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Background: Communication between clinicians and families of dying children in the pediatric intensive care unit (PICU) is critically important for optimal care of the child and the family. Objective: We examined the current state of clinician perspective on communication with families of dying children in the PICU. Design: Prospective case series over a 15-month study period. Setting/Subjects: We surveyed nurses, psychosocial staff, and physicians who cared for dying children in PICUs at five U.S. academic hospitals. Measurements: Clinicians reported on the location of communication, perceived barriers to end-of-life care, and rated the quality of communication (QOC). Results: We collected 565 surveys from 287 clinicians who cared for 169 dying children. Clinicians reported that the majority of communication occurred at the bedside, and less commonly family conferences and rounds. Ten barriers to care were examined and were reported with frequencies of 2%–32%. QOC was rated higher when the majority of conversations occurred during family conferences (p = 0.01) and lower for patients of non-white race (p = 0.03). QOC decreased when 8 of the 10 barriers to care were reported. Conclusions: When a child is dying, clinicians report that communication with the family occurs most frequently at the child's bedside. This has important implications for future ICU communication research as the majority of previous research and education has focused on family care conferences. In addition, findings that QOC is perceived as lower for non-white patients and when clinicians perceive that barriers hindering care are present can help direct future efforts to improve communication in the PICU.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

This Viewpoint discusses the proposals that have been considered in the process of the Uniform Law Commission assessing whether the Uniform Determination of Death Act should be revised and offers pros and cons of each.

Drawing on a recent case report of a pregnant, brain-dead woman who gave birth to a healthy child after over seven months of intensive care treatment, this essay rejects the established doctrine in medicine that brain death constitutes the biological death of the human being. The essay describes three policy options with respect to determination of death and vital organ transplantation in the case of patients who are irreversibly comatose but remain biologically alive.

The Toughest Triage Of all the medical care that will have to be rationed during the Covid-19 pandemic, the most problematic will be mechanical ventilation. One strategy for avoiding debilitating d...

Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.

Two commentaries respond to a case about apnea testing to confirm death by neurologic criteria.

I was a member of the Massachusetts advisory working group that wrote the Commonwealth's crisis standards of care guidance for the Covid‐19 pandemic, and I was proud of the work we did, thinking carefully about whether age should matter and whether priority should be given to essential workers if there was a scarcity of medical resources, about whether protocols should address issues of structural racism, and so forth. But as a critical care physician, I have concluded that, no matter how sophisticated the ethical analysis, the fundamental approach we proposed was flawed and virtually impossible to implement. All the existing allocation protocols that states developed are based on the assumption that clinicians will be faced with the task of selecting which patients will be offered a ventilator from among a population of patients who are each in need of one. The protocols then assign patients a priority category, and the protocols specify “tie‐breaking” criteria to be used when necessary. The problem with this approach for ventilator allocation is that it has no relationship whatsoever to what happens in the real world.

Background: Medical care has shifted from a paternalistic model towards one centered around patient autonomy and shared decision-making (SDM), yet the role of the pediatric patient in decision-making is unclear. Studies suggest that many children with chronic disease are capable of participating in and even making medical decisions at a young age, and yet we do not standardly involve them. Methods: This is a single center survey study investigating physician attitudes towards involvement of children in decisions regarding lung transplantation, utilizing a hypothetical case scenario with systematic manipulation of age and maturity level. We evaluated physician belief regarding ultimate decision-making authority, attempts at reconciliation of parent-child discordance, and views towards utilizing ethics and psychiatry consultation services. Results: The majority of pediatric pulmonologists believe decision-making authority rests with the parents. The effects of age and maturity are unclear. In instances of parent-child disagreement, physician are more likely to try to convince parents to defer to the child if the child is both older and more mature. Physicians are divided on the utility of ethics and psychiatry consultations. Conclusion: Involvement of children in shared decision-making is broadly supported but poorly implemented. Despite evidence that children with chronic disease may have decisional capacity starting at a young age, the majority of physicians still grant decisional authority to parents. There are numerous barriers to involving children in decisions, including legal considerations. The role of age and maturity level in influencing these decisions appears small and warrants further investigation.

