A growing number of medical professionals claim a right of conscience, a right to refuse to perform any professional duty they deem immoral—and to do so with impunity. We argue that professionals do not have the unqualified right of conscience. At most they have a highly qualified right. We focus on the claims of pharmacists, since they are the professionals most commonly claiming this right.

“Death” sits at the center of this issue of the Journal of Medicine and Philosophy. Each article, in its own fashion, touches on the problems of thinking about the nature of death in the light of contemporary scientific and medical advances. Three articles explicitly center on the ongoing debate over the Uniform Determination of Death Act, and three center on thematic issues surrounding death. Despite the topic, the discussion is lively and thoughtful. After introducing each article and sketching their contours, (...) I offer some closing remarks on a central issue dredged up by these articles: the role of evaluative commitments and other interests in selecting criteria for the determination of death. These articles raise interesting questions about the relationship between the nature of “death” and ethical, epistemic, social-political, and economic values. This further opens up interesting lines of inquiry into medical epistemology. Finally, they broach deep questions about the nature of “function” and the relationship between organic and artificially sustained function. (shrink)

In this paper, I introduce the ideas to be discussed in the articles of this journal with reference to an imaginary case involving a pregnant woman declared dead on the basis of neurological criteria. I highlight the fact that although these ideas have proved useful for advancing certain claims in bioethical debates, their implications are not always well understood and may complicate our arguments. The ideas to be discussed are an ethic internal to the profession of medicine; the difference between (...) killing and letting die; the organism as a whole; and the “lives” and interests of the dead. (shrink)

The debate over whether brain death is death has focused on whether individuals who have sustained total brain failure have satisfied the biological definition of death as “the irreversible loss of the integration of the organism as a whole.” In this paper, I argue that what it means for an organism to be integrated “as a whole” is undefined and vague in the views of those who attempt to define death as the irreversible loss of the integration of the organism (...) as a whole. I show how what it means for a living thing to be integrated as a whole depends on the sortal concept by which it is identified. Since interests, values, and ontological considerations besides strictly biological ones affect the concepts by which we individuate and identify living things, those non-biological considerations have a bearing on what it means for a particular kind of living thing to exist as a whole and thus what it means for one of us to die. Even if our bodies may remain organically integrated in some sense despite total brain failure, this fact should not lead us to reject brain death as death. Artificially sustained brain-dead human bodies are not human beings, but the remains of them. While such bodies may be alive in some sense, they are not human beings or human persons. They are not one of us. (shrink)

In debates about criteria for human death, several camps have emerged, the main two focusing on either loss of the "organism as a whole" (the mainstream view) or loss of consciousness or "personhood." Controversies also rage over the proper definition of "irreversible" in criteria for death. The situation is reminiscent of the proverbial blind men palpating an elephant; each describes the creature according to the part he can touch. Similarly, each camp grasps some aspect of the complex reality of death. (...) The personhood camp, in contrast to the mainstream "organism" camp, recognizes that a human organism can still be a biological living whole even without brain function. The mainstream camp, in contrast to the personhood camp, recognizes that a person can be permanently, even irreversibly unconscious, and still be a living person so long as his/her body is alive. The author proposes that hylomorphic dualism incorporates both these key insights. But to complete the picture of the entire "death elephant," a fundamental paradigm shift is needed to make sense of other seemingly conflicting insights. The author proposes a "semantic bisection" of the concept of death, analogous to the traditional distinction at the beginning of life between "conception" and "birth." To avoid the semantic baggage associated with the term "death," the two new death-related concepts are referred to as "passing away" (or "deceased") and "deanimation," corresponding, respectively, to sociolegal ceasing-to-be (mirror image of birth) and ontological/theological ceasing-to-be of the bodily organism (mirror image of conception). Regarding criteria, the distinguishing feature is whether the cessation of function is permanent (passing away) or irreversible (deanimation). If the "dead donor rule" were renamed the "deceased donor rule" (both acronyms felicitously being "DDR"), the ethics of organ transplantation from non–heart-beating donors could, in principle, be validly governed by the DDR, even though the donors are not yet ontologically "deanimated." Thus, the paradigm shift satisfies both those who insist on maintaining the DDR and those who claim that it has all along been receiving only lip service and should be explicitly loosened to include those who are "as good as dead." Even so, a number of practical caveats remain to be worked out for non–heart-beating protocols. (shrink)

Psychological accounts of personal identity claim that the human person is not identical to the human animal. Advocates of such accounts maintain that the definition and criterion of death for a human person should differ from the definition and criterion of death for a human animal. My contention is instead that psychological accounts of personal identity should have human persons dying deaths that are defined biologically, just like the deaths of human animals. Moreover, if brain death is the correct criterion (...) for the death of a human animal, then it is also the correct criterion for the death of a human person. What the nonidentity of persons and animals requires is only that they have distinct criteria for ceasing to exist. (shrink)

Taking the critical turn is one of the main tools of the humanities and inculcates an intellectual discipline that prevents ossification of thinking about issues and of organizational policies in clinical ethics. The articles in this "Clinical Ethics" number of the Journal take the critical turn with respect to cherished ways of thinking in Western clinical ethics, life extension, the clinical determination of death, physicians' duty to treat even at personal risk, clinical ethics at the interface of research ethics, and (...) the pertinence of the Hippocratic Oath to clinical ethics. These articles challenge clinical ethicists to inculcate the intellectual discipline of the critical turn into everyday practice and continuous quality enhancement of clinical ethics. (shrink)

