capacity. (Bernat 2002, 334)

It is self-evident from the aforementionedthree passages (and many similar passagesfrom other scholar-supporters of “wholebrain death”), especially when comparedto Aquinas’s teaching in Summa TheologiaeI, q. 76, a. 1 (see the aforementionedquoted passage) that the philosophicalrationale of “whole brain death” radicallydiverges from the Christian anthropologytaught and held by the Church. In thelatter case, the brain is an organ like anyother organ of the body, that is, an instru-ment of the soul, one that performs func-tions corresponding to its nature. In theformer case, however, the brain itself ismade to assume the role of the soul asthe “supreme boss,” integrating and con-trolling the rest of the body.

Such a philosophical paradigm necessa-rily excludes the soul from consideration.Moreover, it cannot but set up a brain-body dualism, one in which the brainstands apart and over all other organs(including the spinal cord despite the factthat the latter is an integral component ofthe central nervous system) as if it were“an entity in its own right and not a part ofthe body” (Shewmon 2001, 475 note 9).The brain-body dualism is reminiscent ofthe Cartesian mind/body dualism, butwith the difference that it takes placewithin a framework of material monism.That the Church has rejected both Carte-sian dualism and material monism furtherunderscores the incompatibility betweenher anthropology and the dualistic-materialistic philosophy that undergirdsthe “whole brain death” standard.

Note that this dualistic-materialisticphilosophical rationale of the brain as theprinciple of integration of the body wasspecifically created in 1981 by Bernat(Bernat, Culver, and Gert, 1981) and pro-moted by the President’s Commission

(1981) for the justification of “wholebrain death,” which the Harvard Commit-tee had introduced in 1968 without anyprior thought-out rationale. It thenbecame necessary to explain why “braindeath” is death simpliciter, why the patient(severely brain-injured and deeply coma-tose) is said to be dead even though his orher heart is still beating, and his or herflesh warm and pink like other patients inthe intensive care unit, along with othersigns associated with the living.49 The“whole brain death” criterion was thus inneed of a philosophical rationale that cananswer these specific questions. In thecontext of these facts, it is rather difficultto think that the association between the“brain death” criterion and the rationale ofthe brain as the principle of integration ismerely something accidental and contin-gent. This rationale met the above-mentioned need to justify why “braindeath” is death—at least for a while, thatis, until recently, when mounting irrefuta-ble empirical evidence has repeatedly falsi-fied both the “brain death” criterion and itsphilosophical rationale (see discussion inthe previous section).50

For the sake of comparison, one cannothelp but note that, with respect to thetraditional standard for the determinationof death, there has never been a need toadvance a philosophical rationale to defendit. The reason for this is simple. As pre-viously mentioned (see the discussion onthe genesis of the “brain death” criterion),the traditional standard rests on an inte-grated basis and requires “the cessation ofall vital functions of the human body”(Arnet 1973, 221). Death means loss ofintegrative unity; this definition is not spe-cies specific. Phenomenologically speak-ing, human death manifests the samesigns as the death of any mammalianorganism. Thus, in the traditional stan-dard, the signs by which we recognizethe death of a person are no different


from those we use to recognize the deathof our pet dog or cat, namely, no heart-beat, no respiration, complete inertia (noreaction of any sort like an “inanimatestone”), and a cold, gray complexion;51

these immediate signs are soon followedby other more definitive signs of death.This is why the traditional standard(which reflects common sense) has noneed for its advocates to propose any phi-losophical rationale to justify it, becausethe standard itself is already in full accordwith the sound Aristotelian-Thomisticanthropology, which the Church hasappropriated and taught as her own. Iteven may be said that this anthropologyis the undergirding philosophical rationaleof the traditional standard.

It should be noted that the rationale of thebrain as the principle of integration is rootedin a mechanistic conception of life (Loeb1912; Loeb 1916) that is based on Newto-nian physics and a Cartesian worldview.52

Can it be argued that the “whole braindeath” standard, despite its undergirdingneo-Cartesian philosophical rationale, isnevertheless not hostile to Christian anthro-pology? To answer this question, one mustexamine the American Academy of Neurol-ogy guidelines for brain death. The followinginstructions are part of those guidelines:

Spontaneous movements of the limbs …can occasionally occur and aremore frequentin young adults. These spinal reflexesinclude rapid flexion in arms, raising of alllimbs off the bed, grasping movements,spontaneous jerking of one leg, walking-like movements, and movements of thearms up to the point of reaching the endo-tracheal tube.…Profuse sweating, blushing,tachycardia, and sudden increases in bloodpressure [which occur at laparotomy], …[and] muscle stretch reflexes, superficialabdominal reflexes, and Babinski reflexesare of spinal origin and do not invalidate adiagnosis of brain death. (Wijdicks 1995,1007)

