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Presented at the Faculty of Medicine
Bayero University, Kano, Nigeria on 10th January 2013 by Dr Omar
Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Department of
Bioethics King Fahad Medical City Riyadh EM: omarkasule@yahoo.com. WEB: www.omarkasule-tib.blogspot.com
CASE
#1:
·
A
60-year old comatose accident victim suffering from severe multi-organ
traumatic injury and with a signed organ donation card was evaluated in the ERof
a remote rural hospital. There was no other plausible cause of reversible coma
or of brain death.
·
Clinically:
no pupillary reflexes, fixedly-dilated pupils, no corneal reflex, no eye
movements, no blink reflex, no vestibule-ocular reflex, no cranial reflexes,
and no gag reflex. Findings were equivocal regarding the apnea test, cephalic reflexes,
and motor response to pain.
·
Investigations:
jugular vein partial oxygen pressure could not be determined. The EEG was
isoelectric. Bedside trans-cranial Doppler showed no cerebral circulation.
·
Family
members with the exception of the mother were certain of death and asked the
physician not to institute any life support and to call the organ harvesting
team. The doctor was not sure what to do he however convinced the family to
start life support to keep the organs viable until the transplant team arrived
by helicopter.
·
While
walking along the corridor, a nurse overheard members of the family talking
about a 15-year old cousin of the victim lying in a hospital in the capital
waiting for a kidney transplant.
CASE
#2:
·
A
40-year old billionaire stage 4 cancer victim with multi organ failure in ICU
and on artificial life support
·
Determined
clinically dead on the basis of clinical signs repeated after 6 hours (pupillary
reflexes –ve, fixedly-dilated pupils, corneal reflex –ve, eye movements –ve,
blink reflex –ve, cold water test –ve, cranial reflexes –ve, apnea test –ve,
cephalic reflexes –ve, motor response to pain –ve, gag reflex –ve).
·
All
confirmatory tests were also negative (jugular oxygen partial pressure -ve,
EEG=0, CT angiography).
·
Family
members begged the physicians not to withdraw life support and not declare
death until his beloved last daughter arrives from London. She might die from
shock if she does not see him alive before death. They were willing to pay for
the extra days of ICU stay.
·
A
90-year old deeply comatose man with multiple organ failure was admitted to the
last available ICU bed and was put on artificial life supportminutes when the
family refused a DNR order.
·
A
few minutes later ambulances started bringing in over 100 casualties from an
air crash site. The head of the ICU carried out a rapid assessment of the comatose
man showed equivocal clinical signs of brain death;some indicating death and
others not. None of the confirmatory tests was positive.
NATURE
OF DEATH
·
Death
is a process and not an event
·
Death
is failure of the heart and lungs to deliver oxygen and nutrients to cells
·
The
brain is the most sensitive organ to oxygen and nutrient deprivation and is
therefore the first to die
·
Death
of the brain leads to death of the vital centers that control the respiratory
and the cardiovascular systems
·
Brain
is Command-communication-coordination (CCC) center; its death signals loss of
body integrity and coordination
·
Cyclic
chicken-and-egg situation with few exceptions
INDICATORS
OF DEATH
·
Historically3
indicators of death: neurological, respiratory, and cardiac
·
Neurological
failure (consciousness and coma) always came first.
·
Recognition
of brain death as an early indicator is not new
·
New
indicators are able to detect the point of irreversible vital organ failure
earlier
·
As
new knowledge and technology are developed death can be detected earlier
·
Clinical
tests relate more to brain stem death
·
Confirmatory
tests relate more to whole brain death
·
Is
the dichotomy brain stem death vs whole brain death relevant?
ETHICS
AND LAW
·
Ethics
is about morality right vs wrong
·
Law
is about legality legal (can be done) vs illegal (punishable)
·
In
Islamic Law morality = legality because shari’at is positive law + morality
·
In
secular law some moral things may be illegal and some immoral things may be
legal
·
Strictly
speaking we should not have a term for ethics because it is included in the
shari’at
3.0
MOTIVATION OF BRAIN DEATH CRITERIA
·
al umuur bi maqasidiha
·
al ‘ibrat fi al maqasidwa al ma’aani la al alfaadhwa
al mabaani
·
Three
motivations for brain death criteria:
o
harvest
transplantation organs earlier
o
save
intensive care resources by earlier cessation of life support
o
obtaining
tissues for research before deterioration.
USE
OF CRITERIA IN DETERMINING BRAIN DEATH
·
1968:
Harvard criteria: apneic coma with no evidence of brain stem or spinal reflexes
and a flat electroencephalogram over a period of 24 hours.
