In the studio with me this afternoon is dr. Ronald Cranford an urologist at Hennepin County Medical Center in Minneapolis. Dr. Cranford is served as an expert witness in court hearings involving the issue of brain death. Most recently the hearing last week in Ramsey District Court in St. Paul involving Stacy Allison, Dr. Cranford is also chairman of the ad hoc committee on death of the Minnesota Medical Association it is that Committee in 1976 set criteria for determining brain death. Dr. Cranford is also chairman of the Ethics Committee of the American Academy of neurologist. And dr. Cranford has been active in efforts to get the Minnesota state legislature to pass a law including the cessation of brain function in the criteria for determining death. My other guests this afternoon is mr. John marker. He is executive director of the Minnesota Catholic conference headquartered in St. Paul. He has been in its executive director since the conference's Inception in 1967. The Minnesota Catholic conference is a nonprofit organization, which serves as aCoordinating center for the 6 diocese in the state of Minnesota Lake Minnesota Catholic conference opposed brain death legislation submitted two years ago in the Minnesota Legislature. Good afternoon. Gentlemen, welcome. What I'd like to do is Begin by asking you dr. Cranford. If you would reflect outline, the present legal definition for death in Minnesota sort of is a basis for our discussion this afternoon. Well before the two recent rulings one by judge lebedoff and Hennepin County in the ruling you yesterday by joji angolan Ramsey County. There were no specific definition of Death Eater by legislation or common law decision in the state of Minnesota that was one case of 1938 a question of a simultaneous death situation, but essentially Most states were there have been no definite brain death cases before the courts. The Estates have relied on the common law definition of death, which is according to Black's Law Dictionary total cessation of all vitally of all vital functions primarily credit.Ferra torr and I think Most states have relied on that common law definition. Explain then. What is meant by brain death is a medical syndrome that arose about 10 to 20 years ago because of Newark advances in medical technology primarily the respirator from a medical standpoint have brain death arises because patients are admitted to the hospital. They're obviously very critically ill with severe head injuries and so forth are put on a respirator to treat try to treat in a reversible causes of their head injuries. And after. Of time, it's obvious that the brain is not functioning in its entirety and by that, I mean that there is no higher centers of the brain what we call the cerebral hemispheres of the cortex, which is functioning a lower sentence of brainstem is not functioning. These patients have no evidence of brain function whatsoever including respirations when the brain dies, there are no spontaneous respiration to the paces totally supported on a respirator and the soul of the heart can beat on its own autonomously, but of course if the respirator stop the heart will stop in a few minutes. So the Cinderella Rose 10 to Years ago 20-30 years ago. These kids are extremely rare, but because of technology and so forth they become more common and at the end of the County Medical Center, for example, a project 5% of all the deaths occur at our Hospital are brain death. So many situations are there is no brain functioning whatsoever. What are some of the tests that you as an urologist perform when you're trying to determine whether someone's brain has ceased to function totally and irreversibly primarily it it's two things number one is a clinical examination at the bedside doing a neurological exam to see if there's any brain stem function example looking at the pupils to see if they react to light and of course, they don't they're large to see if there's any spontaneous respirations looking for other brainstem reflexes the turning the head to see if the eyes move from side to side which is called a oculocephalic reflex putting cold water in the ears to see again at the eyes TV at the one side. This is called caloric testing again. These are negative. Examination of the body and trying to see if there's any voluntary responses from the body or any involuntary posturing his body would can be related to brain stem problem an examination like this at the bedside buy a reason we experience neurologist neurosurgeon are there physician in these situations may take 5 to 10 minutes of relatively simple bedside examination. So when you determine their cessation of brain function, that's one thing the second essential aspect of the criteria and the concept is the establishment of irreversibility. Whatever is causing the brain to stop has to be an irreversible process. For example, a person can have all the criteria for brain death has no brain stem functioning no higher cortical functioning and it could be an overdose of barbiturates or meprobamate or some other tranquilizers and all these functions can be gone in the patient can recover completely without any neurologic dysfunction whatsoever because of no situation the barbecue area has suppressed all brain functioning, but it wasn't irreversible and that's why We've established a. Of your period of observation to determine irreversibility to a physician in addition to diagnosing brain death at the bedsides for a relatively simple clinical examination have to determine Beyond any reasonable doubt that the cause of the cessation of brain function is irreversible in some