Apr 08 2008

Brain Dead

It is often said of Paris Hilton that she is famous for being famous. Well, Zack Dunlap might have her beat – he is famous for not being dead.

In November 2007 Zack Dunlap was involved in a serious 4-wheel off-road biking accident, a roll-over resulting in severe head injury. He was flown to a nearby hospital where he was treated by trauma surgeons. His condition was critical. At 36 hours after his accident the doctors taking care of Zack feared that he might be brain dead. As Zack was a registered organ donor, they wanted to perform a confirmatory test so that if brain death were confirmed, the process of organ donation could begin.

A PET scan was performed at 36 hours. PET scanning (technically referred to as Technetium-99m hexamethylpropyleneamineoxime brain scan) is a measure of blood flow to the brain. Zack’s doctor, Leo Mercer, showed his parents the scan – his brain was entirely black. No blood flow. This was sufficient to meet criteria for brain death. The process of organ donation began.

About four hours later, while the family was saying their goodbye’s, Zack moved his foot in response to his cousin rubbing a knife blade along his foot. His responsiveness was confirmed by squeezing his nail-bed – he moved his arm with clear purpose. The diagnosis of brain death was set aside, and the process of organ donation was stopped, Zack was returned to full care and he slowly recovered. Zack’s story came up in the news again recently following a TV interview in which he said that he was doing OK.

The story has prompted many questions, and the mainstream media reporting has been ill-equipped to deal with them. How could someone be declared brain dead when they are not really dead? Was his recovery a miracle, a medical mystery, or a simple mistake? Reader responses tend to fall into three categories: those declaring the event a miracle, those worried about the entire notion of brain-death, and those putting the whole thing down to a medical error. Here is a typical comment encompassing the first two themes:

This is truly a blessing from GOD We should always put God first. It really bothers me now, how many people have been pronounced dead and harvest the parts and were really alive. I am a donor myself but I hope with God on my side if and when I am pronounced dead they don’t do that to me. How do you actually know if they are really deceased? I wonder how many other people who have donated their loved ones organs are asking the same question.

There is no need to invoke either a miracle or medical mystery in this case. The simplest explanation is that the PET scan was either in error, or was reflecting a reversible situation. There is much to suggest this in this case, but first let me give some background on brain death.

The concept of brain death developed for those situations in which a person’s body is still viable – their heart is still pumping and their organs work – but their brain is damaged beyond recovery. This is a common situation in the modern world of auto-accidents. Also, the need for organ donation creates the need to be able to declare someone dead before their heart and lungs give out. Brain death is a legal definition, and in the US is determined state by state. However, there are published medical guidelines, and most states follow the guidelines. The American Academy of Neurology published guidelines on brain death are authoritative.

As a practicing neurologist I have conducted numerous brain death exams. The criteria are very strict – there has to be no evidence of any brain activity, including any primitive or automatic brainstem activity. (Nerve reflexes mediated outside the brain do not count against brain death.) A specific and detailed exam is required – above and beyond the routine neurological exam. For example, it must include an apnea test in which all respiratory support is turned off in order to generate a maximum safe respiratory drive and still result in no spontaneous respirations (breathing is mediated in the brainstem). The slightest twitch of brain activity rules out brain death. In addition, it is recommended that the exam is repeated after at least 6 hours (in CT we use 24 hours) to make sure the clinical brain death is persistent. Finally, there cannot be anything reversible that can suppress brain function, like drugs or hypothermia.

Confirmation with certain laboratory tests is optional but useful in some cases. From most to least sensitive, the tests that are used include an angiogram to look for blood flow to the brain, and EEG (electroencephalogram) looking for any brain electrical activity, doppler test for blood flow, a PET scan for metabolic activity, and a somatosensory evoked potential looking for brain responsiveness.

