A Challenging Discussion on the Issues/Definition of Brain Death with Pathologist/Bioethicist Dr. Doyen Nguyen

When does life truly end? It's a question that echoes through the halls of medical institutions and tugs at the heartstrings of families facing loss. Dr. Doyen Nguyen, a pathologist with a rich background in bioethics, joins us to unravel the complexities of brain death—a concept that has reshaped our understanding of mortality and sparked an ongoing debate in both medical and ethical spheres. Her penetrating insights challenge the status quo and provide a fresh perspective on what it means to be truly alive or dead.

As we navigate the turbulent waters of medical definitions and ethical dilemmas, Dr. Nguyen steers us through the history and evolution of death's criteria, starting from the time-honored signs of heart and respiratory cessation to the contemporary, yet contentious, concept of brain death. This journey is not just clinical; it's laden with the emotional gravity of real-life stories, such as the heart-wrenching narrative of a mother's regret after her son's organs were donated following a brain death diagnosis. These stories underscore the profound impact of medical categorizations on individuals and their loved ones, emphasizing the necessity for clear communication and informed consent in the process of organ donation.

Stepping beyond the confines of conventional healthcare, our conversation with Dr. Nguyen illuminates the intersections where medicine meets faith, ethics, and the essence of human existence. Our exploration extends an invitation to listeners to engage with these critical questions and to join us on a path that transcends the physical, touching the spiritual and emotional dimensions of well-being. For those eager to delve deeper into these discussions, we welcome you to connect with us and continue this important dialogue at JacksonFamilyMinistry.com.

https://www.jacksonfamilyministry.com

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Transcript

Speaker 1: 0:04

Welcome to More Than Medicine, where Jesus is more than enough for the ills that plague our culture and our country. Hosted by author and physician, dr Robert Jackson, and his wife Carlotta and daughter Hannah Miller. So listen up, because the doctor is in.

Speaker 2: 0:23

Welcome to More Than Medicine. I'm your host, dr Robert Jackson, bringing to you biblical insights and stories from the country doctor's rusty, dusty scrapbook. Well, I'm privileged today to have a very special guest on the phone with me today, all the way from Portugal, and my guest is Dr Doyen Nguyen, and she is both a pathologist and a bioethicist, if I'm saying it correctly. And Dr Nguyen, welcome to More Than Medicine.

Speaker 3: 1:00

Yes, thank you, dr Jackson.

Speaker 2: 1:04

Well, tell my listeners a little bit about yourself and about your medical training and about your credentials.

Speaker 3: 1:12

Right, okay, very quickly. I did my undergrad pre-med studies at West Shetter State College in Pennsylvania it's now a university. Then I went to Temple University Medical School in Philadelphia where I did six months of rotation in neurosurgery and neurology during my last year of medical school.

Speaker 3: 1:30

I got my MD degree in 1981. Then I did one year of general surgery internship at the Mayo Clinic and I had health problems with low blood pressure so I had to switch to pathology residency. I did that at UCLA and then I went on with hematopathology fellowship at the University of Southern California. After two years of private practice with a group, I worked on research project in diagnostic hematology with my husband he was also an MD. We are both now retired and we were invited to university hospitals in Paris, france, in Cologne, in Germany and London, england, and so we stayed in academic medicine until around 2007 when I left medicine to study Catholic theology, first at Franciscan University of Stubbornville and then at the Pungtypico University of St Thomas Aquinas in Rome, where I obtained my STD. Std stands for Sacred Theology Doctorate, and I did it in moral theology. So now, when you put medicine together with moral theology, what you get is obviously bioethics, and my doctoral work was on the issue of brain death, and most of my subsequent publications are also on the same issue.

Speaker 2: 2:58

Man, that's a mouthful. Well now, Dr Nguyen, I read with great interest an article that you provided for the Journal of American Physicians and Surgeons entitled Brain Death what Physicians Need to Know, and I understood immediately the practical implications for Christian physicians in understanding a precise definition of brain death. So why is a clear understanding of brain death important to physicians and also the non-medical public, like my listening audience?

