Month: October 2020

Brain death, states of impaired consciousness, and physician-assisted death for end-of-life organ donation and transplantation

In 1968, the Harvard criteria equated irreversible coma and apnea (i.e., brain death) with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism (locked-in syndrome), minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. (1) Brain death does not disrupt somatic integrative unity and coordinated biological functioning of a living organism. (2) Neurological criteria of human death fail to determine the precise moment of an organism’s death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. (3) Brain-based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. (4) Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. (5) The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs.

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Determination of Death: A Scientific Perspective on Biological Integration

Medical interventions can allow living human beings who are no longer able to function in an integrated manner to be maintained in a living state. In contrast, medical intervention can also allow the cells and tissues of an individual who has died to be maintained in a living state. To distinguish between a living human being and living human cells, two criteria are proposed: either the persistence of any form of brain function or the persistence of autonomous integration of vital functions. Either of these criteria is sufficient to determine a human being is alive.

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José Saramago

I’m not able to fear death. We will turn skeletons and everything shall end. The skeleton becomes, therefore, the most radical form of nudity.” Interview, 2005

Yes [death had become a taboo]. Today people want to avoid the subject and hide the deaths that happen around them. It is as if the world were a hotel where the dead usually disappear at night, without any guest being able to notice their presence. While movies and television address death, they do not touch the fundamental point of finitude. The deaths are false, the good guys get shot and come back to life. It’s another way to treating death as unreal. Interview, 2005

Death is the inventor of God. Jose Saramago, 2009

In order to protect the physical hygiene of the living, we usually bury the dead. Jose Saramago, All the Names.

Transcutaneous Auricular Vagal Nerve Stimulation and Disorders of Consciousness- A Hypothesis for Mechanisms of Action

Three important structures have been described as cornerstone in consciousness: the ascending reticular activating system (ARAS), the thalamus and the posterior cingulate cortex. First, the upper brainstem is a main structure involved in arousal and awareness. As previously named by Moruzzi and Magoun (19), the ARAS is divided in four groups of nuclei: (1) the classical reticular nuclei (the nucleus cuneiforme, the deep mesencephalic nucleus, part of the pedonculo-pontine tegmental nucleus, and the pontis oralis nucleus), which send projections to the basal ganglia, the hypothalamus (20) and the intra-laminar thalamic nuclei (21), and then project to the cortex through the glutamate pathway; (2) the monoaminergic neurotransmitter system, which involves the locus coeruleus with norepinephrine (NE), the raphe nuclei with serotonin and the substantia nigra and ventral tegmental area with dopamine. This system directly targets the whole forebrain [cortex and subcortex—(22)]; (3) the cholinergic nuclei which include pedunculopontine and laterodorsal tegmental nuclei and project toward several thalamic nuclei and to the basal forebrain; and (4) the autonomic nuclei (parabrachial nucleus and periaqueductal gray matter) which targets the intra-laminar thalamic nuclei, the basal forebrain and other brainstem nuclei (23). Altogether, the ARAS has a main effect on wakefulness and vigilance (19, 24) and autonomic functions (25).
The thalamus is the second important structure involved in consciousness. It presents a complex architecture of nuclei organized as follows: from lateral to medial and from ventral to dorsal. Several specific thalamic relay nuclei communicate with the cortex according to their sensory and motor functions, and are a cornerstone of the contents of consciousness (23). Other thalamic nuclei project widely influence arousal and control the level of consciousness (23). Studies have shown that simultaneous bilateral thalamic infarction, as observed in the bilateral paramedian thalamic artery infarction or in the occlusion of the artery of Percheron, can induce a transient loss of consciousness at the onset of a stroke (26, 27). This temporary loss of consciousness shows that the thalamus is likely one of the primary sources for the ascending control of arousal.
Finally, the posterior cingulate cortex (PCC) is located in the medial part of the inferior parietal lobe and lies within the posteromedial cortex, which also includes the precuneal and retrosplenial cortices (28). This group of structures has been reported as the most metabolically active measured with fluorodeoxyglucose (FDG) PET-scan (29) during resting state (i.e., not performing any task) in healthy persons. The metabolic activity of these structures, using FDG-PET-scan, has also been associated to the level of consciousness in patients with DoC (30).

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CME, Physicians, and Pavlov: Can We Change What Happens When Industry Rings the Bell?

Here I believe one’s point of reference should not be to the great model of language and signs, but to that of war and battle. The history which bears and determines us has the form of a war rather than that of a language: relations of power not relations of meaning.
Foucault

Physicians’ interest in keeping up can arguably be traced to Hippocrates. Because it is a conditioned response for physicians, their learning radar is sensitive to hearing about the latest development, be it a disease, a drug, or a device—anything they can incorporate into their practices. Physicians do not want to be outdated and thus are vulnerable to a pitch about something new. The pharmaceutical and device industries live off of “something new.” Never mind whether it is an advance or not. As long as industry can make it appear “new,” then industry can have its physician speakers bureau and key opinion leaders tout it. Instinctively, as stated earlier, physician audiences will want to hear about it and can often be swayed to prescribe or purchase the “new” drug or device, all under the CME umbrella. As May said in 1961, “. . . the doctor is made to feel he needs more ‘education’ because of the prolific outpouring of strange brands but not really new drugs, produced for profit rather than to fill an essential purpose; and then the promoter offers to rescue him from confusion by a corresponding brand of ‘education.’” Industry’s CME support leads to the increased use of expensive drugs and devices, many of which are unproven to help patients.

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