Drawing on a recent case report of a pregnant, brain‐dead woman who gave birth to a healthy child after over seven months of intensive care treatment, this essay rejects the established doctrine in medicine that brain death constitutes the biological death of the human being. The essay describes three policy options with respect to determination of death and vital organ transplantation in the case of patients who are irreversibly comatose but remain biologically alive.

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)

Frank Miller and I recently argued that the common assertion that ‘brain dead’ patients merely appear to be alive, though in reality are dead, is false.1 This assertion relies on an inaccurate and overly simplistic understanding of the role of medical technology in the physiology of a ‘brain dead’ patient. In response, Symons and Chua endorsed our conclusions regarding the vital status of the ventilated ‘brain dead’ patient, and then pursued the question: what does this imply if we are to (...) preserve the dead donor rule?2 To their credit, Symons and Chua unflinchingly acknowledge that if we seek to maintain the dead donor rule then we must restrict not expand the donor pool because ‘brain dead’ individuals are still living. This would mean fewer organs, and hence more deaths of those on the waiting list. This is the price of holding to the conviction that doctors must never kill patients in order to procure organs for transplantation. Of course, that has always been the price: the dead donor rule is principally a deontic prohibition, not a consequentialist rule designed to maximise good outcomes. Symons’s and Chua’s view is a valid position in the debate on death and the ethics of vital organ procurement, and …. (shrink)

Several bioethicists have recently discussed the complexity of defining human death, and considered in particular how our definition of death affects our understanding of the ethics of vital organ procurement. In this brief paper, we challenge the mainstream medical definition of human death—namely, that death is equivalent to total brain failure—and argue with Nair-Collins and Miller that integrated biological functions can continue even after total brain failure has occurred. We discuss the implications of Nair-Collins and Miller’s argument and suggest that (...) it may be necessary to look for alternative biological markers that reliably indicate the death of a human being. We reject the suggestion that we should abandon the dead-donor criteria for organ donation. Rather than weaken the ethical standards for vital organ procurement, it may be necessary to make them more demanding. The aim of this paper is not to justify the dead donor rule. Rather, we aim to explore the perspective of those who agree with critiques of the whole brain and cardiopulmonary definitions of death but yet disagree with the proposal that we should abandon the dead-donor rule. We will consider what those who want to retain the dead-donor rule must argue in light of Nair-Collins and Miller’s critique. (shrink)

Fifty years have passed since brain death was first proposed as a criterion of death. Its advocates believe that with the destruction of the brain, integrated functioning ceases irreversibly, somatic unity dissolves, and the organism turns into a corpse. In this article, I put forward two objections against this assertion. First, I draw parallels between brain death and other pathological conditions and argue that whenever one regards the absence or the artificial replacement of a certain function in these pathological conditions (...) as compatible with organismic unity, then one equally ought to tolerate that function’s loss or replacement in brain death. Second, I show that the neurological criterion faces an additional problem that is only coming to light as life-supporting technology improves: the growing sophistication of the latter gives rise to a dangerous decoupling of the actual performance of a vital function from the retention of neurological control over it. Half a century after its introduction, the neurological criterion is facing the same fate as its cardiopulmonary predecessor. (shrink)

The organ transplantation enterprise is morally flawed. “Brain‐dead” donors are the primary source of solid vital organs, and the transplantation enterprise emphasizes that such donors are dead before organs are removed—or in other words that the dead donor rule is followed. However, individuals meeting standard diagnostic criteria for brain death—unresponsiveness, brainstem areflexia, and apnea—are still living, from a physiological perspective. Therefore, removing vital organs from a heart‐beating, mechanically ventilated donor is lethal. But neither donors nor surrogates nor the public in (...) general are typically informed of this obviously relevant information. Therefore, donors or surrogates do not provide valid consent for a lethal medical procedure. This is a serious moral failing on the part of the transplant community. To address this concern, I advocate for accurate and fully transparent communication of information to the public to allow for an informed civic dialogue about the ethics and legality of lethal organ procurement. Furthermore, I advocate that systems be put in place by the transplant community to allow for valid consent for lethal organ procurement. (shrink)

