“…we are not the owners of our lives and, hence, do not have absolute power over life. We have a duty to preserve our life and to use it for the glory of God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome.” The Ethical and Religious Directives for Catholic Healthcare Services
Much is being written regarding the sad and terrible events unfolding in California regarding the death of Jahi McMath. What can we take from this regarding the legal definition of death, what the Catholic Church teaches us about ongoing medical interventions in the face of illness and impending death and how to determine death, and what we can do to prepare for our death and the death of our loved ones?
The Uniform Law Commission (ULC) exists to, “provide states with non-partisan, well conceived, and well drafted legislation that brings clarity and stability to critical areas of state statutory law.”
In 1978 the Uniform Law Commissioners created the Uniform Brain Death Act (UBDA). Acknowledging that it needed to be broadly worded to avoid near immediate obsolescence, the Act stated that, “…irreversible cessation of all functioning of the brain, including the brain stem” is death. The Act prescribed that “determination of death be made in accordance with ‘reasonable medical standards’.” The wording “reasonable medical standards” allows for the evolution of medical technology which may yield ever more sophisticated methods allowing for making this determination.
This broad wording proved confusing for States and in 1980 the ULC replaced the UBDA with the Uniform Determination of Death Act (UDDA):
This is essentially the original Act with the addition of the following, “…irreversible cessation of circulatory and respiratory functions” as an alternative standard for determining death. The term “reasonable medical standards” has also been changed to “accepted medical standards.”” This allows for two definitions of death: irreversible cessation of circulatory and respiratory functions and/or irreversible cessation of all function of the brain, including the brain stem.
Section 1: Determination of Death. An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.
Section 2: Uniformity of Construction and Application. This Act shall be applied and construed to effectuate its general purpose to make uniform the law with respect to the subject of this Act among states enacting it.
This Act is not without controversy. Some argue that it is not necessary to allow for the cessation of circulatory and respiratory functions as brain death is death. Further discussion about some of the concerns with this Act can be found here:
What does the State of California say?
California Codes Health and Safety Code Section 7180 states: (a) An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards. (b) This article shall be applied and construed to effectuate its general purpose to make uniform the law with respect to the subject of this article among states enacting it. (c) This article may be cited as the Uniform Determination of Death Act.
7181. When an individual is pronounced dead by determining that the individual has sustained an irreversible cessation of all functions of the entire brain, including the brain stem, there shall be independent confirmation by another physician.
According to the State of California, Ms. McMath has died. Why is this difficult for her family to accept? The problem lies in our inability to reconcile what we see before us with what we know about the dead. When a patient needs respiratory support, without an Advanced Directive, the automatic response is to intubate the patient and begin mechanical ventilation. This provides oxygenated blood flowing throughout the body keeping the heart functioning. Surely we think, someone whose chest is rising and falling, whose heart is beating is alive.
A neurologist (or 2 or 6) may tell me that my loved one’s brain has ceased to function and a PET scan shows no blood flow to the brain, therefore the person lying before me is brain dead. But her chest is moving up and down, she has normal skin color and is warm to the touch. How can she be dead? If mechanical respiratory support is stopped, her chest will fall still and within minutes the heart quits beating due to lack of oxygen. Now she appears dead. It now seems we’ve caused this person’s death by our actions. In reality our earlier intervention has kept her body functioning with invasive procedures when the brain was no longer alive capable of doing so. Without prior intervention, her heart would have stopped and her appearance would have matched our experience with what death looks like.
So, what do the US Bishops say about determining death? The Ethical and Religious Directives for Catholic Healthcare Services (ERDs)
in Section Five: Issues and Care for the Seriously Ill and Dying, Directive #62 states: The determination of death should be made by the physician or competent medical authority in accordance with responsible and commonly accepted scientific criteria.
Thus, according to the Catholic Church, once a physician or competent medical authority has determined that brain death as occurred (as in the case of Ms. McMath) then the patient is, in fact dead. Since patients are given respiratory support while waiting for this determination to be made, what happens next? Once the determination of death is made, both in the eyes of the law and the Church, all artificial respiratory support can be withdrawn. We are not keeping someone alive with respiratory support we are artificially lengthening the time between when the brain became incapable of regulating breathing and their heart stopped due to lack of oxygen.
So, what can we do to minimize this scenario in our own families? Part of being Catholic is preparing ourselves and our families for eternal life. The vigorous debate surrounding the continued care of Ms. McMath’s body is an opportunity for us to educate ourselves as to the Church’s position on death and dying, checking our state’s legal definition of death, and discussing an Advanced Directive with next-of-kin.
Every state government website should have an Advanced Directive form. By learning how our State defines death, speaking with our family and health care providers and thinking about how we would like to be cared for, and making those wishes known through an Advanced Directive, we can lessen the grief and burden to our loved ones if something catastrophic occurs.