Such reflexes and spontaneous move-ments, which can be seen twenty-four toseventy-two hours after the diagnosis of“brain death” (Döşemeci et al. 2004, 18), arenot infrequent. The frequency of some typesof movements can be as high as 75 percent(Saposnik, Basile, and Young 2009, 156).53

Themost spectacular series ofmovements areknown as the Lazarus sign, which can occurspontaneously, or more often in response tonoxious stimuli, especially the removal of theventilator during apnea testing (Saposnik,Mauriño, and Bueri 2001, 211). Brain deathproponents merely disregard these move-ments as reflexes coming from the spinalcord and therefore irrelevant (Bernat 1998,16), as if the spinal cord (which is seamlesslyin continuity with the brain) were not part ofthe central nervous system. The occurrence ofreflexes and movements in what is supposedto be a corpse has not been disclosed to thepublic at large, even though it “has been asource of [cognitive dissonance] and consid-erable stress” to healthcare personnel involvedin the care of “brain-dead” donors (Fox 1993,233; Youngner et al. 1985).If “brain death” is death simpliciter (Bat-

tro et al. 2007, xxi), which means that thesoul is no longer in the body, then what isthe principle that accounts for: (1) thepersistence of the many vegetative func-tions such as assimilation of nutrients,elimination of waste, as well as the feverreaction to infection and gestation of afetus, among others; and (2) the occur-rence of the aforementioned movements?These operations are the manifestations oftwo powers (the vegetative and locomo-tion, respectively), the principle and causeof which can only be the soul (Aquinas2010, I, q. 77, a. 6; q. 78, a. 1), the sub-stantial form of the body and its first prin-ciple of life. This means then that life isstill present in the “brain-dead” patient. Itis precisely here that the “brain death”standard is hostile to sound anthropology


because it classifies as dead patients whoare still alive. Admittedly, these severely illand deeply comatose patients may bedying; nevertheless, however close todeath a person might be, he or she is stillalive and not yet dead. Several scholars, inparticular Truog, have also shown (albeitwithout invoking Thomistic metaphysics)that the “whole brain death” paradigm“confuses the fact that a person is dyingwith the claim that he or she is alreadydead” (Truog and Robinson 2003, 2392),that is, “it mistakes a prognosis with anoutcome” (Truog and Fackler 1992, 1707).

As previously mentioned, John Paul II’sacceptance of the neurological standard asa criterion for the determination of deathpresupposes (and hence requires) that sev-eral prerequisites be fulfilled, the mostimportant of which is the soundness ofthe premise of the brain as the principleof integration. This premise has to be truefor the conclusion (the Pope’s acceptance)to follow. Not only have none of the otherprerequisites been fulfilled, but this pre-mise has also shown itself to contradictboth the physiological reality and soundChristian anthropology. Furthermore,John Paul II also requested the PontificalAcademy of Sciences to sponsor anotherconference (the third one) on the sametopic of “brain death” which took placeon February 3–4, 2005.54 This act alonestrongly suggests that, from the perspec-tive of the Magisterium, the “brain-death”issue still remains unsettled. Pope Bene-dict XVI, in his address to the participantsof the 2008 international congress orga-nized by the Pontifical Academy of Life,made no mention of the neurological cri-terion but gave the following admonitioninstead:

Individual organs cannot be extractedexcept ex cadavere… There cannot bethe slightest suspicion of arbitration[arbitrariness] and where certainty has

not been attained the principle of precau-tion must prevail…. The principal criteriaof respect for the life of the donator[donor] must always prevail so that theextraction of organs be performed only inthe case of his/her true death.55 (BenedictXVI 2008)

TOWARD AN ALTERNATIVE APPROACH

FOR POTENTIAL BRAIN-DEAD DONORS

As a corollary of the aforementioned ana-lysis, an important practical questionarises: What should be the proper courseof action toward patients who are destinedto be declared “brain dead”? The loss ofbrain function, even if it were to be com-plete, only indicates that the soul nolonger has the brain available as its instru-ment for the mental functioning of theperson.56 The result is a state of verysevere mental disability (Shewmon 2009,230), perhaps close to death, but it is notdeath. To equate the death of the patientwith the loss of function of one organamounts to reducing the person to thatparticular organ alone, in this case, thebrain. The patient with severe brain injurydestined to be declared “brain dead” is stilla human person, and as such, “is deservingof respect and dignity, and at the veryleast, the right to his or her life”57 espe-cially since: (1) the patient’s outcome can-not be predicted in the acute phase ofsevere brain injury, and (2) new therapeu-tic modalities (e.g., hypothermia) havemuch improved the outcome of patientswith severe brain injury.58

