Talk:Brainstem death

Oppose merger. It seems this article describes a condition that is different than brain death. Brain death refers to actual death of the brain stem, whereas brain-stem death as described in this article seems to refer to a diagnosis whereby if certain functionality is absent, the brain-stem can be presumed to be dead. 69.140.164.142 05:01, 11 April 2007 (UTC)

The premise that the UK criteria are prognostic rather than diagnostic is precisely this article's conclusion, which you are restating as fact. Opposing merger on the grounds that brain-stem death is not part of the same issue as the definition of cerebral death in the United States is to beg the question and to preclude an international perspective on the issue. VEBott (talk) 12:17, 8 July 2011 (UTC)

Needs to attribute sources

This article has a bunch of information, and it has a bunch of references. But there are no citations within the text pointing to the references.

Also, some of the language used in this article is emotionally loaded ("unfortunate", etc.). Mbarbier (talk) 06:27, 19 December 2007 (UTC)

Serious unrepresentative bias

This article was originally excessively argumentative and expressed a minority viewpoint as the consensus of the profession. It urgently needed complete revision by a competent neurologist, with the minority viewpoint given space proportional to the rather limited support it enjoys amongst those who understand these matters. As it stood it was an example of everything that is wrong with Wikipedia. I have edited extensively but am not qualified to do more than eliminate the most obvious bias towards views stemming essentially from a rejection of all neurological rather than cardiac definitions of death. Tharyps the Molossian (talk) 22:22, 5 April 2008 (UTC)

Bit of a quick review

I was asked to have a quick look at this, with a view to article development. It's a quick look, so excuse rough notes;

• lede's all wrong; needs to 'adequately summarize the whole'

some refs lack dates; format of refs isn't all consistent - this is one of the main probs on GA

• overlinks (e.g. United Kingdon)
• Title might need changing; it is specific to 'brain stem death criteria in the uk' - it doesn't cover 'brain stem death'; this also makes it hard for me to asses if it 'adequately covers the subject' - because the subject remit is unclear
• Makes assumptions about context - e.g. in "background", The Conference sought “to establish - what conference? Where, when? OK, it's defined in the lede, but...that's not what lede is for; see WP:LEDE
• 3 dabs - breathe, [[medulla], anoxia
• 'conclusion' - too short for a section, and sounds a bit WP:OR - we don't draw conclusions
• Language could do with a going-over to reduce the techno-speak; e.g. The clinical syndrome diagnosed by the prescribed bedside tests was conflated with brain death at that time but, while held to be an irrecoverable premortal state, - most of us plebs won't understand it
• Wikilinking needs work. For example, linking 'death' and 'heart' is not appropriate; other links such as e.g. Brain death would help 'build the web' and might help understanding - see WP:LINKING
• other parts of the brain[6][8][9][10][11] - does it really need all those refs bunched up?
• Images (pics) would definitely help
• Per Wikipedia:Manual of Style (numbers), there should be a non-breaking space -   between a number and the unit of measurement.
• Needs copyedit for MOS issues;

• punctuation on refs, for example; Royal Colleges]]<ref name=ref1>Conference of Medical Royal Colleges and their Faculties in the UK. Diagnosis of brain death. British Medical Journal 1976;2:1187-8</ref>, with advice from - that comma needs to go before the <ref>
• Shouldn't have a blank line after the section headings

 Chzz  ►  08:23, 26 March 2010 (UTC)

POV issues

The "controversies" section seems hopelessly one sided and full of likely oiriginal research: "It clearly confused... It assumed... implicitly claimed that... speciousness..." etc. FT2 ^{(Talk | email)} 18:19, 30 December 2010 (UTC)

I don't know what "likely original research" means here. If there is original research, there should be a statement like, "Egor and I in our basement zapped a bloke's brain w/ 200 Megavolts of 75 Herz electricity for 3.5 seconds and got these results." (That would be the forbidden original research!) Otherwise, I would just regard what someone wrote (not based on 2ndary sources) as opinion. (EnochBethany (talk) 04:03, 20 April 2011 (UTC))

I don't think what he's talking about is OR. It seems to be closer to weasel words. - Purplewowies (talk) 04:40, 20 April 2011 (UTC)

Differences Between Brain stem death and Brain death

Someone has conflated "brain stem death" with "brain death", thus perpetuating the confusion which has dogged discussion of these states over the years. I have tried, repeatedly, to edit the first section to put this right and have tried to remove subsequent material relevant to "brain death" so that the article refers only to "brain stem death", hopefully clarifying the issue. I have also tried to remove the disputed 'Controversial aspects' section and renumbered the references accordingly. My efforts have been unsuccessful and I see the corrupt version - no credit to Wikipedia, which I have hitherto admired as a source of accurate information - reposted after I've left. I need expert help with the citations. The automatic formatting doesn't seem to accept the reference renumbering. If someone with the technical skills required will help put this section right, I will make yet another attempt to sort it. But I seem powerless to correct it on my own. DWEDWEvansMD (talk) 15:07, 23 May 2011 (UTC)