Let’s take a look at this case. I only have the details provided by the media (I have called Dr. Mercer but have not gotten through yet), so I can comment on some things and not others. The primary problem I have with this case is that the determination of brain death was made 36 hours following a severe head trauma. Brain trauma causes edema or tissue swelling, just like would happen to any body part after injury. This brain edema increases over about 72 hours and then starts to resolve. Because the skull is a closed space, this swelling squeezes the brain causing temporary dysfunction. It can also cause permanent damage in some cases. But during this period any clinical assessment of the patient in order to determine the amount of permanent brain damage is problematic because you can’t know how much is due to reversible swelling. Patients may look terrible, but then in a few days when the swelling goes down make a remarkable recovery. This is more likely in younger patients because young brains are plump and therefore they swell more and there is less room in the skull to begin with.

In fact when I consult on such cases I also couch my opinions in terms of – we cannot make any definitive statements during this period, we have to wait until the swelling resolves. You can infer how much damage is likely based upon laboratory tests, like a CT scan or MRI which can show the edema and may also show if there is large amounts of blood in the brain or other anatomically visible abnormalities.

In short (with the caveat that I do not have all the facts from a first hand source) I have a problem in general with declaring a young person brain dead 36 hours after a head trauma. Unless there were solid laboratory evidence of irreversible brain death I would always wait at least until the swelling resolves to make this diagnosis.

In this case it appears that is what the team did – they ordered a PET scan. It is possible, even probable, that there were other tests not mentioned in any of the news reports. An EEG would be routine, for example. Relying on just a PET scan is problematic. It is down the list in terms of sensitivity and is not typically the only test used for confirmation of brain death. There is evidence that it can show brain death, but I could not find any studies that measure the probability of a false positive – meaning that the test falsely confirms brain death, as appears to be the case here. In addition, there are some technical aspects of using a PET scan in this manner that create the possibility of error. For example, if the radioactive label is not prepared or injected properly that can result in no signal – which would then be falsely interpreted as no brain activity (this is my guess as the most likely case here). You can scan the liver just to make sure you are seeing some signal and therefore to validate the test. That is one of those details not reported in the mainstream media and I would love to get from the doctor or records in this case.

To summarize – in this case the clinical determination of brain death was made too early to be definitive. The only confirmatory test that was mentioned, the PET scan, is subject to technical errors that could have erroneously resulted in the absence of any signal. In this type of case (especially considering the age of the person) my personal recommendation would have been to either wait a couple of days after the edema mostly resolved, or to do more definitive confirmatory tests, like an angiogram for cerebral blood flow. I suspect that the patient was not thoroughly examined because the doctors were relying upon the PET scan, which was very likely in error. (Relying upon a false test always causes problems.)

It should also be noted that this case is a rare anomaly. The criteria for brain death are very conservative, and if properly employed there is almost no chance (I am tempted not even to say “almost”) of error or of meaningful recovery following a diagnosis of brain death.

But now this case will live on in the public consciousness. Public opinion is likely to be disproportionately affected by this anomalous case rather than the thousands of cases that do not warrant reporting.

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37 responses so far

37 Responses to “Brain Dead”

  1. ADR150on 08 Apr 2008 at 11:14 am

    whats with him being able to hear the doctors declare him dead? is this an unconscious fabrication? can such swelling cause a coma? is there any substance to the claim that people in comas can hear whats going on around them?

  2. DevilsAdvocateon 08 Apr 2008 at 11:53 am

    Dog Bites Man is not news, Man Bites Dog is news, and the media loves a miracle story.

  3. Steven Novellaon 08 Apr 2008 at 12:49 pm

    swelling alone can cause coma, even death, if it is severe enough.

    People is a coma generally do not remember hearing anything once they are conscious – but “coma” is a broad category of states – anything that is not conscious (other than natural sleep). Some hearing may be going on, but there is no evidence that memories are being formed or that there is conscious awareness. The exception may be for the lightest forms of coma – minimally conscious state- as indicated by recent fMRI studies.

