论脑死亡标准中的法律问题

随着医学科学的迅速发展 ,传统的死亡标准已不能适应现实的需要 ,更阻碍了有关医学的进一步发展。有学者提出脑死亡概念 ,国外也有相关立法 ,我国脑死亡立法也已进入实质性程序。本文对脑死亡的概念、意义、标准及国外的规定作了初步的阐述 ,并对我国的立法提出建议。     

Aspects of brain death

The different aspects of brain death are discussed. It is pointed out that the diagnosis of poisoning as the cause of brain death can be checked by toxicological examination of brain tissue and of blood in the sinus of the dura mater, since the metabolism in the brain and sinus blood is markedly reduced while drugs and toxic substances continue to be broken down in the other organs. Particular importance attaches to this difference in the case of crimes of violence creating conditions that predispose to brain death when the significance of a further violent act, e.g. stabbing with resultant haemorrhage, has to be assessed. The simple vital reaction of bleeding does not of itself constitute proof in such a situation, unless it is possible to say with a good degree of certainty that brain death did not occur at the moment when the victim was stabbed. It may, however, be possible to state that brain death that could have been caused by violence has not yet occurred if complex vital reactions, such as inflammation of a wound, are seen.     

Hypothermia Secondary to Glioblastoma Multiforme? Autopsy Findings in Two Cases

Death due to accidental primary hypothermia in cold climates is relatively common, with previous case series reflecting this. In contrast, hypothermia‐related death as a result of an underlying medical cause, such as a brain tumor, is rare. The literature clearly illustrates a theoretical causal relationship between brain neoplasms and hypothermia through the infiltration of the hypothalamus; however, the number of reported cases is minimal. Two cases are presented where autopsy confirmed hypothermia as the cause of death with both cases revealing widespread glioblastoma multiforme in the brain. Both decedents were elderly with a number of comorbidities identified during autopsy that could explain death; however, hypothermia was deemed the most likely cause. It is proposed that both decedents died of hypothermia as a result of the tumor's effect on thermoregulation. These cases underline the importance of forensic pathologists to be aware of the relationship between brain tumors and hypothermia and to not dismiss death as being due to other disease processes.     

自愿适用脑死亡标准的法律设计

自愿适用脑死亡标准是指根据完全民事行为能力人的真实意思表示，尊重其意愿，对其适用脑死亡标准作为死亡判断标准。自愿适用脑死亡标准具有自愿性、科学性和复杂性。预立自愿适用脑死亡标准意思表示制度对自愿适用脑死亡标准有一定的制度意义。     

脑死亡若干法律问题研究

脑死亡是刑法学中与人的生命保护界限密切相关的问题。脑死亡的新观念虽然面临挑战 ,但其科学合理性毋庸置疑。脑死亡的时间应当以全脑机能不可逆性丧失时为准。脑死亡的概念与判定标准 ,有必要在器官移植法中予以规定。     

A critique on the concept of "brain death"

Since the concept of "brain death" was introduced in medical terminology, enough evidence has come to light to show that the concept is based on an unclear and incoherent theory. The "brain death" concept suffers by internal inconsistencies in both the tests-criterion and the criterion-definition relationships. It is also evident that there are residual vegetative functions in "brain dead" patients. Since the content of consciousness is inaccessible in these patients who are in a profound coma, the diagnosis of "brain death" is based on an unproved hypothesis. A critical evaluation of the role and the limitations of the confirmatory tests in the diagnosis of "brain death" is attempted. Finally it is pointed out that a holistic approach to the problem of "brain death" in humans should necessarily include the inspection of the content of consciousness.     

The neurological determination of death: what does it really mean?

The recent Canadian forum's recommendations regarding "neurological determination of death" claim to have determined a "Canadian definition, criteria, and minimum testing requirements for neurological determination of death." In this review the problems with this statement are discussed. The criterion of neurological determination of death does not fulfill the definition of death, because there is continued integration of the organism as a whole. The tests for neurological determination of death do not fulfill the criterion of neurological determination of death because they do not show the irreversible loss of all critical brain functions. The forum has provided no coherent argument for why neurological determination of death should be considered death. I suggest that one cannot invoke expert opinion to clarify a criterion of death, and tests for this criterion of death, without a clear concept of what death is. The forum has clarified tests for what they call "neurological determination of death," but this is not death itself; rather, it is a neurologically devastating state. Whether this state of "neurological determination of death" is enough to justify the morality of harvesting organs prior to death is the real question. A potential solution to this question is discussed.     

Alternative to Brain Death

This article criticizes a range of assumptions that proponents of brain death usually share. It argues that one of the main contentions made in defense of brain death – that the brain is necessary for integrated functioning in a human organism – is mistaken. It then sketches an alternative account of human death that distinguishes between the biological death of a human organism and the death or ceasing to exist of a person.     

