(Original title: Ist Himtod gleich Tod? Merkurstab 1994; 47:456-65. English by A. R. Meuss, FIL, MTA.)

Historical evolution

First of all, a definition: "brain death" as total cessation of integrated brain function, followed by necrosis, has to be clearly distinguished from "locked- in syndrome" (motor paralysis in all parts of the body, with the patient sentient and awake, a condition due to interruption of the corticospinal tracts between midbrain and pons).(1)

Analogous to other organs (renal or liver failure) we should really be speaking of "cerebral failure" rather than "brain death."

Irreversible loss of all brain function causes spontaneous respiration to cease, leading to "cardiovascular death." The syndrome has only been observed with the development of intensive care units. Long-term artificial respiration has made it possible to keep patients alive: the disease as an "artefact of intensive care treatment" usually manifests hours, days or a few weeks after initiating intensive care;(2) and "dying and death have since gained a new dimension."(3)

In ancient Egyptian medicine the rule was that people were alive for as long as they breathed; death was near when the heart no longer "spoke," when the vessels "fell silent."(4) This has continued to be the generally- accepted view up to the present century. It is a reflection of human evolution that the definition of death no longer bases on the heart and respiration but on brain function.(5) The syndrome was first described in 1959 as coma depasse.(6) Many definitions were suggested,(7) with "brain death," a most inappropriate term, finally winning the day. In the field of intensive care medicine, it soon became necessary to develop guidelines and recommendations as to how such patients should be considered.

Another new development which affected the issue was transplantation. The first heterologue attempts (animal to human being) were made between 1906 and 1923. All came to grief on the biologic barrier of immunity. The first homologue attempts (human to human) were made by Varony in Russia in 1936. Rapid development finally came in 1962/63, following immune- suppression with azathioprine and corticoids. The first liver was transplanted in March 1963, the first lungs in June 1963, the first pancreas in 1966, and the first heart on 3 December 1967.

The cyclosporin era began in 1976/78, effectively controlling rejection reactions. As early as 1968, the Pittsburgh technique of perfusion cooling of organs for transplantation had matured to a point where it proved useful."(8,10) As time went on it became necessary to agree on the possible and legitimate moment when organs could be removed.

Several sets of criteria for "brain death" were developed, including the Harvard criteria in 1968, others in England in 1976 and 1979, the USA in 1981, Switzerland in 1983, and in the Federal German Republic in 1969,1982,1986 and in 1993. The German Medical Association has consistently stated that the guidelines can only "aid physicians in making their decision" and are not legally binding.(11,14)

The discussions held over the last two years have shown quite clearly, however, that cerebral failure is not generally accepted as the moment of death (with all the consequences, e.g. removal of organs).

An apt exposition of the problem was made in Denmark in 1989:

I. A person is dead when the following have completely and irreversibly ceased:

1 cardiovascular functions

2 respiratory function

3 cerebral function

II. Cessation of brain function signifies the irreversible beginning of the death process.(15) Unfortunately this is an isolated instance in the literature.

The current criteria of cerebral failure are essentially based on three parameters: (morphology (CT), cerebral circulation (angiography, Doppler ultrasonography, perfusion scintigraphy) and brain function (neurologic examination: EEG, apnea test).

Pathophysiology

The central nervous system (not so much the spinal cord), "which has no vitality of its own and needs 'intensive care' to prevent it perishing prema- turely, is subject to decomposition and decline, atrophy and degeneration, rigidity and death."(16)

Damage may result from rapid acceleration or deceleration, rotation trauma, gas bubbles rupturing the capillaries, parenchymal necrosis and hemorrhage, tissue contusion, neural tract rupture, ischemic lesions and edema. Intracerebral hematomas may increase in size within hours or days. A vicious circle evolves with edema leading to hypoxia which, in turn, increases the edema. Instability of the brain's autoregulatory functions may result in systemic disorders such as circulatory problems, with poor oxygenation causing additional damage. Cerebral edema myelophthisis, known as "edema necrosis," shows in the CT as internal hydrocephalus.