  4. Pages tagged "the early november"on 08 Apr 2008 at 1:51 pm

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  5. Potter1000on 08 Apr 2008 at 3:02 pm

    To # Pages tagged “the early november”,

    Are you sure monetization would really be easier with the WP Affiliate Pro plugin? I’ve tried everything, including WPAP, and I found monetization to be quite sluggish and difficult with all of them.

    Thanks for the post, Dr. No. This is a story I breezed over a little while ago and didn’t think anything more about it, but I remember thinking “gee, I’ll bet Pec’s gonna like that one.” But I also didn’t have any meaningful knowledge on the subject to explain it, so I appreciate it.

  6. Swynndlaon 08 Apr 2008 at 6:57 pm

    Is it possible that the doctors said something like he *might* be brain dead (because of the PET scan) but they wanted to do more checks later on to confirm this, but the family only remembers that the doctors said that he *was* brain dead? Or do we know that the doctors said he was actually brain dead?

  7. deciuson 08 Apr 2008 at 7:55 pm

    Why harvesting organs from victims of accidents, with such a limitless supply of brain-dead people readily available in every church?

  8. pekka son 09 Apr 2008 at 2:59 am

    A while ago I read about a case where some guys skull was opened to ease the pressure on the swollen brain. According to the report he would have died otherwise.

    Is there any evidence of this working? Is this kind of procedure used in the US?

  9. Steven Novellaon 09 Apr 2008 at 6:51 am

    pekka – what you are describing is a craniotomy and it is commonly done to relieve pressure inside the skull following head trauma, a massive stroke or bleed.

  10. Taylor Con 09 Apr 2008 at 10:51 am

    amazing. my uncle was brain-dead for weeks, my dad prayed with him and now he’s back =)

  11. Johnon 09 Apr 2008 at 11:42 am

    That’s quite a claim, Taylor. Do you have evidence to back it up? Dr Novella’s already laid out the medical line: that, if properly diagnosed, the chances of meaningful recovery following brain death are more-or-less nil.

  12. Steven Novellaon 09 Apr 2008 at 1:13 pm

    Taylor,

    Just to clarify – if you are declared brain dead then you are legally dead – you are a corpse according to the law. It would be extremely unusual for someone to be kept for weeks after being declared brain-dead (I have never heard of this, if true it could only be a bizarre legal situation).

    Most likely your uncle was in a deep coma, but not brain dead. Very different situation.

  13. Joe Shmoeon 09 Apr 2008 at 2:04 pm

    “This is more likely in younger patients because young brains are plump and therefore they swell more” – Dr Steve

    It’s just a little creepy to know that Dr. Novella feels about brains much like we do fruit.

  14. badrabbion 09 Apr 2008 at 11:04 pm

    Declaring someone “brain dead” is an important task! Once you are declared “brain dead” then you are dead! It seems to me, therefore, that modalities that are used in declaring someone dead must have a high degree of specificity and sensitivity. It disturbers me to no end to learn as Dr. Novella writes that “I could not find any studies that measure the probability of a false positive” for PET scanning”!

    With all due respect, we criticize herbal ‘medicines’ because they lack proper studies demonstrating their efficacy. Here, we are relying on the results of a modality in order to pass a death verdict on a patient without knowing the power of the test! Terrible!

    Do we know what the power of EEG is in predicting permanent “brain death”?

    It seems to me that we need to know this information before declaring people ‘permanently dead’. Frankly I am astounded that this information is not readily available.

    Also, it seems to me that medical authorities seem to be in a hurry to declare brain death when there is the possibility of organ harvest. I wonder whether we should rethink filling our organ donor cards.

  15. FullFrontalon 10 Apr 2008 at 12:01 am

    Great post, I’ve been searching some time for an update to this story. It seemed likely the team neglected corroborating tests (apnea, cerebral blood flow etc.) but I wasn’t aware he was only 36 hours out from the injury.