实验性脑死亡脑外器官变化

研究了原发性脑死亡垂体、肾上腺、胰腺、脾脏等脏器宏观、微观及超微结构的变化规律．结果如下：（1）胰腺腺泡酶原颗粒减少，胰岛细胞核固缩；（2）脾脏被膜下出血，脾窦扩张淤血；（3）肾上腺皮质及髓质细胞疏松，胞核浓缩；超微结构可见束状带细胞线粒体嵴消失，核质溶解；（4）腺垂体细胞核变小，胞质出现空泡，神经垂体胶质细胞增生，纤维组织排列紊乱，染色浅淡；（5）原发性脑死亡可以引起脑外器官包括垂体、肾上腺、胰腺、脾脏的形态结构变化，但远比脑组织本身的变化轻．     

脑死亡后神经细胞溶酶体酸性磷酸酶变化的研究

在颅内高压致脑死亡动物模型基础上采用酶细胞化学技术对脑死后不同水平神经细胞溶酶体酸性磷酸酶(AcidPhosphatase,ACP)活性变化和定位分布作了同步观察.结果显示,脑死亡后神经细胞ACP活性先增高,继而逐渐降低乃至消失,以大脑和小脑神经细胞为著;脑干神经细胞ACP一直保持较高活性;脑死亡9h内ACP定位无改变.表明神经元ACP活性改变可能是脑死亡神经病理学变化的发病机制之一.     

Single-stranded DNA as an immunohistochemical marker of neuronal damage in human brain: an analysis of autopsy material with regard to the cause of death

Single-stranded DNA (ssDNA) is a marker of apoptosis and programmed cell death, which appears prior to DNA fragmentation during delayed neuronal death. The present study investigated the immunohistochemical distribution of ssDNA in the brain to investigate apoptotic neuronal damage with regard to the cause of death in medicolegal autopsy cases (n=305). Neuronal immunopositivity for ssDNA was globally detected in the brain, independent of the age, gender of subjects and postmortem interval, and depended on the cause of death. Higher positivity was typically found in the pallidum for delayed brain injury death and fatal carbon monoxide intoxication, and in the cerebral cortex, pallidum and substantia nigra for drug intoxication. For mechanical asphyxiation, a high positivity was detected in the cerebral cortex and pallidum, while the positivity was low in the substantia nigra. The neuronal ssDNA increased during the survival period within about 24h at each site, depending on the type of brain injury, and in the substantia nigra for other blunt injuries. The neuronal positivity was usually lower for drowning and acute ischemic disease. Topographical analysis of ssDNA-positive neurons may contribute to investigating the cause of brain damage and survival period after a fatal insult.     

Digital forensic osteology--possibilities in cooperation with the Virtopsy project

In forensic pathology, the reactions that occur in the body from somatic death to cell death are commonly termed "supravital reactions". There are many reports of grossly visible and microscopic supravital reactions; however, few papers are available on the supravital reaction concerning gene expression. The aim of this study was to examine the gene expression of immediate early genes (IEGs) including c-fos, fos-B and c-jun in mechanically asphyxiated mouse brain and lung after somatic death and to identify the IEGs expressed at the point of supravital reaction in the brain and lung. Our results confirm that the expression of IEGs changed after death during supravital reaction and that the alterations differed according to the cause of death and the types of organ examined. In addition, IEG expression significantly increased following mechanical asphyxia. These results suggest that there is a specific pattern of gene expression following asphyxia. It is therefore important to identify the specific genes involved, as this may give significant information to aid in the post-mortem diagnosis of strangulation and hanging.     

刍论中国脑死亡立法

＂脑死亡＂立法属于科技含量高,人权及伦理学混杂的法律进程。全文对脑死亡立法作了理论基础分析,对脑死亡立法的必要性,目前面临的主要问题作了探讨,提出对脑死亡立法的建议。     

Sudden death caused by parasites: postmortem cerebral malaria discoveries in the african endemic zone

This survey presents several cases of sudden deaths in Africa, specifically in Cote d'Ivoire, where the postmortem diagnosis of human cerebral malaria was determined after autopsy followed by pathologic examination of the brain. It is thought that cerebral malaria may be the primary cause of sudden death in nonimmunized persons during or after traveling in such endemic areas of Africa. The target population is composed of tourists, business travelers, and sailors. Because death caused by cerebral malaria occurs so suddenly, it can lead to forensic issues. Therefore, in any cases involving sudden death, it is very important for the forensic scientist to do a systematic evaluation, including pathologic examination of brain tissue, to rule in or exclude cerebral malaria. This practice will reinforce and aid research in progress directed at developing a vaccine and elucidating the role of tumor necrosis factor in this disease. Furthermore, this study will alert the physician to the importance of an effective and well-followed prophylaxis.     

