UNCONSCIOUSNESS,
BRAIN DEATH,
and
THE VATICAN
 

  Nursing Sisters


1. MEDICAL DEFINITIONS: DISORDERS of CONSCIOUSNESS

2. BRAIN DEATH and THE MAGISTERIUM


11.1. David Albert Jones on Stem Cells and the Catholic Church

 

 

 

 

_1. MEDICAL DEFINITIONS:
DISORDERS of CONSCIOUSNESS
   (States of Impaired Responsiveness)

 

 

 

 

 


BRAIN DEATH

[1] permanent cessation of all higher brain function

[2] presumption of imminent asystole [the heart will inevitably stop beating within a short period of time]


COMA

Continuously unconscious and unarousable; no alternation of periods of wakefulness and sleep. "Coma resulting from brain injury or illness usually is a transient state. Within a few weeks, patients in coma either recover awareness, die, or evolve to an eyes-open state of impaired responsiveness such as the vegetative or minimally conscious state. These disorders of consciousness can be transient stages during spontaneous recovery from coma or can become chronic, static conditions." Current controversies in states of chronic unconsciousness" James L. Bernat, MD, Neurology - Volume 75, Issue 18 Suppl 1 (November 2010)


PERSISTENT VEGETATIVE STATE

No evidence of self-awareness or conscious reaction to stimuli; alternate periods of sleep and wakefulness.

(1) no evidence of awareness of self or environment and an inability to interact with others;

(2) no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli;

(3) no evidence of language comprehension or expression;

(4) intermittent wakefulness manifested by the presence of sleep-wake cycles;

(5) sufficiently preserved hypothalamic and brain-stem autonomic functions to permit survival with medical and nursing care;

(6) bowel and bladder incontinence; and

(7) variably preserved cranial-nerve reflexes (pupillary, oculocephalic, corneal, vestibulo-ocular, and gag) and spinal reflexes.


MINIMALLY CONSCIOUS STATE

After completing a systematic review of the literature, the Aspen Workgroup defined MCS as “a condition of severely altered consciousness in which there is minimal but definite behavioral evidence of conscious awareness.” Behaviorally based diagnostic criteria were proposed and published in Neurology in 2002. To establish the diagnosis of MCS, clearly discernible evidence of 1 or more of the following behaviors must be observed on bedside examination:
    •    Simple command-following
    •    Intelligible verbalization
    •    Recognizable verbal or gestural “yes/no” responses (without regard to accuracy)
    •    Movements or emotional responses that are triggered by relevant environmental stimuli and cannot be attributed to reflexive activity (eg, visual pursuit of a moving object).



COMPARISON CHART:

 
CONDITION

SELF-AWARE-NESS

SLEEP-WAKE CYCLES

MOTOR FUNCTION

EXPERI-ENCE OF SUFFERING

RESPIRA-TORY
FUNCTION

EEG ACTIVITY

CEREBRAL META- BOLISM

PROGNOSIS FOR
N
EUROLOGIC RECOVERY

 PERSISTENT VEGETATIVE
 
STATE

Absent

Intact

No purposeful movement

No

Normal

Polymorphic delta or theta, some times slow alpha

Reduced by 50% or more

Depends on cause (acute traumatic or nontraumatic injury, degenerative or metabolic condition, or developmental malformation)

  COMA

Absent

Absent

No purposeful movement

No

Depressed, variable

Polymorphic  delta or theta

Reduced by 50 or more (depends on cause

Usually:
recovery,

persistent vegetative state,

or death

in 2 to 4 weeks

  BRAIN   DEATH

Absent

Absent

None or only reflex spinal movements

No

Absent

Electro-cercbral silence

Absent

No recovery

 LOCKED-
IN SYN-DROME

Present

Intact

Quadriplegia and pseudobulbar palsy; eye movement preserved

Yes

Normal

Normal or minimally abnormal

Minimally or moderately

Recovery unlikely; persistent quadriplegia with prolonged survival possible

 DEMENTIA

Present but lost in late stages

Intact

Variable limited progression

Yes, but lost in late stages

Normal

Nonspecific slowing

Variably reduced

Irreversible (ultimate outcome depends on cause)

 
CONDITION

SELF-AWARE-NESS

SLEEP-WAKE CYCLES

MOTOR FUNCTION

EXPERI-ENCE OF SUFFERING

RESPIRA-TORY
FUNCTION

EEG ACTIVITY

CEREBRAL META- BOLISM

PROGNOSIS FOR
N
EUROLOGIC RECOVERY

Medical Aspects of the Persistent Vegetative State: First of Two Parts, The Multi-Society Task Force on PVS.  NEJM Volume 330:1499-1508 May 26, 1994, Number 21.