·
No
consensus on brain death criteria: variation by country and by institution
·
Brain
death criteria change with time with new knowledge and new technology
·
Criteria
development coincided with rise of organ transplantation? Causal link
CRITERIA
OF BRAIN DEATH: CLINICAL TESTS
·
Eliminate
causes of reversible coma
·
Identify
a plausible cause of brain death
·
Tests
related to the eyes and ears
·
Tests
related to motor response
·
Tests
related to the cough or gag reflex
·
The
apnea test
·
Repeat
of the examination within 24 hours
CERTAINTY
OF DEATH: CONFIRMATORY TESTS
·
No
consensus on confirmatory instrumental tests
·
Tests
done to confirm clinical diagnosis
·
Chemical
tests of blood oxygenation
·
Tests
related to brain electric activity
·
Tests
related to brain blood flow
APPROACHES
TO AN ETHICAL ISSUE
·
1st
epoch: until ~1420H: direct reference to Qur’an and sunnah
·
2nd
epoch: 1420-14xx: use of qiyaas
·
3rd
era: Use of maqasid and qawa’id al shari’at in ijtihad
·
Maqasid
are not new pioneered by Shaikh al Haramain, Abu Hamid al Ghazzali, IbnTaymiyah,
and Ibn al Qayyim al Jawziyat, Abu Ishaq al Shatibi al Maliki al Andalusi
·
Derived
from the sources by induction they provide an intellectual frame work to reason
out difficult situations
·
Qawaid
are axioms of the Law that facilitate logical ethical reasoning
THE
5 PURPOSES OF THE LAW, maqasid al shari’at
·
Protection
of morality, hifdh al ddiin
·
Protection
of life, hifdh al nafs
·
Protection
of the progeny/family, hifdh al nasl
·
Protection
of the mind, hifdh al ‘aql
·
Protection
of resourcesmhifdh al maal
THE
5 PRINCIPLES OF THE LAW, qawaid al shari’at
·
The
principle of intention, qa’idat al qasd
·
The
principle of certainty, qa’idat al yaqeen
·
The
principle of injury, qa’idat al dharar
·
The
principle of hardship, qa’idat al mashaqqat
·
The
principle of custom, qa’idat al ‘aadat
INTRODUCTION
·
Ethical
issues relating to brain death are analyzable according to the purposes of the
Law, maqasid al shari’at, and principles of the law, qawa’id al fiqh,
to reach conclusions of practical importance.
·
3
Motivation to declare death earlier:
o
harvest
viable organs earlier
o
save
intensive care resources
o
obtaining
tissues for research before deterioration.
PRINCIPLE
OF INTENTION, qa’idat al qasd
·
Violation
of the principle of intention, qa’idat al qasd, which requires that
actions be judged by underlying intentions and that the end does not justify
the means.
·
Are
these ends noble enough to justify early death declaration by brain death?
o
Save
the life of the organ recipient?
o
Save
resources wasted by futile medical intervention?
o
Medical
research to advance knowledge?
PRINCIPLE
OF CERTAINTY, qa’idat al yaqeen
·
The
requirement, by the principle of certainty, qa’idat al yaqeen, of
evidence-based proof of death are partially fulfilled by brain death criteria, tests,
and examinations.
·
There
is almost unanimous consensus on clinical tests in determining brain stem death
but no such consensus exists for confirmatory instrumental tests.
·
An
individual practitioner in charge of the patient may not be convinced by the
signs and tests
PRINCIPLE
OF CUSTOM, qa’idat al ‘aadat
·
innamayu’utabar al ‘aadatidhaatradat aw ghalabat
·
al ‘ibrat li al ghaalib al shai’u la al naadir
·
Consensus
on clinical signs as indicators of brain stem death
·
The
principle of custom, qa’idat al ‘aadat, is partially fulfilled because
there is no universal consensus on criteria of brain deat
·
Brain
death criteria vary by country, by institution, and over time.
OUTSTANDING
QUESTIONS…1
·
Do
we do brain death testing routinely or are we selective?
·
Is
repetition of the testing needed after 6, or 24 hours?
·
How
soon shall we act after brain stem death is confirmed clinically?
·
Relevance
of cerebral death vs brain stem death difference?
OUTSTANDING
QUESTIONS…2
·
Feasible?(a)
other causes of reversible coma (b) plausible cause of brain death
·
Protection
of life, maqsadhifdh al nafs, vs and mistakes in death determination
·
protecting
resources, maqsadhifdh al mal, vs delayed death determination
·
Pressure
for organ donation: specific individual vs. general public
·
Near
death vs dead
CONCLUSIONS
·
The
criteria and determination of brain death do not fully conform to principles of
intention, certainty, and custom.
·
Considerations
of organ harvesting, ICU costs, and research have been a driving force behind
development of brain death criteria.
·
These
criteria have been changing with development of knowledge and technology and
have not reached the level of universal consensus having variation by country
and by institution.
·
There
is consensus about the reliability of clinical tests of brain stem death
RECOMMENDATIONS
·
Brain
stem death, determined by clinical examination with or without instrumental
confirmation, should remain the mainstay of death definition
·
The
public interest in organ harvesting and saving ICU resources overrides the doubts
that we may have about clinical criteria of brain death
·
Legal
rulings, fatwa, on brain death should be reviewed every 3 years to take into
consideration new developments in medical knowledge and technology.