Although death by neurologic criteria (brain death) is legally recognized throughout the United States, state laws and clinical practice vary concerning three key issues: (1) the medical standards used to determine death by neurologic criteria, (2) management of family objections before determination of death by neurologic criteria, and (3) management of religious objections to declaration of death by neurologic criteria. The American Academy of Neurology and other medical stakeholder organizations involved in the determination of death by neurologic criteria have undertaken concerted action to address variation in clinical practice in order to ensure the integrity of brain death determination. To complement this effort, state policymakers must revise legislation on the use of neurologic criteria to declare death. We review the legal history and current laws regarding neurologic criteria to declare death and offer proposed revisions to the Uniform Determination of Death Act (UDDA) and the rationale for these recommendations.
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References
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See generally A.Lewis, K.Cahn-Fuller, and A.Caplan, “Shouldn't Dead Be Dead? The Search for a Uniform Definition of Death,”Journal of Law, Medicine & Ethics45, no. 1 (2017): 112-128. See, e.g., Lowry v. Beaumont Health, No. 2:19-CV-13293 (E.D. Mich. Nov. 8, 2019) (Complaint); In re Allen Callaway, No. DG-16-08 (Pondera County Dist. Ct., Mont. Sept. 26, 2016) (Order); In re Mirranda Grace Lawson, No. CL16-2358 (City of Richmond Circuit Court, Va. June 10, 2016) (Order); Winkfield v. California, No. 4:15-06042 (N.D. Cal. Dec. 23, 2015) (Complaint); In re Guardianship of Hailu, 361 P.3d 524 (Nev. 2015); Stinson v. Children's Hospital Los Angeles, No. BS164387 (Los Angeles Sup. Ct., Cal. Aug. 25, 2016) (Order); Shively vs. Wesley Medical Center No. 06-96650-A (Kan. App. 2006); Pierce v. Loma Linda University Medical Center, No. CIV-DS-1608931 (San Bernardino County Sup. Ct., Cal. June 7, 2016).
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See supra note 1 and infra notes 73-73, 81, 92, 100-04, 109, 112 (showing how litigation has destabilized brain death). Throughout this document, we use the term “criteria” to broadly refer to the organ system whose failure has led to declaration of death (i.e. neurologic criteria vs. cardiopulmonary criteria) and we use the term “standards” to refer to the technical medical requirements for declaration of death.
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President's Commission, supra note 17, at 52. Some commentators argue that state-to-state uniformity has failed and we should take a federal approach. See, e.g., Nipper, supra note 23, at 455-456.
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Capron and Kass, supra note 17, at 96-97.
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Id., at 7-8.
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Id., at 831-832.
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J.Downie, M.Kutcher, C.Rajotte, and A.Shea, “Eligibility for Organ Donation: A Medico-Legal Perspective on Defining and Determining Death,”Canadian Journal of Anesthesia56 (2009): 851-863.
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Id., at 46.
54.
Id., at 50.
55.
See Abram, supra note 43, at 1197; President's Commission, supra note 17, at 50.
56.
In settling on “accepted medical standards” the Commission rejected the term in the prior uniform act, “reasonable medical standards,” because it was unclear “whose reasonableness” counts. But the UDDA faces the same problem. It is unclear by whom the standards must be accepted. President's Commission, supra note 17, at 78-79.
57.
President's Commission, supra note 17, at 57.
58.
Id., at 57.
59.
Id., at 30. Ryan, supra note 13, at notes 94-95. The AMA opposed the model because of this. Still other versions were being proposed at this time. J.L.Bernat, C.M.Culver, and B.Gert, “On the Definition and Criterion of Death,”Annals of Internal Medicine94 (1981): 389-394.
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President's Commission, supra note 17, at 57. The criteria were deliberately vague and general to allow the development of medical techniques. State v. Shaffer, 624 P.2d 440, 447 (Kan. 1981).
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Nipper, supra note 23, at 442.