However noble the concept of organdonation is, it cannot justify taking thelife of one sick (and dying) person for thesake of saving the lives of several other sickpersons. Human life, even that of the mor-ibund person, is of infinite value because itis a gift of God. Thus, what we urgentlyneed today is “the restoration of societal


respect for the [sacredness] of human life—respect that was somehow lost in theacceptance of whole brain death as …death of the person” (Diamond 2007,497). Note that this paper is not advocat-ing that severely brain-injured, deeplycomatose patients be supported for anindefinite length of time. Medical decisionmaking involves ethical and prudentialjudgment based on a good knowledge ofthe medical disorder in question, and theclinical/laboratory assessment of thepatient’s clinical course. Such assessmentnecessarily requires that more than onedetermination has been performed andthat a certain amount of time (days orweeks, not hours) has elapsed.

Since “brain death” cannot be shown tobe sound, whether biologically or anthro-pologically, a more humane approachshould be offered to patients with severebrain injury who, instead of being declared“brain dead” within one–two days ofadmission, should be treated aggressively(with a view to recovery, whether full orpartial) and supported through the acutephase of the injury. Admittedly, not everyone of them will survive, but then notevery one of them will die either. If thepatient steadily deteriorates towards immi-nent death (a trajectory which the powersof medical technology are unable tochange),59 then he or she should beallowed to die naturally. The approachproposed here will also cohere with PopePius XII’s admonition, “human life con-tinues for as long as its vital functions …manifest themselves spontaneously or evenwith the help of artificial processes” (PiusXII 1957).

NOTES

1. Scholars on both sides of the “braindeath” debate (e.g., James Bernat, AlanShewmon, and Robert Veatch, amongothers) have pointed out that the term

“brain death” should be used with quota-tion marks because of its inherentsemantic ambiguity. See Shewmon(1989). The discussion in this essay on“brain death” is concerned only with the“whole brain death” standard, the con-ceptual rationale of which was advancedby Bernat, Culver, and Gert (1981),appropriated in the same year by thePresident’s Commission for the Studyof Ethical Problems in Medicine andBiomedical and Behavioral Research(1981), and subsequently adopted world-wide.

2. Jahi McMath, a 13-year-old girl whosuffered cardiac arrest secondary to unat-tended profuse bleeding for five hoursafter surgery of the tonsils and adenoids,was pronounced “brain dead” (withabsence of cerebral blood flow and elec-trical activity) in December 2013 bythree neurologists, including an expertfrom Stanford University. By Octo-ber 2014, however, she could move herhands and feet in response to hermother’s verbal requests and also startedto menstruate. Further studies showedthe following: (1) evidence of brain elec-trical activity and cerebral blood flow; (2)structural preservation of vast areas ofthe brain, despite damage to the corpuscallosum and pons; and (3) changes inJahi’s heart rate in response to hermother’s voice. Jahi’s clinical/laboratorydata were reviewed by four neurologists(including Shewmon and CalixtoMachado), all of whom gave sworndeclarations that Jahi is not “braindead.” See Luce (2015), Matier andRoss (2014), and McGovern (2015).The sworn declarations of the physiciansare available online at Pope (2015).

3. Two notable prelates have spokenagainst “brain death”: the archbishopemeritus of Cologne, Cardinal JoachimMeisner; and the bishop emeritus ofLincoln, Nebraska, Bishop Fabian W.Bruskewitz (see Bruskewitz 2009). In1996 and 1997, Cardinal Meisner statedofficially that “the identification of braindeath with the death of the human beingis from a Christian viewpoint, at thepresent state of the debate, no longerdefensible. A human being cannot anylonger be reduced to his brain function.


Therefore it can neither be said thatbrain death is death, nor that it is asign of death. Moreover, brain death isnot the time of death…. All delibera-tions about organ donation thereforehave to presuppose that the humanbeing in whom “brain death” has beendetermined, according to the rules ofmedical science, is still alive” (Meisner1996, 1, my translation).