cases that's very easy and other cases more difficult to give you a contract for patient comes in who has a severe head injuries and he's examined by a neurosurgeon for example, and there is no brain functioning and in addition to the fact that there's no brain functioning an examination. There's obvious gross wounds to the head to the brain and so forth. Then the importance of that as you've established the cause of the brain not functioning as an irreversible cause in other situations where I've been involved with we've had to wait several days to establish reversibility and then to give you one example, if we find someone and in a home or something and they're brought in and we don't know the history whatsoever. And it's obvious. The brain is not functioning. We put them on a respirator. We can't be certain this not due to drugs are the answer would be to get a drug screen in a situation like that, but it's been well known that you can't screen for every drug in the system. So you can't do a very large drug screen to rule out all causes in a situation like that. You haven't established irreversibility. And therefore you may have to wait several days and indeed we have in some of these cases waited 2 3 4 days and then at that point you can say that if there any drugs in the body, they've been metabolize out of the body and therefore then at that point you can establish irreversibility. So one important factor is the history if you know what's going on Beyond any reasonable doubt if you know that I get a car accident or something like that was obvious injuries. That's one thing. We don't have the history. You have two are in the conservative side to establish this essential element, which is the irreversibility and you may have to wait several days for that. So the criteria for the determination of brain death are simple clinical bedside examination the establishment of irreversibility and if there's any doubt then you can go on to do confirmatory test. What is a brain wave test electrons half a gram or for vessel angiography injection of dye into the carotid arteries and so forth. Okay, very good. Mr. Mark or two or not in your head while dr. Cranford was talking about the establishing some milk establishing the irreversibility. Tell me you your own position and Minnesota Catholic conference's position in that whole matter which seems to be a very important one than one's been this year. I want to backtrack a little and then respond to a question that you asked. Dr. Cranford you asked him to clarify for is the current status or definition of death in Minnesota law important question because that the Forum in which dr. Cranford now come together is the form before the legislature. That's why I first met. Dr. Cranford where in a bill was introduced to have the legislature to find F to find brain-dead specifically in this case. So it's important. I think you're very important to remember that there is no Statute in Minnesota and until about 10 years ago. There were no statutes and hardly any of the states that I know of defining quote death. Either by reason of the heart-stopping or breathing stopping or any other vital function or or brain. So the the definition of death at the hands of quote, the law was not treated by Statute but was treated by the function of the courts in in a case facts situation such as we had in St. Paul question is the patient dead at a given time answer yes or no on that's a question of fact to be decided by the finder of fact, so that's very important up secondly listening to doctor cranford's medical definition of brain death I owe, you know, our position is that we are not in opposition to the concept of having people found to be dead by reason the fact that their brain is permanently he use the word irreversible at permanently dysfunctioning are dead if you will and and that's why I was nodding. I think that the irreversibility Of the symptom ology is extremely important because there are situations in which brain death can be can be mimicked if you will buy my drugs and so forth. So the place where we're dr. Cranford and I come together in terms of any any opposition to each other would be that we have grave misgivings about the legislature getting into the death of finding business Weatherby brain part breath any other vital symptom and not so much with the concept that if a person's brain is dead he or she is dead. Let's get into that question a little bit neurologist another Physicians feel that it is necessary to have a law on the books which includes brain death. Among other forms, there were no specific cases on on brain death before the courts. I think the first one was really brain. They should be for the courts United States was in 1957 Smith vs. Smith and Arkansas since that time ever been repeated two cases before the Lord chords of judicial decisions concerning the validity of the concept, of course in Minnesota. We've had at least two within the last month or so because of these cases coming before the courts and because of the legal uncertainty in these situations and because of the concern of Physicians concerning working with the families the question of transplantation and so forth 18 states now have passed statutory legislation legalizing the concept of brain death and one state of Massachusetts with Supreme Court decision has validated the concept of brain death the first state to legalize brain death row stats to write legislation was Kansas and 1970s. I said so many other States since then, Have legalized a brain death through a statutory legislation. It's a controversial issue. Mr. Martin and I do