I have unmerged Brain death back into a separate article. Purplewowies (talk · contribs) said that "Brain death was merged into this article for a reason." but there does not appear to have been any discussion as to what that reason was. DiverDave (talk · contribs) proposed the merge (last year) and then implemented the merge. The lack of vocal opposition on the talk page does not indicate support, and since this is clearly contested I have undone the bold merge in keeping with WP:BRD. Since I am thoroughly unqualified to add to this discussion from my own knowledge and have not read either article I have no opinion, but should there be further/renewed support for the merger I strongly recommend continuing this discussion here so that it can be explained why they should or should not be separate articles. VernoWhitney (talk) 18:43, 31 May 2011 (UTC)

I assumed that there was a consensus for it to be merged, but I didn't have time to look into it, so I didn't know that the merge was done with no discussion. - Purplewowies (talk) 17:47, 6 June 2011 (UTC)

Globalize

Most of this article pertains only to the United Kingdom and, to a lesser degree, to the United States. This article needs to be expanded to address other countries as well. It needs a much more global perspective. Also, info in some parts of this article does not clearly indicate what countries/regions the info pertains to. For example, in the "Diagnosis" section, there is a list describing the pre-conditions and criteria for "brain stem death". However, it does not clearly indicate what country/region that list of pre-conditions and criteria is for. It isn't for all countries, since the article already said the conditions/criteria vary. It does mention that the list is from the "Code of Practice", but it still doesn't specify what country uses it. However, since further down in that same section (underneath the list) a "UK Code of Practice" is mentioned, based on context it seems like the author might be referring to the same thing as the "Code of Practice", but I can't be sure. It should be clarified. There are numerous other places in the article that need geographic clarification. The article may be able to provide adequate global perspective by adding more information for other countries/regions, however it might be necessary to rewrite parts of the article to adequately address the current lack of global perspective. Mhadj001 (talk) 20:14, 28 May 2011 (UTC)

The Code of Practice is the UK Code specified in the reference list. 'Brain stem death' - as a clinical syndrome which, when diagnosed according to that Code's rules, allows the diagnosis and certification of a patient's death - is a peculiarly British (and British Commonwealth) entity. It is not accepted as a valid basis for the diagnosis of death in the USA or most other parts of the world. Hence there is, in my view, no global perspective. On the contrary, it is essential to recognize the idiosyncratic nature of this UK definition of death which specifically ignores remaining life in the major part of the brain. I have tried to explain this in this piece and am anxious that it be seen as objective. Please let me know what may seem biased in my, perhaps clumsy, efforts to record the history of this attempt to define death on scientifically insecure neurological grounds. DWEDWEvansMD (talk) 17:19, 1 June 2011 (UTC)

This article remains a single authored polemic.

The article concerns a major issue, namely the evolution of the criteria by which a beating-heart cadaver is recognized. Unfortunately, it is written from a perspective which is not only fundamentally critical of a neurological approach to the diagnosis, but also disguises its attack by bringing in different neurological approaches from the United States. One senses, although one cannot be sure, that the approach is motivated as much by religious considerations as by medical ones; it makes use of any medical arguments it can.

The evolution of the British criteria played a major role in the development of the US ones; the Presidential Commission, in order to secure general consent for a non-cardiological definition of death, compromised by requiring the cessation of all detectable brain activity, but the neurological grounds for doing so are weak. By giving them undue prominence, and not counterposing them to other majority viewpoints from other countries, the article ends up citing the Commission's findings as if they were scientific evidence rather than opinion.

In this controversy, cardiologists, electroencephalographers and neurologists tend to take different views according to their specialisation. It is therefore important to know where the authors of any referenced studies are coming from - and whether their primary area is even medecine rather than medical ethics.

Both this article and the one on brain death need major work, to reflect and explain perspectives from other European countries, Latin America and Asia. This is a complex task, rarely accomplished even in specialist published works on the subject. A useful start is Eeelco Wijidicks "Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria" published in the AAN's Neurology, 2002;58;20-25 which can be found at https://www.hods.org/pdf/brain%20death%20world%20wide%5B1%5D.pdf and Haupt WF, Rudolf J. "European brain death codes: a comparison of national guidelines", J Neurol 1999;246:432–437, to be found at http://www.springerlink.com/content/xd202v0ap17p8hng/ It is striking that neither of these key references figure in this articles' notes.