4. The most notable publications in thisregard have been from the PontificalAcademy of Sciences (PAS), a consulta-tive body to the Holy See, and not ateaching arm of the Magisterium,which has supported “brain death” since1985, when the academy organized thefirst conference on the theme of death.The participants at the 1985 conferenceconsisted only of medical scientists. SeeChagas (1986). This proceeding arousedquestions and opposition, such that in1989 the academy organized a secondconference on the same theme of death,this time including philosophers andtheologians. Despite the raised objec-tions from philosophical and theologicalquarters, the academy reaffirmed its ori-ginal position. See Final ConsiderationsFormulated by the Scientific Participants(1992). Regarding the objections, seeSeifert (1992) and Ols (1992). In 2005,the academy organized a third confer-ence, titled “The Signs of Death,” butthe publication of what would havebeen its proceedings was cancelled atthe last minute. The academy organizeda fourth conference, bearing the samename, “The Signs of Death,” in 2006.The invitation to this conference wasextended only to “brain-death” propo-nents. At the last minute, however, twonon-pro- “brain-death” scholars, theGerman philosopher Robert Spaemannand pediatric neurologist Alan Shew-mon, were invited at the explicit requestof Pope Benedict XVI through his per-sonal secretary. Shewmon could notattend; his paper was read at the confer-ence in his absence. For further details,see the narrative of Mercedes Wilsonwho was involved in organizing the2005 conference (Wilson 2009; Shew-mon (2012b, 483–87). The first docu-ment of the proceedings of the 2006

PAS conference is a statement in whichthe academy declares that “brain death isdeath.” See Battro et al. (2007, xxi).Among the signatories of this documentare several highly placed prelates, inaddition to prominent pro-”brain death”scholars. Originally published with thesubtitle “Statement by Neurologists andOthers,” it was published again in 2008,with a new subtitle “Statement by thePontifical Academy of Sciences.”

5. In particular, the drafts, memos, andwork in progress of the Harvard AdHoc Committee, known as the “Beechermanuscripts,” which reveal the innerworkings of the committee and whichare preserved at the Francis CountwayLibrary of Medicine at Harvard, are notaccessible to the public. These recordsare made available only to selected peo-ple, for example, medical historians suchas Mita Giacomini, Martin Pernick, andDavid Rothman. See Pernick (1999, 27note 18).

6. Labels such as “heart-lung preparation”or the oxymoron “living cadaver” wereused to refer to brain-injured potentialdonors because at the time of the Cibasymposium, the term “brain death” wasnot yet invented. Guy Alexander, a Bel-gian surgeon advanced five neurologicalcriteria for death (to be taken up later bythe Harvard Committee) that corre-spond to the features of the coma dépassédescribed by Mollaret and Goulon(1959, 3–15). Joseph Murray enthusias-tically endorsed Alexander’s idea, stating,“These criteria are excellent, this is thekind of formulation that we will needbefore we can approach the legal profes-sion” (Murray 1966, 69 and 73).

7. Notably, David Daub stated the follow-ing at the Ciba symposium: “Under theclassical definition of death, whichshould not be lightly discarded, an irre-versibly unconscious person whose lifedepends on a machine is still alive. Thedoctor may be right to stop the machineand let him die. But until death occurs,interference with his body is illicit: it isnot a corpse” (Daube 1966, 191).

8. Although the transplanted heart wasobtained from a patient declared brain-dead by a neurosurgeon, Barnard did notremove it until the “electrocardiogram


had shown no activity for 5 minutes.”His procedure is more akin to what isknown today as donation after controlledcardiac death. See Barnard (1967, 1271);Hoffenberg (2001).

9. Dean Robert Ebert, letter of invitationto future members of the Harvard Com-mittee. The invitation reads as follows:“Dr. Beecher’s presentation re-emphasized to me the necessity of givingfurther consideration to the problem ofbrain death. With its pioneering interestin organ transplantation, I believe thefaculty of the Harvard Medical Schoolis better equipped to elucidate this areathan any other single group” (quoted inGiacomini 1997, 1474).

10. See Giacomini (1997, 1474). The Har-vard Committee consisted of 13 mem-bers (10 physicians, of which six werepro-brain death). Of note is that norepresentative of the position of the tra-ditional cardiopulmonary death criteriawas invited to participate. Ralph Potter,the theologian member of the commit-tee, later commented that “it was not adeliberative body” (Wijdicks 2003, 975).

11. The explicit language in the workingdrafts was toned down by Dean Ebertin the official Harvard report so thatorgan transplantation, the factor whichhad all along been the driving forcebehind the committee’s endeavor,would appear merely as something ofsecondary importance. This authorrecognizes that presenting this piece ofhistorical evidence might be construedby some readers as ad hominem reason-ing. As demonstrated by philosopherCharles Taylor, however, the ad homi-nem mode of practical reasoning is “cen-tral to the whole enterprise of moralclarification”; it is especially useful for“the identification of contradiction, thedissipation of confusion, or [for] rescu-ing from (usually motivated) neglect aconsideration whose significance … can-not [be] contest[ed]” (see Charles Taylor1995, 37, 53). Similarly, Eerik Lager-spetz has also demonstrated that “thereare legitimate uses for ad hominem argu-ments, and they involve a reference toactions of statements of the [otherparty].” In practical reasoning, sucharguments belong to the category of