not agree on the concept of rain. Nor the criteria that the main concern is how this should be validated legalizing do not agree agree on the concept in the craziest thing. You don't agree upon is how this should be a be legislated or whether it should be through case mod decision. I can give an example of what happened in 1974. There were two cases of a brain dead before the Lord chords in the state of California in one case. He said the floor is case of an individual while I was drunk. I hit a 13 year old girl as she was pronounced brain-dead Oregon for use for donation and this case went before the lower court. And in this case and this is the only one in recent in the last 5 to 10 years were the Lord court has been unwilling to accept the concept of brain death in the for his case worker was unwilling to accept the Concept of brain death in that case because of this organ donation in the California area went down 80 to 90% The Physicians were very concerned in Ministry is very concerned about the relationship of rain duster the question of organ donation that was quite a furor in California in the City Attorney General essentially in California went to the State Medical Association and said to send that you will sponsor a brain. Bill in the next legislative session in California and one was introduced and passed the next year and you create a climate of uncertainty when these cases come before the court. I think this is one reason I think one major reason why I think brain. Should be legislated. The concept should be legislated is so that the public can Society can accept the concept of rain do to help us to deal with the families in situations like this. So they know that brain death signifies a death of the person and in my position has been that it the best way to obtain societal acceptance of the concept of brain death history. Statutory legislation rather than judicial decision. I think a secondary motivation and I want to stress secondary but a very important motivation is a question of facilitation of transplantation and I think by sanctioning the concept of brain death through statutory legislation. Hopefully, you'll facilitate transplantation in these situations as well. So I feel it's a societal decision in the long run the definition of death or the legalization of the concept of brain death and I prefer that rather than a yacht judicial determinations. Mr. Mark Hurd, and we've been through this before a doctor as you well know. Again, we have no quarrel with the concept of establishing death through the through the observation of a brain death. I really do believe how her and you said that you think that one of the best ways to teach Society at the efficacy of the brain death concept would be to have the legislature act on it. I agree that the legislature has a very broad educativa rule with the public-at-large. But that and in my opinion is not always justification for invoking their power is now the danger I see is to get the legislature into the death of finding business. What would where would we be for instance? If 50 years ago the legislature had passed or 30 years ago. The legislature passed laws with said that you're dead when your respiration is permanently stopped now we get into that business about irreversible in permanent because we now have the means of Articuno of the resuscitation. We also have the means of electric shock and cardio stimulants and so forth that we can even bring back the heart that is spontaneous. Question was an irreversible or not. But if the legislature had gotten into the death of finding business back in those days before we found out that these things were reversible and we had statutes on the books. We we might find ourselves in order to buy any situation number one. So what that does is the ledge then passes a a very specific law which takes discretion out of the area of the application of the facts and I think the doctor cranford's discussion of irreversibility of the observations. Of the techniques of diagnosis really are partial answer to that argument. The other argument that I would have would be that that I really don't feel at the legislature should a very philosophic brats and should be involved in defining death for a society because once they enter that Forum experience teaches us and I and I don't mean to demean our current president legislative process, but I'm historical traditional way legislative bodies or lawmaking bodies historically that have gotten into the death of finding business have come about to AB use it in many many instances. Can you give some examples of the Third Reich in terms of they they got into defining person hoods and who's alive and who's dead and you can be defined a door to find a live depending upon A lot of Pride to your other than brain Death III must say on the heels of that statement that we we see no one personally in the on the horizon or in the present seen you the legislatively are medically but but we will refer to that as a general theory and a general images of generalized statement. That's one of the places where these kinds of things can leave and then we think it's a valid observation in one which should be very very strict adult with now one of the needs that I think dr. Cranford was referring to in terms of this kind of legislation was you didn't use those that you didn't use the term malpractice, but I think that that's an end of an Acura sense doctors do fear and legitimately being taken to task legally buy their malpractice or even or even criminal prosecution the improper pronouncement of death in terms of what Society will accept