Speaker 3: 3:38

Well, it's important because, as you will see I will see by the end of this podcast brain death is not a true death. If I put it very bluntly, a patient who is diagnosed brain death is actually still alive. Now, that person who is actually supported by the ventilator may be a death door, but, mind you, dying is not death, and many of these people, especially if they are with a desirable age group 30, 40, 50 years old, with good organs they will be asked to become organ donors, and so the question of hand that we have is brain death donors really truly death?

Speaker 2: 4:26

I understand that and the implications become immediately obvious both to me and to my listeners. Well, now the follow-up question is why is determining death a complicated issue when I was a resident and when you were a resident, all at the same time? We graduated medical school, both in 1981. I routinely visited the bedside of patients who had expired.

Speaker 2: 4:52

When I was on call, I listened for a heartbeat and spontaneous respirations, and if both were absent, I declared them legally dead. What has changed, Dr Nguyen, in the definition of death, especially as it relates now to brain death?

Speaker 3: 5:12

All right, this is a rather complicated question, but I will try to answer my best here. I mean it's a complicated issue because none of us want to be declared dead prematurely. All right, now. Maybe everybody already knows the story of Edgar Allen Paul, the short story, the premature burial Right Now, today, we already eliminate the risk of being buried alive. But what about being declared dead prematurely for some other purpose, right? So before I touch on the issue of brain death, let's first answer the medical question what is death? What is the medical definition of death?

Speaker 3: 5:53

So, scientifically speaking, death is a biological phenomenon and, as such, it should apply equally to related species. What do I mean? Humans? We, okay, we are mammals just like warm blood mammals, just like cats and dogs and cows and horses. So when we talk about the death of human being, we mean the same thing as we do when we talk about the death of a dog or a cat.

Speaker 3: 6:26

Now, the biological phenomenon of death presents itself with a constellation of very recognizable signs, and these signs indicate that a person has died okay, and that the corpse after death is now slowly disintegrating. This process of disintegration starts within minutes of true death. Now look at us. We are living human body. We produce body heat and so we are pink, our body is pink and warm. A corpse you know, I use a corpse instead of a dead body, all right. I mean a corpse cannot produce any energy, so it's temperature okay.

Speaker 3: 7:11

Right after the person died, the corpse, the temperature of the corpse is dropped rapidly to the level of the ambient temperature, right, and so this is why a corpse is cold and gray. And then there are other signs like, especially the fingers. The hands would become extremely rigid within two or three hours and if you let the corpse out in room temperature within two or three days it would beautify and spink. Now, before the widespread clinical practice of brain death, the medical definition of death is based on this. It is based on the cessation of all vital functions of the body, and this is evidenced by the absence of heart beat and respiration beyond the possibility of reccitation. So this is why you and I were residents. When we got morning rounds, it was not infrequent that we found some patients who happened to die a few hours before we did our rounds.

Speaker 3: 8:23

They died in their sleep, so there was no heart beat no breathing there were cold and gray, and often we kind of see a liquid coming out of their eyes. That's the liquid effect, the liquid fraction of the vitreous in the body of the eyes. And then basically, I just answer you that question why is it determining that complicated issue? Because we do not want to call somebody who is dying, who is still alive, dead. So the thing I just described in a simple word describe somebody who is truly dead, cold and gray.

Speaker 2: 9:06

That's correct, okay. Well now what has changed? I mean since you and I were in medical school. Now things are more complex. And what has changed about that definition of death, especially as it relates to brain death?

Speaker 3: 9:21

So what happened was in 1968, this is what happened. It was introduced. The concept of brain death, as well as the determination of brain death, was introduced by the Athok Harvard committee, okay, introduced into the clinical practice by publishing the Harvard report. Now, in the opening sentence of the report, the committee said this our primary purpose is to define irreversible coma as a new criterion for death. Now, anybody who reads this sentence very slowly, like I just did, who recognizes what you are now calling irreversible coma death. But you know, let's say this I am calling a cat a dog. Does that make the cat a dog?

Speaker 2: 10:15

No, ma'am, it does not.

Speaker 3: 10:17

Okay.

Speaker 3: 10:18

So by this sentence alone, it clearly indicates what brain death truly is. It is none other than a state of very, very deep coma. Now, a state of coma that is deemed is considered to be irreversible based on a set of diagnostic criteria that were set forth by the committee. Now, this was set forth completely arbitrarily. Okay, these criteria, the diagnostic criteria, consist of clinical tests performed at the backside, and it consists of the following A coma with complete unresponsiveness even to the most painful stimuli. Okay.