“rules [which] are related to rationality”rather than to the category of logicalrules (see Lagerspetz 1995, 369). Seealso Walton (2008, 190–92), on “non-fallacious ad hominem arguments.” Inthis essay, the purpose of bringing outhistorical evidence is to demonstrate thatthe reason, which has undergirded thepractice of the “brain death” standardsince its introduction, belongs to a typeof ethics divergent from the ethos of theCatholic Church. As such, it constitutesan impediment for the Church to inte-grate “brain death” into her own ethosand mission.

12. From the conclusion of the first manu-script-draft of the Harvard report inApril, 1968.

13. From a late manuscript-draft of the Har-vard report in June 1968.

14. For instance, the chairman of the Har-vard Committee explicitly reiterated thepragmatic need for viable organs in thefollowing statement: “At whatever levelwe choose to call death, it is an arbitrarydecision…. It is best to choose a levelwhere, although the brain is dead, use-fulness of other organs is still present”(Beecher and Dorr 1971, 120).

15. At the 2006 PAS conference, Wijdicks,a leading “brain death” advocate,acknowledged that: “the diagnosis ofbrain death is driven by whether thereis a transplantation programme orwhether there are transplantation sur-geons. I do not think brain death exam-ination now, in practice, would havemuch of any meaning if it were not forthe sake of transplantation” (Sorondo2007, 50).

16. The English version of the documentcarries a non-descript title of “Letter ofJohn Paul II to the Pontifical Academyof Sciences.” In February 2005, the HolyFather was too ill to preside over theopening of the conference; instead, hismessage was read in his absence to theparticipants.

17. The term “brain death” is not used bythe Magisterium, even though it is usedby non-magisterial bodies of the Churchsuch as the Pontifical Academy ofSciences.

18. Some exceptions to the unstoppablesomatic decay and putrefaction of the


body in toto: (1) cryopreservation, and(2) divine intervention which keeps thebodies of many saints incorrupt for cen-turies.

19. The biological notion of “organism as awhole” rests directly on the axiom thatthe sum is more than its parts. There-fore, it is not a concept that can bedefined. Its characteristics can bedescribed, however. Functions whichare characteristic of a human organismas a whole—viewed strictly from the bio-logical perspective—include, for exam-ple, temperature maintenance, waterand electrolyte balance, and immunolo-gical homeostasis, among others.

20. John Paul II reiterated the same idea inhis 2000 address, stating, “the Churchdoes not make technical decisions”(John Paul II 2000, no. 5).

21. This phrase was part of Bishop SanchezSorondo’s contribution to the generaldiscussion session at the 2006 PAS con-ference. See Sorondo (2007, xlvii). Seealso the subsection “The Camouflagingof Death” in Battro et al. (2007, xxix).The idea of the masking of death byartificial ventilation was promoted bythe President’s Commission for theStudy of Ethical Problems in Medicineand Biomedical and Behavioral Research(1981, 33, 35, and 38).

22. As Accad (2015, 224) pointed out, theventilator is a life-support measureadministered to critically ill patients,with or without severe brain injury.Hence, it is rather improbable that theventilator could somehow impede theability of doctors and nurses to recognizeloss of integration, specifically in a“brain-dead” patient, all the while retain-ing that same ability with respect toother (not brain-injured) critically illpatients.

23. The argument, that the decompositionof the “brain-dead” body (deemed as amass of unintegrated organs) is beingdelayed for days, weeks, and months byartificial ventilation, cannot hold either,because to slow down decompositionrequires considerable cooling in additionto oxygenated perfusion, in a manneranalogous to organ preservation techni-ques used in transplantation. Even withthe current state of the art, the viability

of unintegrated organs (in transit fromdonor to recipients) can be maintainedonly for a maximum of twenty-fourhours in the case of kidneys, and amuch shorter time in the case of otherorgans (see Guibert et al. (2011, 128).Furthermore, if the body of the “brain-dead” person is truly a corpse, then itstemperature will quickly drop to the levelof the ambient temperature. Mainte-nance of body temperature is retainedin “brain-dead” organ donors, however,even though it may be lower than nor-mal. As pointed out by Bernat, Culver,and Gert (1981, 390), the presence oftemperature regulation, the control ofwhich is located in the hypothalamus, isfirm proof of the functioning of theorganism as a whole. The persistence oftemperature control in “brain dead” indi-viduals is one of the many incoherenciesof the “brain death” paradigm.

