The debate over the determination of death has been raging for more than fifty years. Since then, objections against the diagnosis of brain death from family members of those diagnosed as dead-have been increasing and are causing some countries to take novel steps to accommodate people’s beliefs and preferences in the determination of death. This, coupled with criticism by some academics of the brain death criterion, raises some questions about the issues surrounding the determination of death. In this paper, we (...) discuss some of the main approaches to death determination that have been theoretically proposed or currently put into practice and propose a new approach to death determination called "weak pluralism" as a reasonable ethical and political alternative to respect diversity in death determination. (shrink)

Background Debates and controversies have shaped the understanding and the practices related to death determined by neurological criterion . Confusion about DNC in the public domain could undermine this notion. This confusion could further jeopardise confidence in rigorous death determination procedures, and raise questions about the integrity, sustainability, and legitimacy of modern organ donation practices.Objective We examined the depictions of ‘brain death’ in major American and Canadian print media to gain insights into possible common sources of confusion about DNC and (...) the relationship between expert and lay views on this crucial concept.Methods We gathered 940 articles, available in electronic databases, published between 2005 and 2009 from high-circulation Canadian and American newspapers containing keywords ‘brain dead’ or ‘brain death’. Articles were systematically examined for content using the NVivo 8 software.Results Our results showed problematic aspects in American and Canadian media, with some salient differences. DNC was used colloquially in 39% of the articles and its medical meaning infrequently defined . The neurological criterion for determination of death was mentioned in less than 10% of the articles, and life support in about 20% of the articles. Organ donation issues related to DNC were raised more often in Canadian articles than in American articles .Interpretation Further discussion is needed to develop innovative strategies to bridge media representations of DNC with experts’ views in connection with organ donation practices. (shrink)

According to the International Register of Organ Donation and Transplantation, Japan is one of the countries with the lowest number of registered deceased donors. In 2019, Japan was ranked 61st out of 70 countries. The authors of this article have decided to explore the reasons for this phenomenon. In the first part of the work, religious influences (Shinto and Buddhism), the tradition of gotai manzoku, the importance of altruism and the family in the perception of death and organ transplantation by (...) the Japanese are considered. The second part of the article presents the arguments of Alan Shewmon, who believes that brain death is not death in the biological sense. Undermining the brain’s death criterion raises doubts concerning death of patients in irreversible coma, what in result discourages transplantology in Japan. In the third part, the authors compare the results of JOTN, IRODaT and the Fact Book of Organ Transplantation 2018 in Japan from 2010 to 2018. The aim of the article is to explain the cultural determinants of transplantology in Japan, taking into account the influence of philosophical and bioethical aspects of human death. (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)

The determination of death by neurological criteria remains controversial scientifically, culturally, and legally, worldwide. In the United Kingdom, although the determination of death by neurological criteria is not legally codified, the Code of Practice of the Academy of Medical Royal Colleges is customarily used for neurological death determination and treatment withdrawal. Unlike some states in the US, however, there are no provisions under the law requiring accommodation of and respect for residents' religious rights and commitments when secular conceptions of death (...) based on medical codes and practices conflict with a traditional concept well-grounded in religious and cultural values and practices. In this article, we analyse the medical, ethical, and legal issues that were generated by the recent judgement of the High Court of England and Wales in Re: A [2015] EWHC 443. Mechanical ventilation was withdrawn in this case despite parental religious objection to a determination of death based on the code of practice. We outline contemporary evidence that has refuted the reliability of tests of brainstem function to ascertain the two conjunctive clinical criteria for the determination of death that are stipulated in the code of practice: irreversible loss of capacity for consciousness and somatic integration of bodily biological functions. We argue that: the tests of brainstem function were not properly undertaken in this case; the two conjunctive clinical criteria set forth in the code of practice cannot be reliably confirmed by these tests in any event; and absent authentication of the clinical criteria of death, the code of practice wrongly invokes a secular definition of death based on the loss of personhood. Consequently, the moral obligation of a pluralistic society to honor and respect diverse religious convictions to the greatest extent possible is being violated. Re A is contrasted with the US case of Jahi McMath in which the court accommodated parental religious objection to the determination of neurological death codified in the Uniform Determination of Death Act. We conclude that the legal system in the United Kingdom should not favour a secular definition of death over a definition of death that is respectful of religious values about the inviolability and sanctity of life. We recommend the legal recognition of religious accommodation in death determination to facilitate cultural sensitivity and compassionate care to patients and families in a pluralistic society. (shrink)

