Brain death in the pediatric patient: historical, sociological, medical, religious, cultural, legal, and ethical considerations.

OBJECTIVE: To detail the origins of the definition of death, the development of the criterion of whole brain death as fulfilling the definition of death, and the tests used to fulfill that criterion.

DATA SOURCES: A review of the literature was performed. No Institutional Review Board approval was necessary.

DATA EXTRACTION: In 1959, patients were described as being in "coma dépassé" or beyond coma. In 1967, the first successful heart transplantation took place, with the organ coming from a brain-dead, beating-heart donor. However, anxiety over the definitions of death did not begin with the modern, technological era, and death itself has never been definable in objective terms. It has always been a subjective and value-based construct. During ancient times, most people agreed that death occurred when a person's heartbeat and breathing stopped. For the Greeks, the heart was the center of life; for the ancient Hebrews and Christians, the breath was the center of life. In the 12th century, Maimonides pointed toward the head, and the loss thereof, as the reason for lack of central guidance of the soul. Physicians neither diagnosed nor certified death. During the Enlightenment, the necessity of heartbeat, breath, and consciousness for the definition of life was questioned, leading to questioning regarding the definition of death. Tests to fulfill the criteria of death, and tests to determine the absence of integration between functions of respiration, circulation, and neurology were introduced. Sensorimotor potential was becoming recognized as defining life, rather than heartbeat and respiration. As new tests were devised to fulfill criteria of death, the physician developed a professional monopoly on meeting the criteria of brain death. In the modern era, the boundary between life and death has been blurred, but the intensive care unit straddles this boundary. We may have situations where the patient is alive but in a coma, without functioning heart, lungs, kidneys, or gastrointestinal tract, with a transplanted liver, a reversed coagulation system, a blocked immune system, and a paralyzed musculoskeletal system.

DATA SYNTHESIS: A human being is a man, woman, or child who is a composite of two intricately related but conceptually distinguishable components: the biological entity and the person. Therefore, human beings can suffer more than one death: a biological death and decay, and another death. Biological death is a cessation of processes of biological synthesis and replication, and is an irreversible loss of integration of the biological units. The reasons for having criteria for death are to diagnose death and pronounce a person dead. Society can then begin to engage in grief, religious rites, funerals, and burials, and accept biological death. Wills can be read, property distributed, insurance claimed, individuals can remarry, succession can take place, and legal proceedings can begin. Also, organ donation can take place, which entails difficult ethical decisions. The Harvard criteria of 1968 were devised to set forth brain-death criteria with whole brain death in mind. Currently, there are several controversies regarding these criteria: a) whether they apply to infants and children; b) whether ancillary tests are necessary; c) what the intervals of observation and testing are; and d) are there exceptions to the whole brain death criteria. Concerning the use of the adult criteria for infants and children, most researchers now agree that the adult criteria apply to infants and children who are full term and > 7 days of age. Concerning ancillary tests, there has been, in our machine- and technology-oriented profession, a great deal of emphasis on the different tests and their ability to fulfill the criteria of whole brain death. However, clinical examination and the apnea test are usually sufficient to fulfill the criteria. Ancillary tests may be desired in some cases, and a variety of these tests is available. (ABSTRACT TR