Defining death

There are three main ways that death can be defined: legally, culturally or clinically. Find out what criteria are used to determine the moment of death.

Legal definition

In Australian law, death is generally defined as either irreversible cessation of circulation of blood in the body of the person or irreversible cessation of all function of the brain of the person. National Health and Medical Research Council.

Brain death (irreversible cessation of all function of the brain) means death of both the upper brain and brain stem. A person who is brain dead has lost both the capacity to think and perceive, as well as the control of basic body functions. Court challenges to consider upper brain death alone have so far failed, but history suggests that our current definition of death is far from permanent.

In the future it may be possible for individuals to define death for themselves by specifying under what circumstances they want to be considered dead. There is already provision for this in some countries.

Cultural and religious definitions

For the Roman Catholic Church death is the 'complete and final separation of the soul from the body'. However the Vatican has conceded that diagnosing death is a subject for medicine, not the Church. In 1957 Pope Pius XII raised the concerns over whether doctors might be 'continuing the resuscitation process, despite the fact that the soul may already have left the body.' He even asked one of the central questions confronting modern medicine, namely whether 'death had already occurred after grave trauma to the brain, which has provoked deep unconsciousness and central breathing paralysis, the fatal consequences of which have been retarded by artificial respiration.' The answer, he said, 'did not fall within the competence of the Church.'

It remains for the doctor and especially the anaesthesiologist, to give a clear and precise definition of 'death' and the 'moment of death' of a patient who passes away in a state of unconsciousness. Pope Pius XII

Followers of religions like Zen Buddhism, and Shintoism believe that the mind and body are integrated and have trouble accepting the brain death criteria to determine death. Some Orthodox Jews, Native Americans, Muslims and fundamentalist Christians believe that as long as a heart is beating--even artificially, you are still alive.

Clinical definition: brain death

Brain death (irreversible cessation of all function of the brain) normally occurs after a stroke, or an impact that causes the brain to swell and push against the skull, preventing blood from flowing to the brain. In the absence of oxygenated blood, brain cells quickly die. The dead cells break down and liquefy. Brain death is quite different from reversible coma (unconsciousness) in which living brain cells remain.

A person can remain permanently unconscious with total or partial brain death. A person with death of only the upper brain (cerebral hemispheres) will not have consciousness, memory, knowledge or thought, but the living lower brain (brain stem) allows the heart to pump, the lungs to breathe and the body to function.

To be legally brain dead, all function of both the upper and lower brain must cease. Because the heart will fail on a brain-dead person, certification of death by brain-death criteria (instead of circulatory criteria) will only be needed when the dead person's body functions are being maintained by an artificial ventilator.

To establish that the brain is dead, certifying doctors must ascertain that:

• there is no evidence of brain function over a period of time
• the loss of function is not a result of drugs, hypothermia (low temperature), hypoglycaemia (low blood sugar) or hyponatraemia (low blood sodium)
• the person has sustained a brain injury sufficient to account for the irreversible loss of brain function. Often this is done by CT scan
• there are no reflex functions associated with coughing, gagging, eye movement, blinking, or dilation of the pupils
• the person makes no attempt to breathe when disconnected from the respirator for several minutes
• during the previous test, the carbon dioxide level of the blood has risen above the point at which breathing is normally stimulated.

These tests are frequently repeated after a further 24 hours as an assurance of irreversibility. A flat electroencephalogram, indicating an absence of brain activity is often used for verification.

Where the 'dead' person's organs are available for donation, two doctors, neither of whom is caring for a potential organ recipient, must undertake the testing and certification.

If the person has received drugs that might invalidate the testing procedure, or if the head is so badly damaged that the tests cannot be performed, death can be determined by total lack of blood flow to the brain. This is done by inserting dyes (angiogram), or radioisotopes into the blood vessels supplying the brain blood vessels, to ascertain that they do not travel to the brain.