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Irreversable Cessation of Breathing

Rabbi Shabtai Rappaport

Irreversable Cessation of Breathing

[12 minutes  19 seconds]

This, the idea of what was later called the Apnea test, I heard myself from Rav Moshe, that once we know that the person’s spontaneous breath stopped, this is considered to be death, this I heard from Reb  Moshe himself. The idea of the brain death, this I saw when Rav Moshe wrote it and I called Rav Moshe twice to understand exactly what he wrote and he verified, he explained to me what he wrote in this tshuva, that when the brain is destroyed it is equivalent to the severing of the head. Because the head does not mean the skull, if we’re talking about the living function of the head, we are talking about the brain. This was the thing of the brain death, Rav Moshe’s agreement to brain death. What was the form in the issue, how can we determine that the brain is dying, is dead. Most of the tests that were needed, demanded or required the moving of the patient to the x-ray room or moving him and doing tests that were impossible to do without moving the person who we think that he is dead and we cannot move a dying person because the moving can kill him. So technically, it was still a problem.

Now let’s talk about why did Rav Moshe think that the stopping of breathing is significant. This is because of the Gemara (in Yoreh Deah) that you mentioned. The Gemara says that we know that a person is dead by checking his breath. Once he stops breathing, he’s dead and he’s legally dead. Again he’s considered to be a legally dead because the Torah says (Hebrew), “all the creatures that have the breath of life in their mouth, in their nose, they die.” Breath of life means that life is defined by the ability to breathe. Now, but what happens if the person lost his breath temporarily, so of course that’s not death. That’s a temporary condition. Death is permanent, that’s the definition of death. We have to know that he’ll never regain his spontaneous breathing.

 

Now I must make a remark because many people made fun of this notion and I have to explain something. When I was a baby, many people, unfortunately myself too, contracted Polio. It’s a kind of paralysis and I fully recovered but some people lost the function of the vagus nerve – the nerve that leads from the brainstem to the diaphragm. So they could not breathe, they died, these people died. So they developed in the ‘50s, the early ‘50s, they developed the iron lung, which was a very heavy machine that raised your chest and deflated your chest – it inflated and deflated your chest. People were in wheelchairs, I remember these people in wheelchairs, and in big machinery with hydraulic systems that raised the chest and deflated the chest. Now they have smaller versions of the same machines, so they claim if a person that loses his spontaneous breathing is considered to be dead, these people should be considered dead.

And of course when we are talking about someone that is dead we are not talking about someone who sits in front of me and is talking to me. Someone that moves, by definition, is alive. We are talking about someone that in the medical profession calls is the Glasgow scale of coma 3, which means he does not move, doesn’t make any sound and has no communication with the world. This is the only point that we begin to ask whether he is dead or not. Someone that sits in a wheelchair and talks and reacts and moves, he is definitely not dead. The cessation of the breathing is the final stage of the death, it is not onset of death. So someone can lose the breathing and can be connected to a ventilator but he is conscious so he’s definitely alive. The thing is when he finished to be alive, he’s unconscious, totally unconscious, in total coma. He cannot move, he doesn’t feel pain, as I said he cannot he doesn’t make any sounds, then we have, he stops breathing and the cessation of breath is final and irreversible, then he’s dead. This is the definition.

Okay, now we’ll go back to what Rabbi Moshe said. Rav Moshe held that this definition of cessation of breath is the good definition and he indicates in the tshuva in the response from ’76 that the cardiac function is only an indication to the reversibility of the pulmonary function. Which means that if the heart beats then we hope that he can regain his breath but once the heart stops beating we know that cessation of breath is final. But if there is respiration and the heart is still beating, even though the heart is still beating, then  the heartbeat by itself is not, does not indicate life because the breath stopped. So that’s why, then we go back to the thing, you can stop the respirator for a few seconds, see if he regains breath or not and if you see there is weak breath, he regains some kind of a breath, you reconnect him to the respirator. If you see that there is no breath, then you leave him as is. But as I said, this idea was not accepted.

