Experts Urge Comprehensive Revision of Controversial U.S. "Death Laws"

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Redefining Death: Experts Urge Comprehensive Revision of Controversial U.S. “Death Laws”

Redefining Death: Experts Urge Comprehensive Revision of Controversial U.S. “Death Laws”

Prominent brain injury expert, Dr. Ariane Lewis, after surveying 41 organizations, advocates for reforming the legal definition of death in the United States.

She emphasizes aligning legal standards for death with medical standards, particularly addressing the unnecessary consideration of hormone function in current definitions.

While many organizations support the revision, there is a divergence of opinions, especially between medical organizations and patient rights groups.

A neurocritical care specialist examined opinions on the “Uniform Determination of Death Act” submitted by 41 advocacy, medical, and transplant organizations in 2023 and is calling for much-needed reform of the U.S. legal definition of death.

The expert points out that the Uniform Law Commission, which had been spearheading the revision, recently announced a pause in their efforts, which is disappointing, but it should not permanently hinder practical fixes to long-standing issues with the “Death Laws.”

Dr. Ariane Lewis, a neurocritical care specialist at NYU Grossman School of Medicine, professor of neurology and neurosurgery, and a medical doctor, said, “This study demonstrates that the majority of medical organizations support revising the Uniform Determination of Death Act to align legal descriptions of neurological death criteria with medical standards.”

Lewis believes that, specifically, the legal description of death needs to reflect medical guidelines, which do not require the consideration of hormonal function when declaring someone brain dead.

Additionally, the “Death Laws” need revision to provide legal guidance for healthcare providers on what to do when family members object to discontinuing mechanical life support for a loved one declared brain dead.

For example, the law needs to clarify when and for how long (if not indefinitely) mechanical ventilation can continue after brain death if the family opposes its removal.

Redefining Death: Experts Urge Comprehensive Revision of Controversial "Death Laws"

Differing Opinions and Insights

Lewis stated that her survey results show that 34 organizations (83%) support revising the “Death Laws.” However, she also acknowledges that there is a diversity of opinions on how to revise the law. Some religious organizations and patient rights groups oppose using the loss of brain function as the standard for declaring death and prefer the traditional definition of death as when the heart stops beating.

Lewis, who is also the director of neurocritical care at NYU Langone Medical Center, has shared her survey results and perspectives with the committee working on revising the “Death Laws.” The committee’s work was paused in late September. Lewis has been one of 100 observers collaborating with the committee over the past three years to revise the law.

A recent study published in the journal “Neurocritical Care” closely examined comments and viewpoints submitted to the committee by 41 organizations affected by the “Death Laws” between January and July 2023.

Historical Background and Challenges

Historically, when a person’s heart stopped beating and they could no longer breathe spontaneously, they were considered dead. However, advances in mechanical ventilation technology changed this situation. In some cases, people can maintain their breathing after suffering catastrophic brain injury leading to a loss of the neurological function required for autonomous respiration. In 1981, such cases led to the creation of the U.S. “Uniform Determination of Death Act,” which defines death as the irreversible cessation of all brain or cardiorespiratory functions. All U.S. states adopted this definition as the legal basis for declaring someone dead.

However, the law did not specify the medical examinations needed to determine whether a person is dead. Additionally, a few states allow family members to object on religious grounds. This includes some Orthodox Jews, Muslims, and Catholics who equate the removal of mechanical ventilation with euthanasia, even after a patient is declared brain dead. Some family members hope to keep their loved ones, who have been declared brain dead, on mechanical ventilation indefinitely, leading to numerous legal challenges against healthcare institutions.

Calls for More Comprehensive Guidance

Lewis believes that more legal guidance is needed for physicians and urges the committee to adopt international and domestic medical standards regarding neurological death. This includes guidelines issued by organizations such as the American Academy of Neurology, the Society of Critical Care Medicine, the American Academy of Pediatrics, and the Child Neurology Society, none of which require considering hormonal function when declaring someone brain dead.

Lewis pointed out, “The loss of ‘all brain functions,’ as stated in the Act, includes the cessation of hormone secretion, which is also encompassed within the definition of death in the Act. However, as per current medical standards, the loss of hormonal function does not require brain-related criteria to declare death.”

The definition in the “Death Laws” is considered overly broad and impractical, as there are currently no established criteria in medicine to assess the cessation of hormonal secretion or when it occurs. Therefore, she suggests that the law should be clarified to specify which brain functions must be lost to legally declare someone dead and recognize that the loss of hormone secretion should not be one of the criteria.

Another study’s findings are that patient rights organizations support revising the law to require obtaining family consent after declaring someone dead before discontinuing mechanical ventilation. Lewis noted that medical organizations are opposed to this position.

Lewis said, “The results of this survey indicate that, while stakeholders support revising the ‘Death Laws,’ there are significant differences in approaches between medical organizations and patient rights groups. Since reaching a consensus seems unlikely, the committee’s work has stalled, and without law revision, it remains unclear what tests are required to declare someone brain dead, and there is no legal guidance for physicians and the public on how to resolve conflicts when family members object to brain death as the standard.”