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President's Commission, supra note 17, at 80 (citing A.M. Capron, “Legal Definition of Death,”New York Academy of Sciences315 (1978): 349-362, at 356).
63.
President's Commission, supra note 17, at 81.
64.
See Mollaret and Goulon, supra note 11; see Ad Hoc Committee of the Harvard Medical School, supra note 8; President's Commission, supra note 17.
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In re Welfare of Bowman, 617 P.2d 731 (Wash. 1980); In re Haymer, 450 N.E.2d 940 (Ill. App. 1983); 10 N.Y.C.R.R. § 400.16; Ala. Code § 22-31-1; Alaska Stat. § 09.68.120; Ark. Code § 20-17-101; Cal. Health & Safety Code § 7180; Colo. Rev. Stat. § 12-36-136; Conn. Gen. Stat. § 19a-504a; Del. Code. tit. 24, § 1760; Fla. Stat. § 765.511; Ga. Code. Ann. § 31-10-16; Haw. Rev. Stat. § 327C-1; Idaho Code Ann. § 54-1819; Ind. Code § 1-1-4-3; Iowa Code § 702.8; Kan. Stat. Ann. § 77-205; Ky. Rev. Stat. Ann. § 446.400; La. Stat. Ann. § 9:111; Me. Stat. tit. 22, § 2811; Md. Code, Com. Law § 5–202; Mass. Gen. Laws Ch. 190B, § 1-107; Mich. Comp. Laws § 333.1033; Minn. Stat. § 145.135; Miss. Code Ann. § 41-36-3; Mo. Rev. Stat. § 194.005; Mont. Code Ann. § 50-22-101; Neb. Rev. Stat. § 71-7202; Nev. Rev. Stat. § 451.007; N.J. Rev. Stat. § 26:6A; N.H. Rev. Stat. Ann. § 141-D:2; N.M. Stat. § 12-2-4; N.C. Gen. Stat. § 90-323; N.D. Cent. Code § 23-06.3-01; Ohio Rev. Code § 2108.40; Okla. Stat. tit. 63, § 3122; Or. Rev. Stat. § 112.582; 35 Pa. Cons. Stat. § 10203; 23 R.I. Gen. Laws § 23-4-26; S.C. Code Ann. § 44-43-460; S.D. Codified Laws § 34-25-18.1; Tenn. Code Ann. § 68-3-501; Tex. Health & Safety Code § 671.001; Utah Code § 26-34-2; Vt. Stat. Ann. tit. 18, § 5218; Va. Code Ann. § 54.1-2972; W. Va. Code § 16-10-01; Wis. Stat. Ann. § 146.71; Wyo. Stat. Ann. § 35-19-101; D.C. Code § 7–601.
66.
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Id.
68.
Ariz. Rev. Stat. § 14-1107; N.C. Gen. Stat. § 90-323.
69.
In re Haymer, 450 N.E.2d 940 (Ill. App. 1983); Iowa Code § 702.8; La. Stat. Ann. § 9:111; N.C. Gen. Stat. § 90-323; Tex. Health & Safety Code § 671.001.
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E.F.M.Wijdicks, P.N.Varelas, G.S.Gronseth, and D.M.Greer, “Evidence-Based Guideline Update: Determining Brain Death in Adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology,”Neurology74, no. 23 (2010): 1911-1918; T.A.Nakagawa, S.Ashwal, M.Mathur, and M.Mysore, “Committee for Determination of Brain Death in Infants and Children. Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations-Executive Summary,”Annals of Neurology71, no. 4 (2012): 573-585.
