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The Changing Definition of What Is ‘Brain Dead’

In December 2013, 13-year-old Jahi McMath went into University of California, San Francisco, Benioff Children’s Hospital of Oakland for a routine medical procedure.

She suffered from sleep apnea and her doctors hoped that removing her tonsils and some surrounding tissues would help relieve the problem.

In the recovery room after the procedure, Jahi suddenly began bleeding from her mouth and nose. Her heart stopped and she fell into a coma.

Although doctors were able to restart her heart, the damage was already done. Starved for oxygen, her brain had suffered widespread damage.

She would not breathe on her own, or open her eyes, again.

Although multiple doctors examined Jahi and proclaimed her brain dead, her family rejected their declaration. After all, Jahi’s heart was still beating.

The state of California does not allow families to dispute a physician’s determination of death, so Jahi’s family moved her to New Jersey. There, families may require — on religious grounds — that death be proclaimed only when the heart has stopped.

Jahi’s heart still beats, but as long as her death certificate remains valid in California, the family cannot move back to their home state with their daughter.

The family has filed a malpractice lawsuit. The suit itself is fairly straightforward: Jahi should not have experienced complications from what is normally a safe surgery.

If she is still alive, then there is no limit on how much the hospital could owe in damages. It could potentially be held responsible to cover the cost of care for Jahi for the rest of her life. That could run into the millions of dollars.

However, if Jahi experienced brain death, then the amount her family could receive caps out at $250,000.

An Alameda County Superior Court judge has issued a tentative ruling, saying he is inclined to uphold previous decisions that Jahi is dead. He’s expected to issue a final ruling within the next two months.

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Meanwhile, while Jahi’s family fights to get her death certificate reversed, the statute of limitations is running out on the wrongful death suit they could file.

So, the question becomes: Is Jahi McMath alive or dead?

And do we, as a culture, need to redefine our decades-old understanding of what it means to be dead?

Related Reading: Cancer-Stricken Woman Fights for Right-to-Die Laws »

The Definition of Death

According to California law, a person is dead following “either irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brain stem.”

And how is cessation of function defined?

“A determination of death must be made in accordance with accepted medical standards,” the law says.

This puts death into a special legal category where the final call is ultimately made by medical experts, not the letter of the law.

For the American Academy of Neurology (AAN), this means a physician performing a clinical examination to determine if the brainstem and cerebrum are functioning. In addition, the test must be performed a second time by a different physician to confirm that the brain is, in fact, dead, according to California law.

However, the heart can continue to beat unassisted. The heart has a self-enclosed nerve web of its own that allows it to beat without input from the brain. This can keep the rest of the body’s organs supplied with blood so they can stay alive and keep functioning as normal even after the brainstem has died.

In fact, there have been several cases of pregnant women who have suffered brain death and have been kept on a ventilator until their children successfully came to term.

Which raises the question: Why is an otherwise-living person with a dead brain considered dead?

“I think that [brain death] is a medical and legal fiction,” said Dr. John Luce, emeritus professor of medicine at UCSF, and practicing physician at the San Francisco General Hospital division of pulmonary and critical care medicine, in an interview with Healthline. “The concept was developed at a time when there was a social, ethical, medical, and legal need for it.”

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New Technology Changes Definition

Long before early humans had any idea of the importance of the brain, people judged when someone was dead using simple observation. The person would stop moving, grow stiff, cold, and bluish, and eventually, start to rot.

Then, as early medicine began to emerge, ancient physicians’ understanding of death grew more precise. When a person stopped breathing and their heart stopped beating, they were dead. And generally, one would swiftly follow the other. This definition remained for thousands of years.

Although scientists had figured out that the brain was vital by the turn of the 20th century, the knowledge wasn’t applicable. Loss of breath or heartbeat invariably resulted in death of the brain as well. But after the close of World War II, medicine experienced a revolution.

Several new innovations came on the heels of one another.

CPR was invented as was the mechanical ventilator, severing the connection between loss of breathing and death.

The intensive care unit (ICU) was established, giving life-saving opportunities to people who would have previously died of heart failure.

And perhaps most crucially, technologies and medicines improved enough to make organ transplantation feasible.

Together, these developments called for a new definition of death. They also raised a whole series of new questions.

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