them all except. And it may be that a doctor, you know, the Flores case and a couple other ones. We have the defendant says I didn't kill the patient the doctor did when he sees the therapy that was keeping the patient quote alive Encore those cases generally have turned out in favor of the doctor in that the the the form of the court in that instance has said no it wasn't the doctor that killed that the patient was the the assailant as the case may be so that I just don't feel that public education. Or the danger of repercussions to the doctor Visa V the criminal or malpractice civil lawsuits are justification for the led states are getting in the death of finding business because the definition of death in our society in a functional way has been established through a very nebulous, but rather well to find system apology of establishing the definition of death and that is the common law and when there is a question, you see this little girl whose death was just a firm now by the Supreme Court yesterday this whole thing took place without a statute and it has been well handled well treated the doctors have been protected the county attorney in the prosecuting staff have have properly handle the situation in a very I think well-educated roll to the public into themselves. They I think the the woman here who may be charged with criminal prosecution as a result of the death of this child. Has had her rights amply protected by determining what was the cause of death and when was death and so forth? And this is all the name of that a statute in my point is we don't need a statue. Cranford before you respond to that. I want to let listeners who raps of just tuned in and let them know that we're discussing this afternoon the concept of brain death and in the studio with me is John markers who is executive director of the Minnesota Catholic conference. And dr. Ronald Cranford who's in urologist at Hennepin County Medical Center Dr. Cranford. Would you care to respond to call to mister Margaret's death is a key factor importance and a great social relevance and it seems to me that the proper public forum for a discussion and determination of brain death would be the It seems to me the the primary reason for the legislature is to represent the will of the people and I don't believe that the Supreme Court is necessarily the proper area to debate these issues and I think this has been pointed out in the courts and then the public defender for example of Louis XIII nose in the Allison case argued strongly that they have to that. This should be a proper subject of legislative action in a situation like this again, I would go back to the point that then and I think mr. Mark and I would agree on this point that public education is important education of the medical legal profession concerning various aspects of brain death and separating it from allowing to die are very important and it seems me along with this and this is where he and I would disagree is that one way to have Society sanction this for the public to be aware of this is for a very vigorous debate and dialogue through legislative hearings. And this is something that I have strongly argued for a 4/8 of reason so that Society accept this and let me give you an example of why I think this is important. A brain death law if it's to be a good one has to be legally mandatory rather than permissive that is the law has to say that a person shall be pronounce did not that a person may be pronounced dead. So the law has to be legally mandatory because the question is one that has not been raised a great deal. He has brain death equivalent to Curtis paratore death because you see when a doctor pronounce a person dead Curtis Pirate Radio, the consent of the family is legally irrelevant. You don't go to the family with the Carters paratore death and ask for their commission and you see if brain death has the same validity as card expired and I think I think it will eventually then from a legal standpoint the doctors obligated weather by Statute or judicial decision or whatever if it's a good one two cars paratore to death to pronounce a person dead regardless of any other circumstances and then to discontinue support which might include the heart continuing to beat and that's right. That's right. Now the other side of that coin and this is how I testify Anastasia Allison case in this is the way I do in practice with and without a Judicial determination with or without a statute how much dress with or without a statute? I still go to the family make it clear to them that it's a medical determination that the person it is dead on the base of brain death, but for humanitarian estic compassionate reasons, I talk to the family see if they have any objections are reservations concerning this and I try to satisfy these objections or reservations before I pronounce the person that Dad and I were talking about to say they accepting this concept that on the one hand we have it has to be legally mandatory if it's equivalent to Curtis prior to her and I think it's a very major social ethical philosophical question is Brain death equivalent to Curtis paratore death and if it is then in general the same circumstances should apply in those situations and I think this is something and have to be vigorously debated and discussed before a broad public forum. And I don't believe these state supreme court is at braudy form in those situations. Did the Stacy Allison case differ from the case of Karen Ann Quinlan the young woman out in New Jersey a few years ago who had taken an overdose of combination of arbitration alcohol and went