On February 27-28, 2025, a Symposium on “brain death” was held at The Catholic University of America titled “ Integrity in the Concept and Determination of Brain Death: Recent Challenges in Medicine, Law, and Ethics .”
Questions addressed at the Symposium included:
How/Can we ensure, with moral certitude, that patients determined to be dead by neurologic criteria are dead according to the standards of a sound Christian anthropology and the law? [emphasis added]
How/Can testing protocols for brain death be improved to accurately, consistently, and efficiently identify which patients are dead by neurologic criteria and which are not? [emphasis added]
As these questions indicate, there is vigorous disagreement among Catholics whether 1) “brain death” truly represents the death of the human person and 2) if it does represent death, whether it can accurately be determined in clinical practice.
This article does not address either of those questions. Rather, it addresses the question: “Can unity on the issue of ‘brain death’ be achieved among Catholics despite a lack of consensus?”
The answer is a resounding yes, for it is an incontrovertible reality that moral certainty does not exist that “brain-dead” patients are dead. To dispute this requires either 1) disregard of Pope Saint John Paul II’s admonition that moral certainty must exist prior to harvesting organs from “brain-dead” patients or 2) denial of logic itself.
In his 2000 Address to the 18 th International Congress of the Transplantation Society , John Paul II unambiguously stated the necessity of moral certainty:
Moral certainty is considered the necessary and sufficient basis for an ethically correct course of action. Only where such certainty exists, and where informed consent has already been given by the [organ] donor or the donor’s legitimate representatives, is it morally right to initiate the technical procedures required for the removal of organs for transplant. [emphasis added]
Regarding when moral certainty exists, in his 1980 Address to the Tribunal of the Roman Rota John Paul II referenced Pope Pius XII, stating that Pius XII “declared in an authentic way the canonical concept of moral certainty in the allocution addressed to your tribunal on October 1, 1942.” That 1942 Allocution provides a foundational articulation of moral certainty for Catholics (English translations cited from The Canon Law Digest, Supplement 1948, by T. Lincoln Bouscaren). In brief, there are three indicators whether moral certainty exists.
1) The first is a caveat which is especially appropriate for a complex subject such as “brain death”: accumulation of a large body of evidence is sometimes necessary before moral certainty can be achieved.
Sometimes moral certainty is derived only from an aggregate of indications and proofs which, taken singly, do not provide the foundation for true certainty, but which, when taken together, no longer leave room for any reasonable doubt on the part of a man of sound judgment.
2) Moral certainty cannot exist if a reasonable person finds the contrary position to be in some way credible, or even probable.
This moral certainty with an objective foundation does not exist if there are on the other side, that is, in favor of the reality of the contrary, motives which a sound, serious, and competent judgment pronounces to be at least in some way worthy of attention, and which consequently make it necessary to admit the contrary as not only absolutely possible but also in a certain sense probable.
3) If moral certainty truly exists, there will be a consensus of opinion. If disagreement exists, further evaluation of the subject is required, with the goal of resolving any areas of controversy.
Now, as the objective truth is one, so too moral certainty objectively determined can be but one…. [If a judge entertains contradictory conclusions, it should] induce him to undertake a further and more accurate examination of the case…. In any event, the confidence of the people… demands that, if it is at all possible, such conflicts between the official opinion of judges and the reasonable public opinion of well educated people should be avoided and reconciled.
If any one of these three criteria is not met, then moral certainty does not exist. And if moral certainty does not exist that a “brain-dead” patient is actually dead, it is unethical to proceed with organ harvesting.
As a single example of the contrary positions and lack of consensus among Catholics on “brain death,” following Session 2 of the Symposium attendees were polled on the current “brain death” guideline:
The 2023 AAN et. Guidelines, as written, provide a valid and reliable guide to the determination of brain death.
Of those responding 44% selected “No, the Guidelines are not valid”; 37% selected “Partially; the Guidelines need to be strengthened”; and 18% selected “Yes, the Guidelines are valid.” Based on these results, it is self-evident that moral certainty does not exist.
This reality has weighty consequences. Accepting those consequences will not be easy, but the calling of a Christian never is. The principal consequence is that we Catholics should advocate for an end to the harvesting of organs from “brain-dead” patients. A non-exhaustive list of strongly recommended concrete action steps includes:
- Decline to be an organ donor at the Department of Motor Vehicles.
- Refuse to be an organ donor after death in advance directives.
- Advocate for easy, readily accessible methods to opt out of being an organ donor for those who have previously opted in.
- Firmly reiterate the Church’s teaching on the need for moral certainty of death as a condition for vital organ procurement.
- Update model advance directive documents and guidance to protect patients from organ procurements that violate Catholic teaching.
- Update the Ethical and Religious Directives for Catholic Health Care Services to address the role of moral certainty in the determination of death.
For additional concrete action steps, I direct readers to two other documents. 1) A Statement released in February 2024 titled “ Catholics United on Brain Death and Organ Donation: A Call to Action ,” which was endorsed by 151 Catholic health care professionals, theologians, philosophers, ethicists, lawyers, apologists, pro-life advocates, and others. 2) An article in Ethics & Medics, published by The National Catholic Bioethics Center, titled “ Informed Consent Should be Required Before Brain Death Testing .”
To summarize, agreement amongst Catholics and society at large on the issue of “brain death” does not exist and will not be achieved in the foreseeable future. However, by this very fact we can be united on the point that moral certainty does not exist that “brain-dead” patients are dead. This is because 1) the body of medical evidence leaves room for reasonable doubt; 2) reasonable people can and do find it credible that “brain death” is not true death; and 3) there exists profound disagreement about “brain death” among experts in medicine, law, philosophy, theology, and more broadly among the general public, such that there is no consensus of opinion on “brain death” nearly 60 years after it was first introduced.