    My experience is in pediatrics where two clinical tests are generally performed anywhere from 48 hours (small babies) to 12 hours (older kids) apart. Confirmatory studies are recommended as well. Even given these standards the diagnosis can be challenging when the patient has a young healthy brain.

  16. Johnon 10 Apr 2008 at 5:05 am

    badrabbi, Dr Novella also wrote (in the previous sentence, no less) “Relying on just a PET scan is problematic. It is down the list in terms of sensitivity and is not typically the only test used for confirmation of brain death.”

    So doctors are not relying on an untested modality – there are (with this case as an exception) other tests in place before brain death is confirmed, and Steve goes into detail regarding these other tests. Please read the post properly before launching into diatribe.

  17. Johnon 10 Apr 2008 at 5:55 am

    I’ve also done a bit of digging around about EEG since you ask, and the literature supports the blog post: more reliable than PET, less reliable than a cranial angiogram.

    To the legal eagles reading this blog, have there been any mentions of lawsuits arising from this case? I imagine this story will have most hospitals doing an urgent review of their own processes.

  18. badrabbion 10 Apr 2008 at 8:29 am

    John,

    No Diatribe. I am just saying that relying on modalities whose power has not been proven is problematic.

    Any test, be it EEG, PET scanning, or angiography should have its power well measured prior to being relied on for brain dead declaration. Has this been done? For PET scanning apparently not.

    Moreover, apriori, we should decide what level of false positive and false negative we would tolerate from these tests. Thus, for example, Leo Mercer should have been able to come to Zack’s parents said something to the effect of: “Your son, by EEG and PET scanning has a 90% chance of being dead. What would you like to do?” Instead, my suspicion is that the doctor did what other typical doctors do which is to say “your son is brain dead, what would you like to do…?” Big difference, John. And this is important in a life or death issue like this.

  19. badrabbion 10 Apr 2008 at 8:38 am

    Antono;

    Great comment post. I hear and agree with you. Question: My understanding of what you wrote is that to declare someone brain dead, a battery of clinical testing is done. Can you tell me, given that this battery is done, what is the chance of false positive and false negative?

    If someone is completely without central reflexes, is unresponsive, has no brain EEG activity 24 hours after a severe injury, what is the chance of ‘brain death’ such that there is so significant recovery long term?

    If someone has all the above signs at 24 hours post injury, what is the chance that she will also have these same signs 1 week after the injury? One month?

  20. wertyson 10 Apr 2008 at 8:40 am

    I remember seeing a description of how this guy was going and as someone who has worked in ABI rehabilitation for a few years I had more than a passing interest in the details. I just can’t believe it happened as described in the media. Brain death diagnosis is based on the complete clinical picture, not on any particular test in isolation. As Dr N says, you repeat the clinical tests and other investigations and any flicker of activity rules out the diagnosis regardless of the other results.

    I hope he is getting a comprehensive ABI rehab program, poor guy.

  21. Antonoon 10 Apr 2008 at 2:28 pm

    badrabbi asked: “what is the chance of false positive and false negative” when all criteria for brain death have been met.

    The answer is a little complicated so please bear with me. I’ll talk about false positives first which are more important from a moral perspective.

    A false positive means a patient is declared brain dead while he is not. But how do we know he is not dead in order to claim it’s a false positive?

    Consider this analogy: mammography is a good test but it occasionally gives false positives i.e. it says there’s a tumor where there is none. But how do we discover mammography’s false positives? We use a “golden standard” test, the biopsy. In these studies the biopsy is considered for all practical purposes to be ~100% sensitive and specific and it is through this comparison that we calculate values for all other tests. The reason we use mammography instead of biopsies to screen women is because it’s faster, easier, non-invasive and has decent sensitivity/specificity. We later confirm all positives with a biopsy.