into a coma. How does that case differ briefly were talking about separating total brain death from cases of persistent vegetative state where there's damage to the higher centers of the brain. The brain stem is relatively intact is in the club, right? Let me jump into the brainstem again is that portion of the brain which stimulates heartbeat and respiration is brain that concerned with reflex activity and maintenance of a kind of spirit or a function is known for its and that portion of the brain can continue to function without with the higher centers. You called. That's right in the Ellison cases only had head trauma injury to the brain. She came in it was obvious. She was critically ill. She was immediately put on a respirator all proper medical procedure Consultants were called and immediately had the patient was examined a very Test for done at that time to determine whether Zenni treatable surgical lesion a blood clot on the brain and this was found. She was admitted at 8:25 at night and at 3 in the morning. All the tests have been done to try to find a retrieval cause severe head injuries. None was found in it at that point was obvious that she'd had brain death because she was totally put on a respirator. She'd lost her last few respirations. In those cases from a medical standpoint case of brain death, whatever the primary in so whether it's a region of the brain head trauma, whatever the cause the pressure inside they had become so great increase in Akron OH pressure exceeds the systolic blood pressure and so in addition to the primary insult to the brain these patients about mass of increased intracranial pressure and there's no blood flowing to the brain and this is what happened to Stacy Allison case in the Quinlan case this series of events did not occur. She took an overdose of medication. She had a respiratory arrest you stop breathing and because of this there was a lack of oxygen or blood to the higher centers of the brain has it was very severe distraction to the higher centers of brain the neocortex, but the lower centers are relatively intact a lower status of brainstem are resistant to lack of oxygen or lack of blood and they can continue to survive in the Quinlan case. She never developed this increased intracranial pressure. She never lost blood circulation to the brain and so she is in a persistent vegetative state you severely grossly demented. And the prognosis there for the determination of how long should continue like this is variable in the brain death cases. The Allison case is a typical example of that within the first few hours or certainly within 12 to 24 hours. You can determine if there's no blood flowing to the brain by your clinical examination. And therefore the prognosis is absolutely zero at that point. So you can separate those cases from a medical standpoint number one and for my broader issue, which we can discuss if you want the Ellison case is a question of pronouncing a person dead on the basis of brain death the argument and they Quinlan case is a question while allowing the person to die which has tremendous social ethical implications you are withdrawing or withholding therapy Cranford mention the public debate the will of the people, you know, the Forum a public discussion. And I agree with that concept and I guess part of our disagreement would be however that I guess I'm not sure that the legislature presents a really meaningful public debate in terms of the public-at-large not to the extent that those debates take place and you and I both been there and you know you before committing the legislature did he sent those debates take place in public and with the media present and to some extent more or less and different issues the media reflects us out to the public. Yes, but there is not only the question public debate, but there's a question of confidence to make a decision. And I don't think that the legislature has the confidence and I don't think the courts have the confidence and that's why they have built-in methods of bringing experts in before them to tell them what are the technical facts of these various technical questions. Only bring death. But any other type of question so both systems of legislation and adjudication before the courts have a very well-designed method of bringing expertise in before them from extra Witnesses, and they rely on the experts. Who is it when the instance of brain death are the medical profession is represented by dr. Cranford. So one of the one of my objections into statue tizing if you will bring death is that that you tend to solidify and make black and white and area of discretion in which proper confidence can be exercised. You know, your point Dr. About you have an obligation in the statute should be mandatory about pronouncing death. The fact is the patient is dead. Say that is the fact of the matter and it's the fact that comes when you pronounce death can be a very discreet thing in some instances. But if you have a statute there will be no discretion. Would you have it then? Mr. Mark hurt that to these kind of court cases would come forward just about every time there is a case such as the Ellison won in the beginning. Yes, and that's precisely what we're saying because there seems to be a before or at least an inordinate amount of these cases coming up in the in the conscious of the medians of 4th. And that's precisely the way new technology definitions related in this kind of thing establish themselves 10 years from now, you won't see cases like this because what the law calls race judicata the matter what we decide and then we'll be well established