Is Life Fair?

“The Lord gave, and the Lord hath taken away; blessed be the name of the Lord” (Job 1:21).

Diagnosing brain death is never an easy experience, even when the medical facts are relatively straightforward. The old fashioned way to die is to stop breathing, have your heart stop beating, and to cease neurologic function, usually all at about the same time. A primary insult to one of these three functions quickly leads to completion of the other two if no intervention is made.

But modern medical technology has made it possible to temporarily separate these mechanisms from one another. Ventilators can preserve respiratory function to a remarkable degree, and there are also many ways to support and maintain circulation. A body with a severely damaged brain may be artificially supported by intensive medical care; it is possible to temporarily maintain respiratory and circulatory function when there is no evidence of brain survival. What to do in this situation has presented medical practice with an ethical dilemma which is unique to our age of the world. Over the past few decades the concept of brain death, or “death by neurologic criteria,” has emerged to help doctors and families determine when further supportive care is medically futile (which is another concept fraught with ethical difficulty). The main problem is that demonstrating that there is no brain function is not as simple as determining that the heart is not beating, and the criteria are much harder to explain to families. Understanding the concept of brain death and how it is diagnosed requires a fair amount of knowledge about neuroanatomy and neurophysiology, which most people don’t have.

Some years ago I had a patient who was a middle aged-man with a wife and teenage children. When I first walked into the hospital room with my team of residents and medical students his wife was sitting at his bedside reading him a novel out loud. He had more tubes and IV bags and medical devices than I think I have ever seen on one person at a time. This man had suffered a cardiac arrest, and heroic efforts had been made to support his heart, lungs, and kidneys. Unfortunately his brain did not tolerate the cardiac arrest and subsequent medical instability, and I was called to help determine just how damaged his brain had been.

His wife was very hopeful that her husband would recover, but after a few days of testing I had to inform her that he was dead by neurologic criteria. Her tears flowed freely, and my heart ached for her in her loss.

We left the room and went directly to see another patient in the same hospital unit, another man who had suffered a cardiac arrest. But this patient had fared much better, and was now awake, talkative, and grateful to God that he had been given a second chance at life. This man was an inmate in the state prison system, and bore the marks of a hard life on his face. He was wearing a bright orange jumpsuit, and was handcuffed to the hospital bed. I asked him how much time he still had left to serve, and learned that he would be released from prison within the next few months.

I was still feeling the emotion of my previous encounter, and was struck by the similarities and contrasts between the two cases. One man, a responsible husband and father, was dead. Another man, a convicted criminal, was going to live and be free. God had called one home; the other he had given time to repent. With emotion in my voice I exhorted this man to stay out of trouble and not to land himself back in prison after his release. “Oh, I won’t, Doc,” he promised. “I am a new man!”

A few minutes later I sat at the nurse’s station, feeling heavy in my heart. I turned to Natalie, one of the residents on the team, and asked, “Is life fair?”

“No, but God is,” was her reply. And she was right.

Alan B. Sanderson, MD is a member of The Church of Jesus Christ of Latter-day Saints and is a practicing neurologist.

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