    Is there a golden standard test for brain death? Yup: it’s the very same criteria we’re discussing in this post. So, it’s inherently impossible to calculate specificity/sensitivity for these criteria. We’ve got no standard to compare them against. It is possible that someday we will discover a better test, but then we’ll throw the old test away and adopt the new one, because for such serious matters only a golden standard test is appropriate.

    By this time you might be thinking that a simple way to measure specificity would be to count all the “resurrections” that have happened when doctors employed these criteria. However, the criteria have been drafted specifically to be conclusive of all brain death cases that have ever been recorded, without any false positives. The reason behind this is that we wanted to create a golden standard test and the only way to do it was to use inductive reasoning and pick the smallest core of signs and symptoms that all brain dead patients (and only them) ever reported had in common.

    So, the current criteria for brain death have in a way a ~0% chance of false positives built-in. Since they were devised by induction, it is possible that some day a patient will come to life despite meeting them; in this case, the criteria will adapt to include even this exception and reach ~100% specificity again.
    [note1: in an effort to simplify the argument, I will not discuss the fact that different countries have different criteria]

    A false negative on the other hand is when the patient is declared alive but is really brain dead. While we would like to reduce the chances for this, it would mean we would have to increase the sensitivity and that would be deleterious to the specificity (i.e. increase false positives). Since our main concern is to protect the patient from an inappropriate termination of life support, the current tests have been tuned for maximum specificity only. Therefore, false negatives can indeed occur and we cannot compute the chances in any meaningful way for we have no golden standard to compare them against.

  22. badrabbion 10 Apr 2008 at 11:55 pm

    Antono;

    As I understand you, you seem to be saying that there is no gold standard for the diagnosis of brain death. This is so because those who are diagnosed as begin brain dead are allowed to die. Thus only a ressurrection would allow us to know when we are mistaken.

    Interesting!

    Ignoring the morality of the experiment, I wonder whether the following can be done:

    1. Use a given standard to diagnose brain death.

    2. Use life support to keep these patients alive.

    3. Measure the percentage of patients who display signs of recovery over a course of time.

    Would this type of experimentation be practical/moral?

  23. arthurgoldenon 11 Apr 2008 at 3:44 am

    It is my understanding (realizing that I am not a Torah Scholar but only a Torah-observant Jew) that the legal system of the Torah does not define dead as brain “dead” but as heart “dead.” Thus, Professor of Physics orthodox Rabbi Leo Levy stated one time during a class that I attended that a heart transplant involves two murders – one when the beating heart is removed from a person who is brain “dead” and two when a beating heart is removed from the person who will receive the heart transplant, even though the recipient will be “resurrected” from the dead.

    I am well aware of the practical implications of this position. While there are organ transplants that are approved under the legal system of the Torah (which are beyond my knowledge to explain) I am aware that Rabbis, the adjudicators of the legal system of the Torah, have ruled that it is not permitted to go to China for organ transplants, even though the Chinese doctors may be very scrupulous about the donor being brain “dead.” In China the issue is how the donor became brain “dead.” Even in the West, there could be “issues” which cannot be ignored.

    Arthur Golden of Jerusalem Israel

  24. Antonoon 11 Apr 2008 at 9:03 am

    badrabbi,

    There has been a little misunderstanding: current brain death criteria are our golden standard test. If we found a better test, we’d use that for diagnosing brain death. We always use the golden standard test to ensure maximum specificity.

    As I read your 3rd step in the study that you propose (measure the percentage of patients who display signs of recovery over a course of time) I sense that you’re troubled by the notion there’s a slight possibility that given enough time a brain-dead person might recover. So, you wonder how much time they allowed for these patients to recover when they drafted those criteria, right?

    There is no such possibility. A “brain-dead” diagnosed person cannot be sustained by life-support indefinitely, unlike coma patients. All brain-dead patients invariably suffer a more “conventional” death within a few weeks. Brain-dead does not mean “he will never recover”; it really means his heart is going to stop no matter how hard we try. So, in drafting the guidelines, they only looked at patients that died shortly after, while on life-support. They did not arbitrary select a deadline and see who had not recovered by then. Real, conventional, cold death is the inevitable outcome of brain death.