in the common-law processes of lovemaking and and I think that that is just as informative and probably a more meaningful and safer way to establish and then this is where dr. Cranford I disagree and it's a very agreeable disagree with but a basic one, I think. The I might mention those states that have had their case law decisions in the Lord Court the vast majority of gone on to pass text her legislation within the next few years. I think they're a couple notable exceptions to that rule New York, for example, but Most states have gone on the past history legislation after these cases have come before the Lord chords and I see my role if I may use that in a sentence as being too full number one to try and and and prevent the establishment of statutory, which I don't think is necessary. Number one number two, if in the wisdom of the legislature these things do come to pass at least we will have sounded the alarm or at least the the the caveats if you will of of Of the entry of the legislative process is into the death of finding business in and I think that's where the usual purpose to you know, and then we're not accusing anybody. But but when the legislature steps into that Arena they better do it very consciously if they're going to do it at all and with great reservation and and great discernment and with I think a proper resolution that this is this is a very sacrosanct area when which which is not entered lightly. Dr. Cranford if the legislature were to pass a brain death law or include cessation brain function in the criteria for determining debt. How would you as a physician handle these cases? Would you change your approach and I'm asking you this personally because I don't want to ask you to speak for all positions are neurologists. But I'm I'm wondering if you as you said earlier you you discuss these cases with with families. Would you continue to do that to you think he has not answered and then two ways number one in my own personal practice and I just alluded to a few minutes ago with her with Statute statute pass. I was still handle the cases the same way and I was still go to the family to see if they have any concerns or reservations again from a compassionate State stamping not because my fear of liability legal liability, so I wouldn't handle them the same way and still go to the families. It would help to have a brain test at you because it would show that Society has sanctioned there so you can go to the family and I think they might understand it better and because of the attendant publicity through legislative hearings and for that matter through these cases more people are aware of the issues and and another thing the background of course is to try to separate these issues of pronouncing death versus long to die. And I think that's absolutely fine. When I hope that legislative hearings would serve that purpose to distinguish these areas one point I would like to make and I'd like to speak to the members of the medical profession in the larger centers where we have the technology. We have the emphasis on basic life support. We run into more and more cases of brain death and hopefully we save more lies has the technology permits to the smaller communities has the technique of cardiopulmonary resuscitation for me to the smaller communities. They're going to run into the same problems that we are and we need to educate the medical profession in the smaller communities to all these various aspects and one concern I have is it if there's a great fear of legal liability or judicial determination to many of these cases this will impede our efforts to educate and 1 plan looking ahead would be to have a statutory legislation on brain death so that when these things go to the smaller communities that we can educate now in the medical profession, but also leave public as well. So I think a statue would have a beneficial effect and Australian my practice but on the practice of other Physicians were going to be more and more involved with these cases of brain death as they received this type of head. They received the newer Technologies on sale in the process. Nnnn, the dynamic is the fear of the doctors have and then I guess I don't like to stay at that way. But let's use it anyway of being bucked ask either malpractice or otherwise for improper application of medicine or whatever. I think the the last decade or even twenty years of seeing that abused and then be used to say is a lawyer at the hands of some lawyers. Okay, but it isn't important than that make another night Mac. Is this that it is it that I make that tends to work on the medical profession and keep them resolving in the Dodge in favor of in this instance life. And and that's not always what I'm saying is the the Spectre of malpractice is not all bad while it's been abused and then and I think has a bad imagery now. It's been a useful Spectre because doctors like wires do have their people who are not ethical sometime and and this Specter of discipline and that's what it is. Does operate any very useful way sometimes and then it would dr. Cranford of saying is that it has come to pass very concurrently or contemporaneously that it sometimes it's counterproductive to and I I guess I'd agree with that. That's part of the Dynamics of this Market a question of the brain If legislation to me is not the critical Factor its acceptance by society says sanctioned by society. And and if the legislature is not the area to debate and dilong these broader social issues then then what is the proper Arena because if there was some more effective Arena to discuss the social issues