In the meantime, I suggest that the original author's constant reversions be marked down as vandalism and that appropriate action be taken. As it stands, this article is a disgrace to Wikipedia. VEBott (talk) 12:07, 8 July 2011 (UTC)

Thank you for your constructive criticism, to which I reply :-

The concept that "brain stem death", as diagnosed by specified clinical tests, is human death is a peculiarly UK and British Commonwealth notion. Its acceptance as death - or "equivalent to death" as it's been put - depends on the belief that there can never again be any capacity for consciousness once that state is diagnosed. Remaining life elsewhere in the brain is considered irrelevant and not looked for - as it is in countries where "brain death" is the neurological standard. There is no approved diagnostic schedule for the diagnosis of brain death in the UK and use of the term "brain dead" to describe patients certified dead on the "brain stem death" criteria is officially discouraged.

It is essential to the understanding of what "brain stem death" is that its confusion with "brain death" be avoided. I have, in the past, tried to make that clear in the preamble and may have another go if I sense encouragement. To that end, I have omitted references to the vast literature on the vexed topic of "brain death" - in its many guises - and fully agree that it would be a monumental task to undertake a balanced review of that field, highly desirable as it must be.

Re balance - I can see what is meant by perceived lack of balance in this article as it has evolved and will be pleased to see what can be done to get rid of contentious material if you'd like me to. But it has to be said that, in the wider context, there has been no balance in presentation of the case for and against acceptance of " brain stem death" as death until Wikipedia published this piece. The concept and criteria were promulgated by the BMJ - Pallis's 'ABC of brain stem death' - and the UK Medical Royal Colleges from the 1980s onwards, backed up by the Department of Health's agents and the broadcasting media, without open debate or even opportunity to read widely available criticism of the science and philosophical concepts involved. The major medical journals declined to publish critical submissions (and still do). We had to resort to the 'Catholic Medical Quarterly' to get a paper into print - though we are not Roman Catholics - and were grateful for its courage to protest. Perhaps that title has given some the idea that there is a religious element to our challenge. That is not the case. We object to the bad science and unwarranted assumptions involved and to their imposition upon sadly uncritical, perhaps because misinformed, worthy people.

I am very concerned to see on Wikipedia a reliable, objective, source of information about this highly controversial matter. There is no such readily available source anywhere else. The public is otherwise subject to less than full and frank information and assurances that this concept is now "accepted practice" and beyond debate.

I leave it to others to comment on the allegation of vandalism - not what I have come to expect from Wiki editors - and await its withdrawal before taking any futher part in this endeavour. DWEvansMD (talk) 13:41, 11 July 2011 (UTC)

Dr Evans, your claim that “the concept that brain stem death, as diagnosed by specified clinical tests, is human death is a peculiarly UK and British Commonwealth” notion is somewhat misleading, as any reading of Wijidicks survey published in the American Academy of Neurology's journal, Neurology would show. The confusion that needs to be avoided is that between death and a permanent vegetative state (which the public often miscall brain death) rather than that between different ways of diagnosing when “brainstem reflexes, motor responses,and respiratory drive are absent in a normothermic, nondrugged comatose patient with a known irreversible massive brain lesion and no contributing metabolic derangements” , which Wijidick presents as the basis of a universal medical agreement.

The countries that happen to be members of the Commonwealth (it's no longer British) account for a sizeable percentage of the world population. If one throws in Hong Kong, Malaysia, Iran and parts of the Arab world, one is talking about an even larger proportion of the world's polities. Many European countries have criteria closer to those applied in the UK than to those in effect in the US.

Stylistic tropes which imply that something can only be true if recognized as such in the US and in countries influenced primarily by work done in the US don't really cut the mustard on Wikipedia.

I'm still unclear from which direction you're approaching this.

I would start by asking you whether you accept the notion of a beating-heart cadaver. If you do not, you are at odds with world medical opinion, not just a section of it.

Secondly, I would ask if it is the issue of complete electroencephalic silence that troubles you. Many neurologists across the world, including in the US, do not recognize this as an essential feature of a corpse, any more than the cessation of the growth of fingernails was considered central to previous conceptions of death.

Thirdly, I would ask if it is the nature of the respiratory tests that you consider lacking in the UK. If so, particularity in this domain is again not something specific to the UK criteria.

Finally, I would ask whether you recognize death as a process rather than as a categorical transition involving the departure of a soul from the body.

OK , those substantive issues aside, let's move on to the question of style. Wikipedia is meant to be an encyclopedia. Despite your suggestion to the contrary, it is not essentially a publisher which gives an opportunity for minority viewpoints rejected by specialist peer-reviewed journals to be published. Wikipedia's concept of balance is not to give equal emphasis, let alone primary emphasis, to minority viewpoints, and it has a specific ban on publishing one's own research. Wikipedia's concept of vandalism may not be what you think it is, but I willingly withdraw the charge in light of your courteous response. Your obvious misconception of Wikipedia's function is clear enough.