    The study you suggest is very interesting. There would be no need to watch them for signs of recovery indefinitely, just look for anyone not dying within a few weeks. I believe it would be ethical for the patients. As far as the public is concerned, it would be questionable to let all those organs go to waste, but I suppose we could focus on people who are not organ donors. Lastly, keeping ICU beds occupied with brain-dead people could be a little problematic but it can be argued that the benefits for the general public would outway any short-term bed shortages.

    That said, I would like to point out that we do not remove life support from every brain-dead patient, so there are always cases which can “resurrect” or at least survive and prove us wrong. For example, gestating mothers have been aggressively kept in life support (including hemodynamic management) for their embryo’s benefit or sometimes other patients have been kept on life support at their relatives request. Therefore, this experiment is running all the time and we are indeed giving ourselves a chance to notice false positives. As I said, it would take just one of those to prove us wrong.

    [Note: I should also mention that our brain death criteria were not drafted purely inductively. They were also created deductively from neurological facts. They are self-evident given what we know about the brain so far.]

  25. bioteleon 11 Apr 2008 at 12:14 pm

    This should be investigated as a criminal case involving an organ harvesting racket.

  26. badrabbion 13 Apr 2008 at 2:05 am

    Antono;

    Once again, a beautifully written response. I am almost convinced.

    I just want to repeat something to make sure I understand you correctly.

    You are saying that upon suspicion of brain death, if the patient is given the “golden test” and the test reveals ‘brain death”, then this test virtually proves brain death; that if this test is positive, in every case, the patient has gone on to die; that we have been watching patients, for whom for one reason or another life support has not been withdrawn despite being diagnosed with brain death, and in no case has there ever been a diagnosed brain dead person who has recovered.

    If I understand you correctly, then I concede my point.

  27. Antonoon 14 Apr 2008 at 6:46 pm

    badrabbi;

    Yes sir, you are correct. And all recorded recoveries have been shown to be due to improper administration of said test.

  28. badrabbion 14 Apr 2008 at 7:05 pm

    Antono;

    Ok, but do we know the rates of improper administration of the test?

  29. arthurgoldenon 15 Apr 2008 at 3:13 am

    I think it is much more important to know about the safeguards against improper administartion of the test. Once it is known that it is possible for there to be an improper administration of the test, there will be a temptation to do so in order to “harvest” the organs.

    Before Darwinism, medical doctors had the Fear of Heaven which would reduce such temptation. Although Dr. Novella rightly points out that Darwinism is about “natural” selection, once the belief in a Higher Power is so weakened by Darwinism, there is more of a risk of human intellect overriding concern about Divine Intellect (where in accordance with the legal system of Torah, premised on Divine Revelation, “brain dead” is not considered really dead).

    If such a standard means I am at risk of not having as much of a possibility of a heart transplant and it might result in my earlier physical death (as already claimed by doctors here in Israel), so be it. On the other hand, for every recipient, there is a donor, so I guess it is 50-50 that the result might be my later physical death.

  30. Antonoon 15 Apr 2008 at 5:29 pm

    badrabbi;

    I cannot find any such studies published after 1970-1984, which would lead me to believe that after standardization of the criteria any cases of improper administration have become very rare; then again, without confirming studies, this is just speculation. As this is not my specialty, I would welcome any further input by neurologists reading this blog.

  31. arthurgoldenon 16 Apr 2008 at 2:22 am

    Antono,

    I am very surprised that on a blog of supposed skeptics that you are so trusting of the ethical behavior of human beings. I am willing to concede that all medical doctors are saints, and by nature I am extremely trusting, but under the legal system based on Torah, when money is involved (such as selling kosher meat), one is not allowed to trust even a saint and in such matters the saint must be supervised by a qualified independent person.