Ethical climate (EC) has been broadly described as how well institutions respond to ethical issues. Developing a tool to study and evaluate EC that aims to achieve sustained improvements requires a contemporary framework with identified relevant drivers. An extensive literature review was performed, reviewing existing EC definitions, tools and areas where EC has been studied; ethical challenges and relevance of EC in contemporary paediatric intensive care (PIC); and relevant ethical theories. We surmised that existing EC definitions and tools designed to measure it fail to capture nuances of the PIC environment, and sought to address existing gaps by developing an EC framework for PIC founded on ethical theory. In this article, we propose a Paediatric Intensive Care Ethical Climate (PICEC) conceptual framework and four measurable domains to be captured by an assessment tool. We define PICEC as the collective felt experience of interdisciplinary team members arising from those factors that enable or constrain their ability to navigate ethical aspects of their work. PICEC both results from and is influenced by how well ethical issues are understood, identified, explored, reflected on, responded to and addressed in the workplace. PICEC encompasses four, core inter-related domains representing drivers of EC including: (1) organisational culture and leadership; (2) interdisciplinary team relationships and dynamics; (3) integrated child and family-centred care; and (4) ethics literacy. Future directions involve developing a PICEC measurement tool, with implications for benchmarking as well as guidance for, and evaluation of, targeted interventions to foster a healthy EC.

Supplemental Digital Content is available in the text., Objectives: Coronavirus disease 2019 patients are currently overwhelming the world’s healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. Data Sources: PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. Study Selection: Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. Data Extraction: References and data were based on relevance and author consensus. Data Synthesis: We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. “First come, first served” is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. Conclusions: Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.

Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.

A 15-year-old girl is scheduled to undergo an upper lobectomy to debulk metastatic Ewing sarcoma. The anesthesiologist recommended placement of a thoracic epidural catheter to provide postoperative analgesia. The patient did not want a needle to be placed near her spine. She was terrified that the procedure would be painful and that it might paralyze her. Although the anesthesiologist reassured her that sedation and local anesthesia would make the procedure comfortable, she remained vehemently opposed to the epidural procedure. The parents spoke privately to the anesthesiologist and asked for placement of the epidural after she was asleep. They firmly believed that this would provide optimal postoperative analgesia and thus would be in her best interest. Experts discuss the pros and cons of siding with the patient or parents.

In their article, Legal and Ethical Considerations Requiring Consent for Apnea Testing in Brain Death Determination, Berkowitz and Garrett (2020) argue that informed consent for apnea testing is le...

Death is defined biologically as the irreversible loss of the functioning of the organism as a whole, which typically occurs after the loss of cardiorespiratory function. In 1968, a Harvard committee proposed that death could also be defined neurologically as the irreversible loss of brain function. Brain death has been considered to be equivalent to cardiorespiratory arrest on the basis of the belief that the brain is required to maintain functioning of the organism as a whole and that without the brain, cardiorespiratory arrest and biological death are both rapid and certain. Over the past 20 years, however, this equivalence has been shown to be false on the basis of numerous cases of patients correctly diagnosed as brain-dead who nevertheless continued to survive for many years. The issue reached national attention with the case of Jahi McMath, a young woman diagnosed as brain-dead after a surgical accident, who survived for almost 5 years, mostly at home, supported with a ventilator and tube feedings. The fact that brain death is not biological death has many implications, notably including the concern that procurement of organs from brain-dead donors may not comply with the so-called dead donor rule, which requires that vital organs be procured from patients only after they are dead. In this article, I conclude with an analysis of options for moving forward and among them advocate for reframing brain death as a “social construct,” with implicit societal acceptance that patients diagnosed as brain-dead may be treated legally and ethically the same as if they were biologically dead.

Dear EditorAs a group of senior medical educators and Harvard Medical School professors, we call into question the article by Masters (2020) about ethics in medical education digital scholarship, i...

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

Healthcare crises, like the COVID-19 pandemic, can lead to a pronounced national-and sometimes supranational-discrepancy between the need for medical care and the ability of the healthcare systems to provide such care. Such need can, among others, consist of personnel, pharmaceuticals, equipment, nutrition, transportation capacity, or reinforcements in general. In the COVID-19 pandemic in particular, personnel and intensive care beds with ventilators have turned out to be the immediate specific bottlenecks. Although all patients need to be given a fair chance to receive medical care, the treating teams need to selectively allot the resources available and hence must make prioritization decisions. This chapter formulates recommendations as to the allocation of scarce resources. It also discusses whether the focus of care should shift from patient-centered deontology to population-centered utilitarianism in healthcare crises.

