In August 1968, a committee at Harvard Medical School published a landmark document titled “A Definition of Irreversible Coma.” In addition to the traditional way of defining death, in terms of the loss of cardiorespiratory function, the committee suggested a new definition of death — brain death — that focused on the loss of neurological function. The report provided a foundation for the eventual adoption of legislation that established brain death as legal death in all 50 states.
The question of whether brain death is “really” death has come under increasing scrutiny in recent years, due in large part to the case of Jahi McMath, whose brain death was contested by her family for nearly five years, during which time the California girl grew, developed, and even went through puberty. McMath died on June 22, following liver failure.
In a recent article in the Journal of the American Medical Association, Harvard bioethicist Robert Truog called attention to how the McMath case highlighted ambiguities around brain death. We spoke to Truog about Harvard’s role in establishing guidelines for the condition, why those guidelines have been controversial, and more.
GAZETTE: Can you talk about the 1968 report that helped lay the foundation for the concept of brain death?
TRUOG: In the 1950s, medicine developed mechanical ventilation, which provided a way of keeping people alive who had very severe brain injury who otherwise would have died from respiratory arrest. There was a lot of concern about whether these people with very severe brain injury would even want to be kept alive and whether it was something we ought to be doing.
This question merged with others that came out toward the end of 1967, when Christiaan Barnard performed the first heart transplant in Cape Town, South Africa, and really captured international imagination about what was going to be possible with organ transplantation. But there was also a question of whether the donors were dead at the time that the heart was removed, or whether it was the removal of the heart that actually killed the donors.
There were a number of groups around the world that began to consider this, but the one that I think certainly had the biggest impact was the one that was formed by Henry Beecher at Harvard Medical School. Early in 1968, Beecher went to the dean of the Medical School and convinced him that this was a very important emerging issue and that he should put together an ad hoc committee to think about it.
The committee was confident that they had developed criteria for defining a state of “irreversible coma.” They were able to diagnose when a patient was never going to wake up again. It was in the subtitle that they mentioned this as a possible new definition of death. If you think about it, it’s not entirely intuitive that just because somebody is permanently unconscious, they are therefore “dead.” And I think the committee recognized this when they wrote the paper. They were confident about the irreversible unconsciousness part. They were tentative about saying that maybe this could be a new definition of death.
And this is really the root of the controversy that has persisted for the past 50 years. That link, between being irreversibly unconscious and being dead, has never really been made in a convincing way.