4. Brain Death 

Read the following story and consider how you would feel if you were Roya.

It was 4:30pm on Saturday, the 7th of  August. It was a very hot day. Roya was the only one at home. Her parents were at their neighbor's (Mr. Maleki) home to visit the wife who was suffering from heart disease.
The phone rang....
	"Is this Mr. Abai`s home?"
	"Yes."
	"May I talk to your father or mother please?  I am calling from the Central hospital"
	"Sorry they are out."
	"Would you please give me his mobile phone number?"
	" Ok, just a moment."

It was late at night but her parents and her brother had still not come home yet. It was the first time that Roya was home alone. She was about to call her father when the door bell rang. Excitedly she rushed to the door. Her father was alone and looked very upset. She had never seen her father like that before.

	"Why are you alone, daddy? Where's mom? Where's Ali?
	"What happened?"
	"They are at the hospital, " he replied trembling with tears in his eyes.
	"Why are both of them at the hospital?"

Roya knew that her brother Ali had gone cycling with his friends this morning. But why were they at the hospital? Shouldn't they be at home by this time? Roya was getting more nervous as these thoughts ran through her mind. Anxiously, she was conscious of every change of emotion going through her father's face. Why? Why? Why? Over and over, she asked herself....trying to make sense of her father's somber mood. In a soft, trembling voice, her father almost whispered...

	" Ali had an accident.  Your mom's looking after him."
At that moment, it was as if Roya's entire world had gone to pieces.
	" Dear child, don't cry....there is nothing that we can do. "

After what seemed like centuries of pain and sorrow....exhausted , with no tears left to cry, Roya went to bed.

Dawn of another day
A letter
	 Roya dearest,
		I have gone to the hospital. Don't worry. I'll be back by noon
							Love, Dad

Roya waited and waited and waited.

The door
Father
	" Dad, dad, dad....", Roya rushed into her father's arms.
	" Roya, my sweet child."
	And they stayed that way for a moment, silent and calm before the storm...
	" Ali's still sleeping. Nothing has changed. My beautiful boy, unconscious, lying on that white bed..."
	"Unconscious?"---a word she had never heard before.
	" I want to see Ali. Please take me with you! Please!"

At the Intensive Care Unit
Her mom
A crying stranger, looking through the window--- a far-cry from the happy, smiling mom that she knew…..through that thin piece of glass---her brother.

Ali?
	"My brother?"…. surrounded by strange instruments, a tiny tube in his nose, a thick one in his mouth and other things attached to his head and body. That mass of humanity that was Ali was silent and still as a log. 

	"No.no. no.no.no....that's not my brother. Aliiiiiiiiiii !!!!!!!!!!" , hysterically Roya started shrieking, sobbing...pounding her little fists on the glass. Suddenly, like a rabid dog, she turned to her father..." What happened to him? What did they do to my brother?", she shouted as she started hitting herself...to take away pain by giving pain.

Blankness

The waiting room
A man in white
	" Mr. and Mrs. Abai. I am sorry to tell you. But we have been observing your son's critical condition since last night. We did whatever we could do to save his life. And I am very sorry to say that your son is in a state of brain death. "

Brain dead, brain dead, brain dead .... words floating in her shocked mind.
	"Is there any hope for my son's recovery?"
Recovery, recovery, recovery...
They stared at the doctor's face, looking for a glimmer of hope. 
	"Unfortunately, there is nothing we can do. There is no treatment for brain death.", offering no hope, the doctor could only lower his face and stare at the floor.

Hearing these words Mrs. Abai cried in pain
Lost in a haze, Roya asked, 
	" What does brain death mean? My brother, Ali, when is he coming home?"

They stopped and looked at her.

The man in white
	"Ali had an accident when he was coming back home yesterday. He crashed into a cement block and suffered from severe head injury and trauma." 
	"But my brother wears a helmet..."
	"According to his friends, Ali wasn't wearing one at that time. His helmet was in his bicycle bag."
	" My child, calm down... Nurse, nurse, Please take Roya to the canteen and get her some ice cream."

Three adults
	"  It has been 24 hours since his accident.  He is still under observation. And we will do whatever we can. But all the medical tests show that his cortex and brain stem cells have no activity. Although his heart is functioning, he is completely dependent on a ventilator for breathing"
	"We do not understand," Mr. Abai replied.
	"Just tell us ...is he alive? Will he be able to move? … to talk? Will he be able to have a normal life?"
	" Unfortunately,  there is no treatment for brain death. And we can do nothing to bring your son back." 
	"Is my son the first one to suffer from this condition? Please do something, anything...."
	" I'm afraid that your son is neither the first or last person to become brain dead. I'm sorry we can do nothing. There is nothing else we can do."
	"Nothing."
	" Yes, nothing. I'm sorry to bring this up during your time of sorrow, but we have to ask you to make an important decision about your son. We can not do this by ourselves"
	"What kind of question is that?" Mr. Abai barked angrily.
	" I am a teacher and what I know is how to teach Mathematics, you are a doctor you should know and decide!"
	"I understand Mr. Abai", replied the Doctor.
	"You and your wife are in a very shocked and emotional state. I know it is not easy to make a decision at this time. . Please read this so that you can understand better what I am trying to tell you."