Healthcare systems increasingly use business models that focus on tangible assets such as finances and facilities. Yet intangible assets, such as values, relationships and human capital, remain critical for understanding the worth of interprofessional healthcare education and collaboration. We implemented a novel interprofessional collaborative pilot exercise to explore the feasibility and usefulness of an Asset Inventory-using KJ methodology and an appreciative inquiry perspective-to identify and better understand intangible assets and their value in interprofessional healthcare education/training organizations, for planning, and as a first step toward informing strategic decision-making. Twenty-eight faculty physicians, nurses, psychosocial and family faculty, educators, health services researchers and administrative staff participated. Participants identified intangible assets in five categories: Philosophy/Mission, Practice/Practical Strategies, Human Capital, Scholarship/Research Productivity, and Partnerships. Participants reported a greater understanding of intangible assets, and increased enthusiasm, organizational confidence, and stakeholder ownership for healthcare education programs. While this study is preliminary, the Asset Inventory may prove useful to enhance understanding of the importance of intangible assets within interprofessional healthcare education/training organizations, to inform planning and decision-making, to identify and foster interprofessional collaborative capacity across clinical and training settings, and to leverage intangible assets in today's rapidly changing business-focused healthcare systems.

This special report is published in commemoration of the fiftieth anniversary of the "Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death," a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of the organism to maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades.

Objectives To examine the circumstance of death in the PICU in the setting of ongoing curative or life-prolonging goals. Data sources Multidisciplinary author group, international expert opinion, and use of current literature. Data synthesis We describe three common clinical scenarios when curative or life-prolonging goals of care are pursued despite a high likelihood of death. We explore the challenges to providing high-quality end-of-life care in this setting. We describe possible perspectives of families and ICU clinicians facing these circumstances to aid in our understanding of these complex deaths. Finally, we offer suggestions of how PICU clinicians might improve the care of children at the end of life in this setting. Conclusions Merging curative interventions and optimal end-of-life care is possible, important, and can be enabled when clinicians use creativity, explore possibilities, remain open minded, and maintain flexibility in the provision of critical care medicine. When faced with real and perceived barriers in providing optimal end-of-life care, particularly when curative goals of care are prioritized despite a very poor prognosis, tensions and conflict may arise. Through an intentional exploration of self and others' perspectives, values, and goals, and working toward finding commonality in order to align with each other, conflict in end-of-life care may lessen, allowing the central focus to remain on providing optimal support for the dying child and their family.

Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.

Debate about the concept of medical futility is often polarized around two views. One is that futility is simply an acknowledgment of the limitations of modern medicine, a corollary of the fact of human mortality. The other is that futility is a judgment that is always grounded in a particular set of values, and that medical professionals have no right to impose their value judgments on patients and families who do not share their perspective. This essay argues that these dichotomous views can be reconciled by appreciating the importance of the context in which the dialogue occurs. When clinicians and families are working collaboratively in a process of shared decision-making, use of the concept of futility in the former sense can be an effective way of capturing the limits of medicine. When communication and trust have broken down and the parties are engaged in a process of conflict resolution, the latter interpretation of futility is necessary in order to demonstrate respect for those who embrace a different set of values and perspectives.

In this paper, we argue that a defence of the moral equivalence of withholding and withdrawing life-sustaining treatment (LST) would be more difficult if withdrawing life-sustaining treatment is considered to be a form of killing rather than letting die. Dominic Wilkinson and Julian Savulescu have defended the equivalence thesis (the moral equivalence of withholding and withdrawing LST) in a number of papers. But Savulescu has also claimed that withdrawing life-sustaining treatment is killing. We argue that if Savulescu is right about this, then he and his co-authors face a very significant hurdle in defending the equivalence thesis, because they would need to argue for the very controversial view that killing and letting die are morally equivalent. After decades of debate, however, there is no consensus on this issue. Fortunately, there is a different option. We should simply reject the claim that withdrawing LST is a form of killing. If we reject this claim, it is far easier to defend the claim that withholding and withdrawing LST are morally equivalent, because we would then only need to claim that different forms of letting die are morally equivalent, rather than claim that killing and letting die are morally equivalent. Savulescu and colleagues should therefore drop the claim that withdrawing LST is a form of killing.

