Brain Death

In modern hospitals in developed countries, deaths are determined usually after a prearranged schedule of resuscitative efforts. By default, death is diagnosed and determined after “full code” or after the failure of intensive resuscitation. In end-of-life contexts, however, various degrees of less-than-full resuscitation and sometimes no resuscitation are allowed after the consent and shared decision-making of the patient and/or surrogates. The determination of brain death is a unique exception in these contexts because such an end-of-life care plan is usually not (...) offered until after brain death is declared. This essay analyzes and critiques three arguments for denying the family and/or surrogate a chance to consent to or forego the diagnostic protocol of brain death and choose an alternative end-of-life plan. First, opponents of consent for the determination of brain death argue that presenting it as a selectable end-of-life plan undermines the integrity of death determination. The second argument is that it is inconsistent to allow foregoing the determination of brain death when the determination of circulatory death is non-negotiable. The third argument is that allowing the patient/surrogate to forego the determination of brain death would jeopardize the fair and appropriate utilization of intensive care resources and potentially reduce organ donor pools. After closer conceptual examinations of these three arguments, this essay concludes that these arguments are conceptually and morally problematic. It defends an alternative patient-centered end-of-life care plan based on consent and shared decision-making. (shrink)

Is it possible to donate unpaired vital organs, foreseeing but not intending one's own death? We argue that this is indeed psychologically possible, and thus far agree with Charles Camosy and Joseph Vukov in their recent paper on 'double effect donation.' Where we disagree with these authors is that we see double effect donation not as a morally praiseworthy act akin to martyrdom but as a morally impermissible act that necessarily disrespects human bodily integrity. Respect for bodily integrity goes beyond (...) avoiding the aim to kill: not all side effects of deliberate bodily interventions can be outweighed by intended benefits for another even if the subject fully consents. It is not any necessary intention to kill or harm another or oneself that makes lethal donation/harvesting illicit but the more immediate intention to accept or perform surgery on an (innocent) person combined with the foresight of lethal harm and no health-related good for him or her. Double effect donation falls foul of the first condition of double effect reasoning in that the immediate act is wrong in itself. We argue further that the wider effects of such donation would be socially disastrous and corrupting of the medical profession: doctors should retain a sense of nonnegotiable respect for bodily integrity even when they intervene on willing subjects for the benefit of others. (shrink)

Authors: Joseph M. Eble, John A. Di Camillo, Peter J. Colosi. --- NEWS RELEASE For Immediate Release February 27, 2024 Contact: Joseph M. Eble, MD Corresponding author 919-667-5206 -/- The statement, Catholics United on Brain Death and Organ Donation: A Call to Action (HTML), was published on February 27, 2024. It was prepared by Joseph Eble, a physician and President of the Tulsa Guild of the Catholic Medical Association; John Di Camillo, an ethicist of The National Catholic Bioethics Center; and (...) Peter Colosi, a philosophy professor at Salve Regina University. -/- Catholic United explains that the criteria for brain death establish only partial loss of brain function. This is now abundantly clear based on scientific studies, a recent effort to lower the legal standard for death, and updated brain death guidelines issued in October 2023. -/- Catholics United bridges a divide among faithful Catholics about whether the concept of brain death aligns with Church teaching. Some Catholics hold that brain death represents true death when there is complete and irreversible cessation of all brain activity, often called whole brain death. Others hold that brain death does not represent true death. Since the existing criteria establish only partial loss of brain function, all the endorsers—whether they accept or reject whole brain death as true death—agree that “the current brain death criteria in widespread use do not provide moral (prudential) certainty of death.” -/- Catholics United calls on health care professionals and institutions to cease organ harvesting that relies on the inadequate criteria, noting that 70% of all donors are declared dead using brain death criteria. “Given the lack of moral certainty of death whenever the current brain death criteria are used,” the statement affirms, “a clear majority of vital organ donors can be presumed alive at the time of organ harvesting.” Since the Catholic Church forbids removing vital organs when this would kill the patient, “it is therefore wrong to remove organs from patients declared dead using these inadequate criteria.” . (shrink)

