BIOLOGICAL DEATH

Total cellular death = decay

CARDIO-PULMONARY DEATH
Total and irreversible cessation of cardiac
and respiratory functions
WHOLE BRAIN DEATH
Total and irreversible cessation of all brain
functions, including brainstem
RESPIRATORY DEATH
Total and irreversible cessation of
respiration
CEREBRAL DEATH
Total and irreversible cessation of cerebral
function

 The only scientific/medical

definition
Accepted in the 18th century
because of medical errors in
establishing death
Currently unacceptable anywhere

 From a medical point of view

arbitrary definition
The most established definition
throughout the ages
Currently most people die with this
definition
Conceptually functions associated
with life: breathing and circulation;
body appears dead (cold, no vital
signs on monitors)

 From a medical point of view arbitrary

definition
Relatively new definition
Initially defined to satisfy needs (i.e., ICU, organ
transplantation)
Conceptually the seat of integration of the
organism; and the seat of mental and
vegetative functions
Currently accepted by all legal systems
throughout the world
Currently strongly debatable among Halachic
authorities and minority of physicians and
cultures

 From a medical point of view arbitrary

definition
Requires proof of irreversibility, either
cardiac or brainstem
Currently integral part of whole brain
death definition
Conceptually respiration is the
inherent sign of life
Currently strongly debatable among
Halachic authorities and minority of
physicians and cultures

 From a medical point of view

arbitrary definition
Currently unacceptable by any
legal system
Conceptually human being is
distinguished by cerebral
manifestations
Problems classic signs of life
present; slippery slope

WHY EXACT DEFINITION?

LEGAL / HALAKHIC

Burial
Treating on the Sabbath
Mourning
Inheritance
Murder
MEDICAL
ICU
Organ transplantation

The 18th century

Uncertainty of the diagnosis of death

Law of the land in Prussia
Moses
The halachic dispute: R. Moses Mendelss
ohn
Mendelson
1729-)
R. Yaakov Emden (1786

R. Moshe Sofer

Moses
Mendelssohn
(1729-1786)

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SAVED BY THE BELL !

IMPROVED BURIAL-CASE
US Patent No. 81,437

Issued: August 25, 1868

Inventor: Franz Vester, Newark NJ

The nature of this invention consists in placing on the lid of the "
coffin, and directly over the face of the body laid therein, a
square tube, which extends from the coffin up through and over
the surface of the grave, said tube containing a ladder and a
cord, one end of said cord being placed in the hand of the person
laid in the coffin, and the other end of said cord being attached to
a bell on the top of the square tube, so that, should a person be
interred ere life is extinct, he can, on recovery to consciousness,
ascend from the grave and the coffin by the ladder; or, if not able
to ascend by said ladder, ring the bell, thereby giving an alarm,
and thus save himself from premature burial and death; and if, on
inspection, life is extinct, the tube is withdrawn, the sliding door
..."closed, and the tube used for a similar purpose

The 20

th

century

ICUs
Organ transplantations
Development of whole brain death
criteria:
1959 - Mollaret irreversible coma
1967 - Christian Barnard
1968 - Harvard criteria
1981 Presidents commission
Current criteria
Heated halachic debate:
Israel
USA

HISTORIC ISSUES
Christiaan Barnard heart transplant
1967-68 Harvard criteria 1968
First heart transplant on December 3rd 1967 in
South Africa Dr. Christiaan Barnard transplanted
a heart taken from a car accident victim (Denise
Darvall) to a patient (Louis Washkansky, Jew).
Second heart transplant on January 2nd 1968 by
Barnard, from a black man (Clive Haupt) who
collapsed a day earlier to a patient (Philip
Blaiberg, Jew).
These transplants were performed before clear
criteria have been established.

