Sonny Dhanani is pediatric critical care physician in Ottawa and is a researcher in death determination.
Ontario Superior Court Justice Lucille Shaw released her long overdue decision this week in the case of a young Brampton woman pronounced dead in September, 2017, six months after closing arguments ended. Shaw concluded that Taquisha McKitty, 27, is in fact dead, rejecting arguments presented by her family that she was alive and had the right to continuing mechanical life support.
Justice Shaw determined that this woman died last September when doctors determined her brain had irreversibly ceased to function. While the wait was painful for everyone, Justice Shaw’s decision was clear: People need and deserve to know with simplicity, clarity and consistency when their family member is dead. At the heart of this ruling is the principle that identifying death has to be carried out in the same manner for all people in society, even if people choose to understand life in different ways.
Why do we need a common definition of death, if we might have different ideas about the nature of life? Some cultures believe that the essence of life is in the air moving in and out of our lungs; others believe that our soul resides in our heart; and still others believe that we exist by virtue of our brain’s ability to interact with the world.
If individuals can choose their own understanding of life, then why must they accept a common understanding of death? Justice Shaw answered this question clearly: With modern critical care, a line must be drawn where death is objectively determined.
Critical care has achieved increasing successes in its mission to keep people alive. The nurses, doctors and caregivers who work in critical care units cherish life. Almost all of our bodily functions can at some point be supported, and even replaced by medicines and technology. For example, dialysis machines replace the key functions of our kidneys, while potent medications can keep fledgling hearts beating. In fact, many people are living having received transplantation of these organs. Whether by machine or transplant, when these organs are replaced, bodily functions can continue indefinitely.
But at the core of this intensive support is the preservation of the brain.
When brain death occurs, there is no blood and oxygen going to it. The brain ceases all function. There are no functions left to be lost. This means there is the irreversible loss of any ability to have thoughts or feelings or memories. There is the irreversible loss of brain-stem functions such as blinking, coughing, and breathing. In this situation, to support or replace the functions of other vital organs, such as the lungs, would lead to a never-ending loop of biochemical reactions without purpose, and the pursuit of organ replacement activities only because they are possible to do.
The tragedy is that the person, their identity and their agency will never return; but without a clear and uniform definition of death, we would be unable to ever say that they have died. It is the permanent loss of the person through the irreversible loss of all brain function that we collectively define as death, and determining this is well established in science.
We know that we can donate organs after death, and the function of these organs persists in others’ bodies. We know we can keep blood cells alive and other tissues functioning, well after a person has died. While we can say that a person’s legacy or tissues “live on,” this is not to be confused with the recognition that the person has died.
None of us, family or caregivers, wants people to die. But all of us want to know when death has occurred. With the availability of modern critical care, brain death has become the ultimate definition of death that allows families to turn their focus to grieving. Many are more accepting of a stopped heart signifying death; this is congruent with this definition, as brain death will quickly follow cardiac death from a lack of circulating oxygenated blood.
The critical-care community is thankful for Justice Shaw’s decision, because people deserve to know when death occurs. Death itself is a certainty, and to remove the certainty of when it occurs is simply to perpetuate the avoidance of its reality. Critical care advances have saved many lives, but we cannot allow the existence of technological care to prevent us from knowing when someone has died. Modern medicine requires that we understand its limits together.