pp. 126-129 in
Bioethics in Asia
Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute
Copyright 2000, Eubios Ethics Institute
All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire 3.8. Breakaway from the Medical Misunderstanding of Approaching Lifefs End
Li Lu, presented by Zhu Shan-kuan*.
Zhejiang Medical University, China; *Nagoya University School of Medicine
Brain death has always been one of the most focused on, yet toughest issues in medicine approaching lifefs-end. Because most of the issues relate with the essence of life, which involves conventional conception, scientific knowledge, moral perspectives and individual and social value. That is the main reason why there are so many different opinions about the phenomena and problems in this area between the clinical medicine and theoretical medicine. Furthermore, it is also the core, yet difficult part , to solve the problem. Therefore, we need re-discuss many of the existing medical issues of approaching lifefs-end with a scientific attitude, in order to break away from all the misunderstandings.
1. Understand both standards and their internal relations dialectically
It seems that all the difficult problems in treatment near the end of life are related to the standards for determination of death. Ever since Prof. Beecher, Harvard Medical School, U.S., first used the term girreversible comah, i.e., the standard of brain death in 1968, the concept of brain death has been accepted in medical circles all over the world, although not understood in some countries. However, the solid target, scope and practice of the standard need further developing. Whatfs more, the process of understanding and accepting the standard varies in different countries when cultures, conceptions and systems differ. In spite of this, the scientific value of the concept of brain death is out of the question.
The scientific nature of the brain death standard consists not only in the irreversible fate of human organs but also in the irreversible fate of consciousness, the total loss of mind irreversibly. Thought and consciousness, the main functions of the brain, are regarded as the chief standards in measuring quality of life, and are also one of the direct targets of medical science. The central feature of the brain death standard can be explained as following: A heart-dead patient may conserve his personalities and character after transplantation. But supposing the brain can also be transplanted, the person being transplanted will not remain the very same person because the operation would change his traits of character such as ideas, beliefs and value as well as his central nervous system. Brain death, or the loss of consciousness irreversibly, means the loss of the essence of life. In other words, brain death indicates the death of human life. In China, as far as the understanding and practicing of the concept of brain death is concerned, doctors and researchers in medical circles, including theoretical medicine show an insufficiently scientific attitude and spirit. The clinical doctors should understand and advocate the most advanced modern medical outlook and death outlook, and disseminate and practice the scientific brain death standard, however, they have failed. While acknowledging that the brain death standard is scientific on one hand, they are unwilling to apply it to their clinical practice, in case they are gtrappedh into life-end medicine. They always evade or even reject it, waiting for the governmental policy-making department of health to decide. They will adopt it only when it is made a law. It will be a long time before the brain death standard is applied in the clinic in China, while the costs of treatment and equipment for incurable patients with apoplexy or accident victims. We, as medical workers, should not ignore the comprehension and practice of the brain death standard, but should take responsibility for helping, the policy-making department to work out a practical and appropriate scientific law.
On the other hand, there are some scholars who depreciate or even deny the heart-lung standard while they praise brain death standard highly. Some separate the two standards and set them against each other, believing the brain death standard to be the sole scientific standard, which is a dogmatic comprehension. It is clear that the traditional heart-lung death standard is established on a scientific basis. Nobody has doubted about the scientific importance of the heart-lung death standard until the brain death standard was advanced. How could they come to depreciate or deny it in a split second? In these high-tech medical times, the traditional standard may show its deficiencies and shortcomings as medical science develops, however, its scientific function and value can not be denied at all. In fact, even the death standard concerning loss of brain function may face a time in future medical practice when its deficiencies are exposed as science develops and comprehension deepens. However, this is not a deficiency of science but its improvement. It has long been known that the human bodyfs essential organs are intricately and closely related. There is no need to suspect the scientific value of the heart-lung death standard. It is central to the way that we comprehend and apply the existing various standards of death, which are scientific of have a scientific identity. At present, in all different countries, including those where the brain death standard has long been put into practice, both death standards should be applied according to circumstances either simultaneously or singly, in determining whether the patient is dead or not. The proposal and application of the brain death standard indicate much further development in scientific death standards.