Critics of organ donation after circulatory death (DCD) argue that, even if donors are past the point of autoresuscitation, they have not satisfied the “irreversibility” requirement in the circulatory and respiratory criteria for determining death, since their circulation and respiration could be artificially restored. Thus, removing their vital organs violates the “dead-donor” rule. I defend DCD donation against this criticism. I argue that practical medical-ethical considerations, including respect for do-not-resuscitate orders, support interpreting “irreversibility” to mean permanent cessation of circulation and (...) respiration. Assuming a consciousness-related formulation of human death, I then argue that the loss of circulation and respiration is significant, because it leads to the permanent loss of consciousness and thus to the death of the human person. The DNR request by an organ donor should thus be interpreted to mean “do not restore to consciousness.” Finally, I respond to an objection that if “irreversibility” has a medical-ethical meaning, it would entail the absurd possibility that one of two individuals in the same physical state could be alive and the other dead—an implication that some think is inconsistent with understanding death as an objective biological state of the organism. I argue that advances in medical technology have created phenomena that challenge the assumption that human death can be understood in strictly biological terms. I argue that ethical and ontological considerations about our nature bear on the definition and determination of death and thus on the permissibility of DCD. (shrink)

Death is frequently seen as the ultimate manifestation of materiality. Without denying this materiality, this article will investigate the discursive character of death and its contingent nature, through the lens of Laclau and Mouffe's [. Hegemony and social strategy: Towards a radical democratic politics. London: Verso] discourse theory. First, the core elements of the discourse of death, such as end/cessation/termination, negativity, irreversibility, inescapability, and undesirability, in combination with life as death's constitutive outside, will be analysed, showing the specificity of this (...) discourse of death. The contingency of death is argued further from a more genealogical stance, through the changes over time in the articulation of death and good death. Finally, the political nature of the discourse of death is illustrated by an analysis of end-of-life debates and the struggle between the hospice and the right-to-die social movements over the exact articulation of a good death. The article concludes by pointing to the necessary and constitutive failure of discourse to capture the materiality of death. (shrink)

In response to recent debates on the need to abandon the Dead Donor Rule (DDR) to facilitate vital-organ transplantation, I claim that, through a detailed philosophical analysis of the Uniform Determination of Death Act (UDDA) and the DDR, some acts that seem to violate DDR in fact do not, thus DDR can be upheld. The paper consists of two parts. First, standard apparatuses of the philosophy of language, such as sense, referent, truth condition, and definite description are employed to show (...) that there exists an internally consistent and coherent interpretation of UDDA which resolves the Reduction Problem and the Ambiguity Problem that allegedly threaten the UDDA framework, and as a corollary, the practice of Donation after the Circulatory Determination of Death (DCDD) does not violate DDR. Second, an interpretation of the DDR, termed ‘No Hastening Death Rule’ (NHDR), is formulated so that, given that autonomy and non-maleficence principles are observed, the waiting time for organ procurement can be further shortened without DDR being violated. (shrink)

The basic question concerning the compatibility of donation after circulatory death protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term “death” nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death can (...) be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of “irreversibility” need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty. (shrink)

The basic question concerning the compatibility of donation after circulatory death (DCD) protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term “death” nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death (...) can be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of “irreversibility” need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty. (shrink)

In this paper, I defend brain death as a criterion for determining death against objections raised by Don Marquis, Michael Nair-Collins, Doyen Nguyen, and Laura Specker Sullivan. I argue that any definition of death for beings like us relies on some sortal concept by which we are individuated and identified and that the choice of that concept in a practical context is not determined by strictly biological considerations but involves metaphysical, moral, social, and cultural considerations. This view supports acceptance of (...) a more pluralistic legal definition of death as well as acceptance of brain death as death. (shrink)

In this article, I examine the standard assumption that ethical disagreements on abortion and human embryonic stem cells research are grounded on metaphysical claims that underlie these ethical issues. Contrary to what some philosophers have claimed, I argue that, although the bioethical positions about the human embryo’s moral status are partly grounded on metaphysical claims, incorporating metaphysical arguments in the debates about the ethics of reproduction will not resolve this issue.

This paper investigates contemporary applications of the Aristotelian conception of potentiality in limit cases of life and death arising from developments in modern science in order to argue that in its current usage, the term is often so far from its Aristotelian context that its philosophical rigor and, hence, usefulness is undermined. By analyzing the account of the soul in Aristotle’s De Anima, I argue for the necessity of a conception of nature that can contextualize the relevant sense of potentiality (...) by giving a telos arising from the subject’s nature, which orients that subject’s potentiality. I argue that these contextualizing components of nature and teleology are necessary for using a philosophically rigorous sense of potentiality. I begin by surveying the current use of potentiality to delineate beginning and end-of-life cases in order to show that these various uses are not robust enough to offer answers to the challenging cases of life and death in a non ad hoc way. I then address John Lizza and Joel Feinberg’s suggestions for making the concept of potentiality more robust, namely, a more specified framework of ‘normal’ internal conditions and ‘important’ external conditions to which the subject’s potentialities can be referenced. I argue that the insufficiency of the current uses of potentiality is more specifically due to a lack of an Aristotelian conception of a teleological nature that directs the subject’s potentiality and further that this Aristotelian framework of the subject’s nature can provide an answer to Feinberg and Lizza call for a context of normalcy of internal features and external environment in a more robust way. In the final section, I turn back to the problematic cases of life and death in order to highlight how, given a more specific and robust conception of a teleological nature, my account can offer three suggestions for applying the concept of potentiality. (shrink)