This unity regarding lack of moral certainty leads to unity in action: we can all unite in advocating for the cessation of harvesting organs from “brain-dead” patients. Let us pray for this unity to be realized.
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Symposium essential question: “How/Can we ensure, with moral certitude, that patients determined to be dead by neurologic criteria are dead according to the standards of a sound Christian anthropology and the law?”.
Moral certitude is not scientific certitude. The difference is certitude. Moral certitude requires a sufficient degree of evidence, whereas scientific requires incontrovertible fact finding. Consequently in medical affairs the priest chaplain, assuming he possesses a good background in moral theology, knowledge of medical matters, frequently advises on a case in which a moral decision involves a less than black and white response – the so-called grey areas in medical ethics. There are cases in which either or both are valid responses. An example may be a presumed brain dead patient that a proxy has the option to decide. Brain dead is not a likeable term for many ethicists. However, for argument sake it’s a useful term. Example. A patient’s brain may emit ‘brain waves’ [neurological activity] that doesn’t indicate any form of cognitive action.
Sometimes a ‘lived example’ is helpful when I asked a neurosurgeon whether the patient who had been shot in the temple, whose eyes followed my movements, was alive. He responded his eyes are responding not his brain. A case in which there’s neurological activity lacking in any form of cognitive response. A form of neurological reflex we perceive in some animals when decapitated.
The major issues affecting the Church were lawsuits that resulted in John Paul II remarking such patients should be tube fed because there’s a chance, however remote, for recovery [thus rendering controversies mute]. Dr Eble here says that the scientific data available leaves a reasonable doubt [certitude a distant projection]. Tube feeding is said by some ethicists a natural form of providing life sustaining care, although it is a medical procedure requiring an MD to make the surgical abdominal incision and insert the tube.
A decision on providing nutrition and hydration encompasses the medical findings, the dignity of the patient, the issue of burden [excessive burden was addressed by Pius XII regarding end of life care in an address to anesthesiologists]. A difficult, heartfelt decision that is left to the next of kin.
The question of whether there will ever be a consensus among Catholics regarding brain death may be answered by the proposition that it may be agreed upon that it is more reasonable to allow death to follow its natural course in such severe cases rather than seek to apply every possible medical intervention.
Karen Ann Quinlan was a big story in the mid 70s.
I don’t see how an eye can follow you without the brain telling it to.
There will never be consensus because it is not a monolithic issue. Each case is different and each case must be evaluated individually. We have enough technology now to accurately assess whether or not people are brain dead. If the cerebral cortex is not functioning, it is irresponsible to keep them alive using a ventilator rather than letting nature take its course.
Removing someone from a ventilator and letting nature take its course is one thing. Keeping someone on a ventilator while cutting them open to harvest their organs is another.
Perhaps, or perhaps a motor function which doesn’t verify intelligent response. For example, the famous headless chicken running around because of its dominant neural spine. Although what I thought may simply have been as you suggest the appearance of eyes following as some portraits evince. What I actually was sure of was fluttering of eyelids. That attributed to extracerebral reflex caused by sympathetic nerve fibers [jargon taken from medical research papers]. Experiments of pain stimulation often cause eye fluttering in diagnosed brain dead persons.
Ethics is a complicated way of explaining common sense! 😂
I have always found Dr. Eble’s articles on this subject to be very well written and very helpful in my understanding of these difficult issues. At my (advanced) age, I have seen much confusion firsthand and as time passes there will be more instances when calm, reasoned thinking will be needed.
In Pope St John Paul II’s address to the International Congress of the Transplantation Society in Rome on 29 August 2000, he defined death as “… a single event consisting in the disintegration of that unitary and integrated whole that is the personal self” Such “loss of that unitary and integrated whole” is otherwise known as brain death, a situation that can coexist with artificially maintained normal physiological parameters and a beating heart. The removal of such artificial means will lead inevitably to cessation of apparent life in the artificially maintained physiological preparation that looks like a human being but is in fact not a being capable of knowing, loving and paying due homage to its Creator. The Creator himself laid down his life on Earth for the benefit of his fellow brothers and sisters when human death was inevitable. I’m sure he looks upon his transplant surgeons and physicians with great love and understanding if He is indeed the God that Catholicism claims Him to be. If not, eternity is not going to be a good experience for me if the uninformed opinion expressed in this article is correct and God ordained. I’m a silly old codger once known as a transplant surgeon who spent 35 years salvaging what could be salvaged from a lost human life and restoring life to another who faced correctable inevitable death.
It can be difficult to realize and admit that much of what a person has done in their career has been a mistake. A case in point: Dr. Bernard Nathanson. Further, God’s mercy is not there simply to endorse our intentions, no matter how well meaning.
Dear Sal Fulminata, I am sorry that the author, whose writings on the subject you find helpful in the understanding of organ transplantation ethics, doesn’t understand the Catholic position on organ transplantation. If he would like to espouse his views on the use of living donors, chosen because of resounding good health, to run the life threatening risk of major surgery to benefit someone else, then he would be addressing a far greater ethical challenge than that which he has outlined here. Living donors have been abandoned in some of the world’s best transplant centres (not all of which are in the United States, Surprise surprise!!) because of post-operative death in the donor. Such is by far the greater moral and ethical challenge than salvaging a little bit of life from a deceased (brain dead ) donor in order to restore full cognisant life in a critically ill patient who, unlike the brain dead, is not faced with the inevitability of death.