Speaker 3: 11:02

So, absence of brainstem reflexes. I do not want to go into the technical detail, but, for example, a gag reflex is a brainstem reflex, an eye blinking reflex is a brainstem reflex. Okay, and the criteria number three is what they call apnea. Apnea is a technical term to say that there is absence of spontaneous breathing, right? So what happened is that when you want to do the apnea test, these comatose patients, obviously they need ventilatory support, they need to support the ventilator. So when I want to do the apnea test, what I do is I pull the ventilator away from them, I disconnect them from the ventilator and they, if they fail in the apnea test, mean that they do not demonstrate any spontaneous breathing.

Speaker 3: 11:51

Now, there are no need to go into the technical detail of these clinical tests for the determination of brain death, but there are two important points. Number one all of these tests only test the brainstem. Our brain has more than a brainstem. Our brain has two cerebral hemispheres okay, and then the brainstem okay. So the test, the clinical bedside test, do not test the whole brain, all right.

Speaker 3: 12:23

And number two is that the brain is not the organ that is responsible for the life of the body. And now, before 1968, what is the definition of death? I mean, the definition of death is based on the cessation of all vital functions. All right, as evidenced by the absence of heartbeat and respiration, and obviously cold and gray, as I mentioned a little bit earlier.

Speaker 2: 13:04

All right, we'll go to question five. Was there any new scientific data applied to the new definition of brain death that was proposed by the Harvard committee around that time?

Speaker 3: 13:16

All right. So the paper absolutely contained no scientific data whatsoever. I mean, it's like I say, I mean it's just a declaration. We decided to redefine irreversible coma as a new definition of death. Right, and there was no scientific data. Now, as you know, we all know in medicine that before you introduce a new drug, a new vaccine, a new therapy, a new diagnostic paradigm, a new diagnostic step, we have to go through several steps of validation. First of all, we have to scientifically validate it on animal studies, and then we validate it on human studies. Well, the introduction of brain death went through none of these things whatsoever. The paper only had one reference, something of a statement of Pope Pius XII. I, absolutely no other reference. All right, so the brain death literally was introduced into the clinical practice as if it were coming down to us in two tablets.

Speaker 2: 14:38

I got you, like the 10 Commandments. Yes, yes, oh, my goodness. Well, this was just totally an arbitrary opinion of multiple neurologists on this committee.

Speaker 3: 14:50

Yeah, Of the 13 members of the committee. Now, most of the members of the committees were transplant surgeons. The chairman of the committee, henry Bitcher, was an histiologist, and several of them were transplant surgeons.

Speaker 2: 15:10

Okay, Well, that to me implies severe conflict of interest.

Speaker 3: 15:17

Yes, yes, exactly it does.

Speaker 2: 15:20

It really does Now. So, looking at this from an objective outside perspective, what do you think was a real underlying reason for the committees wanting to redefine brain death?

Speaker 3: 15:34

Okay, this is a very interesting question, you know. I mean by the time I will go a little bit of how the concept of brain death come about. Okay, because think of it as, like the pregnancy, the gestation of brain death.

Speaker 2: 15:50

Okay.

Speaker 3: 15:51

And by the time it comes to the clinical practice, it's like the birth of brain death, right, okay. So actually, you know, prior to the birth of brain death in 1959, we had a paper by two French neurologists. Their name are Molleray and Goulon, okay, and they describe 23 patients with a new type of coma complete unresponsiveness to any stimuli, absence of brain stem reflex and lack of spontaneous breathing. Right, and then, but did they call these people dead? No, they support these patients until when the patient progress to cardiovascular collapse. That is when they have stopped beating. That's it. Normally it may take one week, two weeks or maybe even as a month, okay, and all of the described features that they describe in their 1959 paper later on was called by the Harvard committee brain death. Okay, now, the Harvard committee considered these patients with these kind of symptoms as death, where Molleray and Goulon say no, okay, they say we cannot call these people dead, right, so that's the first thing.

