CHAPTER THREE | 37

Bedside tests that establish loss of all brainstem reflexes can show
that the destructive storm has indeed run its course, because the
brainstem is often the last structure to be compromised in this
process. Confirmatory tests and, in particular, various sorts of an-
giography (measurements of cranial blood flow) can be very useful
in confirming that the gross infarction that is required for a diagno-
sis of total brain failure has actually occurred.11

At this point, it is important to take note of some qualifications re-

garding the word “total” in the context of total brain failure. O ne
medically based objection to the neurological standard for deter-
mining death is based on a particular understanding of this word.
Critics point out that the destructive storm that leads to “total”
brain failure can leave certain areas of the brain intact. Again, from
the description provided by Shewmon:

It should be mentioned that the self-destruction of the

brain is not complete. Islands of sick but not totally ne-
crosed brain tissue sometimes remain, presumably due to
inhomogeneities of intracranial pressure and/ or blood
supply from extracranial collateral vessels.12

When the preserved areas of the brain do not support any recogniz-
able function, this lack of total anatomical annihilation is less
troubling. As the President’s Commission noted in its report, the
neurological standard for death requires an irreversible loss of all
brain functions, not complete anatomical destruction of the tissue.13
Isolated metabolic or electrical activity in dispersed cells cannot be a
sign that a patient is still alive; after all, such activity, supporting no
function of the whole organism, can continue even in some cells of
a corpse after the heart has stopped beating.

As critics have pointed out, however, the physiological facts are not
so simple.14 In some cases, the preserved tissue in a body with total
brain failure actually does support certain isolated functions of the
brain. Most notably, some patients with total brain failure do not
exhibit the condition known as “diabetes insipidus.” This condition
develops when a hormone known as AD H (anti-diuretic hormone)
is not released by a part of the brain known as “the posterior pitui-
38 | CO NTRO VERSIES IN THE D ETERMINATIO N O F D EATH

tary.” The absence of diabetes insipidus suggests that the “dead”

brain is continuing to secrete the hormone; thus, at least with regard
to this one function, the brain remains functional. It is therefore a
fair criticism of the neurological standard, as enshrined in the
UD D A, that “all functions of the entire brain, including the brain-
stem” are not, in fact, always irreversibly lost when the diagnosis is
made. *

It may be helpful to emphasize that the word “total” in the

phrase,“total brain failure,” refers to the fact that the brain injury
has reached the endpoint of a process of self-perpetuating destruction
of neural tissue. In any event, whether or not the word “total” is
justified, the patient diagnosed with total brain failure is in a condi-
tion of profound incapacity, diagnostically distinct from all other
cases of severe injury. Whether this state of profound incapacity
warrants a determination of death remains a matter of debate, with
advocates of the neurological standard arguing that it does, while
critics maintain that it does not. The release of AD H and other
signs of isolated brain function do not settle the fundamental issue:
Is the organism as a whole still present?

IV. Total Brain Failure: “H ealth” and “Prognosis”

Contemporary controversies about total brain failure as a suitable

standard for human death focus attention on certain medical find-
ings and on conclusions drawn from these findings by critics of
today’s practice. In this part, we will examine two important types
of such findings which are often cited as highly relevant to the de-
bate.

* Researchers suspect that function in the posterior pituitary is preserved partly

because its (extradural) arterial source is distinct from that which feeds other tis-
sue of the brain. The damage that is due to the rise in intracranial pressure, which
leads to total brain failure, can spare these extradural arteries so that a portion of
pituitary is preserved. For discussion of this point, see E. F. Wijdicks and J. L.
Atkinson, “Pathophysiologic Responses to Brain D eath,” in Brain D eath, ed. E. F.
Wijdicks (Philadelphia: Lippincott Williams & Wilkins, 2001).