“The medical question for us now is whether the irreversible loss of all brain function is accompanied by the disintegration and loss of unity to which the Pope refers.”

In his “Is Brain Death the Death of the Human Being?,”¹ Professor Robert Spaemann makes a number of criticisms of the practice of diagnosing death by the brain criterion. In the accompanying article² I have offered criticisms of the current practice of diagnosing it by the clinical criteria alone, but have defended the teaching of Pope John Paul II on the issue of death by the brain criterion. To some extent at least, the criticisms that Alan Shewmon has made, to which Spaemann adverts, are also applicable to the current practice in many Western countries, especially the English-speaking ones, but not necessarily the concept itself.

This issue is confusing because there is some fluidity about the terms being used. I understand death by the brain criterion to mean complete and irreversible loss of all function of the brain. That is the way in which it is legally defined in most jurisdictions. I have argued that testing to ensure that there is no blood flow to the brain ensures that the loss of all brain function has occurred. It has not necessarily occurred if the clinical criteria alone are used. Several countries use the blood flow test as the standard, but most English-speaking countries rely on the clinical criteria alone in most instances.

Reliance on the clinical criteria alone allows the diagnosis of death on the basis of the absence of some brainstem reflexes, the history of the trauma, and the absence of circumstances that might mask the brainstem reflexes. In those circumstances the person might still retain some brain function. In fact, as I explained, many patients diagnosed by the brain criterion using the clinical criteria alone will retain some midbrain functions and the evidence for that is the absence of diabetes insipidus in those cases. There are some other brain mediated functions such as control of blood pressure, which may also be maintained in someone who has been diagnosed by the clinical criteria alone.

The practice of relying solely on the clinical criteria has led to some confusion about what death by the brain criterion means. If it means complete and irreversible loss of all function of the brain then clearly the clinical criteria are not sufficient to diagnose it. Some of the concerns that Spaemann reports in relation to continued activity in someone diagnosed by the brain criterion may apply after diagnosis using the clinical criteria alone, but the teaching of John Paul II was based on loss of all brain function, and he was careful to spell out that he means “the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem).”³ That a patient with loss of all brain function could reach out and touch the body of a nurse, as Spaemann reports, is simpily not possible.

That said, Spaemann also takes up the arguments of Alan Shewmon on the matter of integration and whether the loss of all function of the brain is sufficient to establish loss of integration in the way in which John Paul II used the concept insupporting diagnosis of death by the brain criterion. I agree with the validity of Spaemann's argument that if John Paul II relied on a medical understanding that was mistaken then we would have grounds to question the teaching. However, this issue does need to be addressed, and as I have argued in my own article, it needs to be addressed on the basis of the doctrine about what death is.

Spaemann refers to Shewmon presenting his research results on integration after diagnosis by the brain criterion at a conference in Cuba and reports that there was surprisingly broad acceptance. Shewmon's research was also well received by the U.S. President's Council on Bioethics. In fact it was so well received that the Council dismissed the use of the concept of integration as the basis for diagnosis of death by the brain criterion. Instead, they adopted what they called a "mode of being" view which allows death to be diagnosed on the basis of irreversible loss of spontaneous breathing and irreversible loss of consciousness. The latter view is clearly subject to the criticisms that Spaemann has made of death by the brain criterion.

Most of the President's Council took the "mode of being" view, demonstrating that the majority thinking is far removed from the Church's thought, as represented by the teaching of John Paul II. The Council clearly lacks an ontological view of the human person and makes no apparent effort to relate its understanding of death to the religious view that death is the separation of the soul from the body.

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