When does a human being cease to exist? For millennia, the answer to this question had remained largely unchanged: death had been diagnosed when heartbeat and breathing were permanently absent. Only comparatively recently, in the 1950s, rapid developments in intensive-care medicine called into question this widely accepted criterion. What had previously been deemed a permanent cessation of vital functions suddenly became reversible. -/- A new criterion of death was needed. It was suggested that the destruction of the brain could indicate (...) the death of the organism in the presence of external life support. Soon the so-called brain death became the new worldwide standard. In recent years, however, doubts about this neurological criterion have been growing. Is brain death really our death? -/- This is the question that this thesis seeks to answer. To this end, we shall connect the medical debate about the definition of death to the philosophical debate about personal identity. While we will find that the destruction of its brain does in fact not correspond to an organism’s death, we shall also ask whether the assumption that we are essentially organisms is correct. May brain death be the ceasing to exist of a different entity? -/- Substituting clinical case reports and considerations about human physiology for the use of thought experiments, the thesis takes a novel and philosophically unconventional approach to the problem of what we essentially are. We shall analyse various pathological conditions and their respective effects on the bodily and mental characteristics of our existence. We will conclude that brain death is indeed our death – but for reasons entirely different from those cited in the original justification of this criterion. (shrink)

Although much has been written on the dead-donor rule in the last twenty-five years, scant attention has been paid to how it should be formulated, what its rationale is, and why it was accepted. The DDR can be formulated in terms of either a Don’t Kill rule or a Death Requirement, the former being historically rooted in absolutist ethics and the latter in a prudential policy aimed at securing trust in the transplant enterprise. I contend that the moral core of (...) the rule is the Don’t Kill rule, not the Death Requirement. This, I show, is how the DDR was understood by the transplanters of the 1960s, who sought to conform their practices to their ethics—unlike today’s critics of the DDR, who rethink their ethics in a question-begging fashion to accommodate their practices. A better discussion of the ethics of killing is needed to move the debate forward. (shrink)

Legally defining “death” in terms of brain death unacceptably obscures a value judgment that not all reasonable people would accept. This is disingenuous, and it results in serious moral flaws in the medical practices surrounding organ donation. Public policy that relies on the whole-brain concept of death is therefore morally flawed and in need of revision.

Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny (...) to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an ‘operational definition’ of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing. (shrink)

The dead donor rule (DDR) originally stated that organ donors must not be killed by and for organ donation. Scholars later added the requirement that vital organs should not be procured before death. Some now argue that the DDR is breached in donation after circulatory determination of death (DCDD) programs. DCDD programs do not breach the original version of the DDR because vital organs are procured only after circulation has ceased permanently as a consequence of withdrawal of life-sustaining therapy. We (...) hold that the original rendition of the DDR banning killing by and for organ donation is the fundamental norm that should be maintained in transplantation ethics. We propose separating the DDR from two other fundamental normative rules: the duties to prevent harm and to obtain informed consent. (shrink)

Objective The President's Council on Bioethics in 2008 reaffirmed the necessity of the dead donor rule and the legitimacy of the current criteria for diagnosing both neurological and cardiac death. In spite of this report, many have continued to express concerns about the ethics of donation after circulatory death, the validity of determining death using neurological criteria and the necessity for maintaining the dead donor rule for organ donation. I analysed the dead donor rule for its effect on the virtuous (...) practice of medicine by physicians caring for potential organ donors.Results The dead donor rule consistently impedes physicians in fulfilling their primary duty to act for the good of their prospective donor patients. This compromises the virtue of fidelity. It also weakens many other virtues necessary for physicians to provide excellent end-of-life care.Conclusions The dead donor rule, while ethically powerful in theory, loses its force during translation to the bedside. This is so because the rule mandates simultaneous life and death within the same body for organ donation, a biological status that is inherently contradictory. The rule should be rejected as an ethical norm governing vital organ transplantation at the end of life. Its elimination will strengthen the doctor–patient relationship and foster trustworthiness in organ procurement. (shrink)

The utilitarian construct of two alternative criteria of human death increases the supply of transplantable organs at the end of life. Neither the neurological criterion (heart-beating donation) nor the circulatory criterion (non-heart-beating donation) is grounded in scientific evidence but based on philosophical reasoning. A utilitarian death definition can have unintended consequences for dying Muslim patients: (1) the expedited process of determining death for retrieval of transplantable organs can lead to diagnostic errors, (2) the equivalence of brain death with human death (...) may be incorrect, and (3) end-of-life religious values and traditional rituals may be sacrificed. Therefore, it is imperative to reevaluate the two different types and criteria of death introduced by the Resolution (Fatwa) of the Council of Islamic Jurisprudence on Resuscitation Apparatus in 1986. Although we recognize that this Fatwa was based on best scientific evidence available at that time, more recent evidence shows that it rests on outdated knowledge and understanding of the phenomenon of human death. We recommend redefining death in Islam to reaffirm the singularity of this biological phenomenon as revealed in the Quran 14 centuries ago. (shrink)

Discrepancies between the Uniform Determination of Death Act (UDDA) and the adult and pediatric diagnostic guidelines for brain death (BD) (the “Guidelines”) have motivated proposals to revise the UDDA. A revision proposed by Lewis, Bonnie and Pope (the RUDDA), has received particular attention, the three novelties of which would be: (1) to specify the Guidelines as the legally recognized “medical standard,” (2) to exclude hypothalamic function from the category of “brain function,” and (3) to authorize physicians to conduct an apnea (...) test without consent and even over a proxy’s objection. One hundred seven experts in medicine, bioethics, philosophy, and law, spanning a wide variety of perspectives, have come together in agreement that while the UDDA needs revision, the RUDDA is not the way to do it. Specifically, (1) the Guidelines have a non-negligible risk of false-positive error, (2) hypothalamic function is more relevant to the organism as a whole than any brainstem reflex, and (3) the apnea test carries a risk of precipitating BD in a non-BD patient, provides no benefit to the patient, does not reliably accomplish its intended purpose, and is not even absolutely necessary for diagnosing BD according to the internal logic of the Guidelines; it should at the very least require informed consent, as do many procedures that are much more beneficial and less risky. Finally, objections to a neurologic criterion of death are not based only on religious belief or ignorance. People have a right to not have a concept of death that experts vigorously debate imposed upon them against their judgment and conscience; any revision of the UDDA should therefore contain an opt-out clause for those who accept only a circulatory-respiratory criterion. (shrink)

(No abstract is available for this citation).

Metaphysics often has an important role in deciding ethical questions. Specifically, in the realm of bioethics, metaphysical questions such as the nature of persons, diseases, and properties in general can be crucial to determining what is right or wrong. In this article, I tie together various metaphysical themes that recur throughout the rest of the issue: rationality as an element of human nature, ontological classifications, and kinds of action. I will explain that each has ethical implications. Actions that contravene reason (...) will be morally problematic, whereas our classification of illnesses will have important implications for how we ought to respond to ill persons. Metaphysical questions appear, or are at least suggested, in each article, pointing to the need for metaphysics in answering bioethical questions. (shrink)

Conceptual clarity is essential when engaging in dialogue to avoid unnecessary disagreement and to promote mutual understanding. In this issue devoted to clinical bioethics, the authors exemplify the virtue of careful conceptual analysis as they explore complex clinical questions regarding the essential nature of medicine, the boundaries of killing and letting die, the meaning of irreversibility in definitions of death, the argument for a right to try experimental medications, the ethical borders in complex medical billing, and the definition and modeling (...) of complex disease states. (shrink)