Speaker 3: 17:06

And then in 1966, there was a Siba Foundation Symposium in 1966. And at that time we started having transplants, basically a transplantation of kidney, right, and we use kidneys from truly dead, from cadavers, right, you know, I mean dead after maybe one hour. Now, most of these transplants do not function for a long time. They got either rejection or they fail within weeks, months or maybe at most one year. Okay, so the transplants surgeon. What they want to is they need to expand the recipient pool, because at that time we also had what we call a transplantation of kidney from living related donors.

Speaker 2: 18:01

Okay.

Speaker 3: 18:02

The organs from cadaveric, from that donor, that donor truly through death? Okay, that time we didn't have brain death yet it's very poor. But the quality of kidney from living related donors are very good, okay, but how many living related donors can you find? Okay, so we had the Siba Foundation sponsored symposium in London, and you know. So what was the main issue on the agenda? The issue I'm quoting the issue need to be confronted in order to increase the efficacy of the transplant procedure. Okay, so that was the reason. So what happened was in this, in this symposium, right, there were many people who said well, you know, we'll have to use organs of patients who are comatose and who never wake up, the irrevisibly comatose patients and these kind of patients. You know what they are called. They are called heart lung preparation.

Speaker 2: 19:10

Oh.

Speaker 3: 19:10

That's how you call them Heart lung preparation.

Speaker 2: 19:14

Okay.

Speaker 3: 19:15

They're also called living cadavers.

Speaker 2: 19:18

Living cadavers. Oh they, you see, that's a euphemism.

Speaker 3: 19:23

Oh, yes, I know. Okay, all right, but you already know that right there, there's an intention of doing something to use comatose patients. Then the third thing that happened was a very, very well-known Christian Barnard. First heart transplant, right. So, christian Barnard, he took the heart from a young woman already declared brain dead by neurosurgeon this was in South Africa, right and he transplanted to a recipient and the recipient died 18 days later from extensive bilateral pneumonia. But Barnard's operation was held throughout the world as a major medical triumph. Okay, great, now we can go and do heart transplant.

Speaker 3: 20:14

So that was in December, december of 1967. So guess what happened? Within less than a month, the Harvard Medical School called for an ad hoc committee, all right, to start working on this brain death and that work completely behind closed doors, all right. And then, if you go to, if you have access to the Beecher manuscripts the Beecher manuscript are preserved at the Francis Countway Library of Medicine at Harvard and the records are closed to the public, but for medical historians they can have access to it if they have some introductory letter, anyway. So in the Beecher's manuscript you have correspondence between the members of the Harvard, of the Harvard committee. You also have the draft before the final report. And you know, when you read the correspondence and the draft, what you see is that the real intention for introducing brain death is organ transplantation. And actually John Murray, one of the members on the Harvard committee. He attended the Siba Foundation. Okay, and he insists at the Siba Foundation that we should do something with these comatose people, all right, I understand, I see where this is going.

Speaker 3: 21:52

Yep, all right. So let me you know like, for instance, like Murray, joseph Murray, he wrote. He wrote to Beecher, henry Beecher, the chairman of the Harvard committee. He said patients are stuck up in every hospital in Boston and all over the world are waiting for suitable donor kidneys. At the same time, patients are being brought in debt to emergency wards and potentially useful kidneys are being discarded. All right. And then, like in the conclusion of the first draft of the Harvard report in April 11, 1968, you can read this paragraph the question before this committee cannot be simply to define brain death. This would not advance the cause of organ transplantation, since it would not cope with the essential issue of when the surgical team is authorized legally, morally and medically in removing a vital organ.

Speaker 2: 23:01

All right, I'm just reading, I'm not making any comments.

Speaker 3: 23:04

And then you have. Let me see another language of the manuscript draft. On June, the 3rd, this draft read with increased experience and knowledge and development in the field of transplantation. There is great need for the tissues and organs of the hopelessly comatose in order to restore to health those who are still salvageable. I think the intention is clear. Yeah.

Speaker 2: 23:32

The intention is very clear.

Speaker 3: 23:34

Yeah, and so what happened? But none of these things made it through the final report because you cannot write in like what, like that you know the public, it would have a major alkyd Republic, right. So the introduction paragraph was very well veiled. Okay, say these comatose patients present a burden to the family, you know. So we have to declare them that right. But they also say there's a burden to the hospital because these patients they occupy beds and there are other patients who need beds. So here you see a utilitarian reason Exactly right, anyway.

