The desperately sad story of Archie Battersbee has occupied the news for some weeks. After what appeared to be a dare gone wrong, Archie ended up in hospital on a ventilator with his distraught family trying everything they could to stop the hospital from withdrawing ventilatory support.
The press reports implied that Archie was still alive until the moment the ventilator was switched off, but that they did so indicates that, like the grieving family, journalists have failed to understand what constitutes death. When, finally, his heart stopped after the ventilator was turned off the press reported that he had “finally died”. In reality he had been dead for some weeks.
I will try to explain.
I first became embroiled in discussions over death following a “Panorama” programme broadcast on the BBC in 1980. The programme suggested that a number of people had been diagnosed as irrecoverably brain dead when they were not. The programme caused a furore because it generated enormous fear in the public that medical staff might switch off life support when life was not extinct.
Unfortunately the programme was based on a series of misunderstandings and untruths. As a result one of the Hammersmith Hospital neurologists, Christopher Pallis, and the Glasgow neurosurgeon Bryan Jennett instigated a debate on the programme to be broadcast by the BBC itself. This was a first; a documentary had never before been subjected to such scrutiny. It served to clarify that the original programme had made a large number of errors and had been poorly researched; its defence by a series of experts was demolished. But it prompted Chris to write a short book “ABC of Brain Stem Death”, based on a series of articles in the British Medical Journal, to explain in simple terms what death actually was. This was published in 1983.
Chris had enlisted my help, as one of his old trainees, in the run-up to the debate and in the writing of the book. So I became thoroughly versed in the clinical and philosophical issues about death.
It appears that the lessons of the “Panorama” programme and Chris’s book have still to be learned, forty years on.
The ancients understood that death occurred when breathing stopped. Harvey’s discovery of the circulation led to a new concept – that death did not occur until the heart stopped. Thus it became a belief that if the heartbeat could be maintained, death had not occurred. The introduction of artificial ventilation meant that oxygenation of the heart and other body organs could be maintained almost indefinitely. But if the brain no longer functioned, then ventilation would not sustain life as we would understand it. It would sustain a set of body organs only.
The brain defines self. The lower part of the brain stem (that part between the cortex and the spinal cord) controls breathing. The upper part determines the capacity for consciousness through the activity of a structure known as the ascending reticular formation, which “switches on” the cortical hemispheres. If the brain stem is irreversibly damaged by trauma or anoxia (deprivation of oxygen) then the organism as a whole is dead. Spontaneous respiration is no longer possible and the cortex cannot function. All organs will eventually fail, even if the lungs are ventilated and a heartbeat is maintained.
Rigorous clinical tests are undertaken to establish brain stem and brain death. These are designed to ensure that there is no stem or cortical response measurable. They must be performed by two experienced medical practitioners and include a careful test for apnoea (by stopping the ventilator and observing no spontaneous breathing, and a rise in blood carbon dioxide levels). They are undertaken under a stringent set of preconditions that abolish the possibility of error; for example, a drugs overdose or hypothermia may suppress brain and brain stem function, and therefore it must be certain that the observations do not have a reversible cause. Damage must be proved, and proved to be irreversible; all possible confounders must be accounted for, and backed up by other evidence of structural damage.
The brain stem thus defines life or death. The concept that if the heart is still beating then a patient is alive is a false one. If a mammal is guillotined its head is physically detached from its body but its heart will continue to beat. If blood loss was prevented in such a circumstance, for example by anastomosis of the main arteries into the head with the veins out if it, the heart might continue to beat for some time – despite the unalterable fact that the head is no longer part of the body. Can it reasonably be supposed that such an organism still lives? No. The organism as a whole is dead, even if there is not death of the whole organism. Once the brain is dead, so is the organism as a whole, and if the brain stem is dead this is a sufficient component of brain death. Analysis of all cases where brain stem death has been confirmed, and no preconditions were missed, finds not a single case of recovery.
Families are often sure that their relative is not dead because they appear to make spontaneous movements or react to stimuli. Sadly these are inevitably reflex movements. This needs to be carefully explained. It also needs to be made clear how the tests, simple as they are, confirm that brain stem death has occurred. These tests are clinical, not legal (although they are legally accepted). So the only role of any court in the determination of what should be done when a clinical team decides to stop ventilation is to be certain that (a) the essential preconditions for making the diagnosis were met and (b) that the clinical tests were properly conducted. It is wrong to state that a patient who is brain stem dead is being “kept alive”. They are not.
Pallis also notes the negative effect of ventilating a dead patient on staff, writing “I would emphasise the damaging effect on morale of highly trained staff asked to clean the mouths or treat the pressure areas of patients who are already dead… Whereas the functions of the lungs and heart may be taken over by machines, those of the brain cannot”.
It is unfortunate that, in these circumstances, the media continue to state that the patient is on “life support”. If they are brain stem dead, as judged by the medical criteria, they cannot be, because life is extinct.
What is needed is a nationwide network of experienced and well-informed counsellors who can spend time with relatives explaining the minutiae of death. They need to explain clearly that, as Bryan Jennett puts it, in the act of disconnection [of the ventilator] “the doctor is not withdrawing treatment and allowing someone to die, but ceasing to do something useless to someone who is already dead”. I find it very distressing that cases like Archie’s continue to occur, with desperate and futile appeals to higher and higher courts, and even the United Nations. These are usually reported as implying that the patient is still alive. Perhaps proper explanation by experts will mitigate the distress of families confronted with these terrible scenarios,and facilitate the sad process of letting go..
Reference: Christopher Pallis. ABC of brain stem death. British Medical Journal, London 1983