January 13, 2014 | Posted By Marleen Eijkholt, PhD

Understanding death is difficult. And this issue is an everyday occurrence for clinical ethicists. In questions around withdrawal of life support, or a shift towards comfort care if a patient’s death is imminent, such misunderstanding is a recurring problem. The case of Jahi McMath, which I will deal with later illustrates this. Death is not necessarily a flat line on a screen. Especially when machines interfere, the blibs and curves on the screen keep going. Also death might not mean a total absence of reflexes, such as reflexes to stimuli might not necessarily mean that something is alive or has consciousness.

In the clinic, I cannot necessarily rely on analogies from nature to explain that someone is no longer ‘alive’, for fear of being insensitive about loved ones. But in this blog I can draw on such analogies to illustrate my case. If you behead a chicken (for compassionate or consumerist reasons), it will continue to jump around for a couple of minutes until it bleeds out. This does not mean that the chicken is still alive after you beheaded it. The jumps are a response of the autonomic nervous system and come from a jolt of adrenaline. Similarly, a ‘sensitive-plant’ or the ‘mimosa pudica’ will retract its leaves after you touch it. It moves. See here. I don’t think that this means the plant is alive like a human being or that it ‘understands’ your touch. The retraction of the leaves is a natural reaction. Its movement does not imply consciousness. Finally, during winter time, the breaks of my bike contract and they push on the wheel. This makes it harder for me to cycle. During summer time the breaks expand and cycling is not a problem. The breaks of my bike respond to the weather, but I would not call them ‘alive’.  

 Jahi McMath was declared brain-dead on December 12, but she is still on life support to this day. A judge ruled that the hospital could not take Jahi off the machines. Jahi’s mother continues to say that she expects her daughter to wake up and that she does not accept that Jahi is dead. Recent reports note that her mother considers the fact that Jahi responds to touch and that her heart continues to beat. It is a tragic case. Jahi had a tonsillectomy for sleep apnea, but started bleeding and suffered a cardiac arrest. After several days, the doctors found no more brain function and they declared her brain dead.

We may wonder how the court could have ruled that Jahi’s life support would need to be continued if Jahi was really dead? And why would an institution offer to host Jahi in a living facility? Caplan argued before that  there is no obligation to continue ventilation for a dead patient. He suggested that the hospital’s continuation of life support was a compassionate action to allow the family to come to terms with her death. He suggested that Jahi’s death declaration was non-negotiable, but Caplan’s analysis pre-dates the court rulings. So how could we explain all this negotiation and controversy around her death?

My answer is: I don’t know why the court endorses ventilation support for Jahi, exept only if it is not sensitive to the nuances and understanding of death. Reading some of the proceedings, we see an expert witness confirm that death is controversial. The expert suggests that it is unclear whether brain death or clinical death is the more appropriate definition of death. The expert suggests that as long as her heart is beating he considers her ‘alive’, but does not say that Jahi’s heart is only beating because of a machine.

Defining death is controversial. I alluded to this in a previous post. The US and the UK have different definitions of brain death. The US proceeds from a whole brain death, versus the UK proceeding from a brain stem death, which theoretically seems to means that ventilator support can be more easily withdrawn in the UK. In the UK, parts of the brain can still be functioning, but a person can still be considered dead if there is an “irreversible loss of capacity for consciousness, combined with an irreversible loss of capacity to breathe”. Accordingly, the UK attaches all its meaning of human life in consciousness and breathing. In the US, some individuals may not be declared dead as some parts of their brain are still functioning, i.e. some lower functions such as movement. The US definition depends on the “irreversible cessation of all functions of the brain including the brain stem”. Accordingly, the whole brain is seen as the essence of human life, rather than to attach to specific elements in the brain (like consciousness)*. Clinical death is another definition of death out there, which depends on irreversible loss of breathing function and blood circulation, i.e. the heart stopping. This definition is often abandoned as breathing function and blood circulation can now be done mechanically, as we see in Jahi’s case.

Jahi would not be breathing on her own, there is no blood flow to the brain itself, there is no electrical activity in her brain, and her heart is only beating by a machine. If it is true that she responds to touch, or contracts after certain stimuli this still does not mean she is alive as a human being. Some parts of her body are functioning by machines, and some reflexes are natural reactions like those of a sensitive plant. Movement is no sign of consciousness, as the plant is no human being or the breaks of my bike are no human being either. The case deals with complicated matters, but I hope that the court is not distracted by reflexes to believe that Jahi is alive as a human being, especially as she is only functioning mechanically; mechanical life is not being ‘alive’. To me, the court is not adopting a sensible approach and is not sensitive to the nuances of life or death. It’s a tragic case.

* The US definition of death, proceeding from a whole-brain criterion, does not seem to distinguish between the brain’s organic functions, functions like using oxygen, moving and growing, which are functions that plants also have, and those functions that make humans and, arguably, animals special: i.e. consciousness. 

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1 comments | Topics: Clinical Ethics , Consent


Heddy-Dale Matthias, MD

Heddy-Dale Matthias, MD wrote on 01/25/14 7:46 PM

I am very concerned about the lack of good thinking and writing by the bioethics community on the Munoz case in Texas. Here's what I think has been lost in this discussion:

1. The woman has been dead for over two months. At the moment she is declared dead, further care constitutes assault and battery (in this peculiar case on a corpse).
2. Her physicians should ALL refuse to care for a corpse. By their collusion in this case, they have allowed their ethical and medical obligations to be obscured and co-opted.
3. The Texas Medical Board should sanction these physicians for unethical behavior and malpractice.
4. The status of her fetus should have NEVER been an issue in the care of the corpse. It seems that as of this morning people involved in this case are breathing easier because the fetus is "non-viable," although it is unclear whether this means the fetus in non-viable because of gestational age or birth defects.
5. Although a judge would be pleased if the family were in agreement that the "substituted" judgement of the patient would wish the ventilator turned off, this is NOT a case of substituted judgement, because the patient is dead.
6. I feel the bioethical community has done little to elucidate this case, and has, as I saw on Fox News tonight, again muddied the waters.
7. It is our obligation as physicians and ethicists to present clear ethical and medical issues to the public, medical, and legal community.

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