Other factors indicating a poor prognosis include the absence of periodic sleep patterns in the EEG.(1)

Ischemic damage due to circulatory failure or inadequate resuscitation, for instance, is biphasic. Initially, when the oxygen supply is interrupted, serious but not absolutely irreversible damage is caused to the brain. If the first phase has been too long, the second, post-ischemic phase results in serious and often irreversible damage. It is the recirculadon phase. Several factors are involved:

a) Post-ischemic hypotension: acid equivalents are washed out from the brain, resulting in vasodilatation and a drop in blood pressure. The hypotension tends to be of extended duration if the cause is cardiac, as heart and circulation do not resume function immediately. This is the reason for the much shorter period available for brain revitalization after cardiac arrest.

b) Disseminated intravascular coagulation develops shortly after onset of ischemia and is enhanced in the early recirculation phase. Additional factors are increasing thrombocyte aggregability in the ischemic phase; serotonin release from aggregated platelets leading to vasoconstriction; damage to peripheral organs (heart, kidneys, pulmonary shock) may prevent reoxygenation and increase cerebral edema; changes in blood viscosity with decreased flow rate and impaired microcirculation.(17)

c) Post-ischemic cerebral edema with increased intracellular osmolality and loss of membrane potential results in massive electrolyte shifts. Onset of recirculation causes massive fluid volumes to enter brain tissues, increasing edema and thus causing a rise in intracranial pressure.

d) Multiple metabolic imbalances develop in addition.

This brief outline shows that circulation may start again after ischemia but generally ceases again within a short time (a few minutes) if the cerebral edema has reached a critical level.(18)

Complete cessation of cerebral circulation causes death of the brain as an organ, with irreversible loss of function. This results in dissociation of the lost brain function from persisting peripheral organ functions if circulation and respiration are supported in intensive care (the latter by use of a respirator). The brain represents only about 3% of the total organism,(19) but loss of cerebral function has serious consequences for the whole. Cerebral failure involves the loss of higher brain functions: consciousness, mentation, perception, and sensory perception. Cranial nerve and brain stem reflexes are absent (dilation of pupils, fixed pupil, comeal reflex, vestibular reflex, cough and retching reflexes, no reaction to aspiration). Extensor spasticity progresses to general loss of muscle tone. The vital functions of the brain stem are lost: diabetes insipidus, absence of circadian variations in temperature, blood pressure and, pulse, and of their physiological control. Metabolic imbalance results from failure of the hypothalamic-pituitary, and diuretic system.

Extended periods of artificial respiration and other measures may provoke a wide range of strange, "meaningless" phenomena: profuse sweats alternating with rubor in some parts of the body, phases of hypo- and hyperthermia, inexplicable variations in blood pressure and pulse rate that may come up suddenly and just as suddenly disappear again, extensor spasms or twitching of muscle groups in the extremities. These phenomena have no apparent purpose; they are merely reflex movements not controlled by the ego and lacking in coordination.(20,25)

Anthroposophic aspects Past, present and future all coexist in the human being. This can be seen in the biology of the newbom. The neurosensory system is fully developed at about two months before birth, the rhythmic system reaches maturity at birth, while the metabolic system and especially the limbs are still in the fetal stage.

No other newborn beings show this triunity to the same degree as humans who are born post term in the head, on term in the heart and respiratory systems, and prematurely in their limbs.(26)

A. Portmann distinguishes three functional regions in the neurosensory system: the elementary apparatus which controls the simple functions and is mainly located in the spinal marrow and parts of the extended marrow. Reflex-type reactions are part of this system.

A second, superior system is the autonomic apparatus. Elementary functions are combined for the higher functions of metabolism, reproduction, alternation of sleeping and waking states, hunger and satiety - all the changes known to us as "moods." This apparatus is located in the my elencephalon, the hypothalamus, the basal ganglia of the forebrain and in me splanchnic nervous system.

The somatic apparatus concerns the sphere of the senses and the higher functions (orientation in space, relationship to the environment). It is the "site of highest integration," located in the metencephalon, mesencephalon, hemispheres of the telencephalon with the cerebral cortex.

The elementary and autonomic apparatuses show a high degree of structural complexity even in the lowest mammals. "This part of the nervous system shows the fewest differences, relatively speaking, and these apparatuses are always fully developed at an early ontogenetic stage."(27)

The neurosensory system mainly serves mental activities that take place in the waking state. "Sensory perception, ideation, memory and thinking are made conscious by them. Its processes are directed outward and inward, the impulse being to perceive or rather to convey sensory perceptions."(28) "The senses have significance not only for the soul, for the creation of an inner world, not only for maintenance of the body (perceiving ongoing processes, the state of well-being, the condition of the organs, the activity of the limbs); they are the places where entities from the earthly and cosmic periphery enter into the inner human being (or evoke counter reactions from the inner life)."(28)