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V.R.Shah, “Aggressive Management of Multiorgan Donor,”Transplantation Proceedings40 (2008): 1087-1090; A.M, Bronheim, “Management of the Organ Donor,”Seminars in Cardiothoracic Vascular Anesthesia2 (1998): 100-105; R.A.Fisher and J.W.Alexander, “Management of the Multiple Organ Donor,”Clinical Transplantation6 (1992): 328-335; M.J.Ali, “Essentials of Organ Donor Problems and Their Management,”Anesthesiology Clinics of North America12 (1994): 655-671; J.Wong, H.L.Tan, and J.P.S.Goh, “Management of the Brain Dead Organ Donor,”Trends in Anesthesia and Critical Care13 (2017): 6-12; K.Zambergs and H.Vyas, “Management of Potential Organ Donor,”Paediatrics and Child Health25 (2015): 234-238.
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A.L.Dalle Ave and J.L.Bernat, “Inconsistencies between the Criterion and Tests for Brain Death,”Journal of Intensive Care Medicine (2018).
73.
Winkfield v. California, No. 4:15-06042 (N.D. Cal. 2015).
74.
Winkfield v. Rosen, No. RG15760730 (Alameda County Sup. Ct., Cal. Dec. 22, 2017) (Declaration of D. Alan Shewmon, filed with Plaintiffs' Motion to Bifurcate the Issue of Whether AAN and AAP Guidelines Meet the Statutory Definition of “Dead” Under the Uniform Determination of Death Act).
75.
See President's Commission supra note 17.
76.
In re Haymer, 450 N.E.2d 940 (Ill. App. 1983); Fla. Stat. § 765.511; Haw. Rev. Stat. § 327C-1; Iowa Code § 702.8; Ky. Rev. Stat. Ann. § 446.400; La. Stat. Ann. § 9:111; Md. Code, Com. Law § 5–202; Minn. Stat. § 145.135; Mo. Rev. Stat. § 194.005; N.J. Rev. Stat. § 26:6A; N.C. Gen. Stat. § 90-323; Tex. Health & Safety Code § 671.001; Va. Code Ann. § 54.1-2972; Ga. Code. Ann. § 31-10-16.
77.
Ga. Code. Ann. § 31-10-16.
78.
In re Haymer, 450 N.E.2d 940 (Ill. App. 1983); Fla. Stat. § 765.511; Haw. Rev. Stat. § 327C-1; Iowa Code § 702.8; Ky. Rev. Stat. Ann. § 446.400; La. Stat. Ann. § 9:111; Md. Code, Com. Law § 5–202; Minn. Stat. § 145.135; Mo. Rev. Stat. § 194.005; N.J. Rev. Stat. § 26:6A; N.C. Gen. Stat. § 90-323; Tex. Health & Safety Code § 671.001; Va. Code Ann. § 54.1-2972; Ga. Code. Ann. § 31-10-16.
79.
See supra Section II.E.
80.
See President's Commission, supra note 17.
81.
In re Guardianship of Hailu, 361 P.3d 524 (Nev. 2015).
82.
The Harvard standard and the AAN standard are similar, but not identical. One key difference between them is that the Harvard standard required that an electroencephalogram demonstrate no brain activity, whereas the AAN standard is a clinical determination unless a portion of the clinical determination cannot be performed. Notably, after publication of the Harvard standard, the Chair of the ad hoc committee who authored the standard reported that the committee did not feel strongly about the need for an electroencephalogram to determine brain death. Nonetheless, because this test was included in the Harvard standard, the Court remanded for evidentiary findings to clarify whether the Harvard or the AAN standard represented the accepted medical standard. See Lewis, Cahn-Fuller, and Caplan, supra note 1.
83.
Lewis, Bernat, Blosser, et al., supra note 5.
84.
AAN, supra note 2.
85.
Lewis, Bernat, Blosser, et al., supra note 5.
86.
An Act Relating to the Determination of Death, Nev. A.B. 424 (2017), enacted as 2017 Nevada Acts Ch. 315, codified at Nev. Rev. Stat. § 451.007.
87.
Nev. Rev. Stat. § 451.007. See also Section IV.B, infra (discussing constitutionaliy of this formulation).
88.
N.J. Admin. Code § 3:35-6A.4.
89.