There are currently two legally established criteria for death: the irreversible cessation of circulation and respiration and the irreversible cessation of neurologic function. Recently, there have been technological developments that could undermine the irreversibility requirement. In this paper, I focus both on whether death should be identified as an irreversible state and on the proper scope of irreversibility in the biological definition of death. In this paper, I tackle the distinction between the commonsense definition of death and the biological definition (...) of death to show that even the commonsense concept of death is specified by biological facts. Resting on this argument, I argue that any definition of death is a posteriori. Thus, irreversibility is part of any definition of death because the actual phenomenon of death is irreversible. In addition, I show that the proper domain of irreversibility in a definition of death is circumscribed by physical possibilities and that irreversibility in the definition of death refers to current possibilities for the reversal of relevant biological processes. I conclude that, despite recent technological advancements, death is still irreversible. (shrink)

The classification of preserved hypothalamic activity in brain death and brainstem death as functional or non-functional has become a subject of debate. While proponents of the neurological criterion claim that these activities lack functional significance (Shemie et al. 2014), Nair-Collins and Joffe (2023) argue for their functional physiological role. However, the interpretation of the term "function" within the medico-legal framework, where death is characterized by the irreversible cessation of all brain functions, remains unclear. -/- My intention here is not to (...) engage in a debate over the validity of different viewpoints regarding the functional significance of preserved activities in the hypothalamus or the heart. Rather, I aim to highlight the critical importance of exploring and defining the concept of function in medicine, which currently lacks clarity. My point is that, whatever our position in the brain death debate, reaching a consensus on this conceptual matter would minimize misunderstandings and establish a robust foundation for further insightful analysis. (shrink)

The Uniform Determination of Death Act (UDDA) provides that “an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.” We show that the UDDA contains two conflicting interpretations of the phrase “cessation of functions.” By one interpretation, what matters for the determination of death is the cessation of spontaneous functions only, regardless of their generation by artificial means. By the (...) other, what matters is the cessation of both spontaneous and artificially supported functions. Because each UDDA criterion uses a different interpretation, the law is conceptually inconsistent. A single consistent interpretation would lead to the conclusion that conscious individuals whose respiratory and circulatory functions are artificially supported are actually dead, or that individuals whose brain is entirely and irreversibly destroyed may be alive. We explore solutions to mitigate the inconsistency. (shrink)

50 years after its introduction, brain death remains controversial among scholars. The debates focus on one question: is brain death a good criterion for determining death? This question has been answered from various perspectives: medical, metaphysical, ethical, and legal or political. Most authors either defend the criterion as it is, propose some minor or major revisions, or advocate abandoning it and finding better solutions to the problems that brain death was intended to solve when it was introduced. Here I plead (...) for a different approach that has been overlooked in the literature: the philosophy of science approach. Some scholars claim that human death is a matter of fact, a biological phenomenon whose occurrence can be determined empirically, based on science. We should take this claim seriously, whether we agree with it or not. The question is: how do we know that human death is a scientific matter of fact? Taking the philosophy of science approach means, among other things, examining how the determination of human death became an object of scientific inquiry, exploring the nature of the brain death criterion itself, and analysing the meaning of its core concepts such as “irreversibility” and “functions”. (shrink)

Laura Specker Sullivan (2022) makes a fairly compelling case for the value of the perspectives of Buddhist practitioners in neuroethics. In this study, Tibetan Buddhist monks have been asked, among other things, whether consciousness, in brain-injured patients in a minimally conscious state, entails a duty to preserve life. In our view, some of the participants’ responses could be used to inform the bioethical debate on death determination.

A defense of the view that (i) to be alive is to be actively undergoing (not merely capable of undergoing) certain vital processes, that (ii) to die is cease to be capable of undergoing those processes (not to cease undergoing them), and that (iii) organisms in cryptobiosis (suspended animation) are not undergoing those processes but are capable of doing so, and are neither alive nor dead.

The biophilosophic justification for the idea that “brain death” is death needs to support two claims: that what dies in human death is a human organism, not merely a psychological entity distinct from it; that total brain failure signifies the end of the human organism as a whole. Defenders of brain death typically assume without argument that the first claim is true and argue for the second by defending the “integrative unity” rationale. Yet the integrative unity rationale has fallen on (...) hard times. In this article, I give reasons for why we should think of ourselves as organisms, and why the “fundamental work” rationale put forward by the 2008 President’s Council is better than the integrative unity rationale, despite persistent objections to it. (shrink)