Now, the brain death, to determine brain death, because of the cessation of blood flow to the brain is a difficult issue. In the early ‘80s, the question of organ transplant started coming up with the invention of cyclosporine – or the discovery of cyclosporine – that represses the immune reaction very efficiently. And the question of death determination regarding organ transplant was really raging because in the case of an organ transplant, you really want the person to be supported on the life support system in order for his heart to function or his kidneys, his liver later, to function so you can harvest them. Because once the heart stops beating, then when the aeration stops to the organs then the organs die. So there is no benefit, you cannot use them for transplants.

So then, Rav Moshe, at that time, Rav Moshe was nifter in ’86, so in ’85, he issues a tshuva to Dr. Bondi. So now, I want to tell you about the history of this response. At that time, Rav Moshe could not write because he had problem with his eyes, he stopped writing in ’83 or ’84, but he still was asked many questions, he was asked to rule very important rulings. So he used to say the things in Yiddish, and someone wrote it, then he reviewed, someone read him the written tshuva and then it was sent off. The tshuva that I’m speaking about now is a tshuva of this kind that Rav Moshe said it and it was read to him and sent off.

This is tshuva to Dr. Bondi where Rav Moshe writes again that, about heart transplants, this tshuva regards organ transplantations and then the Harvard criteria were published for brain death, then Rav Moshe said that the Harvard criteria is an acceptable criteria in halacha and that anyone who is brain dead according to this criteria is considered to be dead to halacha.

Anyway, recent development, recent – the late 80s and early 90s – brought with itself the new Apnea test, which actually obviates the whole issue becomes superfluous that we not talk about brain death anymore. We are talking about the strictly halachic definition of cessation of breath.

Interviewer: Let me stop you for one second, do you know who Rav Moshe dictated the letter to Rav Bondi to?

Yes, Mordechai, Rav Mordechai Tendler, my brother-in-law. This letter was dictated, this tshuva was dictated to Rav Mordechai Tendler.

Interviewer: And how do you know that?

 

Rav Mordechai told me at that time. But it was no surprise, because there was nothing new in this tshuva. When I received a copy of this tshuva, there was nothing new in this tshuva more than what was written eight years ago about the “pulling the plug”  issue.

Rav Moshe said that the real test to see whether a person is alive or dead is the spontaneous breathing, the Apnea test. Now in the early tshuva from ’68, Rav Moshe writes that the then organ transplant that Christian Bernard did in Tel HaShomer was double murder, you murder the donor. Why did you murder the donor? We’re talking about the year ’68, ’68 was before the invention of life support system, before the introduction of the ventilator. So the person whose heart was still beating had to breathe, he was still breathing and his heart was beating, breathing spontaneous breath and his heart was beating. Only his EEG, he had flat EEG, his cortex was not functioning, it was dead. This is what they called brain death at that time, that the thinking part of the brain was dead. But actually, nowadays we say that this person was in coma. He was breathing, he was alive. Spontaneous breath is the definition of life so he was definitely alive at that time. That’s why taking the heart of a living person is murder.

The tshuva from ’76 talks about life-support system. Someone who is being ventilated, someone who – that his breathing is not spontaneous but it is mechanic. As Rav Moshe says, this is not a sign of life, so this person is dead, they are not alive. So there is no contradiction, it’s not that the technique change, it’s not the change in times or techniques or diagnoses, it’s a change in circumstances. The first tshuva talks about someone who is breathing on his own and the second tshuva talks about someone who is not breathing on his own. And here lies the difference, it’s as simple as that.

Okay, so this concludes Rav Moshe’s opinion about the definition of death. It really depends on the spontaneous –  person being able to breathe. Here was a technological change really, because as I said in the late 80s, after Rav Moshe was nifter – in the beginning  90s the acceptable test for brain death was the Apnea test. So really the hospitals did it to determine brain death. But regardless of brain death, the Apnea test is the correct test to show that the person is dead not because his brain died, but because he cannot breathe spontaneously and a person who cannot breathe spontaneously is considered to be dead.

Of course, provided, he is dead, provided he doesn’t move he doesn’t talk to you, he lies like a stone or Glasgow scale of coma 3, this is the definition according to Rav Moshe.

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