D.M.Greer, H.H.Wang, J.D.Robinson, P.N.Varelas, G.V.Henderson, and E.F.M.Wijdicks, “Variability of Brain Death Policies in the United States,”JAMA Neurology73, no. 2 (2016): 213-218.
90.
Lewis, Bernat, Blosser, et al., supra note 5.
91.
A.Lewis, N.Adams, P.Varelas, D.Greer, and A.Caplan, “Organ Support after Death by Neurologic Criteria: Results of a Survey of US Neurologists,”Neurology87, no. 8 (2016): 827-834; A.Lewis, N.Adams, A.Chopra, and M.Kirschen, “Organ Support after Death by Neurologic Criteria in Pediatric Patients,”Critical Care Medicine45, no. 9 (2017): e916-24; A.Lewis and D.Greer, “POINT: Should Informed Consent Be Required for Apnea Testing in Patients with Suspected Brain Death? No,”Chest152, no. 4 (2017): 700-702; A.Lewis and D.Greer, “Rebuttal From Drs Lewis and Greer,”Chest152, no. 4 (2017): 704-705; R.D.Truog and R.C.Tasker, “Counterpoint: “Should Informed Consent Be Required for Apnea Testing in Patients with Suspected Brain Death? Yes,”Chest152, no. 4 (2017): 702-704; R.D.Truog and R.C.Tasker, “Rebuttal from Drs Truog and Tasker,”Chest152, no. 4 (2017): 705-706.
92.
See, e.g., In re Allen Callaway, No. DG-16-08 (Pondera County, Mont. 2016); In re Mirranda Grace Lawson, No. CL16-2358 (City of Richmond Circuit Court, Va. 2016); Winkfield v. California, No. 4:15-06042 (N.D. Cal. 2015); In re Guardianship of Hailu, 361 P.3d 524 (Nev. 2015); Stinson v. Children's Hospital Los Angeles, No. BS164387 (Los Angeles Sup. Ct., Cal. 2016); Pierce v. Loma Linda University Medical Center, No. CIV-DS-1608931 (San Bernardino County Sup. Ct., Cal. 2016); Shively v. Wesley Medical Center, No. 06-96650-A (Kan. App. 2006).
93.
President's Commission, supra note 17; see also supra Section II.F.
94.
M.Y.Rady and J.L.Verheijde, “The Clinical Determination of Brain Death: Practice Limitations,”European Journal of Neurology22, no. 12 (2015); e85-e85; J.Tibballs, “A Critique of the Apneic Oxygenation Test for the Diagnosis of Brain Death,”Pediatric Critical Care Medicine11, no. 4 (2010): 475-478.
95.
Lewis, Adams, Chopra, and Kirschen, supra note 91; Lewis, Adams, Varelas, Greer, and Caplan, supra note 91.
96.
A.Lewis, P.Varelas, and D.Greer, “Prolonging Support after Brain Death: When Families Ask for More,”Neurocritical Care24, no. 3 (2016): 481-487.
97.
10 N.Y.C.R.R. § 400.16(d).
98.
New York State Department of Health and New York State Task Force on Life and the Law. Guidelines for Determining Brain Death (Nov. 2011), available at <https://www.health.ny.gov/professionals/hospital_administrator/letters/2011/brain_death_guidelines.htm> (last visited October 28, 2019). A new trial court decision suggests that New York hospitals have less discretion than anticipated on what constitutes reasonable accommodation. Nakar v. New York Presbyterian Hospital, No. 1780/2017 (Kings County Supreme Court, NY Jan. 15, 2019).
99.
Nev. Rev. Stat. § 451.007.
100.
In re Mirranda Grace Lawson, No. CL16-2358 (City of Richmond Circuit Court, Va. 2016); see also Lewis, Cahn-Fuller, and Caplan, supra note 1.
101.
In re A.C., No. DG-16-08 (Pondera County Dist. Ct., Mont. Sept. 23, 2016).
