Dr. Richard G. Nilges (1919-2011) on “Brain Death”
At the bottom of this post is an essay by my father on the ethics of organ donation and the definition of death, reproduced at this site.
Dad told us not to sign organ donor cards. He told us that the gooey talk about “giving your body to Science” covered up the brutal economics of hospitals to whom your death represents a financial windfall. He emphasized that “organ harvesters”, whom he called ghouls, need the organ to be living and were using flat EEGs as the only indicator of death, when flat EEGs are often observed in intoxicated patients.
He retired early under pressure but wrote and spoke extensively about this issue in retirement. His allies were chiefly among the right-to-lifers but he seemed more emphatic that older people, who represent as he represented a valuable resource of memories and work, were risking their lives when hospitalized.
Dad preserved his own life honorably as a Survivor. He held down a job outside his assisted care facility and traveled extensively in retirement. Using Skype I was able to have good talks with Dad from Hong Kong in his last days.
When younger he was not extreme in his “right to life” views and believed that abortion might be justified in certain circumstances, but his specialty, neurosurgery, primarily involved him with the end of life, where old people, many of them who’d never had a chance to speak with forgiveness and love to children, like mine, estranged by divorce, were treated as resources and money machines by hospitals. His definition of personhood resembled that of Peter Singer, the Australian ethicist who now teaches at Princeton, because it included the person’s memories and ability to connect through language.
Intolerant of “alternative lifestyles”, he nonetheless worked heroically (sometimes for 16+ hours straight) in the operating theater to save motorcycle outlaws who’d been thrown across Archer avenue in their to him foolish pursuit of the high. He was often underwhelmed by the aliteracy and stupidity of his patients, for my Dad was like me no end of an intellectual snob. But somehow he realized that behind most badassed dudes there’s usually a long-suffering wife yearning for a last kind word, or a beautiful daughter needing a hug, and wanted to use his skills to perhaps provide that moment.
He had what the Chinese call a good heart, but his generation had been taught by Hitler that hey, you’ve got to hide your love away.
But in Chicago, where he practiced, old people found intoxicated on the street and brought in to Swedish Covenant were regarded by some (by no means all) cops and EMTs as human garbage…and the American economy runs on the strange proposition that the more people you make redundant, the more engineers you lay off, the more computer programmers you decide can’t be retrained, the more single mothers you brutalize, the richer we’ll all be.
Dad hit the roof in 1965 when I was arrested in a sit-in to persuade Chicago’s schools superintendent Ben Willis to merely obey the Supreme Court’s 1954 decision to integrate schools, and he hit it again when Mom had her Girl Scouts raise money for the Black Panthers’ Children’s Breakfast Program. But Dad treated white and black patients equally with skill and compassion, and a black patient gave him a special card saying “honorary black man” during the 1968 riots when Dr. King was shot, to protect him.
I came to realize after my divorce and my Dad’s unhappiness over my decision that “blackness” for him represented not taking care of your family and being irresponsible, even as Chris Rock says there’s a difference between “blacks” and “n-rs”. And even though Dad did not approve, owing to his influence I made a decision that although the marriage was as far as I could see over, I would be responsible both about paying child support and spending time with the kids…without expecting extra credit per Chris Rock: “Ah takes care o’ mah kids: what you want, a cookie?”.
As a result, although I worked in Silicon Valley, I was always myself broke: it was a big deal for me when I bought a manual transmission Ford Escort in 1985 with neither radio nor air conditioning, and drove it from the West Coast to Princeton to take a new job at the university.
I suppose I could have gone to Dad to fund a one-time payment to my ex-wife similar to the one Steve Jobs’ mistress was demanding at the same time I was divorced, but basically, I decided to sort of grow up. In addition, I never could stand the way Dad would whine and carry on about money, and how guilty he’d make me feel; that is why I’ve stuck it out here in Hong Kong. Even as the old British colonizers were probably loth to go back to Britain as younger sons and hear their fathers’ complaints about their failures, I’ve done my best to hang on here.
I was lucky to have him as father…warts and all, for what father does not seem a dork at times to his sons? My own sons are totally grossed out, I imagine, by my use of Jane Fonda aerobics.
I want all of his professional competitors to show up at his funeral and call him a great man but it probably won’t happen. As it is, I am struggling desperately at this time to find an affordable flight to make it to Chicago for his funeral. I’d set aside money but it wasn’t enough: then, unexpectedly and last night, I was loaned some more by a lovely woman friend after she heard my story. I am going to HKIA to see what I can find this morning.
If I don’t make it, I shall go in September when I’ve saved more to visit his gravesite. He is buried in Indiana, next to Mom.
I never got Dad to read Adorno, but I think he was unheard for the same reason Adorno is hard to “get”: his central message was about the “brutalization” of medicine, and Adorno also saw that thought itself was being influenced by the strange (positivist) idea that somehow it must be hard, brutal, cold, even when thought is attempting to reify compassion (as in identity politics and certain forms of administrative political correctness).
It seems a social law that his type of verbose compassion is either unheard or when heard, profoundly offensive. For we learn all too well that it’s better to be “scientific”, exact, even as we fail to learn real science, real math. Adorno and my Pop fell between the cracks because they (in particular Dad) were scientific enough to realize that humanities (including medical decision making, and the theoretical analysis of radio listening) had their own topoi which needed to be kept separate from “scientific” tests (whether “brain death” or idiot answers to idiot questionnaires).
Here is his article.
The Death of the Brain (page 38)
Richard G. Nilges, M.D.; copyright 1990
“Evil committed for a good purpose remains evil.”
“Even when it succeeds?”
“Above all when it succeeds.”