24. The 1968 Harvard Ad Hoc CommitteeReport did not include nor refer to anyscientific data to support the validity ofthe clinical test-criteria of the “brain-death” standard. The report containsonly one single reference, referring toPope Pius XII’s allocution to an interna-tional group of anesthesiologists in 1957(Harvard Medical School 1968, 340).

25. Even at the 2006 PAS conference, theproblem of the lack of consensus cameup on numerous occasions (Sorondo2007, xxxi-xxxii, lxiii, 43–8, 99, 176,and 219). For instance, for some of theparticipants, the presence of hypothala-mic function indicates that the patient isnot “brain dead,” while for others, thisneuroendocrine function of the brain isconsidered irrelevant. In particular, Ber-nat mentioned three future goals con-cerning the doctrine of “brain death,”two of which are concerned with estab-lishing a consensus, stated as follows: (1)“an international consensus on the clin-ical tests for brain death,” and (2) “aconsensus on the role of confirmatorytesting in brain death” (Bernat 2007,176).

26. For a detailed discussion on the pro-blems with the clinical tests for “braindeath,” see Nguyen (2016).

27. Note that during the years precedingJohn Paul II’s 2000 address, the


academic literature was not lacking inscholarly publications pointing out thenumerous inconsistencies of the “wholebrain death paradigm”; and this, in itself,was an indicator of a lack of consensusabout the “brain death” concept. See, forexample, Youngner (1992), Halevy andBrody (1993), Veatch (1993), RobertTaylor (1997), and Truog (1997). Atthe same time, the medical literaturewas not lacking in reports of patientswho met all the criteria of “whole braindeath,” but did not undergo organexplantation and continued to live onfor months. Some of these cases were“brain dead” pregnant mothers who,with life support, were able to carrytheir pregnancies to term (see, forinstance, Dillon et al. 1982; Heikkinenet al. 1985; Bernstein et al. 1989; andShewmon 1998b).

28. A comparison between the latest 2010American Association of NeurologyGuidelines for Brain Death Determina-tion and those advanced by the HarvardCommittee show that the bedside clin-ical test-criteria have remained basicallyunchanged. What has changed is theincreased number of possible confirma-tory tests; but as ancillary tests, they areoptional. The committee initiallyrequired EEG testing and stressed itsimportance; but by the 1970s, theEEG became an ancillary test and wasdropped from every “brain-death” pro-tocol being developed in the UnitedStates.

29. The battery of bedside clinical testsrequired for the determination of“whole brain death” is identical to thatperformed in the United Kingdom forestablishing “brainstem death,” eventhough these two subtypes of “braindeath” differ from one another on theconceptual level.

30. For additional details on severe braininjury, see Nguyen (2016).

31. “When CBF [cerebral blood flow]reaches about 20 ml/100 mg/min, EEGisoelectricity occurs” (Patel 2007, S101).In humans, the normal cerebral bloodflow averages about 50 mL/100 mg/min. The flow-threshold at which neu-ronal injury becomes irreversible isaround 10 mL/100 mg/min.

32. Bernat (2004, 162) asserts that “absentintracranial blood flow proves irreversi-bility” of the loss of all brain functions.Bernat also insisted, during the 2006PAS conference, that testing for intra-cranial circulation must be performedduring the acute period, “not three orfour days, or a week later” (Sorondo2007, 177). But this acute period iswhen the patient is most likely in thepenumbra condition. Moreover, as Wij-dicks pointed out during the same con-ference, “our experience with cerebralblood flow is still limited with insuffi-cient validation” (Sorondo 2007, 178).The point, as stated succinctly by Shew-mon, is that “even tests of cerebral bloodflow could be misleading, given thatnone of the standard “confirmatory”tests for brain death has been validatedto possess sufficient sensitivity to reliablydistinguish penumbra-level flow from noflow, particularly in the posterior fossa”(Shewmon 2012a, 5).

33. According to Soifer and Gelb (1989,816), the “general acceptance of the con-cept of brain death depended on thisclose temporal association betweenbrain death and cardiac arrest.”

34. Machines cannot reverse death; whatthey can do, however, is to delay themoment of death, and as such theylengthen the process of dying. A dyingorganism is not dead yet.

35. Wijdicks and Bernat consider “chronicbrain death survivors” as cell cultures(Sorondo 2007, lxxiii). A cell culturelacks telos. The interactions of cells in acell culture do not result in the emer-gence of an organ and its holistic proper-ties. In contrast, the interactions of thecells of an organ in a living body aredirected toward a telos; and, likewise,the interaction of the various organs ofa system in a living body is also directedto the same telos. That telos consists basi-cally in an uninterrupted endogenous“fight” against the tendency of increasingentropy, thereby manifesting life andmaintaining the integrative unity of theorganism. Such a telos disappears oncedeath occurs. Furthermore, one of themanifestations of the unstoppable entro-pic process in a dead body is the prolif-eration of bacteria in the gastrointestinal


tract resulting in an accumulation oftoxic substances leading to putrefactionand decomposition. This phenomenon isobviously not observed in the survivorswith chronic “brain death.”

