tag:blogger.com,1999:blog-6206360557488781408.post7915735060568090147..comments2023-07-29T00:40:35.293-07:00Comments on Narrative Inquiry in Bioethics Forum: “Reasonable Accommodation” for Families of ‘Brain Dead’ PatientsUnknownnoreply@blogger.comBlogger3125tag:blogger.com,1999:blog-6206360557488781408.post-23504906794201199892012-07-21T06:19:51.742-07:002012-07-21T06:19:51.742-07:00Thanks for your comments. I would extend the exemp...Thanks for your comments. I would extend the exemption only to those few instances of clearly defined, established religious rejection, such as the Ultra-Orthodox. Some Islamic Imams reject “brain death” though many do not, so that case would be included. I would not include a mere belief in miracles for the reasons you stated, or accept a fly-by-night religious sect’s leader who announces that he, as the ultimate authority, rejects brain death.<br /> <br />The long-term physiologic support of a young brain dead patient is among the saddest medical situations I can imagine. I agree that giving families a firm date for stopping could relieve them of their burden but some have threatened or taken legal action which usually accomplishes their goal. And as we all learned from the sad case of Emilio Gonzales, the public media is a difficult place to enforce a futility regulation.<br /><br />James L. Bernat, M.D.James L. Bernatnoreply@blogger.comtag:blogger.com,1999:blog-6206360557488781408.post-54507332096461831822012-07-20T17:40:56.344-07:002012-07-20T17:40:56.344-07:00Follow-up: would you limit the accommodation to pe...Follow-up: would you limit the accommodation to people who belong to an Ultra-Orthodox group (or maybe also the just plain old Orthodox)? Or can any claim of belief in God and miracles suffice to justify such accommodations? (We had a 15 year old ‘survive’ for over 6 months, and a 19 year old ‘survive’ for 4 months. Neither were Orthodox or Ultra-Orthodox, or even Jewish. And I don’t think either of those are records, though I think the pattern is clearly the younger the patient, the longer they can be kept ‘alive’ by cardiac standards.)<br /> <br />Down here in Texas they might take these cases to ‘futility review’ though I am not so cold-hearted as to be a fan of that approach. I just think it is more humane to the family to take some of the burden off them, and give them a date after we’ve given them some time to adjust/accept the situation.<br /> <br /><br /> <br />Jeffrey P. Spike, Ph.D.Jeffrey Spikenoreply@blogger.comtag:blogger.com,1999:blog-6206360557488781408.post-23995664383110402182012-07-20T08:51:56.925-07:002012-07-20T08:51:56.925-07:00When Religious Beliefs Conflict with “Brain Death”...When Religious Beliefs Conflict with “Brain Death” Declaration<br /><br />In his commentary, Jeffrey Spike made several insightful observations on the ethical dilemma faced when family members, for understandable emotional reasons, cannot accept the finality of the death of their loved one. I agree with all of the points he made. But because the current case includes the additional factor of how physicians should respond when the patient’s religious beliefs conflict with the standards of ordinary medical practice, I conclude that further accommodations are reasonable.<br /><br />In my experience as a neurologist performing “brain death” determinations and as a bioethicist performing ethics consultations in several of these cases, the majority of conflicts with family members result from their difficulty in accepting that a “brain dead” person is actually dead. They often see the condition solely as coma from which it should be possible to recover. Frequently, they also have an emotional inability to accept the finality of the state, usually resulting from the suddenness of the brain injury that has instantly converted a young vibrant life into a moribund state. The comments Jeffrey Spike made all pertain to this situation and are thoughtful and reasonable.<br /><br />The inability of the family to accept “brain death” in this case, however, turns on the presence of a religious doctrinal belief system that rejects the equivalency of “brain death” and human death, and requires the permanent cessation of respiration and circulation. This conflicted situation is rarely encountered in most clinical settings but does occur, as in this case, when a devoutly Orthodox Jew suffers a severe brain injury leading to a clinical determination of “brain death.”<br /><br />In their poignant case report, Martin Smith and Anne Lederman Flamm explain the basis for the Orthodox Jewish doctrinal rejection of “brain death” declaration, and discuss how some states in the United States have accommodated this belief system into public laws. I emphasize a point they made that this topic remains an area of active rabbinic dispute within Orthodoxy, with strong arguments citing Talmudic passages (and the writings of Maimonides) supporting the consistency of “brain death” determination and Jewish law. It is true that, despite the merits of this argument, it currently represents a minority interpretation of Jewish law. <br /><br />The question at issue here has both ethical and public policy dimensions: how to simultaneously maintain respect for religious beliefs while permitting uniformly accepted medical practices. Smith and Flamm offer several reasonable observations on how to reach accommodation in such conflicts with which I agree. In my own experience of a single case in which this conflict arose, we transferred the patient to a New York City hospital within the patient’s Orthodox Jewish community where treatment was continued until his heart stopped beating. <br /><br />In my opinion, because the religious disagreement justification differs from the emotional distress justification when a family cannot accept the finality of “brain death,” I believe that the response of physicians and society also should differ. Because of our respect for religious beliefs, we should have a greater willingness to accommodate the religious disagreement. I advocate taking steps to work with families to continue treatment at least temporarily or arrange for other physicians to do so. Although it seems understandable that a health insurer might not wish to continue reimbursement for medical care after death has been declared, in my experience, no insurer has reached that decision, perhaps to avoid bad publicity. I applaud the laws in New Jersey and New York that have formalized this exemption.<br /><br />James L. Bernat, M.D.James L Bernatnoreply@blogger.com