How Jahi McMath's Case Exposed the Limits of Brain Death

Before ventilators and heart-lung machines, death was straightforward. A heart stopped, breathing ceased, and a body eventually began to decompose. Physicians in earlier centuries had crude but telling ways of confirming it: a cloth held to the mouth and nose to check for movement, or, in the case of medieval popes, a small hammer tapped against the head to see whether anyone woke up.

Mechanical ventilation changed the calculation. In this episode of Medical Ethics Unpacked, Arthur Caplan, PhD, founding head of the Division of Medical Ethics at NYU Langone Medical Center, joins Dominic Sisti, PhD, of Penn Medicine, and Steve Levine, MD, of Compass Pathways, to trace how brain death became a legal and medical category and why the debate over its boundaries has never really settled.1 The conversation builds on ground the trio covered in an earlier episode on the ethics of organ transplantation, where cardiac death and circulatory-death donation first came up.2

From Ventilators to a New Definition of Death

By the mid-20th century, physicians faced a problem that earlier generations never had to solve. Heart-lung machines and ventilators could keep a body's heart beating and lungs cycling long after the brain had stopped functioning, and no one was sure whether switching off that support amounted to homicide.

Caplan described the moment as a convergence of 3 separate pressures: new life-support technology, an absence of any clear line between coma and death, and the emerging field of organ transplantation, which had no legal definition of a deceased donor to work from. Physicians needed rules, and until the 1960s and 1970s, they largely had none.

Caplan pointed to Willard Gaylin's 1974 Harper's essay, “Harvesting the Dead,” as an early and provocative attempt to grapple with what medicine's growing power over the dying body might mean.3 Gaylin envisioned a future in which comatose bodies, kept alive on machines, could be maintained for research and drug testing. Sisti and Caplan agreed the Gaylin piece functioned less as a policy proposal than as a warning about where the technology could lead if left unchecked.

Why Death Diagnosis Is Partly a Social Convention

Caplan argued that the moment of death has never been a purely biological line, even before ventilators complicated things. Different cultures have historically drawn that line in different places, from waiting for ancestors to gather before declaring a soul departed to treating a beating heart, even one sustained mechanically, as proof of life.

Modern technology added a new twist: physicians could now sustain a body's appearance of life well past the point at which recovery was possible. Caplan noted that brain-dead pregnant patients have carried fetuses to viable delivery for months, demonstrating how far organ support can extend physiological function even after death has been declared.

"We could fool death a little bit," Caplan said.

The Case of Jahi McMath: Staying on Ventilator for 5 Years

Sisti brought the conversation to Jahi McMath, a 13-year-old girl declared brain dead in December 2013 following complications from a routine tonsillectomy at Children's Hospital Oakland.4 Her family disputed the diagnosis and, with legal help, arranged to have her transferred out of California.

New Jersey is the only state that allows individuals or families to opt out of neurologic criteria for death in favor of cardiopulmonary criteria on religious or moral grounds. McMath's family used that provision to have her moved to a facility there, where she remained on a ventilator for nearly 5 years and, according to later reports, underwent physical changes consistent with puberty before her eventual cardiac death.

Caplan and Sisti differed slightly on how to characterize what followed. Caplan described the years of continued support as, in his view, difficult to reconcile with a body that had already met accepted brain death criteria, while Sisti pointed to cultural and philosophical traditions, citing Japan as an example, where brain death is not universally accepted as equivalent to biological death.

Both agreed the case exposed a genuine tension in the current standard, which is built around permanent loss of the brain's integrated, whole-function capacity rather than the complete absence of any cellular activity. Caplan maintained that isolated hormonal or cellular activity, such as the thymic function that may explain McMath's continued development, does not equate to the organized, integrated brain function the diagnosis is meant to rule out.

Where the Brain Death Debate Goes From Here

The conversation turned to persistent vegetative state and whether it should ever be treated as equivalent to death for purposes of organ donation. Caplan noted that courts have long permitted withdrawal of feeding tubes and other support in PVS cases, as in Nancy Cruzan's, without ever classifying those patients as dead, and he was cautious about collapsing that distinction further.

He was more direct about diagnostic technology. Caplan suggested that advances such as more accessible functional imaging could eventually sharpen the brain death exam, much as the stethoscope and mirror once replaced the Pope's hammer and cloth.

The episode also discussed the growth of "neomort" or bio-emporium programs, in which patients who wanted to be organ donors but were medically ineligible can, with family agreement, have their bodies maintained briefly after death for research purposes such as testing artificial organs or immunosuppressive drugs. Caplan said he helped establish such a program decades after first encountering the idea in Gaylin's essay and argued the practice should eventually be formalized in advance directives rather than left to ad hoc family consent.

Bottom Line

Brain death remains legally settled but philosophically unresolved, built on a definition that Caplan defends as sound while acknowledging it depends on judgment calls that have shifted with technology since the 1960s. The Jahi McMath case, and the slow institutional response it prompted, illustrates how bioethics debates can take decades to reshape practice even after the underlying questions are raised.

“This field of death, definition of death, [and] understanding [of] brain death [has] a powerful influence,” Caplan said. “It’s been slow, but of course it would be slow, because people are very nervous.”

Check out the recent episode of Medical Ethics Unpacked on brain death here: Medical Ethics Unpacked: The History and Ethics of Brain Death

Editor’s note: Reported disclosures include Janssen Pharmaceuticals for Levine. Sisti and Caplan have no reported disclosures.

References

1. Levine S and Sisti D. Medical Ethics Unpacked: The History and Ethics of Brain Death. HCPLive. Published on July 9, 2026. Accessed July 9, 2026. https://www.hcplive.com/view/medical-ethics-unpacked-history-ethics-brain-death

2. Levine S and Sisti D. Medical Ethics Unpacked: Ethical Issues in Organ Transplantation. HCPLive. Published on October 2, 2025. Accessed July 9, 2026. https://www.hcplive.com/view/medical-ethics-unpacked-the-rushed-rash-donor-transplantations

3. Gaylin W. Harvesting the dead. Harper's Magazine. September 1974

4. Shewmon DA, Salamon N. The Extraordinary Case of Jahi McMath. Perspect Biol Med. 2021;64(4):457-478. doi:10.1353/pbm.2021.0036