A pamphlet…

"What is Brain Death?"

The Anatomy of the Brain
The brain consists of two parts: the Higher brain and the lower brain. The higher brain includes two hemispheres and the Cerebral Cortex. It is responsible for several higher functions, including intellectual function, speech and emotion. The lower brain includes the Brain Stem , which is the final pathway between cerebral structures and the spinal cord. It is responsible for a variety of automatic functions, such as control of respiration, heart rate and temperature.	

A moment that seemed like eternity
	" I'm sorry, I can't read this just now. What does it mean?", a distraught Mr. Abai said.
	"In your son's current state, unfortunately, his brain cells, cortex as well as brain stem, are dead and have no function. Therefore, as you can see, he can neither move nor talk. Even his respiration is dependent on the ventilator. If we turn the ventilator off his heart will stop too."
	"Do you mean he is dead now? But his heart is pumping and his body is warm!"
	"That is what I was trying to say, you should decide because there are a variety of opinions and each country has its own regulations to deal with brain dead patients." 
	" You told us that my son is not the first brain dead patient here.  What happened to  the others?" 

It was a very difficult situation. The kind of situation where there were no clear, cut answers. The kind of situation that called for a change of scene, some fresh air to breathe...a stagnant silence followed. 

In the end, they could only stare at each other…

In a different place but not a different time
Roya, desperately hanging on to her innocence, painting images of her brother...
"Ali is the smartest and best brother in the whole, entire world. He attends    university, you know. He is so kind. He helps me with my mathematics problems."

Reality

Questions
1. Imagine you were Ali's father, mother, or sister (Roya)?
2. Brain death is one of the ways to recognize death.  In most countries people would just be told Ali was dead. Is brain death a confusing term?
3. How well did the doctor explain the situation?
4. Each person may think they are doing the best in the situation, but they may not be. Roya and Ali's father tried to protect Roya from the school, but where would you want to go if your family member was taken to hospital?
5. Look at the picture of the brain, and identify the missing regions.

Teacher's Notes
Materials on brain death are available in some countries from the organ donation networks, and these may be a good source of teaching material. Certain countries, like Japan, have debated the issue for many years and have abundant literature. There is confusion about the issue in materials so use reliable sources.
There is background material below on brain death, and a technical description.  Japanese language notes are also available. Several pictures of the brain are available.  You could white out some areas and ask students to fill in the regions if you wish.
The story continues in the chapter on Organ Transplants. See also Euthanasia. There is a short version of this chapter available also.

What is brain death?
Brain death is defined as the irreversible loss of all functions of the brain. Although diagnosis of this condition varies country to country in general it can be determined in several ways. First - no electrical activity in the brain; this is determined by an EEG. Second - no blood flow to the brain; this is determined by blood flow studies. Third - absence of function of all parts of the brain - as determined by clinical assessment (no movement, no response to stimulation, no breathing, no brain reflexes.) 
The criteria may be legally applied in some conditions, with exclusions for persons who are very young, in drug overdose, or whose bodies are very cold, because of the reliability of the criteria. There are also other conditions, like locked in syndrome, persistent vegetative state or coma which are distinct from brain death, because the persons in those states are alive. Sometimes writers and the media gets confused.

There are several ways in which a person can become brain dead, these include: 
-	Anoxia caused by drowning, respiratory diseases, or drug overdose.
-	Ischemia - Blockage of an artery leading to the brain or in the brain, heart attack (stoppage of the heart for a period of time), bleeding in the brain.
-	Intra-cranial hematoma - caused by a head injury (a blow to the head) or a ruptured aneurism.
-	A gunshot wound to the head - causes destruction of brain tissue and swelling of the brain.
-	Intra-cranial Aneurysm - the ballooning of a blood vessel supplying the brain - can cut off blood supply or rupture. 
-	Brain tumors - can destroy brain tissue and increase pressure within the brain.
When any of the above occur, they cause swelling of the brain. Because the brain is enclosed in the skull, it does not have room to swell, thus pressure within the skull increases (this is "intra-cranial pressure"). This can stop blood flow to the brain, killing brain cells and causes herniation of the brain (pushing the brain outside of its normal space). When brain cells die, they do not grow back, thus any damage caused is permanent and irreversible.

A persons' heart can still be beating because of the ventilator and medications helping to keep the blood pressure normal. In most countries of the world a person who is declared brain dead is legally dead. Japan is one exception, and leaves the decision up to the person’s prior expression on the organ donor card, with their families agreement.