Histomorphometric characteristic of human brain in acute alcoholic intoxication

Different brain sections were studied in 20 subjects, who died of ethanol intoxication and in 14 subjects who died of injuries of the heart and main vessels, in order to detect histological changes in the brain and for the purpose of defining spatial and quantitative ratios between cerebral tissue structures in alcoholic intoxication. Different histological, stereometric and morphometric tools were made use of. It was demonstrated that, in alcoholic intoxication, there occur severe disorders of the circulation with affection of vessels in the brain; there are also dystrophic and necrotic changes in neurocytes, glial cells and white substance. The square of neurons shrinks due to death of some of them in the cortex of hemispheres, thalamus and cerebellum. As for the medulla, they are more resistant, there, to ethanol. The diameter of capillaries in the studied brain sections diminishes due to a reduced tonus of cerebral arteries; the quantity of such vessels increases within a standard area, which is conditioned by the compensatory opening of reserve capillaries. All this can be important in dealing with issues of thanatogenesis and of forensic medical diagnosis in death of alcoholic intoxication.     

Brain Death - Too Flawed to Endure, Too Ingrained to Abandon

The concept of brain death has become deeply ingrained in our health care system. It serves as the justification for the removal of vital organs like the heart and liver from patients who still have circulation and respiration while these organs maintain viability. On close examination, however, the concept is seen as incoherent and counterintuitive to our understandings of death. In order to abandon the concept of brain death and yet retain our practices in organ transplantation, we need to either change the definition of death or no longer maintain a commitment to the dead donor rule, which is an implicit prohibition against removing vital organs from individuals before they are declared dead. After exploring these two options, the author argues that while new definitions of death are problematic, alternatives to the dead donor rule are both ethically justifiable and potentially palatable to the public. Even so, the author concludes that neither of these approaches is likely to be adopted and that resolution will most probably come when technological advances in immunology simply make the concept of brain death obsolete.     

英国法上"死亡"定义之考察

本文从英国判例法和医学行业标准两个方面考察了英国法上“死亡”这一概念的发展过程,阐释了传统的心跳和呼吸停止标准与脑死亡标准的关系以及英国社会目前对死亡定义所存在的疑虑和争议,并且指出了英国法对我国的借鉴意义。本文通过对英国法上死亡定义的考察,以期对我国目前正在进行的脑死亡法的起草工作有所助益。     

Intrapulmonary aquaporin-5 expression as a possible biomarker for discriminating smothering and choking from sudden cardiac death: a pilot study

The diagnosis of mechanical asphyxia as a cause of death, especially smothering and choking lacking evident injury, is one of the most difficult tasks in forensic pathology. The present study investigated the intrapulmonary expressions of aquaporins (AQPs; AQP-1 and AQP-5), as markers of water homeostasis, in forensic autopsy cases (total n=64, within 48 h postmortem) of mechanical asphyxiation due to neck compression (strangulation, n=24), including manual/ligature strangulation (n=12) and atypical hanging (n=12), smothering (n=7) and choking (n=8), compared with sudden cardiac death (n=14) and acute brain injury (n=11). Quantification of mRNA using a Taqman real-time PCR assay system demonstrated suppressed expression of AQP-5, but not AQP-1, in smothering and choking, compared with that in strangulation as well as sudden cardiac death and acute brain injury death. Immunostaining of AQP-5 was weakly detected in a linear pattern in the type I alveolar epithelial cells in smothering and choking cases, while cardiac and brain injury death showed marked positivity, and most strangulation cases had AQP-5-positive granular aggregates and fragments in intra-alveolar spaces. These observations indicate a partial difference in pulmonary molecular pathology among these causes of death, suggesting a procedure for possible discrimination of smothering and choking from sudden cardiac death.     

Skull Fracture with Brain Expulsion in a One-Level Jumping-Fall

Abstract:  Here presented is the case of a one-level jumping-fall with extensive skull fractures and brain expulsion. The body was found on the basement floor at the foot of the stairs. At the autopsy, the skull was extensively fractured, with about half of the brain expulsed several feet away from the body. The cause of death was established as a craniocerebral trauma with brain expulsion. The circumstances and manner of death were still unclear at that time. A low fall seemed very unlikely considering the severity of the skull and brain damage. The police investigation clearly revealed that the man, in a paranoid psychotic state, attacked his wife with a knife and then was witnessed by his children to have hit his head several times with a hammer. Afterwards, they saw him running to the top of the basement stairs and jumping to the bottom of the stairs head first.