CH A PT ER T W O
T ERM IN OLOGY
A
lthough commonly used to identify the neurological stan-
dard for determining death, the term “brain death” is
highly problematic. Three difficulties, in particular, are
noteworthy.
F irst, the term “brain death” implies that there is more than one
kind of death. This is a serious error, perpetuated by such state-
ments as “the patient became brain dead at 3:00 a.m. on Thursday
and died two days later.” Whatever difficulties there might be in
knowing whether death has occurred, it must be kept in mind that
there is only one real phenomenon of death. D eath is the transition
from being a living, mortal organism to being something that,
though dead, retains a physical continuity with the once-living or-
ganism. Some will argue that such a transition does not occur
instantaneously or that there are cases in which there is no way to
k now if the transition has, in fact, occurred. But, problems of
“knowing” aside, there is only one real phenomenon that clinicians
and families struggle to recognize.
Second, the term “brain death” implies that death is a state of the
cells and tissues constituting the brain. In fact, what is directly at
issue is the living or dead status of the human individual, not the
individual’s brain. In other contexts, it may be useful to talk about
the death of parts of the body— the death of a cell, for example, or
the “death” (irreversible failure) of an organ, such as a kidney or a
liver. In current law and medical practice, the condition that war-
rants a determination of death using the neurological standard is not
the “death of the brain” in this sense.
17
18 | CO NTRO VERSIES IN THE D ETERMINATIO N O F D EATH
For this reason, evidence of continued activity of the pituitary
gland, or of similar residual brain tissue function in patients diag-
nosed with “brain death,” is not decisive in determining whether
these patients are living or dead.* The question is not, H as the whole
brain died? The question is, H as the human being died? This criticism
can be leveled perhaps even more sharply at the commonly em-
ployed phrase “whole brain death,” which, if taken literally, implies
that every part of the brain must be non-functional for the diagno-
sis to be made. In reality, and somewhat at odds with the exact
wording of the UD D A, “all functions of the entire brain” do not
have to be extinguished in order to meet the neurological standard
under the current application of the law to medical practice. In
Chapter Four, we take up the question, “O n what grounds might
we judge the persistence of certain functions (e.g., AD H secretion
by the pituitary gland) to be less important than other functions
(e.g., spontaneous breathing)?”
T hird, death itself is not a diagnosis; that is, the phenomenon of
death and the selection of the appropriate standard for determining
it are not strictly medical or technical matters. Thus, any term cho-
sen as a label for a medical diagnosis should not contain the word
“death.” It is not death that is diagnosed but rather a clinical state
or condition made evident by certain ascertainable signs. Calling the
condition of the patient who meets a set of diagnostic tests “brain
death” begs the question of whether this condition does or does
not warrant a determination that the patient has died. What is
needed is a separate, non-prejudicial name for the condition that
describes the state of the patient: a name that does not, by its use,
commit one to any judgment about whether the death of the hu-
man being has occurred.
O ther commentators over the years have noted similar difficulties
with the term “brain death.” In response, various terms have been
suggested to replace it as the name for the clinical diagnosis. The
* This evidence is discussed more completely in Part III of Chapter Three.
CHAPTER T WO | 19
table below compiles some of these terms, along with references to
their respective sources in the scholarly literature.
Table 1: Different Terms for One Clinical State
Term Sources
(Whole/ Total) Brain Terms most commonly used
Death today
Total Brain Failure Preferred term of this report
Coma Dépassé Mollaret and G oulon, 1959
(“Beyond Coma”)
Irreversible Coma Harvard committee, 1968
(Total) Brain Infarction Ingvar, 19711; Shewmon,
19972
Irreversible Apneic Coma Zamperetti, et al., 20043
Brain Arrest Shemie, et al., 20064
Each term has advantages and disadvantages. Although the choice
of an appropriate term is important, it is more crucial to maintain a
distinction between naming the medical diagnosis of a condition
and declaring an individual dead on the basis of that medical diag-
nosis. In this report, we will employ the term “total brain failure”
for the medical diagnosis. The precise meaning of “total” in this
composite term is discussed in Chapter Three. Here, at the outset,
we emphasize that total brain failure is, by definition, an irreversible
condition. Thus, to be more explicit one could employ the term,
“total and irreversible brain failure.” We will use the more familiar
terms, “brain death” or “whole brain death,” when such use is war-
ranted by the specific context, for example, in describing the history
of the concept or in referencing works by others who themselves
use these more familiar terms.
Because there is no perfect term, the choice of one is necessarily
somewhat arbitrary. Nonetheless, an exploration of the strengths
and weaknesses of the different terms can be useful in understand-
ing the relevant clinical and pathophysiological facts. This will
become clearer in Chapter Three, where we assume different per-
spectives on the clinical condition that is at the center of the debate.
20 | CO NTRO VERSIES IN THE D ETERMINATIO N O F D EATH
EN DN OT ES
1 D . H. Ingvar, “Brain D eath— Total Brain Infarction,” A cta A naesthesiol Scand
Suppl 45 (1971): 129-40.
2 D . A. Shewmon, “Recovery from ‘Brain D eath’: A Neurologist’s Apologia,”
L inacre Q 64, no. 1 (1997): 30-96.
3 N. Zamperetti. et al., “Irreversible Apnoeic Coma 35 Y ears Later. Towards a
More Rigorous D efinition of Brain D eath?” Intensive C are M ed 30, no. 9 (2004):
1715-22.
4 S. D . Shemie, et al., “Severe Brain Injury to Neurological D etermination of
D eath: Canadian Forum Recommendations,” C M A J 174, no. 6 (2006): S1-13.