Speaker 3: 24:14

So the Harvard report did not give any any real logical what I say philosophical rational to support why brain death should be a new definition of death. And for this we have to wait until 1981, when we had the president commissioned. Now, in the meantime we had a fight between those who have pro brain death and those who are against brain death, you know. And then you know, it came to the government, the United States government appoint this president commission to study the whole issue, and the president commission is actually supporting the Harvard report and came out with a rational explaining why brain death is that it say that the brain is. I say in layman term yeah, the brain is the boss of the body. The technical term is that the brain is the master integrator of the body. But this means is that when we say that the brain is the boss of the body, it means that when the brain is dead, then the body is dead.

Speaker 3: 25:22

Well, now the term brain death is ambiguous, because is the brain actually dead? I mean, actually, you know, hardly any of these patients diagnosed brain death had an autopsy, a post mortem examination in which you can evaluate the brain. Okay, now there are a few very small numbers of the thousands and thousands and thousands of patients have been diagnosed brain death. We may have only most two digits or three digits number of patients who have the brain of brain death, patients who have their brain being examined by a post mortem examination. In all of these case the brain is not dead because, when I can speak as a pathologist, yeah, you take the brain out and the brain is firm and they stay as a whole on your, on your hands. Okay, that brain would be liquefied, it'd be like a soft jello, soft cottage cheese. It will fall all over the place.

Speaker 3: 26:26

Okay, so the term brain death does not indicate the brain is dead. Okay, the other thing is is the brain the boss of the body? Now, you and I, we study embryology, right? So the very first evidence of the formation of the nervous system is what we call the neural groove. All right, that is for the formation of the future brain and the future spinal cord. The neural groove does not appear until the end of the first month of pregnancy. In the meantime, the cardiovascular system is already working.

Speaker 2: 27:05

That's correct.

Speaker 3: 27:06

So my point is this the brain is the last organ to appear among all of the other organs. Okay, so how can the one that appear last is the boss and control everything? Now here I make an analogy the brain appeared is the last one that appeared in the formation of organs, in the development of organs, in the embryo, in the fetus. It's very similar to the story of creation First of all we have plants, then we have animals, and then man. Man is the last one to appear on Earth. Now ask yourself if, for some reason, we get a huge atomic bomb, all of the man, all humanity disappear? Would the rest of creation disappear? No, okay. So the brain, even if the brain is dead and brain dead patient, is actually. The brain is not dead. The brain is damaged here, there, okay, in different parts, in different regions. The body, the human person, is still there.

Speaker 2: 28:13

I am.

Speaker 3: 28:14

You know, when we speak about human person, people always say oh well, you know your dad, his brain dead, his body is alive, but he's no longer here. Well, look, I as a person, when I go to school, my body go to school.

Speaker 2: 28:31

That's right.

Speaker 3: 28:33

When I sit down and eat, my body eats. You know, I am my soul and I am my body. It's not. I have a body, you know. So when we use our language, we say I have a body, we think of it as I have a pen, I have a car, I have a cup, and then we have a utilitarian understanding of the body and this makes us to fall into the trap of people who want to promote brain death. Anyway, I should stop here so that you can proceed with the next question.

Speaker 2: 29:04

Yeah, let's go to the last question. So here's my last question, because I want my listeners to understand this. Why is it important to my average patient and my average listener who has to fill out paperwork for end-of-life decision-making, such as for being an organ donor? Why do they need to understand these things?

Speaker 3: 29:27

Right, you know, we know that. You know. If we want to be an organ donor, all we have to do is tick Mark, say, okay, I want to be an organ donor when we go to apply for the driving license. Right. And in the United States, organ donation requires what I call informed consent. Informed consent means that you consent after you know what is involved. Okay. And then the average person say, okay, you know, I'm dead so you know, I can give my organs.

Speaker 3: 29:59

But what they don't understand is organ donation today is taken from brain dead person. Okay, if you go to the hospital and look at the patient whose diagnosed brain death, they have the ventilator, they're connected to the ventilator, they are warm and pink and they are still making pee pee. They're still making urine. You only need to look at the side of the bed, of the bed and you look at the urine bag, okay, and you hear people who support brain death and say, well, the person is already dead, but it's a machine that keeps them alive. It's not a machine that keeps them alive, it's a machine that is the ventilator and the medication that supports them. Because they are still alive. Okay, and they are.