36. For a detailed discussion, see Shewmon(2001, 467–71).

37. Shewmon (2001, 467–68) lists a litany ofpersistent holistic functions found in“brain-dead” survivors.

38. The empirical evidence is such that Ber-nat had to admit, albeit not in public butonly in private correspondence, that “theintegration argument alone is inade-quate.… I have struggled to discernwhat else is important in addition tothe integrator theory” [Bernat’s personalcorrespondence cited in Whetstine(2006, 122)]. Publicly, Bernat and hiscolleagues simply disregard the litany ofintegrative functions reported by Shew-mon on brain-dead patients, stating:“Oh but we didn’t mean or care aboutthose functions,” cited in Youngner andArnold (2001, 530).

39. See Genesis 1.40. A substantial form is that which gives

esse simpliciter such that at its coming,something is said to be generated simpli-citer; and at its leaving, something is saidto be corrupted simpliciter (Aquinas2010, I, q. 76, a. 4). As substantialform united to the body to form a singlecomposite entity (the human being), thehuman soul, which is also an incorporealprinciple that can subsist on its own(Aquinas 2010, I, q. 75, a. 2), commu-nicates the esse of its own subsistence tothe body. Consequently, “the esse thatbelongs to the whole composite [ofbody and soul] is also the esse of thesoul itself” (Aquinas 2010, I, q. 76, a.1, ad. 5).

41. The soul is present as a whole in eachpart of the body. “Whole” must beunderstood, not as quantitative whole-ness since the soul is not divisible, butas wholeness with respect to perfectionand essence. Note also, that “whole” doesnot mean that the soul is in each part ofthe body with respect to each of thesoul’s powers, but rather with respect tothe power of each part. Furthermore, therelation of the soul to the whole is primoet per se (primarily and essentially),

whereas its relation to the parts is perposterius (secondary) insofar as they areparts ordained to the whole (Aquinas2010, I, q. 76, a. 8).

42. As a result, the once living body that isnow a corpse becomes cold (its tempera-ture drops rapidly to the ambient tem-perature) and gray. Other signs, such asrigor mortis and putrefaction follow later.

43. This seemingly insignificant fact is actu-ally of fundamental importance, becausefor a living mammal, to be alive is toresist entropy. To resist entropy involvesenergy production. The numerous inter-related metabolic activities throughoutthe body generate heat, and varioushomeostatic mechanisms are involved tokeep the human organism in a dynamicsteady state. This includes the mainte-nance of a constant body temperature,the regulation of which involves boththe brainstem and spinal cord (Pia1986, 8).

44. In St. Thomas Aquinas’s days, theremoval of a vital body part from oneorganism followed by its insertion intoanother organism was something unim-aginable. We can therefore safely pre-sume that Thomas’s statement aboutthe soul being present in each part ofthe body refers to the normal situationwhere the part (or organ system) is anintegral part of the original whole. Sucha premise would also provide us with ametaphysical understanding of organrejection, a topic beyond the scope ofthis paper, however.

45. A representative (“vicar” or “stand-in”) ofa person is needed only when the personhim- or herself cannot be present on site,or when he or she no longer has thecompetence to perform the task in ques-tion. In the case of the soul, however, thesoul has no need for any organ to be its“vicar” or “stand-in” to do its task ofinforming the body (integrating thebody) because the soul itself is alreadypresent and active in the whole bodyand in each part of the body (Aquinas2010, I, q. 76, a. 8).

46. For a detailed discussion on holisticemergent properties, see Shewmon(2001, 459–62).

47. Aquinas was responding to the follow-ing objection: “If something is such


that when it is taken away, the union ofthings that had been united is dis-solved, then it seems to be a mediatorbetween those things. But whenbreathing [spiritu] ceases, the soul isseparated from the body. Therefore,breath, which is a subtle body, is amediator in the union of the body andthe soul” (Aquinas 2010, I, q. 76, a. 7,arg. 2). Thus, if we were to interpretAquinas’s explanatory response to meanthat a corporeal part can serve as thecause of the integration of the otherparts of the body, then we would fallinto the very error stated in the objec-tion itself.

