liminal 🦠 on Nostr: Great piece BrianAppavu! We need more critical discussions like this, and that's what ...

Great piece BrianAppavu (nprofile…m2wf)! We need more critical discussions like this, and that's what MedSchlr (nprofile…ndkz) is working towards.

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A recent New York Times guest essay by Drs. Sandeep Jauhar, Snehal Patel, and Deane Smith has stirred significant discussion:

“A Simple Change in the Definition of Death Could Save Lives” (NYT, July 30, 2025)

In this piece, the authors argue for a redefinition of brain death—a topic that demands rigorous scrutiny, not only because of its implications for organ donation, but because it touches on fundamental truths about life, death, and consciousness.

As a critical care neurologist who has spent the better part of the past decade assessing brain death in children with catastrophic brain injuries, I understand how devastating these situations are. I also lead research funded to investigate covert consciousness, and I carry a longstanding personal interest in the philosophy of the mind. For these reasons, I feel compelled to critically examine the proposal set forth in this essay.

Understanding Death by Neurologic Criteria

The authors correctly state that there are two pathways for declaring death in modern medicine: (1) irreversible cessation of circulatory and respiratory function, and (2) irreversible cessation of all functions of the brain, including the brainstem—commonly referred to as brain death or death by neurologic criteria (DNC).

They omit, however, the rigorous standard that defines DNC. According to the American Academy of Neurology (AAN), DNC is "the permanent loss of all function of the entire brain, including the brainstem, in a patient who has sustained catastrophic brain injury." This is not a casual diagnosis. It requires a meticulous exclusion of confounding factors such as metabolic derangements or sedative pharmacotherapy, an established mechanism of catastrophic brain injury, and a detailed neurologic exam demonstrating:

1. Unresponsiveness to external stimuli

2. Fixed, non-reactive pupils

3. Absence of brainstem reflexes (corneal, gag, cough, oculocephalic, and oculovestibular)

4. Absence of motor responses to pain

5. No spontaneous respirations during an apnea test

When parts of this examination cannot be safely performed, ancillary tests such as SPECT imaging may assess cerebral blood flow. While these tests don’t directly assess brain function, they support the diagnosis.

Importantly, when performed properly, a brain death exam has never been shown to result in a false declaration of death. Errors that have occurred are attributable to improper execution, but not when the exam is performed rigorously and appropriately.

Organ Donation and Normothermic Regional Perfusion

The authors highlight a genuine and urgent issue: the shortage of viable organs for transplantation. While donation after circulatory death (DCD) is an established pathway, organs procured via this route are often suboptimal. This has led to increasing interest in a technique called normothermic regional perfusion (NRP), where circulation is briefly restored to preserve organs after DCD.

Critics of NRP argue that reviving circulation—even artificially—after death by circulatory criteria undermines the determination of death itself. The ethical tension here is real. But it does not justify redefining brain death as a workaround to increase organ supply.

Conflating Coma with Brain Death

At the heart of the authors’ proposal lies a deeply problematic shift: they suggest redefining brain death to mean “irreversible coma” or “no chance of meaningful recovery.” This reframing is misleading on both scientific and philosophical grounds.

Death by circulatory arrest does not exclusively occur in irreversible coma. Patients may choose to withdraw life-sustaining therapy due to other medical conditions—advanced cancer, irreversible lung disease, multiorgan failure, or perception of a future quality of life that is not desired—while remaining conscious. To equate circulatory death with irreversible coma is both inaccurate and reductive.

Predicting recovery from coma remains imprecise. Despite advances in neuroimaging and biomarkers, no single test reliably predicts functional recovery after coma. Numerous guidelines emphasize this uncertainty, and recent efforts—such as the Neurocritical Care Society’s Curing Coma Campaign—aim to fill these gap.

Moreover, studies show that withdrawal of life support based on poor prognoses can itself be a self-fulfilling prophecy, leading to death in patients who might have recovered if care had continued. One recent 2025 study in JAMA Network Open found that nearly 64% of patients who died following WLST after cardiac arrest might have had potential for recovery.

Consciousness: Still a Mystery

Despite centuries of exploration, consciousness remains poorly understood. While neuroscience has given us powerful theories—global neuronal workspace theory, integrated information theory, and others—we still lack a unified model that explains the subjective experience.

Descartes’ famous dictum—Cogito, ergo sum (“I think, therefore I am”)—remains a philosophical foundation. Materialist science has expanded our grasp of the neural correlates of consciousness, but in the neurocritical care unit, we continue to encounter phenomena that challenge our understanding.

Covert consciousness, or cognitive motor dissociation (CMD), exemplifies this. Patients who appear behaviorally unresponsive may show willful brain activation on EEG or fMRI, or detect patterns of stimuli in passive paradigms.

The use of EEG or fMRI to detect covert consciousness in the ICU is still largely in the experimental realm, and not used as standard of care across the United States. Emerging research has identified that biomarkers of covert consciousness are associated with recovery in some patients, but are imperfect and susceptible to false negatives. This underscores how limited these emerging tools are, at present day, in detecting residual consciousness.

If we struggle to detect consciousness reliably in real time, how can we redefine death based on irreversible unconsciousness?

The Philosophical Error: Hume’s Guillotine

In A Treatise of Human Nature, philosopher David Hume warned against deriving normative claims (“ought”) from descriptive facts (“is”). This logical fallacy—later called “Hume’s Guillotine”—applies directly here.

The authors observe a factual problem: not enough organs for transplantation. From this, they propose a moral imperative: redefine death. But this leap lacks logical coherence. The truth of a biological definition cannot be subordinated to a utilitarian goal, no matter how pressing.

As Bertrand Russell put it in The Problems of Philosophy:

“The truth or falsehood of a belief depends upon whether the belief corresponds to a fact, not upon any other circumstances, however useful the belief may be.”

We must not conflate utility with truth.

Rebuilding Trust in Medicine

In the aftermath of the COVID-19 pandemic, public trust in the medical profession has declined. Surveys show increased skepticism toward physicians and healthcare systems. One contributor to this distrust is the perception that clinicians prioritize institutional goals over patient autonomy and transparency.

Proposals like this—however intentioned—risk reinforcing that perception. Rewriting the definition of death for the sake of utility is fundamentally manipulative and compromises the ability of clinicians to maintain long-term trust with the patients they serve. We must ground our clinical practice in truth, not utility.

The organ shortage is a legitimate problem worthy of solving. Clinicians and the public are likely to come that consensus, if faced openly and honestly. This problem must be addressed ethically, transparently, and without compromising foundational definitions that underpin our responsibilities as physicians and scientists.

Disclaimer: The views and opinions expressed in this post are solely my own and do not represent those of my employer or any organization with which I am affiliated. This content is intended for informational purposes only and should not be considered medical advice. Please consult a qualified healthcare professional for any medical concerns or decisions.

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