2. Brain death should not be limited to the classification of the stages of death in a heart-lung death standard
It has been widely accepted in medical circles that death is composed of three successive stages, namely, the approaching death period, clinical death period, and biological death period. The proposal of the concept and standard of brain death has created a new problem in classification of death stages, for it is hard to explain which period brain death belongs to. It would be contradictory if we divided brain death itself into periods. A so-called gnear approaching death periodh was advanced by some scholars, classifying brain death as before the first stage (approaching death period) of the former three stages. However, it is difficult to find an explanation for that indicators of heart-lung function in brain death and indicators in the suggested classification do not agree. Seemingly conscious of the dilemma, some theoretical articles and textbooks suggested a comprehensive classification, which introduces solid indicators of brain death standard into the former classification based on a heart-lung function standard. But they still could not find a scientific way completely out of the plight. Whatfs more, it is unfit for clinical practice. Though both standards are interrelated, they apply two different concepts to determining death stages. Both classification cannot fit into the same death stage criterion, which fits for brain function indicators as well as heart-lung function indicators. For instance, what stage of death has a patient reached when in vegetative state, or he falls into a coma irreversibly, or has lost heart-lung function but still remains brain function and lives on artificial devices to maintain heart-lung function. The former classification could only be applied when the death is a natural one, without any artificial intervention. The loss of heart-lung function means that other body organs will soon lose their functions. Today, as high-tech develops, a great number of special cases have emerged, such as, loss of heart-lung function with brain function remaining or vice versa. In cases like these, neither the former classification nor the so-called comprehensive one is able to draw a clear line. Therefore, it is necessary that we set up a new medical death classification on the basis of brain death, independent of heart-lung function, for which the stages could be called approaching death period, clinically dead period, and biologically dead period. Just like the two kinds of death standards, this new classification could coexist with the former one. We expect experts and authorities in medical circles to study it carefully and seriously, then work it out on a scientific basis. A viewpoint from Harvard Medical School believes that biologically there are brain death, brain stem death, cerebrum death and new cortex death at different anatomical levels. The brain stem dominates fundamental life characteristics while the cerebrum and new cortex control advanced neural activities and consciousness. In the latter cases, patients may sometimes revive. The former (brain stem and brain) provide firmer evidence for determining brain death. Hence, general cases could be treated in clinical practice according to the earlier classification of stages of death. While for special cases, in which the brain functions are involved, the new classification would be preferred.
3. There is no certain causality [relationship] between the brain death and euthanasia. The former involves scientific comprehension, the latter belongs to moral conception.
Some people believe that it is worthless to discuss euthanasia because it is too early to do so. The discussion should be held on the premise of the legalization or confirmation of brain death. Obviously, they have confused the content and value of the two different concepts: euthanasia and brain death. In discussion of euthanasia we used to regard the patient experiencing brain death as one kind of euthanasia, taking it into account that the concept and criterion have just been introduced into China, and the need for greater awareness. However, there are thousands of patients who are brain dead, and whose illness has exhausted their relatives, doctors and also the whole of society. Thus for the time being, in the cause of life-end medicine, brain death has been admitted to the theoretical discussion concerning euthanasia, which is improper but merely a makeshift. Cognitively, we should always make it clear that the brain dead should be excluded from the object and scope of euthanasia that we are now discussing and determining. The subjects of the euthanasia are mainly those patients who request it for themselves because they cannot endure the extreme physical and mental pain since their illness has irreversibly reached an advanced stage and no further treatment can help. In fact, there are no certain causality between the brain dead and euthanasia. In other words, once the scientific value of brain death is accepted by medical circles and by law, the brain dead could be removed from the ranks of living creatures. He is biologically dead, or he is dead indeed. Logically, there is no need to discuss whether we should or could practice euthanasia, and the related social moral issues. Neither should the discussion of euthanasia be affected by the determination of the brain death standard, nor should it be bound to the legalization of brain death. Scientific cognition is involved in brain death and its standard, while the issue of euthanasia is of conception, of cognition in ethics. These two subjects are related to each other closely, but they are not the same thing. The debate and practice of euthanasia started far earlier than the actual proposal of brain death. In countries like America, Holland, Singapore and Japan, the practice of euthanasia is not at all influenced by the legalization of brain death. It is unrealistic and unreasonable to set up, hard and fast, causality relations between brain death and its legalization and discussion of euthanasia. Except for the above mentioned manifestation, the reason for this kind of misunderstanding may also lie in the fact that people want to avoid some real existing social ethical problems, complicated and tough.