and he and I are both aware of the implications of all these areas and we wanted to distinguish between pronouncing death versus along today. If this is not the proper Arena to debate these areas and then I would say fine in the sky near What legislation if there's a better Arena and I think it we have an obligation as a medical profession to educate people and I don't know what a better Reno and form would be then the legislature. I don't know if it's better. But my point would be that it's safer that you in terms of the caveats that you heard me Express and that would be the exact thing that's happened here in St. Paul and Minneapolis, but more notably recently in case in st. Paul with the is it that these days Alice in case we have seen this case but forward and up into the public Consciousness and in a proper way, you know through the operation of law. It has been very well and responsibly handled. I think from what I've seen of it by the news media both print and electronic and and I think that's probably the safest way. That that that that's a very very valid question. I don't think that we are in that big a hurry to too involved. No going back to your to the question that was asked would this statute if it were in place affect your personal activity in terms of applying the principles to practice what would you do if you have a patient who dies and you go to the parents and say poo poo brain dies and you go to the next of kin or whoever's in charge and say your son or daughter is dead and I'm going to declare I'm dead and then they say but I hear she's breathing and the heart's beating and she feels warm. That don't do it. I think with a statue in place you have to do it and you would be deprived of the discretion of leaving in place this therapy in terms of of Humane reaction to the family for even 24 hours because you have the matter of the expense the hospital administrator would be after you for utilization committee perhaps and you know, I'm and I'm emphasizing though. I rather dramatic scene you understand but I think it happens and appreciate your concern. My answer to that would be that with the legislative hearings and an extensive a public forum in discussing these issues. The families would accept this determination and you wouldn't have the conflicts in the egg in the end and I'm really concerned about the egg and suffering that I see and families who don't accept this and and I agree with that hanging with judicial determinations. That would be a proper interpretation to say that at the announcement of brain death is legally obligatory with or without a statute. So I don't think it'll be unduly restrictive on the medical profession in the bills that have been passed in the 18 states. Deceptively are proper and I don't think they'll be unduly restrictive on the medical profession. What you're saying is that the bills have been passed in the one that was considered before the Minnesota Legislature. We are tantamount to a codification of the facts into statutory law. Yes, and therefore we get back to our old Nemesis should the legislature be passing statute about this business. And and is that or is it not the proper and the best form for public education debate and so forth. I would agree that it's a good form for public debate and conscience raising, but I still have that comment about the legislature being competent and even getting into the death of finding business. I see that is a very very serious serious question 1 which I answer in the negative gentleman in the few minutes that we have left us. I'd like to talk for just a few moments about the condition the doctor Cranford describes his persistent vegetative state and how persons who are in that state are treated and the and what we might expect to see in Future in terms of either court cases or legislation when that comes up because I suspect that I'm speculating that that has legislation is proposed and we may see it again. This next session with these cases coming up that that too will be discussed and I guess I'd like to have both of your ear feeling so that your feelings from the feeling from both of you on that how that should be dealt with how people should be treated in that situation. Someone who in the Judgment perhaps of a physician is never going to come out of that coma is going to be in a bed for 30 or 40 years. From a medical standpoint from Jeopardy Allison case if there was a brain death, you know what the beginning that the prognosis for any meaningful function return of brain function is zero in cases like the Quinlan case of persistent vegetative state. Number one. You don't know the prognosis at the beginning you may have to wait anywhere from a week or a month later by the in one interesting is by the time you're certain of the prognosis that is irreversible distraction to the hair centers of the brain their off respiratory support. They don't need the respirator at that point. You can withdraw them from the respirator and they continue to breathe on their own as in the Clinton case and at that point they can continue on for a while. I can depend on case 2 or 3 years and even longer 20 30 40 years so they can continue to vegetate if you will prepare a long. Of time crucial question there and that is a question of allowing to die and withdrawal of extraordinary means to support a separate from the pronouncement of brain death. Those cases are handled a variety of ways. It depends on how the patient feels or how the patients Express things were before they be In this position of the family and so forth in these are crucial decision to me. The question