In 1959 two French neurologists, Pierre Mollaret and Maurice Goullon, coined the term coma dépassé to designate a state beyond coma. In this state, patients are not only permanently unconscious; they lack the endogenous drive to breathe, as well as brainstem reflexes, indicating that most of their brain has ceased to function. Although legally recognized in many countries as a criterion for death, brain death has not been universally accepted by bioethicists, by the medical community, or by the public. I (...) this paper, I defend brain death as a biological concept. I challenge two assumptions in the brain death literature that have shaped the debate and have stood in the way of an argument for brain death as biological. First, I challenge the dualism established in the debate between the body and the brain. Second, I contest the emphasis on consciousness, which prevents the inclusion of psychological phenomena into a biological criterion of death. I propose that the term organism should apply both to the functioning of the body and the brain. I argue that the cessation of the organism as a whole should take into account three elements of integrated function. Those three elements are: 1) the loss of integrated bodily function; 2) the loss of psychophysical integration required for processing of external stimuli and those required for behavior; and, 3) the loss of integrated psychological function, such as memory, learning, attention, and so forth. The loss of those three elements of integrated function is death. (shrink)

Bioethics, neuroscience, medicine are contributing to a debate on the definition and criteria of death. This topic is very controversial, and it demonstrates clashing views on the meaning of human life and death. Official medical and legal positions agree upon a biological definition of death as irreversible cessation of integrated functioning of the organism as a whole, and whole-brain criterion to ascertain death. These positions have to face many criticisms: some scholars speak of logical and practical inconsistency, some others of (...) invalid scientific theory about the supreme integrator. In this paper some criticisms are exposed and discussed in order to reconstruct the state of the art in bioethical debate. -/- . (shrink)

In this issue of the Report, James L. Bernat proposes an innovative and sophisticated distinction to justify the introduction of permanent cessation as a valid substitute standard for irreversible cessation in death determination. He differentiates two approaches to conceptualizing and determining death: the biological concept and the prevailing medical practice standard. While irreversibility is required by the biological concept, the weaker criterion of permanence, he claims, has always sufficed in the accepted standard medical practice to declare death. Bernat argues that (...) the medical practice standard may be acceptable on the ground that proving circulatory or brain permanence is sufficient to assure complete accuracy for death diagnosis. -/- The topic requires public deliberation: processes to survey people's opinions and mechanisms to channel their opinions into policy-making. What is at stake is the nature of our society. Do we want an expertocracy, in which an enlightened few design policies for the greater good of the majority and exploit the lack of public knowledge to achieve compliance? (shrink)

A brain death case is presented and reinterpreted using the narrative approach. In the case, two Japanese parents face a dilemma about whether to respect their daughter’s desire to donate organs even though, for them, it would mean literally killing their daughter. We argue that the ethical dilemma occurred because the parents were confronted with two conflicting narratives to which they felt a “narrative responsibility,” namely, the responsibility that drives us to tell, retell, and coauthor the (often unfinished) narratives of (...) loved ones. We suggest that moral dilemmas arise not only from conflicts between moral justifications but also from conflicts between narratives and human relationships. (shrink)

The dead donor rule justifies current practice in organ procurement for transplantation and states that organ donors must be dead prior to donation. The majority of organ donors are diagnosed as having suffered brain death and hence are declared dead by neurological criteria. However, a significant amount of unrest in both the philosophical and the medical literature has surfaced since this practice began forty years ago. I argue that, first, declaring death by neurological criteria is both unreliable and unjustified but (...) further, the ethical principles which themselves justify the dead donor rule are better served by abandoning that rule and instead allowing individuals who have suffered severe and irreversible brain damage to become organ donors, even though they are not yet dead and even though the removal of their organs would be the proximal cause of death. (shrink)

In this paper, I would like to argue that brain-dead small children have a natural right not to be invaded by other people even if their organs can save the lives of other suffering patients. My basic idea is that growing human beings have the right to grow in the form of wholeness, and dying human beings also have the right to die in the form of wholeness; in other words, they have the right to be protected from outside invasion, (...) unless they have declared their wish to abandon that right beforehand. I call this the principle of wholeness. Natural rights, which were discussed by Hobbes and Locke in the 17th century, have to be extended to include the right to grow and die in the form of wholeness in the age of scientific civilization, where peripheral human lives are being threatened by aggressive biomedicine and other advanced technologies. (shrink)