Organ transplantation from living related donors in Bangladesh first began in October 1982, and became commonplace in 1988. Cornea transplantation from posthumous donors began in 1984 and living related liver and bone marrow donor transplantation began in 2010 and 2014 respectively. The Human Organ Transplantation Act officially came into effect in Bangladesh on 13th April 1999, allowing organ donation from both brain-dead and related living donors for transplantation. Before the legislation, religious leaders issued fatwa, or religious rulings, in favor of (...) organ transplantation. The Act was amended by the Parliament on 8th January, 2018 with the changes coming into effect shortly afterwards on 28th January. However, aside from a few posthumous corneal donations, transplantation of vital organs, such as the kidney, liver, heart, pancreas, and other body parts or organs from deceased donors, has remained absent in Bangladesh. The major question addressed in this article is why the transplantation of vital organs from deceased donors is absent in Bangladesh. In addition to the collection of secondary documents, interviews were conducted with senior transplant physicians, patients and their relatives, and the public, to learn about posthumous organ donation for transplantation. Interviews were also conducted with a medical student and two grief counselors to understand the process of counseling the families and obtaining consent to obtain posthumous cornea donations from brain-dead patients. An interview was conducted with a professional anatomist to understand the processes behind body donation for the purposes of medical study and research. Their narrative reveals that transplant physicians may be reticent to declare brain death as the stipulations of the 1999 act were unclear and vague. This study finds that Bangladeshis have strong family ties and experience anxiety around permitting separating body parts of dead relatives for organ donation for transplantation, or donating the dead body for medical study and research purposes. Posthumous organ donation for transplantation is commonly viewed as a wrong deed from a religious point of view. Religious scholars who have been consulted by the government have approved posthumous organ donation for transplantation on the grounds of necessity to save lives even though violating the human body is generally forbidden in Islam. An assessment of the dynamics of biomedicine, religion and culture leads to the conclusion that barriers to posthumous organ donation for transplantation that are perceived to be religious may actually stem from cultural attitudes. The interplay of faith, belief, religion, social norms, rituals and wider cultural attitudes with biomedicine and posthumous organ donation and transplantation is very complex. Although overcoming the barriers to organ donation for transplantation is challenging, initiation of transplantation of vital organs from deceased donors is necessary within Bangladesh. This will ensure improved healthcare outcomes, prevent poor people from being coerced into selling their organs to rich recipients, and protect the solidarity and progeny of Bangladeshi families. (shrink)

Volume 20, Issue 6, June 2020, Page 40-42.

A “universalist” policy on brain death holds that brain death is death, and neurologic criteria for death determination are rightly applied to all, without exemptions or opt outs. This essay argues that advocates of a universalist brain death policy defend the same sort of coercive control of end-of-life decision-making as “pro-life” advocates seek to achieve for reproductive decision-making, and both are grounded in an illiberal political philosophy. Those who recognize the serious flaws of this kind of public policy with respect (...) to abortion must apply the same logic to brain death. (shrink)

This paper provides a new rationale for equating brain death with the death of the human organism, in light of well-known criticisms made by Alan D Shewmon, Franklin Miller and Robert Truog and a number of other writers. We claim that these criticisms can be answered, but only if we accept that we have slightly redefined the concept of death when equating brain death with death simpliciter. Accordingly, much of the paper defends the legitimacy of redefining death against objections, before (...) turning to the specific task of defending a new rationale for equating brain death with death as slightly redefined. (shrink)

With regard to organ donation, Germany is an ‘opt-in’ country, which requires explicit consent from donors. The relatives are either asked to decide on behalf of the donors’ preferences, if these are unknown or if the potential donor has explicitly transferred the decision to them. At the core of this policy lies the sociocultural and moral premise of a rational, autonomous individual, whose rights require legal protection in order to guarantee a voluntary decision. In concrete transplantation practices, the family plays (...) an even more important role. Potential donors and their families decide while being embedded in relations, a point which does still not gain full recognition. This particular discrepancy between policy and practice creates conflicts, which remain taboos of academic inquiry and public discourse. Our analysis shows a plurality of the family’s role in the transplantation process, which reveals an inner tension of the organ donation system. This tension provokes epistemic opacity on the one hand and different collective strategies as responses to discursive exclusion on the other. In future deliberations about organ donation, it is important to create spaces for open discussion, but also practices of communicative engagement, which take care of the needs and emotions attached to taboos. (shrink)

With no statutory definition of death, the accepted medical definition relies on brain stem death criteria as a definitive measure of diagnosing death. However, the use of brain stem death criteria in this way is precarious and causes widespread confusion amongst both medical and lay communities. Through critical analysis, this paper considers the insufficiencies of brain stem death. It concludes that brain stem death cannot be successfully equated with either biological death or the loss of integrated bodily function. The overemphasis (...) of the brain-stem and its consequences leaves the criteria open to significant philosophical critique. Further, in some circumstances, the use of brain stem death criteria causes substantial emotional conflict for families and relatives. Accordingly, a more holistic and comprehensive definition of death is required. (shrink)

The essay examines Robin Cook’s Coma and Priscille Sibley’s The Promise of Stardust that dramatize the reified and disposable status of the brain-dead patients who are classified as nonpersons. The essay argues that the man-machine entanglement as depicted in the novels constructs a deterritorialized and entangled form of subjectivity that intervenes in the dominant biomedical understanding of personhood and agency that we notionally associate with a conscious mind. The essay concludes its arguments by discussing Alexander Beliaev’s Professor Dowell’s Head which (...) depicts human subjectivity as an essentially embodied and distributive phenomenon and interrogates the Cartesian mind body dualism embedded in the dominant biomedical narratives. (shrink)