The full content of Annals is available to subscribers

Subscribe/Learn More  >
On Being a Doctor |

The Man with No Heart

Ari Mosenkis, MD
[+] Article, Author, and Disclosure Information

From University of Pennsylvania School of Medicine, Philadelphia, PA 19104.

Requests for Single Reprints: Ari Mosenkis, MD, University of Pennsylvania School of Medicine, 415 Curie Boulevard—700 CRB, Philadelphia, PA 19104; e-mail, mosenkis@hotmail.com.

Ann Intern Med. 2005;143(12):915. doi:10.7326/0003-4819-143-12-200512200-00011
Text Size: A A A

As I was en route to the parking lot on a cold autumn night, my pager started beeping. I was a new renal fellow on call, and this was an all-too-familiar, yet still unnerving, occurrence. The number to call back was one I didn't recognize: the OR. When I returned the call, I learned that a heart transplant had failed with disastrous complications. The patient was hypotensive and grossly volume overloaded. The transplant team was requesting intraoperative dialysis.





Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
A Straw Man with No Heart
Posted on January 2, 2006
David Goldblatt
University of Rochester (NY; emeritus)
Conflict of Interest: None Declared

TO THE EDITOR: Dr. Mosenkis (1) tells the harrowing story of a man whose newly transplanted heart ceased to function. An extracorporeal membrane oxygenation device (ECMO) provided circulation and oxygenation. The patient awoke from operative anesthesia as a "man with no heart" and remained that way until a second, successful transplant could be performed. "Figuratively," the author says, his courageous patient "did have a heart all along."

Unfortunately, Dr. Mosenkis digresses to a flawed discussion of definitions of death. He states that many persons debate "brainstem death or cardiovascular death. According to proponents of [a brainstem] definition, a person is considered dead when the brainstem dies, even though the most vital of the brainstem functions, breathing, is easily and effectively replicated by a machine." He poses a rhetorical question: might not his patient, by analogy, be considered dead because his "heart and circulatory functions," the traditional criteria by which death is judged to have occurred, ceased for two days, even though his circulation was maintained artificially? Dr. Mosenkis sensibly dismisses the idea: the patient was awake and "by any definition . . . was alive."

In the United Kingdom and some other countries, death is legally defined as irreversible loss of all brainstem functions. Ancillary tests of higher brain function are not required for the diagnosis of brainstem death, "because death of the brainstem is regarded as equating with death." (2) Although "bedside clinical criteria for determining [whole] brain death and brainstem death are identical,"(2) the whole brain definition used in the United States has theoretical and practical advantages. (3) In either way of defining death by cerebral criteria, there must be unresponsive coma without confounding anesthesia, other drug effect, or hypothermia; absence of brainstem reflexes; and apnea. (2-4)

The lost function most relevant to diagnosing death is not breathing or heartbeat; it is consciousness. Irreversible coma is always the diagnostic sine qua non. By limiting his consideration of definitions of death to two functions for which machines can compensate, and bringing his patient into the discussion, Dr. Mosenkis made his man with no heart into a straw man"”a bit of wizardry that even L. Frank Baum did not imagine. David Goldblatt, MD University of Rochester School of Medicine and Dentistry Rochester, NY 14642

Correspondence to 232 East Lake Road, Penn Yan, NY 14527; dgoldblattmd@verizon.net

References 1. Mosenkis A. On Being a Doctor. The Man with No Heart. Ann Intern Med. 2005;143:915. 2. Swash M, Beresford R. Brain death still-unresolved issues worldwide. Neurology 2002;58:9-10. 3. Bernat JL. Ethical Issues in Neurology, Second Edition. Boston: Butterworth-Heinemann 2002:251-252. 4. Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria Neurology 2002;58:20-25

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Topic Collections
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.