Is death synonymous with the cessation of brain activity?

Jahi McMath, 17, was deemed brain-dead in 2013 after a routine tonsil surgery went wrong.

Three years on, she is said to be alive, with video footages showing twitches and movements – and her family members are hastening the court to revoke her death certificate. The court will rule in the next two months whether the appeal should proceed.

At the age of 13, the Californian teenager was diagnosed with sleep apnoea and admitted to UCSF Benioff Children’s Hospital for a tonsillectomy. She regained consciousness after the operation. Nonetheless, shortly after, she suffered a cardiac arrest that left her with severe brain damage. Doctors pronounced her as effectively dead with no chance of survival if the ventilator was removed.

However, the family persisted in keeping her on life support and moved her to a facility in New Jersey, where the state law prohibits doctors from removing brain-dead patients from ventilators over families with religious objections.

Interestingly, in 2014, her family members noticed some movements that signalled she was alive, despite medical opinion that stated otherwise. It was said she could even move her foot on command.

Such incredible recovery from brain death – as noted by their attorney Chris Dolan – would be a medical first and Dolan argued that the Jahi was no longer brain dead, as brain scans show electrical activity. He added that she does respond to verbal commands from her mother.

‘Deceased’ girl is fed nutrients to keep brain alive

Rooted in strong Christian beliefs, Jahi's mother, Nailah Winkfield said she is compelled to fight to keep her daughter alive. The family initiated their own methods to keep Jahi “alive” by feeding her with 'nutrients' through a feeding tube, which they believe would supposedly keep her brain at optimum efficiency.

But the Children's Hospital Oakland spokesman Sam Singer dismissed the approach as “wrong and unethical”, claiming that Dolan would mislead the family and the public that there is hope or any food that could possibly bring back the deceased young lady.

“This is a deceased young woman,” he said. “No amount of food, medicine, medical machinery, time or hope is going to bring her back.”

Neurologist believes girl’s movements are real

Supporting the family's belief that Jahi is alive, Dr Alan Shewmon, a professor emeritus of paediatrics and neurology at UCLA and an ardent critic of how brain death is defined, said videos recorded by Jahi’s family from 2014 to 2016 show the teen is still alive. Video clips of McMath twitching her fingers show she still has brain function.

Shewmon’s new finding which was culled from a study of 49 videos of the teenager recorded by her relatives in the two-year period proved that Jahi is alive and that her condition is improving over time.

He attested that though he himself did not witness the movements, the videos were reviewed by forensic experts who found no evidence of post-recording alternations. This, he hopes, could lend support to the family in their attempt to revoke the death certificate and declare her as legally alive.

Happy family: Jahi (right) pictured here with her mother Nailah, stepfather Marvin and younger sister at their wedding before her cardiac arrest. Photo credit: Susana Bates/Daily Mail
Happy family: Jahi (right) pictured here with her mother Nailah, stepfather Marvin and younger sister at their wedding before her cardiac arrest. Photo credit: Susana Bates/Daily Mail

“The video recordings, as crude and unsystematic as they are,” he wrote, “represent the only way at present to decide whether Jahi is permanently comatose or in a minimally conscious state with intermittent responsiveness.”

The documents stated that McMath seems to move her extremities when nudged by simple commands. He believes the girl is not brain dead, although she remains irrevocably and severely neurologically disabled after the surgery.

According to Dr Shewmon, some of her movements in response to commands lasted as long as 10 seconds, especially when her heartbeat was above 80. “There is a very strong correspondence between between the body parts requested,” he explained, “and the next body part that moves. This cannot reasonably be explained by chance.”

Could have the movements been manipulated?

The living-death saga has opened up a series of dramatic issues surrounding the way death is defined. Not just that, it also sheds light on ethical and philosophical issues concerning the removal of life support. Despite Dr Shewmon’s report, many healthcare practitioners see brain death as indisputable. Several doctors, including two hired by the court, have said brain-dead patients can still twitch and move slightly.

Lawyers representing the hospital and its doctors argued that Jahi was properly declared dead and described the family’s position as “not supported by the law, logic or medicine”.

The hospital’s lawyer, Jennifer Still, however claimed that “body movements could be easily manipulated”. "Often the camera only shows a convenient angle, such as a close up of her foot or hand," Still wrote.

Still said the family has not subjected McMath to tests accepted by the American Medical Association (AMA) to determine whether someone is brain dead.

“The core issue is whether or not she is clinically brain dead and meets the standard definition of brain death,” said David Magnus, a medical professor and director of Stanford’s Centre for Biomedical Ethics.

But if Jahi really did do the things as recorded on the video, “that would be a huge challenge, medically and scientifically,” Magnus said. “It means what people believe they know about brain death based on decades of experience and evidence would turn out to be false.” “… It’s ridiculous to think you could do an examination based on videos that were sent to you.”

A fundamental issue that needs to be redressed

“It’s an unprecedented case,” said Lawrence Nelson, a lawyer, bioethicist and associate professor of philosophy at Santa Clara University.

“Either you are alive or you are not. If you are alive, but you are very badly brain damaged, you are a person and have moral and legal rights. If you are not alive, then you have none of those rights. Whether or not Jahi is alive or dead is huge and fundamental.”

There has never been a recorded instance of a brain-dead person regaining cognitive capabilities, said Thaddeus Pope, a professor and director of the Health Law Institute at the Mitchell Hamline School of Law.

“Everybody, even the plaintiffs, agrees that Jahi was (brain) dead in December 2013,” Pope said. “What her family is saying is that she is not dead now. That is significant because there has never been a case ever in human history where somebody was correctly declared dead and had it rescinded later.”

Marjorie Shultz, a retired UC Berkeley professor of health law and medical ethics, said there should be more input from family members when discussing the fate of a brain dead patient. “We are going to have to move in that direction and revisit it, legally and collectively. We will continue to learn more about what is going on in the brain of people who are minimally conscious, or something in the twilight zone between unquestionably dead and unquestionably alive.” MIMS

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