In Chapter 1 I discuss the basic problem which made me undertake the issue of human death. That problem was the dualism in the depiction of human nature which has not been fully overcome yet, the dualism which leads to the emergence of new difficulties in contemporary attempts at adequately solving the problem of human death. They include the separation of soul from the body in the moment of death, and the borderline between the moment of death and the moment (...) of resurrection. Chapter 2 is devoted to the presentation of a new anthropological perspective, of an anthropology build “from the bottom up”, that is “from foundations”, and taking into account man’s rooting in the biological environment, and thus also in the genetic heritage taken over from our pre-human ancestors. That anthropology brings new aspects into traditional anthropology by extending it to include new ways of explaining the genesis of the human body and spirit, and new depictions of man’s death. In Chapter 2 I will also present the concept of evolution proposed by P.T. de Chardin, which I appreciate for its comprehensive evolutionary perception of the world. This concept has provoked various responses, but it certainly provides a creative inspiration for further attempts at applying the idea of evolution to various issues. The general framework of the evolutionary model proposed by the French researcher turns out to be useful also when applied to the evolutionary understanding of human death. Chapter 3 contains a discussion of the principal premises of the evolutionary concept of human death taken from analyses carried out by T. Wojciechowski concerning the issue of time, space, and the structure of variable material beings. A being is variable because it has a temporal structure, and the changes that occur are the derivatives of that structure. The temporal structure may be seen as endless, in which a being, even though its existence had a beginning, will exist for ever. Material substance should not be seen statically, but in dynamic and evolutionary terms. In evolution, time becomes a driver of development, an element shaping and directing the evolution of the entire cosmos. Man’s substance has been made capable of two levels of being and acting: the spatial and temporal level, and the endless and immanent level. Together, they form the one essence of man. Thus, the human person is partially immersed in the material cosmos, and partially elevated above it. Chapter 4 presents the evolutionary approach to the moment of man’s death. The views of T. Wojciechowski will be presented in which the moment of death is seen as a moment of transformation and perfection of the structure of the essence of human existence. Furthermore, the issue of the relationship existing, according to T. Wojciechowski, between man’s death and resurrection will be discussed. Understood in evolutionary terms, the moment of death is the time when the structure of human existence is transformed. Death transfers man fully into eternity and enables his life on a higher level of existential being. The element of flesh is retained, but changes its nature. Such view of death allows it to be understood as the moment of resurrection and the culmination of the evolutionary process of life. Death is therefore an “invention” of the evolution and should be seen as a natural and positive phenomenon. At this point, I also propose a solution to the question about reconciliation between temporal and endless existence. In Chapter 5 I take up the issue of consequences flowing from the postulated understanding of human death. They have been pointed to by T. Wojciechowski, but need to be further developed and clarified. He believed two lines in man’s development need to be recognized: that of natural and that of supernatural evolution. Both have the same direction, while occurring on different planes. In each of these lines, death is a natural element of life, pre-planned and, so to say, “encoded” in the cosmic matter. Therefore, the treatment of biological death as the consequence of sin is not only contrary to the evolutionary understanding of life, but in addition artificially combines that which is natural with that which is supernatural. Man’s authentic experience of his own present is a condition of his achieving full existential perfection in the moment of this death. Full engagement in the present is, in a way, a harbinger of the future; thus, the life “here” and “there” may not be inherently inconsistent. In the light of the evolutionary concept, death is not a punishment, but the most positive experience of man’s life in that it enables him to achieve full existential perfection. Chapter 6 is devoted to a substantiation of the possibility of evolutionary transformation of the structure of human existence in the moment of death. An adequate cause needs to be identified which could substantiate that transformation and achievement of perfection. I believe an appropriate substantiation can be found in God’s creative act, interpreted in evolutionary terms. The process of evolution, with its subsequent stages, is only a necessary condition for that “transformation” and “elevation”. The sufficient condition is fulfilled by the continuous creative intervention of God. The concept of God’s creative activity in the moment of man’s death finds its continuation in Chapter 7, where I present a detailed analysis of God’s activity at the time of man’s death. The concept of God’s creative activity extended over the entire process of evolution makes it possible to consider the moment of death as the moment of man’s resurrection. The moment of death is thus a moment of creation in evolutionary terms. Thus, as long as man is related to temporal and spatial elements, his development, or creation, continues. Death is only the completion of the final stage of creation, which may be painful and evoke fear, but in fact should give hope, for it involves resurrection. I also propose that the creative act in the moment of man’s death-resurrection be considered a basic action of God, which explains the manner in which God’s activity is contained within the framework of the creative act, encompassing also the moment of death-resurrection. The final Chapter 8 describes a didactic model illustrating the concept proposed here. I use the analogy of white light dispersion effect in the prism, and compare the incident ray to the creative act, and the dispersed rays going through the prism to the line of man’s natural and supernatural evolution. This model also shows the difference in the perspectives from which the phenomenon of death is seen by God and by man. (shrink)

