Pulling the Plug: Misconceptions on Death Fuels Controversial Debates

by Jusmita Saifullan

The holiday season is usually a time of warm spirits, love, and well-being. Unfortunately this was not the case for 13-year-old Jahi McMath and her family as 2013 neared its end. Jahi made headline news and ignited a controversial debate in both scientific and mainstream communities following her tragic medical accident.

The tragedy unraveled after Jahi’s doctor recommended tonsil surgery—a very routine procedure—as a treatment for her sleep apnea at Children's Hospital in Oakland, California on December 9. Initially showing no problematic signs post-surgery, Jahi experienced sudden cardiac arrest on December 12, followed by excessive bleeding after she was resuscitated, at which time doctors pronounced her “brain-dead.“ Despite strong confirmations of her death by physicians and her unlikelihood of regaining consciousness, the teen’s family refused to accept the diagnosis, stating: “As long as her heart is beating, she is still alive.” this sentiment became the family's mantra as they battled against hospital law for Jahi to remain under life support through the remainder of 2013 and into 2014.

Healthcare professionals continue to argue against the mainstream public opinion regarding the current criteria necessary to determine an individual's death. Opposing the expertise of doctors and textbook definitions that cite “brain—death” as akin to clinical patient “death,” the McMath family, as well as much of the public, insists on the possibility that she may regain consciousness. This opposition stems from a misconception of the definition of death and the blurred ethical lines regarding clinical treatment for brain-dead individuals.

Medical dictionaries describe death as “the irreversible cessation of all vital functions [of the body] especially as indicated by permanent stoppage of the heart, respiration, and brain activity.” Along the lines of neurological activity, a patient is classified as brain-dead “when the entire brain, including the brainstem, has irreversibly lost all neurological function.” Brain death results from any condition that results in a lack of blood and oxygen circulating to the brain and can be caused by abnormalities or injuries from either natural causes or trauma. In Jahi’s case, her cardiac arrest disallowed oxygen circulation to her brain, leading to her diagnosis of brain death.

Multiple tests were performed on Jahi to affirm this diagnosis. Physicians tested cranial nerves for function by engaging various parts of the brain stem that should trigger mobile responses from non-brain-dead patients. In addition, they performed apnea tests in which carbon dioxide gas is administered to the lungs at a certain level. The patient’s inability to gasp for breath above a specific concentration indicates the loss of brain function. After Jahi failed both tests; physicians declared that there was no blood flow to her brain and no signs of electrical activity.

The McMath family’s struggle to accept their daughter’s death stemmed from a lack of public education about the ethical treatment of brain-dead patients in clinical practice. Some medical ethicists and medical experts believe that Jahi’s case has not educated, but fueled, the public’s misconception that a person is still living when brain- dead, perhaps based on varying subjective definitions of death, or due to confusion of brain death with comas or vegetative states.

Robert Arnold, M.D., the Director of Clinical Training at the University of Pittsburgh's Bioethics Center, agrees that the public’s distorted definition of death is a contributing factor to the controversy of Jahi’s death. “Cases like Jahi’s are infrequent, and should not be used by the public to guide their understanding of death,” said Arnold, a published author on the ethics of clinical care and doctor-patient communication. It seems that the public uprising against taking Jahi off life support stems from their inability to grasp “death“ at the level of the brain is medically the same as  “death“ at the level of the heart or body.

Regarding the judge's decision to extend Jahi’s time on life support for a limited period of time, Arnold expressed that this verdict was most likely “the judge's attempt to split the differences” for both the family’s values and the state's law. “Jahi is dead, so the hospital is put under no obligation to care for her,“ he said. However, Arnold does acknowledge the emotional toll that making decisions for brain-dead patients puts on the family: “I truly feel sad for the parents, since this was something no one expected.“

For Arnold, it is ultimately ethical for a hospital to remove Jahi, or any brain-dead patient, from life support. Although he admits subjective morals can be more complicated, continuing life support or endeavoring to perform further medical procedures on Jahi  is unethical, a view supported by the physicians at Oakland's Children's Hospital who refused to perform a tracheotomy for breathing and a gastric intubation for feeding (surgeries needed for Jahi’s transfer to another  facility) because they deemed performing  surgeries on the deceased as being unethical.

Jahi McMath's case is not the only one to cause such divisive debates between the scientific community and the public. However, as Arnold emphasized, these rare cases should not be used as a basis for determining one’s viewpoint on the broad and extensive subject of the ethical treatment for patients in  unconsciousness or vegetative states whom  are treated under different, distinct guidelines. The tendency for the public to make the faulty generalization that brain-dead patients are classified alongside comatose patients leads to the false hope phenomenon. This prevents families of brain-dead patients from grieving their loss and instead puts public pressure on the medical community to care for patients who will no longer benefit.