102.
See, e.g., Stinson v. Children's Hospital Los Angeles, No. BS164387 (Los Angeles Sup. Ct., Cal. 2016); Pierce v. Loma Linda University Medical Center, No. CIV-DS-1608931 (San Bernardino County Sup. Ct., Cal. 2016); Shively v. Wesley Medical Center, No. 06-96650-A (Kan. App. 2006). See also K. Durbin, “Monroe Co. Parents Proposing ‘Bobby's Law’ in Honor of Son Taken Off Life Support,” The Blade (Dec. 2, 2019).
103.
See supra Section II.F.; President's Commission, sup; ra note 17.
104.
Lewis, N.Adams, A. Chopra, and M.Kirschen, supra note 91; Lewis, Adams, Varelas, Greer, and Caplan, “Organ Support after Death by Neurologic Criteria: Results of a Survey of US Neurologists,”Neurology87, no. 8 (2016): 827-834; Lewis, Varelas, and Greer, supra note 96; 10 N.Y.C.R.R. § 400.16; N.J. Rev. Stat. § 26:6A; Cal. Health & Safety Code § 1254.4; 210 Ill. Comp. Stat. § 85/6.24; In re Allen Callaway, No. DG-16-08 (Pondera County, Mont. 2016); In re Mirranda Grace Lawson, No. CL16-2358 (City of Richmond Circuit Court, Va. 2016); McMath vs. California, No. 4:15-06042 (N.D. Cal. 2015).
10 N.Y.C.R.R. § 400.16; Cal. Health & Safety Code § 1254.4 (also requiring accommondation of non-religious objections).
109.
But cf. Nakar v. New York Presbyterian Hospital, No. 1780/2017 (Kings County Supreme Court, NY Jan. 15, 2019).
110.
Lewis, Cahn-Fuller, and Caplan, supra note 1.
111.
J.Vazquez, “13-Year-Old Jahi McMath Moved to New Jersey Hospital, Lawyer Says Condition Improving,”CBS News (San Francisco), June18, 2013; S.G.Mozumder, “Mother of NJ Teen Declared Brain-Dead Fights to Keep Him on Life Support,”India Abroad, June6, 2018; R.Sanchez, “California Family Given More Time, Can Keep Son on Ventilator,”CNN, June12, 2016.
112.
Vazquez, supra note 111. The families in several Philadelphia cases recently tried to transfer the patients across the river to New Jersey. See, e.g., In re Jaden Auyeung, No. 681-MI-2018 (Philadelphia Orphans Court 2018); Banerjee v. CHOP, No. 18-2571 (E.D. Pa. 2018).
113.
Lewis, Adams, Chopra, and Kirschen, supra note 91; Lewis, Adams, Varelas, Greer, and Caplan, supra note 91.
114.
Lewis, Adams, Chopra, and Kirschen, supra note 91; Lewis, Adams, Varelas, Greer, and Caplan, supra note 91; Lewis, Varelas, and Greer, supra note 96.
115.
Lewis, Varelas, Greer, supra note 96.
116.
Id.
117.
Lewis, Adams, Chopra, Kirschen, supra note 96; Lewis, Adams, Varelas, Greer, and Caplan, supra note 91.
118.
N.J. Stat. Ann. § 26:6A-7.
119.
Nev. Rev. Stat. § 451.007.
120.
ADD cites for these activities
121.
Wijdicks, Varelas, Gronseth, Greer, supra note 70; Nakagawa, Ashwal, Mathur, Mysore, supra note 70; Lewis, Bernat, Blosser, et al., supra note 5; President's Commission, supra note 17.
122.
Shah, supra note 71; Bronheim, supra note 122; Fisher and Alexander, supra note 41; Ali, supra note 71; Wong, Tan, Goh, supra note 71; Zambergs and Vyas, supra note 71.
123.
President's Commission, supra note 17.
124.
Id.
125.
See Dalle Ave and Bernat, supra note 72; supra notes 73-74.