Health implications of politically charged phenomena are particularly difficult for physicians to discuss with their patients and communities. Addressing climate change and its associated health effects involves trade-offs between health and economic prosperity, necessitating that physicians weigh the potential benefits and risks of discussing climate change health effects. We argue that the potential benefits of physician communication and advocacy ultimately outweigh the potential risks. Therefore, physicians should be supported in their efforts to educate their patients and communities about climate change health effects. Furthermore, democratic deliberation could prove helpful in addressing disagreements among physicians within a practice about such politicized health topics.

Distinguishing between disorders of consciousness, particularly between the vegetative state/unresponsive wakefulness syndrome (VS/UWS) and the minimally conscious state (MCS), has been a growing c...

The concepts of medical futility and rationing are often misunderstood and lead to significant consternation when resources are stretched and pediatric intensive care unit (PICU) beds are unavailable. While the two concepts overlap, each has its own distinct application and moral justification. Most importantly, we should avoid using one to justify the other. Bioethics professionals should assist critical care clinicians in clarifying when each rubric should be applied as well as how to develop policies to standardize the approach.

Voluntary Euthanasia Canada now permits physicians to hasten the death of a patient by means of physician-assisted suicide or voluntary euthanasia. This development creates a new pathway for organ ...

Two thinkers have crafted visions of how they believe health-care resources ought to be allocated if there were universal health-care coverage in the United States. One is The Ends of Human Life (1994), in which Ezekiel Emanuel proposes to base resource allocation on community preferences. More recently, Charlene Galarneau has written Communities of Health Care Justice (2016), partly in response to Emanuel's earlier work. Both thinkers center their visions of just health care on communities, albeit differently structured from one another. This essay examines the similarities and differences in their proposals for resource allocation and addresses questions that arise from their proposals, such as: What are the advantages of their community-based approaches compared with more universal, nationalized options? What might prevent communities from excluding certain individuals from active participation? And finally, does positing active engagement in a community, all by itself, guarantee that justice and fairness will be served? The essay concludes that although community allocation of health services has some desirable elements, allocating resources in a centralized, national manner would be more efficient, practical, and more likely to prevent bias and discrimination against those at the margins of their communities.

Historically, the practice of medicine has been a physically intimate endeavor. Physicians have used their hands to palpate and reveal the secrets hidden within the body. Smelling the breath for the ketosis of diabetes or tasting the skin for the saltiness of cystic fibrosis were among the physician's essential practices. Today, perhaps the most defining characteristic of a brilliant clinician is the ability to synthesize many images-from electrocardiograms, ultrasounds, CT scans, and so forth-into a coherent picture that can guide our diagnosis and treatment. Yet this is rapidly becoming a Sisyphean task. Just as we are about to drown in a deluge of data, AI is throwing us a life preserver, to save not only our patients but ourselves. But where will AI take us?

OBJECTIVES: There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.DATA SOURCES: We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.STUDY SELECTION: Three authors screened titles and abstracts in duplicate.DATA SYNTHESIS: Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.CONCLUSIONS: Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

Trustworthiness before Trust If Black communities are to participate in Covid-19 trials, clinicians, investigators, and pharmaceutical companies must provide convincing evidence — sufficient to ove...

In this issue of JAMA, contributors to the World Brain Death Project present an international consensus report on criteria for the diagnosis of brain death, or

Jahi McMath's case has raised challenging uncertainties about one of the most profound existential questions that we can ask: how do we know whether someone is alive or dead? The case is striking in at least two ways. First, how can it be that a person diagnosed as dead by qualified physicians continued to live, at least in a biological sense, more than four years after a death certificate was issued? Second, the diagnosis of brain death has been considered irreversible; in fact, there has never been a case of a person correctly diagnosed as brain-dead who improved to the point that the person no longer fulfilled the diagnostic criteria. If the neurologist Alan Shewmon is correct that, prior to her cardiac arrest in June 2018, McMath no longer met the criteria for brain death and was actually in a minimally conscious state, this case could have momentous implications for how we think about this diagnosis going forward. In this essay, I will offer a hypothesis that could, perhaps, explain both these aspects of the case. The hypothesis is based on differences in how we distinguish between biological and legal categories. The law tends to prefer to draw bright-line distinctions between categories, whereas biological categories tend to fall along a spectrum, without sharp distinctions.