Alireza Bagheri supports a policy on organ procurement where individuals could choose their own definition of death between two or more socially accepted alternatives. First, we claim that such a policy, without any criterion to distinguish accepted from acceptable definitions, easily leads to the slippery slope that Bagheri tries to avoid. Second, we suggest that a public discussion about the circumstances under which the dead donor rule could be violated is more productive of social trust than constantly moving the line (...) between life and death. (shrink)

I criteri neurologici per accertare il decesso, da impiegare in alternativa a quelli cardiorespiratori se il paziente ha subìto lesioni cerebrali e si trova collegato alle apparecchiature per la ventilazione artificiale, sono entrati nell’uso comune della pratica medica occidentale da circa quarant’anni ed il consenso di cui essi godono nella comunità scientifica sembra, a prima vista, essere ancora oggi molto solido. Si diceva a prima vista, perché se si esamina con attenzione la letteratura dal 1992 ad oggi, si possono scoprire (...) i crescenti numeri del dissenso: ripensamenti e critiche provengono soprattutto da esperti di area medico-biologica, che associano le loro voci a quelle di filosofi, teologi, studiosi di etica. I motivi del dissenso sono molteplici, e l’ampia letteratura che li documenta riguarda la teoria scientifica posta a fondamento dei criteri neurologici, ed evidenzia le contraddizioni, teoriche ed applicative, derivanti dall’uso di quei criteri. (shrink)

Since 1968, the irreversible loss of functioning of the whole brain, called brain death, is assimilated to individual’s death. The almost universal acceptance of this neurological criterion of death had decisive consequences for the contemporary medicine, such as the withdrawal of mechanical ventilation in these patients and organ retrieval for transplantation. The new criterion was successfully accepted in part because the assimilation of brain death state to death was presented by medicine --and acritically assumed by most of societies-- as a (...) scientific and objective fact. Nevertheless, many people do not think that the patients suffering brain death are actually dead. We show here that those people are not necessarily wrong. It can be argued that, in fact, the justification of the neurological criterion is not scientific but moral. We outline the thesis that the problem surrounding the vital status of brain dead patients is due to a confusion between factual and normative questions. Furthermore, we claim that the donation of organs and the withdrawal of life-support could be ethically acceptable even if the patients suffering brain death are considered as alive. As an alternative to the dead donor rule, we propose a justification for organ donation of brain-dead patients based on the (moral) concepts of harm and consent : what truly justifies the procurement of organs on those patients is not that they are dead, but that they wish to donate their organs and that, since they have irreversibly lost their brain, they cannot be harmed. (shrink)

Alongside a revival of interest in Thomism in philosophy, scholars have realised its relevance when addressing certain contemporary issues in bioethics. This book offers a rigorous interpretation of Aquinas's metaphysics and ethical thought, and highlights its significance to questions in bioethics. Jason T. Eberl applies Aquinas’s views on the seminal topics of human nature and morality to key questions in bioethics at the margins of human life – questions which are currently contested in the academia, politics and the media such (...) as: When does a human person’s life begin? How should we define and clinically determine a person’s death? Is abortion ever morally permissible? How should we resolve the conflict between the potential benefits of embryonic stem cell research and the lives of human embryos? Does cloning involve a misuse of human ingenuity and technology? What forms of treatment are appropriate for irreversibly comatose patients? How should we care for patients who experience unbearable suffering as they approach the end of life? _Thomistic Principles and Bioethics_ presents a significant philosophical viewpoint which will motivate further dialogue amongst religious and secular arenas of inquiry concerning such complex issues of both individual and public concern. (shrink)

When I was fifteen, I was having serious doubts about the existence of a supernatural entity benevolently looking over me, and—perhaps even more disturbingly—about the possibility of an afterlife in which I would again see my friends and relatives and exist happily ever after. It was at that point that I started reading the writings of Bertrand Russell,1,2 one of the most controversial philosophers and political activists of the Twentieth century.

The Japanese Transplantation Law is unique among others in that it allows us to choose between "brain death" and "traditional death" as our death. In every country 20 to 40 % of the popularion doubts the idea of brain death. This paper reconsiders the concept, and reports the ongoing rivision process of the current law. Published in Hastings Center Report, 2001.

We give a mechanism for how awareness could (indeed *must*) continue after death.