This article, from Alfredo De Matteo at the Confederazione Triarii, (Confederation of the Triarii) explains the process of evaluating “brain death” , and that rejecting registration as an organ donor, in Italy at least, does not protect one against the premature assessment of “brain death”.
Two recent news stories allow us to focus on an aspect of so-called brain death that almost always remains in the background and which, in reality, precedes the transplant issue itself. And so we think it’s worth reiterating.
In the first case, a fifty-year-old man was admitted to intensive care in Pescara after being violently shot while trying to defend his eighteen year-old son during an argument. A few days later, the process of determining brain death began, culminating in the declaration of death, which was followed by the so-called organ donation.
In the second news story, in Verona, an eighteen-year-old boy, hit on the head with a bottle during an argument, was hospitalised in very serious condition. Here too, the hospital, just two days later, began the procedure for determining brain death. There is no information on whether organ removal will also be performed on this patient, but at this point the issue of consent to organ donation appears frankly marginal.
Yes, these are two different episodes but they share the same operational pattern: the attack suffered, the hospitalisation of the patient, unconscious and in very serious conditions, the activation of the same evaluation procedure a few days later. It is precisely this sequence of events that clears the field of a widespread misunderstanding: the issue of brain death is not primarily linked to that of transplants.
The removal of vital organs certainly represents one of its most obvious and brutal consequences, but it would be a mistake to think that brain death is only determined against potential donors.
In fact, Italian law establishes that “death is identified with the irreversible cessation of all brain functions” and the DM 11 April 2008 provides that, when certain clinical conditions occur, the doctor must immediately notify the Health Directorate so that the planned procedure is activated. The will regarding organ donation therefore belongs to a subsequent and distinct plan.
In other words, not being a donor does not protect against the detection of brain death, and family members do not have a right of veto over the death detection procedure when the conditions established by law are met.
Brain death in fact establishes the moment when a severely brain-damaged human being legally ceases to be a patient. According to our legal system, once the assessment is complete, he is comparable to a corpse; and even if the removal is not carried out, there is no longer any basis for continuing therapeutic treatment aimed at his survival.
Criteria for “brain death”
But what are the criteria through which such a definitive consequence can be achieved?
The point deserves much more attention than it normally gets. Neurological assessment, in fact, does not simply consist of passively observing an organism until the unmistakable traditional signs of death appear. It requires a series of clinical tests, including the absence of consciousness and brainstem reflexes and the verification of the absence of spontaneous breathing through the so-called apnea test. 1
The apnea test itself is one of the aspects that most conflict with medical ethics: to verify whether the patient is still capable of breathing independently, the concentration of carbon dioxide in the blood is allowed to increase to the values established by the protocol, while the patient does not receive normal mechanical ventilation. Medical literature recognises that complications such as hypotension and hypoxemia may occur during this procedure and provides criteria for discontinuing the test if significant clinical instability occurs.
The issue takes on particular significance precisely because we are faced with an individual whose death is being determined: if the premise were wrong, those procedures would be performed on a living and severely brain-damaged patient, precisely at the moment when he or she would need maximum protection and care.
Nor is there, at the international level, a single universally-applied protocol. Over the years, numerous studies have documented differences between countries and health systems regarding prerequisites, duration of observation, number of examiners, use of instrumental tests, and assessment methods. Precisely to reduce this variability, the World Brain Death Project was developed, which proposed common international recommendations; the very fact that harmonisation was necessary demonstrates how significantly the criteria have historically differed.
Yet, a radical consequence depends on the outcome of these tests: on one side of the border, we have a very serious patient to care for, on the other, a presumed body.
Intensive care medicine today allows for the prolonged support of severely brain-damaged organisms that require ventilation, continuous care, specialised personnel, and intensive care beds. With the declaration of brain death, that problem disappears at its root, because there is no longer, legally, a patient to care for.
Evidently, the legislation does not declare its purpose to free up beds or save resources. But this doesn’t stop us from asking an uncomfortable question: how functional is a definition of death to the healthcare system (and the system in general) that allows us to transform a severely brain-damaged patient, potentially in need of care for an indefinite period, into a subject for whom there is no longer any therapeutic duty?
The issue is not marginal, because it brings us back to the very origins of the paradigm. Italian law does not simply state that the irreversible cessation of brain function constitutes a sign from which to deduce that the organism is dead; it establishes that death is identified with that cessation.
It is precisely at this point that the question becomes anthropological: Medicine and law have arrogated to themselves the power to establish that a human being whose brain function is considered definitively compromised no longer belongs to the world of the living.
This makes it reductive to focus the debate exclusively on donation. Even if not a single vital organ transplant were performed tomorrow, the fundamental question would remain intact: is that human being truly dead?
And the question concerns everyone, donors and non-donors alike, because brain death does not only determine when organs can become available, but when a severely compromised human being ceases to be considered a patient for treatment.
The reader will allow us a bitter reflection in the margins: when upon renewal of the identity card2, we are asked whether we consent to organ donation, we can still decide what will be done with our bodies, but not when we can be considered corpses.
That decision has already been made. And not by us.
by Alfredo De Matteo. This article first appeared at confederazionetriarii.it and is reproduced here by permission.
About Confederazione Triarii. The Triarii were, as is well known, those units of the Roman army ready to intervene in the terrible moment of a battle in order to reverse the negative fortunes. In that sense, anyone who, having understood the immense crisis we are experiencing in every institution and at every level, wants to work to save what is still good that remains and restore the subverted order can be considered a Triario. Our Confederation wants to be an operational instrument in this regard.
- Brain death, transplants, organ predation, euthanasia: from Harvard criteria to our ID card, Renovatio 21 ↩︎
- Sudden illnesses and brain death: an unstoppable combination for organ hunting, Renovatio 21 ↩︎
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