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What Should We Think of “Brain Death” and “Unresponsive Wakefulness”

November 17, 2017

He spent fifteen years in a state of “unresponsive wakefulness”, often known as a “vegetative state”. At the age of 35, this young man recovered a state of minimal consciousness, and thus reopened the debate on what prognosis to give in cases of severe brain damage.

How could the young man’s condition improve? Thanks to a neurosurgical operation, a repeated electric stimulation of a cranial nerve called the “vagus nerve”. This result, published on Monday, September 25, 2017, in the journal Current Biography, was obtained by a team from Lyon, composed of members from the CNRS’ Institute for Cognitive Sciences-Marc-Jeannerod, and from the civil Hospices of Lyon.

“We wanted to explore the effects of stimulating this patient’s vagus nerve: we discussed it with his family and obtained their permission, along with that of the Ethics Committee,” explains Angela Sirigu in the columns of Le Monde’s annex Science et Medecine.

There were no immediate results. But after a month of this stimulation, a double improvement was observed. The patient followed an object with his eyes, and he obeyed simple orders, which he did not do before. “For example, when we asked him to turn his head to the right, he would do it very slowly,” says Angela Sirigu.

The patient also reacted to a form of “threat”: he would open his eyes wide when someone came very close to his face. His mother reported that he would stay awake longer when a therapist read him a book. “We saw a tear trickle down his cheek as he listened to music he loved,” adds Angela Sirigu, explaining his reactions on the emotional level. The young man has since passed away, but there seems to be no connection between his death and the stimulation that improved his condition.

“An age-old dogma would have it that there is no chance of improvement for patients who have been severely brain-damaged for more than a year. But this dogma is false, as this study confirms. Cerebral malleability, our brain’s capacity to remodel and adapt is sometimes astonishing,” explains professor Steven Laureys, director of GIGA-Consciousness in Liège, a leading institution in this field.

This result will not fail to reopen a bitter medical, scientific, philosophical, and ethical debate about the prognosis of a patient with a severe consciousness disorder.

This debate is nothing new, even in the Church: an article published on September 3, 2008, on the first page of L’Osservatore Romano contested the concept of brain death, which is an  insufficient motive for declaring true death.

This article was published on the occasion of the fortieth anniversary of the “Harvard Report” which, in 1968, replaced cardiac arrest as the sign of clinical death with a flat electroencephalogram. According to the author, Lucetta Scaraffia, an Italian historian and journalist, “the scientific justification of this choice is challenged by new research”, and this “fortieth anniversary of the new definition of cerebral death seems to be an opportunity to reopen the discussion on the scientific level, as well as within the Catholic Church”.

For John Paul II, “the criterion adopted for declaring certain death, that is, the complete and irreversible cessation of all cerebral activity, if rigorously applied, does not seem to conflict with the essential elements of serious anthropology,” as Fr. Lombardi, director of the Holy See Press Office, recalled on September 3, 2008.

Did he perhaps speak too hastily, thus jeopardizing the progress in neurosurgical technology and its capacity to stimulate patients perhaps prematurely considered to be in a state of irreversible brain damage?

Professor Allan Kellehar, from the University of Bath in the United Kingdom, has been calling for years for a modification of the definition of death, which is based entirely upon medical terms. According to him, a debate is needed to determine whether it is right for brain death to be the impetus to unplugging a patient and removing his organs. Today, death is more difficult to determine since it is technically possible to keep a person in a state of brain death alive for an indefinite amount of time.

This debate seems essential to him because using the criterion of brain death results in pressure from certain doctors, especially because of the need for organs.

Today in France, about 1,500 patients are presently in a state of unresponsive wakefulness or minimal consciousness, after a cranial traumatism, a heart attack, or a stroke.