BRAIN-DEATH IN THE PEDIATRIC-PATIENT - HISTORICAL, SOCIOLOGICAL, MEDICAL, RELIGIOUS, CULTURAL, LEGAL, AND ETHICAL CONSIDERATIONS

Objective: To detail the origins of the definition of death, the devel opment of the criterion of whole brain death as fulfilling the definit ion of death, and the tests used to fulfill that criterion. Data Sourc es: A review of the literature was performed. No Institutional Review Board approval was necessary. Data Extraction: In 1959, patients were described as being in ''coma depasse'' or beyond coma. In 1967, the fi rst successful heart transplantation took place, with the organ coming from a brain-dead, beating-heart donor. However, anxiety over the def initions of death did not begin with the modern, technological era, an d death itself has never been definable in objective terms. It has alw ays been a subjective and value-based construct. During ancient times, most people agreed that death occurred when a person's heartbeat and breathing stopped. For the Creeks, the heart was the center of life; f or the ancient Hebrews and Christians, the breath was the center of li fe. In the 12th century, Maimonides pointed toward the head, and the l oss thereof, as the reason for lack of central guidance of the soul. P hysicians neither diagnosed nor certified death. During the Enlightenm ent, the necessity of heartbeat, breath, and consciousness for the def inition of life was questioned, leading: to questioning regarding the definition of death. Tests to fulfill the criteria of death, and tests to determine the absence of integration between functions of respirat ion, circulation, and neurology were introduced. Sensorimotor potentia l was becoming recognized as defining life, rather than heartbeat and respiration. As new tests were devised to fulfill criteria of death, t he physician developed a professional monopoly on meeting the criteria of brain death. In the modern era, the boundary between life and deat h has been blurred, but the intensive care unit straddles this boundar y. We may have situations where the patient is alive but in a coma, wi thout functioning heart, lungs, kidneys, or gastrointestinal tract, wi th a transplanted liver, a reversed coagulation system, a blocked immu ne system, and a paralyzed musculoskeletal system. Data Synthesis: A h uman being is a man, woman, or child who is a composite of two intrica tely related but conceptually distinguishable components: the biologic al entity and the person. Therefore, human beings can suffer more than one death: a biological death and decay, and another death. Biologica l death is a cessation of processes of biological synthesis and replic ation, and is an irreversible loss of integration of the biological un its. The reasons for having criteria for death are to diagnose death a nd pronounce a person dead. Society can then begin to engage in grief, religious rites, funerals, and burials, and accept biological death. Wills can be read, property distributed, insurance claimed, individual s can remarry, succession can take place, and legal proceedings can be gin. Also, organ donation can take place, which entails difficult ethi cal decisions. The Harvard criteria of 1968 were devised to set forth brain-death criteria with whole brain death in mind. Currently, there are several controversies regarding these criteria: a) whether they ap ply to infants and children; b) whether ancillary tests are necessary; c) what the intervals of observation and testing are; and d) are ther e exceptions to the whole brain death criteria. Concerning the use of the adult criteria for infants and I children, most researchers now ag ree that the adult criteria apply to infants and children who are full term and >7 days of age. Concerning ancillary tests, there has been, in our machine- and technology-oriented profession, a great deal of em phasis on the different tests and