Speaker 3: 30:47

You know, all of the life functions are done by the body. The ventilator only brings in air. That's it. The ventilator cannot make the blood circulated from the heart. The ventilator cannot make the heart to pump, cannot make the kidney to produce urine and so on and so forth. It brings the oxygen into the body. Just like when somebody has a cancer of the feeding tube and you give them of the oesophagus and you give them a feeding tube right into the stomach it brings in the food, but the stomach has to digest the food and the guts they have to absorb the food. That's the work of the body, of a living body Anyway.

Speaker 3: 31:31

So nobody at the department of motorbike is told that, ok, that's here, organ donation. After that, it means that organ donation when you are declared brain dead. So what happens is the consent is really not informed. We are being tricked. And then the same thing when you go to the website of the organ procurement organization, the OPO there's nothing, it's just a bunch of, how you say, appeal. But let's use the word propaganda, ok, to tell you that organ donation is good, in a sense of what does not give you, what is entailed, ok. So this is why you need to fill the paperwork and say I do not want to be an organ donor, ok. And so the first thing is uncheck it from your driver license.

Speaker 2: 32:34

OK.

Speaker 3: 32:34

And in your paperwork whatever the end of life of paperwork you have to really make precise that you do not want to be an organ donor. Because what if we comma told you cannot speak? And then our family members, they may make us to be organ donors. Now I tell you a story. This is a real story from a lady, a mother in Germany. Ok, and she went on YouTube but it's all in German and so people will not be able to understand, but I understand German and she was telling the story.

Speaker 3: 33:05

She said her son had an accident right and he became irreversibly comatose. She was told that he was brain dead and she was asked to agree to organ donation and she agreed. And what happened was when they brought out his body and she looked at his face. Now, his face before organ donation and his face after organ donation was markedly different. And the other thing I want to say is that during the organ harvesting in the operating room, the brain dead patient remained on the ventilator, all right. So note that, yeah, they're not disconnected from the ventilator, anyway. So this woman, she saw tremendous sign of suffering on her son's face. Then she realized that her son suffered very much during this removal of the organ.

Speaker 2: 34:06

Hmm, hmm. I'm sorry to hear that. I'm sorry to hear that.

Speaker 3: 34:11

Yeah, now you know what happened. Can you publish this kind of scientific paper? No, because unfortunately it's an anecdotal experience. Well, we go to peer review and you know who are on the peer review, so you know you don't get that in peer review paper. Okay, but there are enough how you say testimonies.

Speaker 2: 34:38

Yeah.

Speaker 3: 34:39

One story is enough, yeah.

Speaker 2: 34:40

Yeah so, but when you have multiple people telling the same story, it becomes very convincing.

Speaker 3: 34:48

Mm-hmm.

Speaker 2: 34:49

It does All right. Well, dr Nguyen, our time is running out, but this has been a fascinating discussion and I really do appreciate your expertise on the subject. I'm satisfied that my listeners will be very, very intrigued to have learned all of this information. I may have to have you come back another time and let's discuss this again from a different angle. Would you be willing to do?

Speaker 3: 35:16

that for me? Yes, I would be willing to do that for you, and you know, I would like to make sure. One thing that I would like the audience to do is please spread the word. At least take out organ donation from your driver license.

Speaker 2: 35:32

Yes, yes.

Speaker 3: 35:35

Unless you want to be, unless you want to be, to undergo what we call VV section. Yeah, this is a technical term, okay, yeah, vv section meaning to be kept alive.

Speaker 2: 35:46

That's right. That's the Zacharite we open up while you're still alive, all right? Well, you're listening to More Than Medicine. I'm your host, dr Robert Jackson. My guest today is Dr Doyen Nguyen, and I'm just so delighted to have her as my guest today, and we'll be back again next week. Thank you very kindly for being with us.

Speaker 3: 36:08

Thank you, Dr Jackson.

Speaker 1: 36:13

Thank you for listening to this edition of More Than Medicine. For more information about the Jackson Family Ministry Dr Jackson's books, for the schedule of speaking engagements, go to their Facebook page, instagram or their webpage at JacksonFamilyMinistrycom. This podcast is produced by Bobsalon Audio Production at Bobsaloncom.