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Neocortical Death and Human Death

Proposals to make neocortical death, sometimes called cerebral death, a medical and legal indication of human death are becoming more common.’ Increased sensitivity to the futility and costs of providing life support for patients long after they could be considered dead guarantees that interest in the proposals will continue for some time. Neocortical death would be an acceptable indication of human death if 1) it is consistent with our concepts of human death, 2) it can be diagnosed with certainty and 3 ) it is sufficiently understood by the general public to be accepted as public policy. In this paper the phrase “neocortical death” will refer to permanent loss of consciousness due to the irreversible cessation of whatever chemical and biological functions of the brain are needed to support consciousness. By consciousness is meant “the state of awareness of the self and the environment.”* Although it is not yet known with absolute precision just what areas of the brain provide this awareness, it is generally agreed that after infancy3 consciousness depends on activity in the cerebral hemispheres, especially in the cerebral cortex. When it is known that extensive destruction to these areas has rendered impossible any return to awareness we can speak of “neocortical death.” Two major types of neocortical death are now generally acknowledged: persistent vegetative state (PVS) and permanent coma. Following Jennet and Plum4 and Cranford ,5 persistent vegetative state in this paper will be used to designate permanently unconscious patients manifesting cycles of wakefulness and sleep and responding to verbal stimuli and light. Often these patients display facial signs of interest-perhaps tearing of the eyes, suggestions of smiling or reflexes of suckingand their hands may grope. Survival can last for years or even decades. The second type of neocortical death is permanent coma. Patients in this state are also permanently unconscious but differ from those in PVS because they do not manifest wakefulness and sleep cycles (their eyes usually remain closed) nor sustain the level of activity observed in the latter. Some permanent comas evolve into PVS. Others do not and, unless extremely vigorous efforts are made to sustain life, death can be expected in approximately six months to a year.6 Neither PVS patients nor those in permanent comas are brain dead according to current criteria. They are not brain dead because parts of their brain, most notably the brain stem, continue to function. They are neocortically dead because they have suffered irreversible cessation of the brain functions necessary for any level of consciousness. They do not normally need a respirator but they do need medical nutrition and hydration. The position of this paper is that 1) neocortical death is consistent with our concepts of death and 2) at least some instances of neocortical death can, or soon will be, diagnosed with certainty but 3 ) neocortical death is not, and in the foreseeable future will not be, well understood by the general public. Hence we should forsake efforts to establish it as a legal indication of death not because it is an inappropriate indication of human death or cannot be diagnosed but because lack of understanding by the general public will make this issue needlessly divisive for society.