Determination of Death

As modern medical technology has made the definition and determination of death increasingly complex, the transplant era has made both problems increasingly urgent. Virtually every physician and surgeon in the world wants to have his say. When the World Medical Association met in Sydney last week, 212 members from 28 nations debated the issues. They eventually adopted a tentative guideline document, the Declaration of Sydney, subject to detailed reconsideration next year. Simultaneously, a committee of 13 top-ranking Harvard professors proclaimed their code in the Journal of the A.M.A.

The documents were remarkably similar. Although the Sydney assembly could not agree on a precise definition of death, there is now a virtually worldwide consensus on the following criteria for establishing that irreversible coma, or death, has indeed occurred:

1) Total lack of response to external stimuli, even the most painful that can ethically be applied.

2) Absence of all spontaneous muscular movements, notably breathing. If the patient is on a mechanical respirator, this may be turned off for three minutes in order to establish that he is incapable of breathing for himself.

3) Absence of reflexes. The dilated pupils must not contract when a bright light is shone directly into them. There must be no eye movements in response to pouring ice water into the ears, no muscular contractions after hammer-tapping the tendons of the biceps, triceps or quadriceps.

4) Flat encephalogram or absence of "brain waves."

Significantly, the heart received least attention from the thanatologists. Both the difficulty and the urgency of their task resulted largely from the fact that a heart-lung machine can keep major parts of a body "alive" long after effective death. The long-held notion that death can be pinpointed in time, four or five minutes after heart action and breathing have stopped, is erroneous, said Cleveland's Dr. Charles L. Hudson, principal U.S. delegate in Sydney.

"Death," Hudson said, "is a gradual process at the cellular level, with tissues varying in their ability to withstand deprivation of oxygen. Medical interest, however, lies not in the preservation of isolated cells but in the fate of a person. Here the point of death is not so important as the certainty that the process has become irreversible."

No Murders. It was this point of irreversibility that most concerned the Harvard committee. Under the chairmanship of Dr. Henry K. Beecher, it outlined a series of technical steps to ensure that any flat EEG is really an accurate recording, then added that the tests "shall be repeated at least 24 hours later with no change." On its face, this language appeared to rule out the prompt transplantation of an accident victim's heart, but the committee felt that it was necessary to cover a few special cases. A victim of barbiturate poisoning may recover full brain function after 24 hours, or even longer, in deep coma. But in cases of massive head wounds, said Neurosurgeon William Sweet, a member of the committee, the brain damage would be the dominant consideration. Then the physician might decide, long before 24 hours had elapsed, that all hope was gone.

The Harvard group and the Sydney assembly agreed that it is best to have at least two physicians share the responsibility of determining death. And if there is any prospect of a transplant, those physicians must not be members of the transplant team. On the need for this division of authority, Sir Leonard Mallen said: "Doctors must never be in a position where it could be said that a donor was murdered to obtain an organ for a transplant."

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