Katrina Bramstedt: Brain death diagnosis should be left to the experts

9:30 AM Thursday Nov 8, 2012

In his new book, Catholic bioethicist Nicholas Tonti-Filippini attempts to portray surgeons involved in organ donation as modern-day grave robbers.

As described in an Australian newspaper, Professor Tonti-Filippini poses that some patients who are diagnosed as "brain dead" are not really dead because there is some mid-brain function. He argues that brain blood flow testing should be performed to ensure these patients are not prematurely declared dead and inappropriately have their organs donated.

So what is brain death and how is it diagnosed? According to the Australian and New Zealand Intensive Care Society, whole brain death is required for the legal determination of death in Australia and New Zealand. A patient must be declared dead by a physician in order for deceased organ donation to be permitted.

Brain death occurs following a severe brain injury associated with significant elevation of pressure in the skull, called intracranial pressure. As the brain swells, exposure to oxygen reduces and intracranial pressure increases. Eventually brain blood flow ceases and the entire brain, including the brainstem, permanently dies. There is no recovery from brain death.

Neither myself nor Professor Tonti-Filippini are neurologists and those clinicians are the experts and undertake ongoing research. In fact, the Quality Standards Subcommittee of the American Academy of Neurology updated its practice parameters for determining brain death in 2010.

The academy also created a brochure which explains the key features of brain death diagnosis to families: the person is in a permanent coma, and the cause of the coma is known; all brainstem reflexes have permanently stopped working; and breathing has permanently stopped.

If these three items are verified and there are no confounding factors (such as hypothermia) or situations that could mimic neurological death, doctors can diagnose irrecoverable brain death. If there is uncertainty, confounders, or mimicking conditions, then a diagnosis of brain death cannot be made and further testing, such as brain blood flow imaging, is performed.

It seems Professor Tonti-Filippini doubts the certainty of the three diagnostic parameters and asks the public whether the present approach is acceptable. The problem with his method is that few of us are neurologists and most lack the scientific preparation to analyse Professor Tonti-Filippini's doubts.

His fears have the potential to spread and affect the community's views of organ donation, with families refusing to honour their loved one's wish to be an organ donor, and people removing their name from the donor registry or simply refusing to register.

Research and academic debate are critical to ensure clinically and ethically appropriate practises. But Professor Tonti-Filippini's claims seem merely a lightning rod of emotive oration. Along the way, patients with end-stage organ failure potentially endure more suffering as their waiting time for an organ increases.

Now is the time for professional societies in the spheres of transplantation and neurology to weigh in. Now is also the time for adults to talk to their families about their wishes and values about organ donation.

* Katrina Bramstedt is Associate Professor of Medical Ethics at Bond University.