126.
But cf. In re Guardianship of Hailu, 361 P.3d 524 (Nev. 2015) (allowed to advance to trial on this question); McMath (same).
127.
President's Commission, supra note 117.
128.
Lewis, Bernat, Blosser, et al., supra note 5. However, despite acceptance of these standards, it is worth noting variability in institutional standards persists. See Greer, Wang, Robinson, Varelas, Henderson, Wijdicks, supra note 89.
129.
In re Guardianship of Hailu, 361 P.3d 524 (Nev. 2015); Nev. Rev. Stat. § 451.007; Greer, Wang, Robinson, Varelas, Henderson, Wijdicks, supra note 89; McMath v. California, No. 4:15-06042 (N.D. Cal. 2015).
130.
Nev. Rev. Stat. § 451.007.
131.
Mason's Manual of Legislative Procedure §§ 51 & 518 (2010 Edition); Arkansas Bureau of Legislative Research, Legislative Drafting Manual § 4.5 (2010) (“If the bill adopts … the standards or manual of a private entity, avoid adopting future revisions of the document referenced. If future changes are included in the incorporation by reference, a delegation of authority has occurred.”); Washington State Office of the Code Reviser Statute Law Committee, Bill Drafting Guide 37 (2019).
Lewis, Adams, Chopra, and Kirschen, supra note 91; Lewis, Adams, Varelas, Greer, and Caplan, supra note 91; Lewis, Varelas, and Greer, supra note 96; 10 N.Y.C.R.R. § 400.16; N.J. Rev. Stat. § 26:6A; Cal. Health & Safety Code § 1254.4; 210 Ill. Comp. Stat. § 85/6.24; In re Allen Callaway, No. DG-16-08 (Pondera County, Mont. 2016); In re Mirranda Grace Lawson, No. CL16-2358 (City of Richmond Circuit Court, Va. 2016); McMath vs. California, 2015. No. 3:15-06042 N.D. Cal.
138.
N.J. Rev. Stat. § 26:6A.
139.
10 N.Y.C.R.R. § 400.16; Cal. Health & Safety Code §1254.4.
140.
210 Ill. Comp. Stat. § 85/6.24.
141.
141 In re Long Island Jewish Medical Center. 641 N.Y.S.2d 989 (Queens County Supreme Court, NY Feb. 28, 1996); A.L.Flamm, M.L.Smith, and P.A.Mayer, “Family Members' Requests to Extend Physiologic Support after Declaration of Brain Death: A Case Series Analysis and Proposed Guidelines for Clinical Management,”Journal of Clinical Ethics25 (2014): 222-237; L.S.M.Johnson, “The Case for Reasonable Accommodation of Conscientious Objections to Declarations of Brain Death,”Journal of Bioethical Inquiry13, no. 1(2016): 1-5-15; P.A.Kahn, “Bioethics, Religion, and Public Policy: Intersections, Interactions, and Solutions,”Journal of Religion and Health55 (2016): 1546-1560; J.M.Luce, “The Uncommon Case of Jahi McMath,”Chest147 (2015): 1144-1151; M.S.Bosek, J.A.Anderson, L.W.Vernaglia, S.P.Morrigan, and T.R.Bard, “Refusal of Brain Death Diagnosis,”JONAS Healthcare Law Ethics & Regulation9 (2007): 87-94; M.L.Smith and A.L.Flamm, “Accommodating Religious Beliefs in the ICU: A Narrative Account of a Disputed Death,”Narrative Inquiries in Bioethics1 (2011): 55-64; D.Berner and S.Gaeta, “Religion Based Non-Acceptance of Brain Death, an End-of-Life Ethical Dilemma,”Critical Care Medicine40 (2012): 304; R.S.Olick, E.A.Braun, and J.Potash, “Accommodating Religious and Moral Objections to Neurological Death,”Journal of Clinical Ethics20 (2009): 183-191.
