Catholic Medical Quarterly Volume 72 (3) August 2022

Ethics in Medicine

Brain Stem death and the case of Archie Battersbee

Dr Adrian Treloar

The CMA Ethics Committee discussed the case of poor Archie Battersby at their meeting on the 18th June 2022. Archie’s case gives some insights into the issues of brain stem death and also withdrawal of intensive, or extraordinary care. At the outset we expressed our deepest and heartfelt sympathy for Archie and his family at such a time of loss and crisis. Archie, a teenager, was found with a ligature around his neck in March this year. He has sustained severe brain damage and his doctors have said that he is probably brain stem dead and they have applied to the high court stop treatment. [1,2]

Canon O’Leary presented a paper and pointed out that defining what constitutes the death of a human person is a question of philosophical anthropology, and not just a medical, still less legal matter. Moreover, death is understood in light of what it means to be a living human person. He reminded us that, since the human person is a substantial body-soul union, death involves the separation of the soul from the body and an irrev- ocable loss of the integrity of the body and soul.

For Locke, however, personhood was defined in terms of consciousness such that an unconscious human could come to be seen as no longer really a living person. This has been reflected into part of the judgement on Archie where Mrs Justice Arbuthnot said "He has no pleasure in life and his brain damage is irrecoverable.” She also said (rightly) that “the devotion of Archie's family was "extraordinary". And that "If Archie remains on mechanical ventilation, the likely outcome for him is sudden death and the prospects of recovery are nil". [1]

In many ways this highlights an “activist” way of thinking about human life. To be seen as a living human requires that we actually exercise at least some intellectual attributes or abilities such as consciousness, the ability to feel pleasure or make choices etc.

The alternative (Christian) view is that to be alive is most fundamentally constituted by the primacy act of being. To be a member of the Human Family it is enough for us to be alive. We do not have to qualify otherwise. As human beings, we do not have to pass any intellectual test to be considered human. Nor should people be seen as less human because they are disabled, unconscious or unable to experience pleasure.

It was submitted to the Court that it is "very likely" Archie is "brain-stem dead". [2]

His mother objects to that on the grounds that he needs more time to recover, has a beating heart and also that he grips her hand spontaneously. Of course upper motor neuron injuries may indeed leave reflex activities such as gripping a hand intact. But there is a lot about Archie that is not dead yet. His other organs are functioning we understand. We heard that feeding had, at times been suspended. We felt that sometimes in such cases, feeding may need temporary cessation for intercurrent medical issues to be addressed but hydration should/would be continued. From what we understood, that was the reason for feeding having been suspended.

Taking the case to Court, we hear that the Christian Legal Centre has pointed out that brain stem guidelines suggest that bodily death inevitably and rapidly follows Brain Stem Death. And that the expected rapid bodily death has not happened yet for Archie whose injury was in March. Therefore they state (not unreasonably really) that either the guidelines are wrong or Archie is not brain stem dead.

The Christian Legal Centre also pointed out that there seem to be no universally accepted tests for brain stem death. Even though they may be hard to agree upon, it does not seem right that brain stem death is differently defined in different countries. Great care and certainty is needed in such tests if, as result of these tests, death is to be certified. As is pointed out later, the substantial certainty about the philosophical definition is death is not matched by the ability to define the moment of death, or by the ability of tests of brain function to establish that. Medicine abounds in uncertainty and expert opinion is not always right. We noted (in a separate branch of medi- cine) that despite hugely sophisticated tests, it is known that babies in the womb deemed irredeemably incompatible with being born alive and/or severely disabled by doctors (and recom- mended for abortion) confound those doctors by being born perfectly normal.

Does Brain Stem Death equate with death?

The majority view of the medical profession is that, following brain stem death the body is a living cadaver which can be harvested for organs. Some note with concern that removing a beating heart (which gives a much better outcome for transplant than a heart which has stopped and then needs resuscitation) looks like removing a heart from a living body. Others note with concern that good transplant practice includes careful support of cardiovascular, respiratory and renal function etc.

But on the other hand, if the brain stem is truly dead, then the part of the body that interconnects and drives the body is inoperable. And the body is irretrievably unable to function as a whole. [3]

People who are brain stem dead cannot spontaneously breathe and they require constant ventilatory and other support. Indeed, they may require complex management as without a functioning brain stem, they show considerable instabilities in their circulation etc. Those instabilities are so great that quite expert care is needed to prepare for organ harvesting. [4] But in fact, if the prognosis is very poor (which is a given in people who are brain stem dead) then it is licit to limit or remove extraordinary care. Therefore they can be removed from the ventilator and treatment withdrawn. Organ harvesting may also occur although some will worry a lot more about removing the beating heart in such a situation. A significant effect of the concept of brain stem death is that it allows people to conclude that the person is dead and that that the person is not being killed by removing their heart.

Brain stem death can be seen as compatible with the anthropology of St Thomas Aquinas and his consequent understanding of death. For him, all living things have a principle of life (the soul) that configures the organism’s matter into a living, integrated body. In humans, the particular kind of principle of life, the rational soul, configures all the constituent physical reality into an integrated, co-ordinated, organic whole, the living human body, with which it (the soul), along with its intellectual and volitional powers, enjoys substantial union. This substantial union of body and soul is the living human person. For Aquinas, the human person is not just the soul, or just the mind. Nor is the human conceived only in terms of active mental powers. For, even when not being exercised these powers remain by virtue of the soul in which they are rooted. Thus, the living being remains a truly human being. It is only when there is no longer the substantial union of soul and body that the once living human person can be pronounced dead.

