In this blog post, we will examine the meaning of death, dignified death, and the relationship to organ transplantation through the lens of brain death, and explore the related social and ethical issues.
Brain death is a topic frequently covered in the media, often alongside social issues related to death with dignity or cases of miraculous recovery through medical treatment. The former involves ethical and social questions regarding how to define “being alive,” while the latter stems from the fact that there is still no treatment capable of reversing brain death itself. In this post, we will examine whether brain death truly constitutes death and how it relates to the controversy surrounding death with dignity.
Before delving into this discussion, it is necessary to have a precise understanding of brain death. While many people have a general idea of what brain death is, they often fail to distinguish its exact meaning from other states of impaired consciousness. To understand this, we first need to briefly examine the functions of the brain.
The cerebrum is the region of the brain responsible for all human cognitive functions. Our ability to remember how to ride a bicycle or to feel the wind while riding is made possible by the normal functioning of the cerebrum. Furthermore, the brainstem plays a crucial role in distinguishing between brain death and a vegetative state. The brainstem generally consists of the midbrain, pons (bridge brain), and medulla oblongata (breathing brain), and serves as a passageway for the nerves connecting the brain to the spinal cord. The midbrain is involved in eye movements, vision, and hearing. Scenes in TV dramas where light is shone into the eyes of a traffic accident victim to check for a response are common; this is a test to verify midbrain function. The medulla oblongata is responsible for breathing, yawning, blood circulation, and the movement of muscles around the neck. The pons connects the cerebrum and the cerebellum and, together with the medulla oblongata, helps maintain regular breathing. Therefore, the brainstem can be seen as responsible for the functions that humans perform unconsciously to sustain life.
To understand brain death based on the brain functions explained above, let’s first examine the vegetative state. A vegetative state refers to a condition in which the cerebrum has suffered extensive damage or the connection between the cerebrum and the brainstem has been severed, resulting in the loss of all cognitive functions. Consequently, the individual cannot perceive external stimuli or respond to them intentionally, nor can they move their body of their own volition. However, since areas responsible for essential life-sustaining functions—such as the brainstem—remain active, the heartbeat can be maintained and life sustained as long as adequate nutrition is provided. Therefore, while individuals in a vegetative state generally do not require a ventilator, they must be fed artificially. Additionally, there are very rare cases of regaining consciousness, and recent studies have reported limited brain activity in some patients through brain imaging tests, indicating that ongoing research is being conducted in this area.
Brain death refers to a state in which the entire brain—including not only the cerebrum but also the brainstem and cerebellum—has suffered irreversible damage. Because the parts of the brain responsible for vital functions are damaged, unlike in a vegetative state, breathing can only be maintained by a ventilator. However, even in such cases, the organs gradually lose their function, and generally, within a few days to about two weeks, the heart ceases to function, leading to cardiac arrest. Furthermore, confirming a diagnosis of brain death requires multiple neurological examinations and legal procedures, with repeated verification conducted at regular intervals. Although there are occasional reports of people “waking up” from a state of brain death, these cases are mostly explained as confusion between a vegetative state and brain death or as misdiagnoses during the initial diagnostic process.
The issue of determining brain death involves not only scientific aspects but also social and ethical concerns. Before examining these discussions, it is necessary to first consider what death actually is. Is a person in a state of brain death truly dead? As explained earlier, even a person diagnosed with brain death can generally maintain cardiac function for a certain period of time. Based on this point alone, it is difficult to conclude that brain death equates directly to death. In forensic medicine and civil law, death is generally defined as a state in which both cardiac and respiratory functions have ceased. The organs essential for sustaining life include the heart, lungs, and brain, and the state in which all these organs have ceased functioning is referred to as cardiopulmonary death. Generally, if one of these organs loses function to an irreversible degree, the other organs will eventually cease functioning as well. From this medical perspective, there is a view that since brain death ultimately leads to cardiopulmonary death, brain death can also be understood as a stage of the process of dying.
So why do we distinguish between brain death and cardiopulmonary death? From a medical perspective, it is because life can be sustained for a certain period even in a state of brain death through the use of a ventilator. However, when considering not only the medical perspective but also the social perspective, there is another reason: the issues of organ transplantation and decisions regarding life-sustaining treatment are closely linked to brain death.
In South Korea, active euthanasia is not permitted. On the other hand, discontinuing or withholding futile life-sustaining treatment for patients with no prospect of recovery who are in the terminal stage is permitted under certain conditions in accordance with the “Act on Decisions Regarding Life-Sustaining Treatment.” Generally, euthanasia refers to the act of actively hastening a patient’s death, while discontinuing life-sustaining treatment means accepting a natural death in a situation where treatment is ineffective and there is no prospect of recovery. Therefore, the two concepts are distinguished legally and ethically. Regarding patients in a vegetative state, judgments may vary depending on the individual patient’s condition and legal requirements, and as various ethical debates are ongoing, this article will not address the issue in detail.
Meanwhile, in South Korea, the determination of brain death holds significant legal implications regarding organ donation from brain-dead individuals. Under the “Act on Organ Transplantation,” when organs are donated through lawful procedures, the time of death is determined based on the time of brain death determination. If organ donation does not occur, the patient will eventually experience cardiac arrest; however, if organ donation does occur, legal procedures proceed based on the time of brain death determination. Thus, the law assigns a distinct legal significance to brain death in the specific context of organ transplantation. South Korea’s brain death determination procedures are conducted according to standards that are relatively strict by international standards. While some argue that the brain death determination process should be shortened to minimize organ damage, counterarguments consistently emphasize the need to consider both the accuracy of brain death determination and ethical concerns.
The law can be described as a system that reflects the social values and ethics of its time. Therefore, this article has explained the issues surrounding brain death, focusing on legal aspects while examining both medical and social perspectives. However, it will be difficult to fully resolve various issues such as brain death, death with dignity, and organ transplantation without also considering economic and ethical factors. Questions such as how broadly to define the scope of “being alive” and to what extent economic factors should be considered are topics that will require ongoing discussion. Furthermore, since medicine has not yet reached the stage where it can fully understand and treat all diseases and disorders of consciousness, there is a need for continued social debate and research on issues related to brain death and the vegetative state.