The head is an offprint, a kind of elimination of the ego, astral body and ether body. These three higher aspects of the human organization create their organ, forming it out fully, and then eliminate it; they are then free, able to enter and leave again, the organ having become permeable. Here we have the greatest differentiation, form and plastic principle - organization at the level of perfection.29 Cerebral failure merely means that the brain is no longer open to those three higher aspects. The sense organs are almost physical apparatuses, a gulf "extended into the human being by the outside world."(30)

We deal with the outside world, communicating with it, making our mark on it and being influenced by it in three areas. In the metabolism this happens through nutrition; we impose our will on the environment and take action in it. The things we attempt, desire and do, the unfulfilled seeds of the will, provide us with the capacities for a future life.

In the rhythmic system we inhale and exhale, and live in the world of feelings; we live life in the present as we practice and learn.

In the neurosensory system, an imponderable breathing process occurs between us and the environment, skills, talents and capabilities point to an earlier life. This imponderable breathing process occurs mainly through the 12 senses(31,32) and plays a role in making human evolution possible and maintaining it in time.

Failure in each one of these three areas of communication or relation has its own specific quality and consequences. Paralysis in the sphere of the limbs makes it more difficult to perform an action: the limb itself becomes outside world.(33) Paralysis in the metabolic sphere prevents active involvement with matter so mat the energies normally evolved in the process gradually fade away. Failure of the rhythmic system - even lack of ability to move in rhythm, rigidity - is a serious pathological sign and signifies that the present life will soon be ended.

Lack of external stimuli when organ function is normal clearly indicates absence of the imponderable breathing process. Without those external stimuli proper human development is seriously affected - "wolf children" are a good example. If cerebral function itself ceases, (irreversible failure) the imponderable breathing process cannot take place consciously. It is then no longer possible to maintain a fully human existence as the necessary external stimuli cannot be taken in and digested.

The body-oriented integrative power of the ego organization graduallyweakens. The organization of the human head and the central nervous system can no longer perform their function as offprint and have become impermeable to the ego, astral body and ether body. A dying process ensues. The brain as the "indispensable intermediary" between environment and human being is no longer able to perform its function, which is to maintain the specifically human aspect.(34) Physiologic respiration ceases and is taken over by a respirator in the case of such a patient. We are thus able to ensure only one aspect of respiration, which is to supply air and maintain the gas exchange in the lung.

Form is embodied in the human physical body. It arises from the twelvefold zodiac.

The breathing life in the etheric fulfills another function, for the breathing process yields the images of all our internal organs. Images of our organs, initially immaterial, are created "via the breathing process." Physiologic res- piration enables the human being to have a share in the form which is created out of the starry heavens. Those images are inhaled, as it were. They become reality (including form) as matter is deposited in the images.(35)

The image nature of respiration and the creation of form are seriously affected by artificial respiration. With the form-creating life taken away, the individual is no longer able to maintain true humanity by taking hold of it again and again and giving it shape. Thus the process of dying begins.

In sleep, ego and astral body have separated from the ether and physical bodies. The human being does not become a plant, however, because the activities of astral body and ego nature still continue.(33) "Because the ether body remains connected with the physical body during sleep, vital activities continue."(36)

The moment the ether body leaves the physical body, disintegration sets in. Processes of dissolution and autodigestion begin, with the chemical forces acting the way they do in the outside world. Death ensues, and decom- position starts. The ether body is then connected with the astral body in the absence of the physical body. The latter is left to the forces of gravity and becomes a decomposing corpse in the physical world.

The spirit takes a different path, one that only becomes possible once ego, astral body and ether body have separated from the physical body. Different laws then apply: the inner world (thoughts and life of feeling) becomes outer world, pouring out into the realm of the stars; the outer world of our actions becomes inner world. We work through the incarnation that has just ended and prepare for the next.

After death (separation of ego, astral body and ether body) new qualities emerge that cannot be seen as a linear continuation of life. The characteristics of life (growth, flow, nutrition, warmth) leave the body, which becomes a corpse and is left to physical forces such as the force of gravity. Dissolution, autodigestion, decomposition and decay begin.

Loss of consciousness and self awareness, serious as it may be, does not signify the death of the individual. Loss of a physical function or of an organ (there is, of course, a hierarchy of the organs and their functions) cannot be equated with death of the individual. In a case of renal failure or another condition resulting in loss of kidney function, we will, of course, initiate dialysis to allow life to go on. Quite rightly, we do not speak of a "kidney dead person."