 

 



 Behavioral features of disorders of consciousness

 “The Vegetative and Minimally Conscious States: Diagnosis, Prognosis and Treatment”, Ron Hirschberg, MD   Joseph T. Giacino, PhD, Neurologic Clinics Volume 29, Issue 4 (November 2011)   773-786  [Table 1, p. 776]

Behavior Coma Vegetative State Minimally
Conscious State

Eye opening

None

Spontaneous

Spontaneous

Spontaneous movement

None

Reflexive/ Patterned

Automatic/ Object Manipulation

Response to pain

Posturing/None

Posturing/ Withdrawal

Localization

Visual response

None

Startle/ Pursuit (rare)

Object recognition /Pursuit

Affective response

None

Random

Contingent

Commands

None

None

Inconsistent

Verbalization

None

Random vocalization

Intelligible words

Communication

None

None

Unreliable

 

 


11.3. Magisterial Support of Stem Cell Research: Opposition to Destruction of Embryos

 

 

 

 

 

_2. BRAIN DEATH and
 
THE CATHOLIC MAGISTERIUM

   

 

 

 

 


2.1. (1989) THE PONTIFICAL ACADEMY of SCIENCES DETERMINES that THE  CONCEPT of  BRAIN DEATH is LEGITIMATE and USEFUL

From the 1989 Working Group of the Pontifical Academy of Sciences:

“Final Considerations... “ in The artificial prolongation of life and the determination of the exact moment of death. Working Group, 19-21 October 1985, p. 81.

DEATH… has in fact occurred when:

a. spontaneous cardiac and respiratory functions have irreversibly ceased, which rapidly leads to a total and irreversible loss of all brain functions, or

b. there has been an irreversible cessation of all brain functions, even if cardiac and respiratory functions which would have ceased have been maintained artificially.


2.2. (1998) Dr. ALAN SHEWMAN CHALLENGES ASSUMPTIONS CONCERNING THE  CONCEPT of  BRAIN DEATH

“Chronic ‘Brain Death’:Meta-Analysis and Conceptual Consequences”
D. Alan Shewmon MD, Neurology 1998; 51: 1538-1545 ,
Department of Pediatrics, Division of Neurology, UCLA Medical School, Los Angeles, CA.

 

   2.2.1. ARTICLE ABSTRACT
 

 

 

 

Objective: One rationale for equating “brain death” (BD) with death is that it reduces the body to a mere collection of organs, as evidenced by purported imminence of asystole despite maximal therapy. To test this hypothesis, cases of prolonged survival were collected and examined for factors influencing survival capacity. Methods: Formal diagnosis of BD with survival of 1 week or longer. More than 12,200 sources yielded approximately 175 cases meeting selection criteria; 56 had sufficient information for meta-analysis. Diagnosis was judged reliable if standard criteria were described or physicians made formal declarations. Data were analyzed by means of Kaplan-Meier curves, with treatment withdrawals as “censored” data, compared by log-rank test. Results: Survival probability over time decreased exponentially in two phases, with initial half-life of 2 to 3 months, followed at 1 year by slow decline to more than 14 years. Survival capacity correlated inversely with age. Independently, primary brain pathology was associated with longer survival than were multisystem etiologies. Initial hemodynamic instability tended to resolve gradually; some patients were successfully discharged on ventilators to nursing facilities or even to their homes.


Conclusions: The tendency to asystole in BD can be transient and is attributable more to systemic factors than to absence of brain function per se. If BD is to be equated with death, it must be on some basis more plausible than loss of somatic integrative unity.

The equivalence of “brain death” (BD) with death is one of the few bioethical issues of this decade considered relatively settled [1] (p 115) . Together with Veatch, [2] I prefer to place “brain death” in quotation marks on account of its semantic ambiguity. [3] For purposes of this paper, the term will be taken to mean “whatever most people understand by the term `brain death’ [with whatever ambiguity and inconsistency that entails],” or equivalently, “a clinical neuropathologic state fulfilling official diagnostic algorithms and legally equated with death in most jurisdictions [regardless of the rationale for, or validity of, that equation].”) What has been settled, however, is merely statutory definition and diagnostic protocols. [1] [4] [5] Beneath this superficial consensus there is tremendous confusion about the fundamental rationale for equating the death of one particular organ with death of the entire organism. [2] [3] [6] [7] [8] [9] [10] In the United States and most other countries where a quasi-official rationale has been articulated, the rationale is that the brain is the “central integrator” or “critical organ” of the body, and its destruction or irreversible nonfunction entails a loss of somatic integrative unity, a thermodynamic “point of no return,” a literal “disintegration” of the organism as a whole. [1] [11] [12] [13] [14] [15]

 

   2.2.1. ARTICLE CONCLUSION
 

 

 

 The phenomenon of chronic BD implies that the body’s integrative unity derives from mutual interaction among its parts, not from a top-down imposition of one “critical organ” upon an otherwise mere bag of organs and tissues. If BD is to be equated with human death, therefore, it must be on some basis more plausible than that the body is dead. Whether other rationales, such as loss of “personhood” from a biologically live body, might be conceptually more viable or desirable for societal endorsement is beyond the scope of this physiologic inquiry.