belonging to die is much more complicated has more profound social ethical implications in the pronouncement of death. And of course the other thing with the brain death syndrome, is that one good aspect of it if there is a good aspect. I think there is is a question Morgan donation. This is some good that can come out of this in time and time again, I've seen situations where great benefit was drive to the family and a grief-stricken situation the question organ donation. This is not possible in a persistent vegetative state the hospitalization to prolong the pro long-suffering to the family are all relevant factors in the persistent vegetative state. These have been handled differently legislative hearings if they are held should try to distinguish between for example brain death and which is a pronouncement of death vs. For example living will legislation, which is a form of a line today or so long to die withholding or withdrawing extraordinary means to support anything. At the market and I would agree that we however this is handled. We should do our very best to distinguish these issues and then not confuse them together. The two issues are and in my opinion clearly distinguishable on the fact that is the withdrawing or withholding of of life-saving support versus the pronouncement of death. And while they are distinguishable there is an area in which they come together. And then one of the area's I think I'm going to come together is in a confusion in the in the legislative process perhaps if if the legislature and I'm going to make my point again, but if the legislature can say your dead when your brain is dead. There really would be nothing for them to nothing. No reason why they shouldn't say you're you're dead when your brain is non-cognitive now, that means it's still alive but not functioning and what would call a normal way making that issue, but however, the The living will statute or bill which was introduced the legislature and was before this last legislative session is the bill that has to do with with the business about allowing people to Die the death with dignity and so forth. This is a very very very serious area because the question is Comes very quickly transferable in allowing a person to die by either withholding therapy that could preserve their life and their function or withdrawing it with consent or without the consent of the patient or at least the next of kin in the nuts with the Karen. Ann Quinlan case was about that Karen Ann's father wanted to withdraw therapy that she was on and they got into this big thing about going to the court and getting a court order support so that that was different and you then take that third step and this is where people come in and become very fearful about the allowing to die at the living will and some more than that. Is it when you have a patient who was in that state and who's prognosis is not good, maybe maybe totally ultimately unknown but at least not good. Do you go beyond withdrawal and take it pause definition of action to 2% But a death in the course, that's the euthanasia thing and the many people oppose the statute simply on that grounds alone, and it's much more complicated. Necrons won't because they see that is a very small transitional step and the first steps before you get there have to be this. No, let me make another point. I'll be very pretty for this. The law and its current status does say that people do have the right to die with dignity and to refuse therapy and until recently I would have said without going to court and getting a court order and that's become up is get it now buy a case of such as the Karen Ann Quinlan case, but the many many times doctors will consult with the patient and in the absence of the patient's confidence with his next to Kin and and what I would call a patient to meet Hospital vicinity and decide whether or not to terminate life-saving therapy and in the face of a of a hopeless prognosis, and this is done all the time. It's done almost daily in our hospitals anywhere throughout in the patience of comes spontaneously in this is done and then and then there are the horror stories work was on and on that. So, you know, we ran into at public debate again, I think public debate is called for in this issue to Enlighten the public about what is the issue and how should it be proper use out? I like to just one issue which I think is very broad issue. And and mr. Market is concerned that if there is a bill introduced on brain-dead that there may be a living will legislation. There may be other legislation and his concern is with active euthanasia. And I sure he's concerned about that. My position is that if we develop a reasonable Humane policy towards number one pronouncement of death and then allowing today, it will not be the need for euthanasia and I think again legislative hearings is one way to approach this I share his concern about euthanasia and I think the way to prevent it is to develop a reasonable social policy towards these other issues the cases of euthanasia and I'm talking about avert euthanasia or request me of things are extremely rare extremely rare few cases of a long to die or unfortunately or whatever extremely common and I think we have to develop some reason policy out of societal level and I just a medical level I suspect we'll be hearing a good deal more about this in the coming months. Dr. Ronald Cranford from the Hennepin County Medical Center in Rolla. Is there thank you for being with us this afternoon? And mr. John marker in the tourney and executive director for the Minnesota Catholic conference. Thanks both.