4. Terminal care is worth paying attention to, but it also requires controlling
In a certain sense, the modern cause of terminal care is the rapidly advancing society, high-tech medical science and fast developing economy. However, in China, some places still lag behind, medical and human resources fall short. Under this circumstances, it is not wise and practical that many hospice organizations are starting up and growing in some big and medium-sized cities at too high cost in man power and material resources, with new Hospices being set up, new wards for terminal care being adding, and qualified medical staff being provided. This is very likely to lead to new waste and be a minus with regard to medical resources and financial investment. As far as terminal care itself is concerned, its function and its influence are undoubtedly limited. We should contain the causes of terminal care within a certain scope even if it is to be a part of the scheduled development of Chinese health care. Solicitude towards patients at the end of their lives out of humanitarianism, has always been and will always be a sacred and bound duty of medical science and medical workers, which gives the patients warmth, esteem and sympathy, stresses their life qualities, respects their wills, and also supplies a prerequisite for developing terminal care as part of routine work in hospital treatment and for developing family medicine combined with community science on a primary health care basis. It is the feasible model of for development of Chinese terminal care at present, a standpoint for the cause, and where the value of the cause lies.
Some people believe that euthanasia can be substituted by terminal care, thus solving many problems. They think terminal care more acceptable and suitable than euthanasia. This perspective simplifies the problem. Both of them respect the life quality, life values and dignity of patients approaching life-end. People encounter problems with policies and techniques when they carry out terminal care. It is more complicated to perform euthanasia because many ethical, social, legal problems caused by the relationships between individual and society, value and dignity, science and knowledge, life quantity and life quality, are voluntariness and involuntariness, directness and indirectness, actively and passively, have to be answered. We are confronted with a comprehensive ethical problem relevant to our outlook on death, ethics, and medical values, which does not appear in the case of the terminal care. Developing the cause of terminal care cannot take the place of exploration of euthanasia for of medical science, socio-cultural, and legal reasons. Also terminal care cannot solve problems that are related to euthanasia regarding life quality in social medicine, and the reasonable utilization of resources in health economics, and cannot decide whether patients approaching life-end should choose death or senseless survival with mental and physical suffering. Even the best hospice can not remove the extreme pain suffered by dying patients. Scientific and reasonable euthanasia is the most important link in satisfying dying patients' wishes, approaching death without pity or pain, improving our valuation of death and the quality of lifefs end. It is based on sufficient knowledge of self-value and death, based on calm confrontation with death and voluntary acceptance of death. Terminal care can not face patients at ease, also can not face the sensitive, realistic and important problem that advanced stage incurable patients and their relatives apply for termination of patients' lives sensibly and voluntarily. To brain death patients, terminal care appears even more senseless and worthless.
The dying patients themselves are the objects of terminal care, while their families are less important in this case. Death, to a degree, is not a misfortune to the dead, and also not a misfortune to the living. It depends on the situation in each case and the attitude people share. We often hear that we should accept and face death bravely, but as far as terminal care is concerned, we have over-stressed the misfortune death brings to the dead and the living. It is impossible to avoid death which every human being will experience sooner or later. As for many dying people and their relatives, death is not the beginning of suffering but the beginning of freedom from suffering. The greatest pain dying patients and their relatives suffer is the never-ending stalling of death. In addition, were the chief attention to be paid to the relatives in terminal care, what should we do when confronted with the relatives of those who die of emergencies or accidents, who theoretically should have been consoled and paid attention to, since they are filled with great sorrow for the sudden death of their family members, without any mental and psychological preparation. However, this particular group is still being neglected in terminal care. Indeed, in the field of medicine at lifefs end there are still a number of problems waiting to be solved, both theoretical and practical.
Qiu Renzong: Study of Human Body and Ethics: Chinese Views, Bulletin of Natural Dialectics, (3): 33, 1993.
H. Tristram Engelhardt: The Foundations of Bioethics (Chinese), Human Publishing House of Science and Technology, 1996.
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