48. Much of the autonomic nervous systemis found in the spinal cord. The latter isan integral part of the central nervoussystem and in continuity with the restof the brain; there is no anatomical lineof demarcation between the two. Forinstance, the sympathetic system of thespinal cord continues to control the vas-cular tone in “brain-dead” patients (seeKita et al. 1993). Likewise, temperatureregulation involves not just the brain butalso the spinal cord, “with [a] gradedcontrol mechanism organized in a cra-nio-caudal direction from narrow-bandto wide-band control” (Pia 1986, 8).

49. This is the essence of the reasons whythe 1981 President’s Commission under-took its study of defining death (see Pre-sident’s Commission 1981, 3–4). AsBernat (2006, 36) pointed out morethan once, the President’s Commission“chose as [its] conceptual foundation theanalysis of death that [he] publishedwith [his] Dartmouth colleagues.”

50. Under the weight of the irrefutableempirical evidence that falsifies the ratio-nale promoted by the 1981 President’sCommission, in 2008, the President’sCouncil on Bioethics (2008, 50–64)advanced another philosophical ratio-nale, known as the “fundamental vitalwork” or the “needy mode of being”rationale. Because it has many overtflaws (not discussed here), it has notbeen invoked by Catholic supporters of“brain death.”

51. A side-by-side comparison made byTruog and Robinson between: (1) liv-ing patients, (2) “brain-dead” patients

and, (3) the “bodies” (cadavers) ofpatients whose death is determinedaccording to the traditional standard,shows that the “brain death” groupshare many features of the living (suchas heart-beating, perfusion, functioningvital organs, capacity of reproducing –none of which is present in the thirdgroup). The absence of the capacity forconsciousness is the one feature thatthe “brain death” group shares withthe group of traditional death (seeTruog and Robinson 2003, 2392,table 1).

52. Bernat and his colleagues advanced theirrationale of the brain as the principle ofintegration of the body in 1981. It wasnot until 2006 that Bernat acknowledgedLoeb as the source for his theory, how-ever (see Bernat 2006, 38). In themechanistic approach: (1) organisms areseen as machines, (2) their goal-orientedprocesses or phenomena (both biologicaland psychological) are explained in phy-sicochemical laws, and (3) the notion ofa central controller is paramount. Assuch, the mechanistic approach obviatesthe need to appeal to any extra-physicalvital force (e.g., the soul) as the principleof life, which is the principle of somaticintegrative unity and growth. It shouldalso be noted that Loeb’s mechanistictheory of life has been supplanted bynewer theories which better reflect bio-logical reality, namely the systems per-spective of life and the concept ofautopoiesis (see Maturana, Varela, andBeer 1980).

53. The phenomenon of spontaneous move-ment in “brain death” was mentioned atthe 2006 PAS conference as somethingof frequent occurrence. For instance,Austrian neurologist Lüder Deecke sta-ted that such movements can occur when“the nurse gives an injection or the[blood pressure] cuff is laid on or the[blood] specimen is taken for compat-ibility [in preparation for organ harvest-ing]. Then the dead patient can makewithdrawing movements, even thosethat would give points in the GlasgowComa Scale” (Sorondo 2007, 20).

54. See note 4.55. It is reasonable to think that Benedict

XVI, as a non-medical person, used the


term cadavere in its traditional sense andnot in the oxymoronic sense of “heart-beating cadaver” (another term to desig-nate a “brain-dead” donor).

56. A diagnostic evaluation only gives asnapshot in time about the condition ofthe patient at that particular moment.One single determination in the earlyphase of any severe injury, includingsevere brain injury, is insufficient to pre-dict whether the patient’s condition willimprove or will get worse, let alone todeclare that the loss of function of thebrain is permanent or irreversible. Todetermine that something is permanentrequires that some extended period oftime has elapsed. The case of JahiMcMath is a case in point in this regard(see note 2).

57. The quoted phrase is from the anon-ymous reviewer whom I would like tothank for the suggestions to modifythe last section of this paper.

58. For a more detailed discussion onimproved outcome in comatose patientswith bilateral fixed and dilated pupils,see Nguyen (2016).

59. “Personal statement of Edmund D.Pellegrino, M.D.,” in President’s Coun-cil on Bioethics (2008, 116).

ORCID

Doyen Nguyen http://orcid.org/0000-0002-4405-4081

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BIOGRAPHICAL NOTE

Doyen Nguyen, M.D., S.T.L., is both aphysician (specialized in hematopathol-ogy) and a moral theologian. She is cur-rently pursuing her doctorate in theologyat the Pontifical University of St. ThomasAquinas (Angelicum) in Rome. She maybe contacted at [email protected].


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http://www.lifeissues.net/writers/wils/wils_03braindeath.html

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