Victor Hugo, History of a Crime (1877)
What is the brain? A structure, yet it is far more than a structure. It is incredibly complex; its functions could be multiplied toward infinity, perhaps beyond. It is an inward mirror of the real self, or the real self mirrored in the mirror; it is a jelly of thought- capturing webs in the cranial crucible. Who can describe the eloquent complexities of our brains, those universes within our heads?
Yet what is the brain compared to its epiphany, the mind. And the mind? The shimmer of whispering moonlight on darkly rippling water, a single cloud on the horizon of a summer day, autumn’s demented wind loosening the last of the bronzed leaves, all these are the mind. Without the mind, would they be there? As spectral emanations of the laws of motion and physics, of color, perhaps they would; perhaps not.I now approach the unapproachable. I have already gone too far in speaking even of the mind, according to current reductionistic philosophy. But I would go beyond to the soul, that epiphany of epiphanies. In thirty-three years of practice both as doctor and neurosurgeon, I have treated brains, minds…and souls. But a most reductionistic of materialistic philosophies destroys my trinity by declaring minds and souls null and void, reducing everything we used to call human to the laws of neurophysiology in neuronal nets. With this, the pale hand of death has entered our thinking and our society. And the crassly utilitarian concept of brain death becomes the microcosm of the death of the mind and soul of our society.
For a society should be judged by how it treats its most helpless members. And who are more helpless than the so-called brain dead? Why do I say so-called? Does not the death of the brain mean the death of the person? I doubt this. I think the idea of brain death is a manifestation of the simple-minded pragmatism of our society, lost in a philosophy outmoded even a century ago. What is real, what is right, is what works; success justifies pragmatic metaphysics and ethics. We forget basic human rights, we forget ideal essences beyond appearances, we forget souls and lose our own when we simplistically and pragmatically declare people non-persons and brain dead so that their hearts, livers and kidneys can be transplanted into others.
Is the soul, the transcendent ego, or the personality really within the brain? The soul could be the form of the body, as Aristotle claimed and medieval Catholicism confirmed. I fear that somehow we are violating souls yet escaping from the tendrils of their bodies when we practice “organ retrieval” (to use a euphemism of the transplanters) on people who are alive in the sense that their hearts are still beating.
Richard Strauss, on his deathbed, awoke from his penultimate coma and declared that he had just heard the final notes from his Death and Transfiguration: “Dying is just as I composed it in Tod and Verklarung.” Christian mystics have described a “fine point of the soul” while in states of prayerful suspended animation. How many trumpet calls to eternity, how many prayers and even mystical visions have we doctors blunderingly interrupted while “harvesting” (another transplant euphemism) living organs?
I have seen many “brain dead.” They do not look dead. It is true their respirations are passive, the machines breathe for them; but their hearts beat, their blood circulates, they are rosy and warm. The young men are handsome, the young women beautiful, even in their brain deaths. Such a person can be declared legally dead, and as a “prime donor candidate” the vital organs can be transplanted.
The public must understand–and this point is too often glossed over the transplanters and their apologists–that brain death is not about turning off the ventilator; it is about continuing the ventilator to take organs. The doctor writes on the chart that, according to accepted medical criteria for brain death, this person is dead. The body (or is it still the person?) is then carted to surgery with the ventilator going, the heart beating, the skin warm and pink. The natural circulation of the precious vital organs must be preserved till the last possible minute. In surgery a paralyzing agent without anesthesia is administered, then the vital organs are removed while the heart still beats–till it is removed. Then there is no doubt that the person is dead; the soul has fled.
I have tried to ease my conscience by using the strictest possible criteria for brain death: at least forty-eight hours of repeated observations that there are no functions of the brain, no signal, even a faint reflex, that this brain is trying to make to me, and two “flat” electroencephalograms (EEGs) separated by twenty-four hours and both showing “electrocortical silence.”
Yet there are “accepted medical criteria” for brain death requiring no EEG and less than six hours observation. The “accepted criteria” evaluate only brain stem reflexes and the absence of breathing. This should be frightening to all of us. Mistakes might be made with such short periods of observation; barbiturate intoxication can simulate brain death and could be missed. Possibly even more important, this desire to assert oneself, to play God and decide who shall die and decisively pronounce death in a hurry brutalizes my profession. Where is pity, where is love, where is even the basic doctor-patient commitment in those “doctors” who act as though they have pumps for hearts and ice water for blood?
At considerable expense our society allows convicted murderers years for appeals from death sentences. We often do not give our innocent brain dead even forty-eight hours to make as sure as humanly possible that there is no chance, even a one-in-ten-million chance, the last infinitesimal chance there may be some flicker of nerve cell activity in the depths of their brains, a spark of life somewhere in the labyrinths of their minds.
The push is for the pragmatically useful, the rapid estimation of brain death. The fresher the organ, the less the time since the brain injury or stroke, the greater the chance for a successful transplant. And the rights of the individual donor be damned! Only a faceless “society” and the well-funded recipient patient, who needs the organ for further “useful” existence, are important. Furthermore, the callous comment has been made by younger members of my profession that “dead people are less trouble.” It is far more difficult for the medical and nursing staff too maintain a brain dead or potentially brain dead patient in the intensive care unit unit for forty-eight hours than to declare death in less than six hours, while the patient is still in the emergency room.
“Death is the great economy in health care,” reducing the problem to the bottom line of money saved, when the going rate for intensive care is over one thousand dollars a day.
But this is what I mean by the brutalization of medicine, the loss of the soul of what should be a most noble profession of healers, not killers, the final solution by the reduction of everything to the bottom line of effort, time and money saved.
Vox clamantis in deserto.