 

 


2.3. (2008) THE PONTIFICAL ACADEMY of SCIENCES REFUTES Dr. SHEWMAN and REAFFIRMS that THE  CONCEPT of  BRAIN DEATH is LEGITIMATE and USEFUL

 MS-WORD DOC     PDF DOC

http://www.vatican.va/roman_curia/pontifical_academies/acdscien/2009/excerpt_signs_of_death_5l.pdf

From the volume The Signs of Death, The Proceedings of the Working Group of 11-12 September 2008, The Pontifical Academy of Sciences Vatican City, Scripta Varia 110, September 2008.

    [2.3.1.] According to the post-Second Vatican Council and contemporary Catechism of the Catholic Church, ‘The unity of soul and body is so profound that one has to consider the soul to be the “form” of the body:[2] i.e., it is because of its spiritual soul that the body made of matter becomes a living, human body’ (n. 365). So, from a philosophical and theological point of view, it is the soul that confers on the body the unity and the essential quality of the human body, which are reflected in the dynamic unity of the cognitive (and inclinational) activities with the sensitive and vegetative activities that not only co-exist, but can also work together in a participation of the nervous system with the senses and the intellect (and in a participation of the biological and sensitive inclinations with the will). Thus, Aristotle, using a geometric analogy of contemporary relevance that is explicitly appropriate for this operative order as well, declared that the vegetative is in the sensitive and this is in the intellective in the same way that a triangle is in a square and this is in a pentagon, because this last contains the square and even more.[3] This dynamic organic unity between the activity of the intellect, the senses, the brain and the body does not exclude but, on the contrary, postulates, at a biological and organic level, that there is an organ which has the role of directing, coordinating and integrating the activities of the whole body. Each specific function carries out its activity as an integral part of the whole. In contrary fashion, the fact of suggesting a sort of equivalence or equality of functions and of their activities leads us to acknowledge their relative independence, which is contradictory to the idea of ‘organism’. So the brain is the centre of the nervous system but it cannot function without the essential parts of its connectivity throughout the organism, in the same way as the organism cannot function without its centre. We are not brains in a vat, but neither are we bodies without a brain.

    [2.3.2.] Therefore, brain function is necessary for this dynamic and operative physiological unity of the organism (over and above its role in consciousness), but not for the ontological unity of the organism, which is directly conferred by the soul without any mediation of the brain, as is demonstrated by the embryo. However, if the brain cannot assure this functional unity with the organic body because the brain cells are dead or the brain has been separated from the organism, the capacity of the body to receive the being and the unity of the soul disappears, with the consequent separation of the soul from the body, i.e. the death of the organism as a whole.

    [2.3.3.] The formula constituting the source of the definition of the Council of Vienna that the soul is ‘forma corporis’, postulates, from the operative and dynamic point of view, the other formula of St Thomas (for that matter not cited by Prof. Spaemann) to the effect that ‘the government of the body belongs to the soul in that it is its motor and not its form’[4] and thus ‘between the soul and all the body, in that it is a motor and the principle of operations, occurs something intermediary, because, through a first part moved first, the soul moves the other parts to their operations’ (‘inter animam secundum quod est motor et principium operationum et totum corpus, cadit aliquid medium; quia mediante aliqua prima parte primo mota movet alias partes ad suas operationes’). [5]Thus the overall formula obscured by tradition and by Prof. Spaemann is: ‘the soul unites to the body as a form without an intermediary, but as a motor it does this through an intermediary’ (anima unitur corpore ut forma sine medio, ut motor autem per medium).[6] Therefore, when the cells of the brain die, the individual dies, not because the brain is the same as the mind or personhood, but because this intermediary of the soul in its dynamic and operative function (as a motor) within the body has been removed – ‘that disposition by which the body is disposed for union with the soul’.[7] One must see this intermediation of the brain not as delegation from outside but as a part of reality and this is what the traditional notion of ‘principal organ’ or ‘instrumentum coniunctum’ seeks to express. St Augustine, who was the source of this Thomistic doctrine of the government of the body by the soul through an organ which is the principal instrument, is very clear in asserting avant la lettre that brain death is the death of the individual: ‘Thus, when the functions of the brain which are, so to speak, at the service of the soul, cease completely because of some defect or perturbation – since the messengers of the sensations and the agents of movement no longer act –, it is as if the soul was no longer present and was not [in the body], and it has gone away’ (Denique, dum haec eius tamquam ministeria vitio quolibet seu perturbatione omni modo deficiunt desistentibus nuntiis sentiendi et ministris movendi, tamquam non habens cur adsit abscedit [anima]).[8] Therefore, in reality the objections to the criterion of brain death as death advanced by Prof. Spaemann and Dr. Shewmon do not hold up either at a physical/biological or a philosophical level.

    [2.3.4.] We also disagree with Dr. Shewmon’s conclusion that the worldwide consensus on the equivalency of brain death with human death is ‘superficial and fragile’. Although practices vary between countries, there does exist a consensus of sufficient strength to permit the successful declaration of brain death in dozens of countries in the developed Western world and the non- Western and developing world that have addressed this question and possess the necessary state-of-the-art technology.

 

 


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