Someone in cerebral failure receiving artificial respiration cannot, anthroposophically speaking, be called dead. The symptoms described above make this quite clear. The physical body does not fall into decay. Physio- logical processes arising from the interaction of physical body and ether body stimulated by astral body and ego continue; respiration, circulation and metabolism can also be observed to proceed, with blood pressure, spinal reflexes and elimination, reflecting astral body activity, still present.

The coordinating function of the ego is usually no longer observable, nor are higher nerve functions. Consciousness and self awareness have gone. Hormonal regulation tends to be seriously affected; purposeful processes are no longer possible, and "meaningless" reaction patterns appear.

Part of the gesture and character of death is the irreversible separation of functions into disintegrating individual parts and absence of coordinated activity, with centrifugal forces dominant. The situation is one of multiple organ failure. The life-maintaining centripetal, centered principle is an ego- controlled gesture.

With cerebral failure, centrifugal forces gradually make their appearance. Tendencies of dissolution, of weakening, develop that point to a slow dying process. We do not diagnose cerebral failure and then decide what treatment is necessary. Instead we must undertake the treatment of a seriously ill individual, often unable to prevent cerebral failure in the process.

Intensive care offers the opportunity - and we are obliged to take it - to maintain incarnation. It is not in our power to prevent death. Irreversible cerebral failure thus is a serious condition which rapidly leads to death in the above sense unless help is given from outside. Intensive care allows us to intervene from outside and maintain life for a time. Cerebral failure (with treatment given) marks the beginning of a dying process. Anthroposoph- ically speaking, this cannot, however, be equated with death nor with a state of consciousness similar to deep sleep.

The brain and spinal cord are given maximum protection from the outside world by their bony integument. The spinal marrow must be con- sidered to be an organ that has remained at an earlier stage of evolution, a bone marrow of me first order - the brain being bone marrow of the second order - "...a metamorphosed earlier bone marrow... that has been such in the past but has been metamorphosed into the brain."(37 )The brain is the "instrument" for higher soul activities. These are "guided" by the brain. It is the place were we create our "thought-out ideas." There human beings do not act by means of reflex movements but reflect on things, and in this sense the brain is the instrument of inner activity. Reflex movements are compulsive by nature (a stimulus evokes a movement response without our thinking about it), and there we see the activity of me spinal marrow.

In dream life, with daytime waking consciousness gone, images appear on the horizon that have the same direct necessity. They arise compulsively, without our conscious doing, like reflex reactions in the waking state that result in movements, but retain their image character.

"Occult investigation shows that a mysterious spinal marrow exists in the brain which is the instrument of dream life." This spinal marrow becomes active "when people are asleep and dreaming. Its activity is then of a kind appropriate for a spinal marrow, arising from necessity"(37)

In cerebral failure, "reflex-type" movements occur that are spinal in origin but generally arise without stimulus, and seemingly without reason - a caricature of a dream?

Ego and astral body are archetypal images and as such spiritual. Blood system and nervous system are images of them. The ether body, on the other hand, takes its orientation more from the physical body.

On the one hand, the blood presents itself to me outside world rather like a writing tablet; on the other, it exists for the inner world. The ego also has two aspects. It lakes up impressions of the outside world, and it can also be given up to an inner world. Impressions are inscribed in the blood via the nerves.

"In ordinary life, as it generally goes, the process is such that an effect transmitted via the nerve inserts itself in the blood as though on a writing

tablet and has, thus, inscribed itself in the instrument of the ego.(37) Inner feelings and ideas, which should be higher, "moral or intellectual ideas," extreme inner concentration, engage the nerve, which is withdrawn from the blood, as it were.

"Contents of the conscious mind are primarily taken hold of by the nerve, thus separating nerve activity from blood activity." The nerve is released from connection with the blood; the activities of the nervous system become retrograde, as it were. "The ego is consciously lifted out of the astral body's sphere of action."(37) At the nerve ends, we rebound and "life goes out in the world beyond the senses."

This is the occult physiological process of conscious spiritual training. Spiritual training involves a temporary, occult physiological separation of nerve and blood which is deliberately induced in inner exercise.

Cerebral failure thus marks the beginning of a dying process, with the individual on the threshold. In spiritual terms, the connection between sense organ and blood is broken at the distant periphery. This is the irreversible, physically pathologic caricature of conscious spiritual training.

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