Brain Dead is Actually Just Dead.

I have been following the story of Marlise Munoz with sadness and horror over the last couple of months.

If you’re not familiar with the story, Marlise Munoz is a woman who died, likely of a pulmonary embolism, and was resuscitated. She was fourteen weeks pregnant when she died, and the hospital decided to keep her on a ventilator due to a misinterpretation of a Texas state law.  The law in question states that life sustaining support cannot be removed from a pregnant patient, and the hospital, disregarding Marlise’s wishes and the wishes of her husband, kept the body on a ventilator.  The law does not apply in Marlise’s case; since the woman is not alive, she cannot be considered a patient, and the support here is not life sustaining, since she is no longer alive.  Even the drafters of the law now say that it is being misapplied; that it was never intended to apply to dead people.

Because, and it is important to be clear on this matter, brain death is death.

What brain death means is that the brain has stopped functioning.  The process for confirming this state is rigorous, involving tests and often having to be confirmed by multiple physicians.  And while the ventilator may keep the blood oxygenated, and the heart may keep beating, the body is still dead.  The heart has its own electrical system that will allow it to keep beating for some time as long as it is supplied with oxygen.  With the brain stem no longer stimulating breathing, normally the heart would stop very quickly after the brain dies.  When the lungs are artificially inflated with oxygen, this allows the heart to continue beating, but it does not mean that the person is alive.  Other vital functions handled by the brain, such as the release of hormones needed for gastric and kidney function, as well as to maintain metabolism and blood pressure.  The dead body can no longer maintain the correct temperature, and must be kept warm using blankets or warm IV fluids.  But this does not mean that the person is alive.  Indeed, with the medical technology that we now have, a corpse could be kept warm and “breathing” for some time; perhaps indefinitely.  The hormones needed for continued function can be replaced and the blood pressure can be corrected using medication.  But this doesn’t mean that the person is still alive.

Brain death is not the same as a coma, or a persistent vegetative state.  This is not the Terri Schiavo case, in which the patient was still alive but unlikely to recover.  Brain death is the irreversible cessation of brain function.  It is not a prolonged loss of consciousness, nor is it brain damage.  Brain death is death.

Indeed, the body continues to deteriorate when it is dead.  Maintaining the body on a ventilator at that point constitutes a high-tech, temporary sort of embalming.  It is not and cannot accurately be called “life support,” as there is no longer a life to support.  This is why the ability to determine an actual point of death is now so important… otherwise, we could warehouse hundreds, maybe thousands of intubated corpses, just waiting for the body to deteriorate enough that the ventilation and the heating was no longer sufficient to maintain the appearance of living flesh.

Removing a person from a ventilator is a difficult thing; the body may still appear to be alive, and one may feel, in a very visceral, lizard brained way, that the removal of the machines is ending that person’s life.  I saw both of my parents removed from ventilators shortly before death; neither were dead at the time, but both were beyond hope of recovery.  My father passed almost immediately after support was removed; the cancer had already done so much damage to his body that it was no longer capable of sustaining life.  My mother couldn’t breathe well enough to even stay awake, and when the breathing support was removed, she gasped and fought for air for several hours before dying a natural death.

In Marlise Munoz’s case, this would not happen.  Because Marlise Munoz is dead, and dead brains no longer stimulate respiration.  She would just deflate, and begin to decompose.  Because Marlise Munoz is dead.

Her husband knows that she is dead, and has been fighting desperately to get the hospital to take her off of the ventilator.  Erick Munoz has said in a statement that her limbs are stiff, that she no longer smells the same as she did, and that there is nothing human left in her eyes.  I understand what he’s saying.  When I saw my mother, shortly after her death, the absence of her desperate, shallow breathing made the bed appear empty.  She didn’t look like my mother anymore; she didn’t even look human.  She looked like some kind of cave-dwelling lizard or a horror movie prop.  I remember looking at her body in the silence of that sunny spring morning, and wondering at the change.

There are muscles in the face that are active even in sleep; even in repose.  They were still active in my mother’s face when she was heavily sedated, and even after breathing support was removed.  They are responsible for our facial expressions and micro-expressions, some of which are involuntary.  After the brain dies, the personality that both formed and inhabited that face is gone; the strings are cut, and the face hangs slack.  Not slack in the way of a sleeping person, but utterly slack.  Slack in a way that I’ve never seen on any living person.

Marlise Munoz died in the fourteenth week of her pregnancy, and now with her fetus at twenty-two weeks gestation, it has been determined that the fetus is abnormal to the point that it is not viable.  Its lower extremities are deformed to the point that gender cannot be determined; it has brain abnormalities and possibly a heart problem.  I was discussing the issue with my sister, who is a specialist in high-risk obstetrics, and she says that the way the fetus was described, it may have hydranencephaly, a condition in which one or both hemispheres of the brain are missing, and the cavity is filled with spinal fluid instead.  Such a fetus, assuming that it could be kept alive, would be unlikely to ever learn to walk, or talk, or feed itself.  She says that it is possible that such a malformation occurred due to an interruption in the supply of oxygen to the fetus during a specific point in its development.  If this were the case here, that interruption may have been due to Marlise Munoz’s death.  Because Marlise Munoz is dead; she is not being kept alive by these machines… her corpse is being employed as a sort of macabre incubator.  My sister says that it is almost impossible to incubate a healthy fetus in a dead body, because the body is no longer capable of monitoring or correcting its own blood pressure or blood flow, both of which are essential throughout the pregnancy.

A court has ruled that because Marlise Munoz is dead, and because her fetus is not viable, that she needs to be taken off of the ventilator.  The viability of the fetus should have had no bearing on this decision, and Marlise Munoz should have been allowed to die a quiet and clean and dignified death.  Even if the fetus were viable, its rights do not outweigh the rights of the deceased woman, and her family.  One of the great comforts available in the inevitability is that it will be over; this is essential to those who need to let go of a deceased loved one.  I am glad both for the sake of my mother’s dignity and for the sake of her family that she was allowed to die among people that loved her, in a quiet, private way.  Death is terrifying, but it comes to us all.  There is no cheating it, no avoiding it, and no bargaining with it.  It is normal and natural… the great equalizer.

I do not know how Erick Munoz will recover from watching his wife’s body be used in this way; the thought of it happening to me or to someone I know terrifies me.  I am glad that their one year old son will likely not remember any of this, and glad that he is too young to understand what is happening.  I hope for a quiet end to this terrible drama; I hope that the hospital does not appeal the court’s decision and continue to drag this out to the point of viability.  And I hope that Marlise Munoz is finally permitted to be dead.

Update: Yesterday, January 26th, the hospital removed Marlise Munoz from the ventilator ahead of the court ordered deadline.

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