The Girl is Brain Dead but the Emperor Has No Clothes

Oh, my, what a predicament.  Jahi McMath has been released from Oakland Hospital to the custody of the coroner and her family.  She has been issued a death certificate.  And she's being transferred to an undisclosed care center, where it is hoped she will begin receiving artificial nutrition.  This is the height of both irony and tragedy.

The comments by physicians and bioethicists in the CNN articles all harken to the idea that there appears to be no error, she meets criteria for brain death and thus she's "legally dead."  This misses the point.  Her parents don't care if she's "legally dead."  The legal definition does not comport with their own intuitions about death and her mother says as much.  She will accept that her daughter is dead only when her heart stops beating.  I can understand why a person may take this stance.

Real (Cardiac) Death and Invented (Brain) Death: The Oakland Case

This article in the January 4th, 2014 New York Times reports on the tragic case (the "Oakland Case") of a 13-year-old girl who suffered complications from elective surgery in early December 2013, whose condition deteriorated and who has been declared brain dead.  While it is not articulated directly in the article, her parents appear to object to the medico-legal conceptualization of brain death and they wish to force the hospital to continue to provide care for her.  A judge has placed an injunction against the hospital, prohibiting them from removing her from life support (in this case, this most likely means mechanical ventilation) until Tuesday January 8th, 2014. The medical establishment at the hospital where she is/was a patient has clearly taken the path of defending the concept of brain death and their rights and responsibilities under the laws concerning brain death -they have refused to insert a tracheostomy or a permanent feeding tube into the girl - and they may have, and we may be tempted to, ascribe her parents' behavior to anger, grief, bereavement, etc.  But I think this case illuminates some broader issues about bioethics, brain death, and organ procurement.

For those unfamiliar with the medico-legal definitions, brain death is a diagnosis that is made after severe brain damage from a variety of insults.  It is a very specific diagnosis that is based on a host of physical examination techniques and sometimes corroborating diagnostic studies, and it means that there is evidence of irreversible cessation of ALL brain function that has been caused by total lack of blood flow to the brain.  A patient who is declared brain dead is legally dead.  I have diagnosed brain death dozens of times.  The medical mantra is that, properly diagnosed brain death always means that there is NO brain function and that "real death" (that is, cessation of heartbeat) will inevitably ensue in coming weeks or months as the body cannot continue to  function without brain function.  But isn't this interesting!  That we need to reassure people that "real death" will inevitably ensue seems to reveal that we recognize that brain death is not real death, but that it will, after time lead to real death!  (Of course, all paths lead to real death, eventually.). Clearly this landscape is fertile ground for cognitive dissonance.  Let's explore why.

Logic Based Medicine: The Case of Activated Charcoal

Like all good things, Evidence Based Medicine (EBM), when taken to far, runs the risk of making us overwrought and becoming cliche.  I think we are reaching this point.  Given Ioannidis' meta-research findings that most published research findings are false (does he consider the irony that that may apply to his findings too?) the corrupting and corrosive influence of industry on research programs and guideline construction, the biases of academic researchers intent on grants, prestige and promotions (as well as honoraria to supplement paltry academic salaries - I was there once, and I did it too), and the zealousness of "experts" who wish to interpret the evidence in the form of an edict for all to follow (euphemistically called "guidelines"), and several other disturbing trends, it becomes apparent that in the end we must rely upon our own judgment and logic to discern the proper path to follow.  And so it is with Activated Charcoal (AC) administration, an agent used in overdoses and toxic ingestions that has a remarkable capacity to adsorb ingested substances and theoretically limit their toxicity.  (It is not barbecue charcoal, the photo is tongue-in-cheek.)