‘Brain Death’ Marks the True End of a Person’s Life

The answer, both medically and legally in almost every state, is that she died on Aug. 11. Journalists who assert otherwise not only mistake their opinion for facts but foment fears that brain death is a tool for overeager transplant surgeons, cost-conscious hospitals or windfall-seeking heirs. Such an attitude can haunt healthcare proxies with the feeling they’re killing their loved one.

I’ve experienced the ambiguities of death as a family member as well as a physician. When my grandmother’s pulse grew thready, I looked at the screen monitoring her vitals: 240 beats per minute. Those beats weren’t getting much blood to her brain, but they were still her beats—a reaction to pain and the pangs for more air. My mother stroked her mother’s hair and pressed a rosary into her palm. A moment later I felt the pulse stop. Looking up at the monitor I could see the heart rate drop—200, 100, 60, 40—her heart’s inborn slowing as each node shut down. A few minutes later, the intensive-care physician entered the room, listened to a motionless chest, looked at the clock to mark the time, turned to my family and said, “I’m sorry.” I shut the monitor off. The others in the room had been staring at it like a countdown and could still see the occasional sputtering heart contraction blip across the screen.

When did my grandmother die? The official time of death is what her doctor wrote in the chart. I felt exactly when her pulse stopped a few minutes earlier, but I wasn’t her physician, so my observation carries no official weight. The machine kept ticking off futile twitches of a heart starting to stiffen until I shut the monitor off, so the time of the last contraction can’t be known. There is no way to determine precisely when enough of her brain’s tissue had stroked out that it could no longer manage her body and facilitate the mind of the person I loved.

I once treated a patient who was told she wouldn’t survive the night. She said goodbyes to family, received last rites and slipped into unconsciousness. I woke her up accidentally the next day, and in her delirious state she said, “Now I have to die all over again.” Her despair suggests a definition of death like

Ayn Rand’s

: “I will not die. It’s the world that will end.” The “I” is a perceptual and experiencing one: a construct of the mind. It is the mind’s relationship to the brain on which both medicine and law rest their confidence in brain death.

As a physician I have a practical obligation to act on the accepted definitions as they evolve with scientific knowledge and society’s needs—approaching these questions with humility over sensationalism. As a neurologist I’ve declared patients dead: some in a manner similar to my grandmother’s case, and others with a careful examination, with flat brain waves on the monitor, with scans showing no blood going to the brain, with tracers showing a metabolically inactive brain, and with a test demonstrating the patient’s brainstem no longer reacted to built-up carbon dioxide by taking a reflexive gulp of air.

As far as can be ascertained by medical science, there is no evidence of an active mind without a living brain. Ancient cultures understood death as expiration—literally, the lungs breathing out one’s spirit. Later, attention was paid to the circulation of blood and the role of the heart. Humans put ourselves in a strange position in the mid-20th century when we developed ventilators that can do the work of breathing when a patient’s lungs can’t, or chemicals and machines that can keep a heart pumping.

This is frequently described as life-supporting equipment, but a more precise term is “organ-supporting equipment.” Lungs and hearts and brains are intimately related, but the first two are replaceable. The brain is what makes you, you. When it stops functioning, a person dies.

Dr. Stanley is a resident in neurology at Brigham & Woman’s Hospital.