    So, as I wrote a day ago:

    “I think it is much more important to know about the safeguards against improper administartion of the test. Once it is known that it is possible for there to be an improper administration of the test, there will be a temptation to do so in order to “harvest” the organs.”

    Let me add now that without adequate safeguards, the test can be properly administered but the results are falsified.

  32. eiskrystalon 18 Apr 2008 at 5:44 am

    Why was the cousin running a knife blade across the guys foot? That sounds like it’s right out of an urban myth.

  33. Fifion 20 Apr 2008 at 9:22 am

    Arthur Golden – “Before Darwinism, medical doctors had the Fear of Heaven which would reduce such temptation.”

    Well the most obvious problem with this claim is that organ transplants weren’t a possibility in pre-Darwin medicine. That and the obviously horrible things that were done to people with mental illnesses in the name of God and casting out demons, etc.

    With all due respect to your religious faith, people throughout the ages who have faith that God exists have murdered, raped, pillaged and committed all kinds of antisocial, unethical and, yes, even immoral acts. Sometimes even in the name of their God. Religion really has no ethical high ground – particularly considering how many wars for land and power are currently being waged in the name of various Gods. I’d think the “fear of having one’s license revoked tomorrow” would have a much more chilling influence on most doctors than the “Fear of Heaven” ever did (people being people, some far off reckoning once one’s shuffled off the mortal coil is going to have less power than immediate reward or punishment for many).

    And, well, the discussion regarding how many people used to get buried because they appeared dead (but weren’t actually) is pretty disturbing. I’d imagine that the more rapidly someone is buried, the more often this kind of thing occurred.

  34. Fifion 20 Apr 2008 at 10:56 am

    I also have to wonder why there’s the assumption that a doctor would want to declare someone dead so as to be able to remove their organs for transplantation (barring a family member or Important Person needing that organ now and there being a in-hospital conspiracy, which seems to be people’s general fear about signing on as an organ donor)… I’d think the potentially brain dead person’s treating physician would prefer to be able to save their own patient and that would be their primary concern.

    My understanding regarding the ethical issues surrounding organ transplantation in China is that the organs are taken from prisoners who have been executed. Brain death isn’t the primary ethical issue, political oppression and profiting off state sanctioned murder is. Where ever there’s money to be made, there’ll be someone who’ll find a way to justify it to themselves…whether the person is a doctor or a religious leader, the temptation is there and gets acted upon.

  35. Fifion 20 Apr 2008 at 11:50 am

    Minor correction since I didn’t mean to imply that all people are tempted or act upon temptation. Rather what I meant to convey is that people who will be tempted by money, power or some other personal motivation to take unethical actions exist in all professions – certainly there are examples of religious leaders who cannot overcome various temptation to act immorally (or who may actually act unethically on moral grounds), as well as doctors, government officials and people in other professions who can’t resist the temptation to act unethically. This is the whole point of having fail safe kinds of checks and balances – to remove as much human error or bias as possible. Obviously perfection is the ideal not usually the reality in the real world!

    From what I’ve read, most illegal and unethical organ harvesting is being done in poor countries – it’s cheaper, much less dangerous and much more profitable. Sometimes you can even get people to “agree” to sell an organ they’re in such dire financial need or need other medical help.

  36. NeuroLogica Blog » Back from the Deadon 27 May 2008 at 12:35 pm

    [...] wrote previously about the case of Zack Dunlap, who was declared brain dead after a serious injury and while being [...]

  37. wambroise1on 18 May 2012 at 11:13 pm

    So Steven Novella, as you stated about ” if properly employed there is almost no chance (I am tempted not even to say “almost”) of error or of meaningful recovery following a diagnosis of brain death.” and I’m pertaining to the part with “almost”, so what would be that small chance of recovering from brain damage, or at least certain parts of the brain… I am really interested in finding out, if you can email me at wambroise1@gmail.com

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