Dr. Christiaan Barnard

Normal brain

Brain stem

Cardiac center-
Vasomotor center-
Respiratory center-
i.e. VITAL centers

MEDICAL CRITERIA
PRE-REQUISITE
Known etiology (i.e., trauma, anoxia, tumor)
No reversible underlying conditions (i.e.,
hypothermia, hypotension, CNS depressants,
metabolic disturbances)
CLINICAL
Coma (GCS=3)
Absent brainstem reflexes (i.e., pupils, corneal,
gag, cold caloric)
Absent spontaneous respirations (apnea test)
CONFIRMATORY TESTS
Absent blood flow (TCD, MRA, Scan, Angiography)
Absent brainstem electrical activity (BAER, SEP)

ETIOLOGY

Consequenceofseverebraindamage

Cerebral edema

CLINICAL
TESTS

Glasgow Coma
Scale

No response of both pupils to bright light

Do NOT have to be fully dilated (most mid)

Dolls eye oculo-cephalic reflex

Eyesmoveinrelationtohead
Indicatespositivedollseyes=normalresponse
Absentdollseyes=brainstemdamage

Oculo-vestibular
reflex

clottedbloodorwax
maybluntresponse
headat300-
50cccoldwaterwait60secforresponse-

APNEA TEST

Continuous monitoring of BP-

.and saturation
Measure paCO2 prior to test-

Preoxygenate for
10 minutes with
100% oxygen

Detached from-
ventilator
- Oxygen given at
3 - 6L/min

Watch for any

evidence of breathing
chest, abdomen,
monitor

pCO2 increases
3 mmHg/min
Breathing occurs
early

CONFIRMATO
RY TESTS

Transcranial doppler =
TCD
sensitivity 91 99%
Portable, bedside procedure
probe at temporal bone above
zygomatic arch or vertebrobasilar
arteries
must show lack of diastolic or
reverberating flow and documentation
of small systolic peaks
complete absence of flow NOT reliable
as suggests technical problem

Carotid angiogram

Radionuclide angiogram
Normal perfusion

Brain death absent flow

BASIC HALAKHIC
SOURCES
Bavli Yoma 85a / Yerushalmi Yuma 8:4
collapsed building; verifying the moment
of death nostril / heart / navel
Maimonides Shabbat 2:18-19
Shulchan Aruch Orach Chayim 329:3-4
Responsa Chacham Zvi - #77
Responsa Chatam Sofer Yore Deah
#338


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HEART
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or

HALACHIC POSITIONS
Biological death universally unacceptable
(halachically - unlawful delaying of burial)
Cardio-pulmonary death R. Eliashiv, R.
Wasner,
R. Waldenberg
Brain death R. Auerbach
Respiratory death (confirmed by either
brain death or cardiac death) R.
Feinstein, Chief rabbinate of Israel, R.
Goldberg, R. Yosef, R. Sternbuch
Cerebral death universally unacceptable
(defined alive by all halachic authorities)

HALACHIC POSITIONS
(CONT)
BASIC POSITIONS vs CONFINING
FACTORS
Reliability (=scientifically) of
diagnosis
Reliability (=distrust) of physicians


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Brain-Respiratory Death
Act-2008

NEW ISRAELI LEGISLATION

Accepted March 24 2008

Procedural aspects:
Two expert physicians, specified medical fields (list of
medical fields attached), uninvolved in the treatment of
the person, or organ transplantations
A medical-public committee responsible for the training
and education of the physicians, and for inspection and
control (10 members physicians, Rabbis, lay experts)
Medical aspects:
Prerequisites, clinical criteria, and confirmatory tests in
all cases (list of the tests attached)
Legal aspects:
Medically confirmed whole brain death according to this
law is the legal moment of death
Family members are entitled to obtain all the medical
information for consultation
Families who reject brain death on religious ground can
request to continue artificial respiration until cardiac
arrest

NEW ISRAELI LEGISLATION

Interpretation

BASIC POSITIONS
Fundamental legal acceptance of
respiratory/whole brain death criteria as the
moment of death
Allowing continuous respiratory support to
those who do not accept brain death criteria

CONFINING FACTORS
Reliability (=scientifically) of diagnosis: Strict
medical criteria + objective confirmatory
tests in every case
Reliability (=distrust) of physicians: Training
and supervisory public committee; Specified
physicians; Ad hoc consultation with Rabbi

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ZTL
APPROVES NEW DONOR
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