However, in Aquinas’ view, whilst the soul, as form, is united to the body without any intermediary, there is an intermediary between body and soul in so far as the soul is ‘motor’ of the body. The soul operates as ‘motor’ through an intermediary that is first moved by the soul. In turn, this intermediary ‘‘moves’ all the other bodily parts and functions. Hence, when this ‘operative intermediary’ no longer functions, there is no longer present that by which the body is disposed for union with the soul. Disintegration of body and soul ensues. Death occurs. Based on what we now know about the brain, the brain can be identified as this ‘operative intermediary’. Hence when the brain dies completely (whole brain death), so does the human person.

In some respects, this may seem similar to Descartes’ location of the soul in the pineal gland. However, for Aquinas, writing so many centuries earlier, the body and soul are united as one substance. This makes his view very different from Cartesian dualism whereby the body is merely the vessel or container of the soul such that body and soul are two different substances. [4]

Importantly St John Paul II held that the concept of brain stem death, understood as the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem) appears to be based on a sound anthropology that can provide the requisite “moral certainty of death” to permit organs to be harvested for transplantation. He wrote:

“Here it can be said that the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology. Therefore a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgement which moral teaching describes as ‘moral certainty’. This 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 donor or the donor's legitimate representatives, is it morally right to initiate the technical procedures required for the removal of organs for transplant.” [5]

Five years later, he reiterated that “within the horizon of Christian anthropology, it is well known that the moment of death for each person consists in the definitive loss of the constitutive unity of body and spirit. Each human being, in fact, is alive precisely insofar as he or she is ‘corpore et anima unus’ (Gaudium et Spes, 14), and he or she remains so for as long as this substantial unity- in-totality subsists.”

He also restated that in light of this, the death of the person is not an event which any scientific technique or empirical method can identify directly. Nevertheless, and significantly, he called for research into identifying ‘signs of death’:

“From the clinical point of view, however, the only correct way - and also the only possible way - to address the problem of ascertaining the death of a human being is by devoting attention and research to the individuation of adequate ‘signs of death’, known through their physical manifestation in the individual subject”. [6]

He also restated that in light of this, the death of the person is not an event which any scientific technique or empirical method can identify directly. Nevertheless, and significantly, he called for research into identifying ‘signs of death’."

“To achieve the moral certainty required to state that someone has died calls, then, for collabora- tion between science, philosophy and Church teaching. The rigorous position of science must be listened to in the first instance, but building upon the data supplied by science, anthropological considerations are also essential, so too rigorous ethical reflection that entails listening attentively to the Church’s Magisterium”. [6]

So, from a Catholic point of view there are several (slightly separate) issues.

  • Firstly, the definition of death is clear and philosophically sound. Death is the moment when the human person has irreversibly ceased to function as an integrated whole. It is the moment when the human soul separates from the human body. But being certain of that when other parts of the body are clearly living can be very difficult.
  • The diagnosis of death is a post factum act. We can state when we think is has happened, but we cannot discern the precise moment when it happens. The anthropological definition may be sound, but its measurement may not be.
  • Nonetheless, St John Paul II supported the careful use of brain stem death criteria. He told us that “ human experience shows that once death occurs certain biological signs inevitably follow, which medicine has learnt to recognize with increasing precision. In this sense, the ‘criteria’ for ascertaining death used by medicine today should not be understood as the technical-scientific determination of the exact moment of a person's death, but as a scientifically secure means of identifying the biological signs that a person has indeed died.”
  • Pope John Paul went on to state that if the criteria for the diagnosis of Brain Stem Death are rigorously applied and death is “morally certain”, then organs may be harvested.
  • Notwithstanding that, many still worry about the removal of a beating heart and may well yearn to see transgenic pig hearts and other options etc as alternatives.

Medicine abounds with stories of people who were found to be breathing after they had been certified dead.

So there is much to reflect upon. The Catholic view affirms the value and dignity of all human life and not just that human life which is conscious or which can experience pleasure etc. The qualification for being a part of the human family is simple;- we are human and we exist. That reflects the Church’s view of the inviolability of life from the moment of conception.

What might all that mean for poor Archie. Firstly, we thought that given the severe nature (we understand ) of his injury and his poor prognosis, then it might well be licit to remove his ventilator, in the knowledge that he would die. And (as St John Paul II suggested) it may be morally right to initiate the technical procedures required for the removal of organs for transplant.

But that said, the hospital appear to have moved very rapidly towards withdrawal of care. Archie is very young, and recovery takes a long time. The family want more time.

There is a huge caveat here. Dame Cicely Saunders wrote that a bad death lives on in the memories of those left behind. It is undoubtedly in Archie’s best interests for his family to be comforted at the present time. Theirs is a truly awful loss. And the hope and courage of his mother is a true inspiration. Even if the prognosis is inevitable death (which we did not argue it was not) at least some more time for possible improvement or even just extra time while his family adjust to the inevitability of death would be a kind and pastoral use of resources. If death is the inevitable outcome, that does not automatically mean that it should happen as soon as it possibly, ethically or legally can.

CMA (UK) Ethics Committee meetings occur on the same day as each Council meeting and are open to all CMA (UK) members.


[1]  Archie Battersbee treatment should stop, judge rules - BBC News. June 13th 2022

[2]  Archie Battersbee 'likely brain stem dead', court told - BBC News. June 7th 2022.

[3]  McKeown D, Bonser R, Kellum J (2012). Management of the heartbeating brain-dead organ donor British Journal of Anaesthesia . BJA: British Journal of Anaesthesia, Volume 108, Issue suppl_1, January 2012, Pages i96–i107,

[4]Treloar A. Descartes’ error on the nature of the Human Soul. Catholic Medical Quarterly Volume 70(3) August 2020.

[5]  Address of the Holy Father John Paul II to the 18th International Congress of the Transplantation Society (August 29, 2000). Tuesday 29 August 2000.

[6]  Letter of John-Paul II to The Pontifical Academy of Sciences