What you have done is to reproduce the arguments of the article you had to publish in the Catholic journal because no neurological or general medical journal found it of an acceptable standard of argument. You have advanced a basis for diagnosing death quite at odds with that of neurologists worldwide, namely “the observation of the bodily circulation” and “ascertaining the complete absence of oxygen uptake by the brain over a period of time sufficient to ensure tissue necrosis on every part of the brain”.

I'd rather not put an ad hominem argument, but I would really like to know whether you approve of heart and liver transplants from bodies on respirators at all. Some of your early publications suggest otherwise.

What I am most concerned about, however, is the irresponsibility of Wikipedia giving such prominence to a perspective which is likely to cause great alarm and distress to the relatives of victims of the kind of accidents that result in brain-stem death.

Constructively, I would suggest that the article be rewritten by somebody who understands and sympathises with the neurological basis of the UK criteria, integrating Wijidick's survey of differences across the planet. The article should also explain the paradoxes of a US position that defines death in terms of the loss of whole brain function but requires only testing of brainstem function to diagnose it (cf JM Elliot's Brain Death in Trauma, SagePub, 2003) with no other mandatory tests of brain function, a fact about which Dr Evans sytematically misleads the reader. It would then be appropriate, following Wikipedia guidelines, for Dr Evans to write a short criticism section that expressed the key points of his own approach, with the understanding that it should not aspire to be of anything like the same length as the main article.

If I were a neurologist, I would write the main piece myself. In the meantime, one can only hope that somebody from the Queen's Square education department will get off their bum and do so. Until something better is available, I am minded to remove all the tendentious material from the article. VEBott (talk) 05:24, 17 July 2011 (UTC)

I have no expertise in this area whatsoever, but from a lay person's perspective, this article appears to violate Wikipedia's policies banning original research WP:OR and requiring a neutral point of view WP:NPOV. In particular a Wikipedia article should not have a "Conclusion" section, which suggests a preferred point of view, nor should it have contentious sentences which are not tied to a source. The views presented here may be an important balance to accepted practice, but Wikipedia is not the place to publish them.--agr (talk) 02:23, 18 July 2011 (UTC)

User: VEBott, we are clearly so far apart - to judge by your assertion that the confusion to be avoided is that between death and a vegetative state, when the whole thrust of this article is aimed at avoiding confusion of 'brain stem death' with brain death and with death itself - that I must ask you to read my chapter titled 'The demise of "brain death" in Britain' in 'Beyond brain death - the case against brain based criteria for human death' edited by Potts, Byrne and Nilges and published by Kluwer Academic Publishers in 2000 - and David Hill's chapter titled 'Brain stem death : a United Kingdom anaesthetist's view' in the same volume - before we go much further into detail and specifics. You will find the essential basic information about the origins of this novel concept and UK redefinition of death therein, and further information about it in 'Finis Vitae - is brain death still life?' edited by Roberto de Mattei (of the Italian National Research Council) and published by Rubbettino in 2008 (a new edition is due shortly). The latter is a record of the Proceedings of a Pontifical Academy of Sciences conference held in Rome in 2005.

When you have read our chapters and the many other contributions to those anthologies - some of them much weightier than ours - I dare to hope that you will understand that "brain stem death" originated in the UK as a clinical syndrome, diagnosable on the basis of a series of simple bedside tests applied in carefully prescribed circumstances (the preconditions) which reliably heralded imminent, or fairly imminent, death and which therefore justified or required the withdrawal of useless and unkind life-support measures (particularly mechanical ventilation). The diagnostic criteria were officially promulgated in 1976 for that prognostic purpose. Their subsequent change of use - to criteria for the diagnosis of death itself - had no scientific or philosophical basis. There was no open, informed, debate about this enormous leap. It appeared to be driven by transplant considerations - specifically the need to obtain hearts in viable condition. There was no other purpose to be served by it. The adoption of the concept and practice had much to do with the publications of one neurologist - Chris Pallis - whose 'ABC of brain stem death' was the truly un-peer-reviewed polemic (sponsored by the BMJ). It was very difficult to get criticism into journals for which he acted as reviewer or referee. In more recent times, it has been possible to get criticism into on-line publications, open-access peer-reviewed journals, and www.bmj.com 'Rapid responses'.

I trust you will appreciate that the presence of this article on Wikipedia, imperfect as it is (though we will try to improve it, maintaining objectivity), has provided the only readily available source of unalloyed information for those dissatisfied with the didactic statements asserting the acceptance of "brain stem death" as (a form of) death which are all they get from the Department of Health and its transplant agencies. I know that many, including young doctors and medical students, have had their eyes opened to the facts of this matter - having been taught that there's no longer any controversy about it - and have been grateful to Wikipedia for making them available.

The term "beating-heart cadaver" is an oxymoron. A cadaver is a dead body, a corpse.

David W.Evans 81.107.34.21 (talk) 21:24, 18 July 2011 (UTC)