This paper aims to determine whether it is necessary to propose the extreme of putrefaction as the only unmistakable sign in diagnosing the death of the human organism, as David Oderberg does in a recent paper. To that end, we compare Oderberg’s claims to those of other authors who align with him in espousing the so-called theory of hylomorphism but who defend either a neurological or a circulatory-respiratory criterion for death. We then establish which interpretation of biological phenomena is the (...) most reasonable within the metaphysical framework of hylomorphism. In this regard, we hold that technology does not obscure the difference between life and death or confect metaphysically anomalous beings, such as living human bodies who are not organisms or animals of the human species who are informed by a vegetative soul, but instead demands a closer and more careful look at the “fuzzy area” between a healthy organism and a decaying corpse. In the light of hylomorphism, we conclude that neurological and circulatory-respiratory criteria are not good instruments for diagnosing death, since they can offer only probabilistic prognoses of death. Of the two, brain death is further away from the moment of death as it merely predicts cardiac arrest that will likely result in death. Putrefaction, the criterion that Oderberg proposes, is at the opposite end of the fuzzy area. This is undoubtedly a true diagnosis of death, but it is not necessary to wait for putrefaction proper—a relatively late stage of decomposition—to be sure that death has already occurred. Rather, early cadaveric phenomena demonstrate that the matter composing a body is subject to the basic forces governing all matter in its environment and has thus succumbed to the universal current of entropy, meaning that the entropy-resisting activity has ceased to constitute an organismal unity. When this unity is lost, there is no possibility of return. (shrink)

Constantin Reliu had been working for twenty years as a cook in Turkey when he returned to his hometown of Barlad, Romania, to discover that, there, he was dead. His former wife had, unbeknownst to him, at some point during his stay in Turkey registered him as deceased in Romania. He has since been living a legal nightmare trying to prove to Romanian authorities that he is, in fact, alive. Reliu is not alone in finding out that the legal system (...) is not as attuned to physiological activity or biological assessment by doctors in determining death as one might think. If one starts with the assumption that death is a purely biological concept, solely the province of doctors, Reliu's story seems entirely unrelated to the concept of death in the medical context. A brain scan would not lead to a reversal of his being assessed as dead. The story is a reminder, however, that how death is used is not just biological, and therefore that the standard of death even in the clinic must answer to cultural considerations. Values, the law, and custom matter a great deal in determining who is alive and who is not, whether in the courtroom, the coroner's office, or the clinic. (shrink)

The December 2008 White Paper (WP) on “Brain Death” published by the President’s Council on Bioethics (PCBE) reaffirmed its support for the traditional neurological criteria for human death. It spends considerable time explaining and critiquing what it takes to be the most challenging recent argument opposing the neurological criteria formulated by D. Alan Shewmon, a leading critic of the “whole brain death” standard. The purpose of this essay is to evaluate and critique the PCBE’s argument. The essay begins with a (...) brief background on the history of the neurological criteria in the United States and on the preparation of the 2008 WP. After introducing the WP’s contents, the essay sets forth Shewmon’s challenge to the traditional neurological criteria and the PCBE’s reply to Shewmon. The essay concludes by critiquing the WP’s novel justification for reaffirming the traditional conclusion, a justification the essay finds wanting. (shrink)

According to the biological definition of death, a human body that has not lost the capacity to holistically organize itself is the body of a living human individual. Reasonable doubt against the conclusion that it has lost the capacity exists when the body appears to express it and no evidence to the contrary is sufficient to rule out reasonable doubt against the conclusion that the apparent expression is a true expression. This essay argues that the evidence and arguments against the (...) conclusion that the signs of complex bodily integration exhibited in ventilated brain dead bodies are true expressions of somatic integration are unpersuasive; that is, they are not adequate to exclude reasonable doubt against the conclusion that BD bodies are dead. Since we should not treat as corpses what for all we know might be living human beings, it follows that we have an obligation to treat BD individuals as if they were living human beings. (shrink)

In dicephalus conjoined twinning, it appears that two heads share a body; in cephalopagus, it appears that two bodies share a head. How many human animals are present in these cases? One answer is that there are two in both cases—conjoined twins are precisely that, conjoined twins. Another is that the number of humans corresponds to the number of bodies—so there is one in dicephalus and two in cephalopagus. I show that both of these answers are incorrect. Prominent accounts of (...) biological individuation, which treat the organism as an integrated whole, reveal that in these and other cases of conjoined twinning the ‘twins’ share a single human animal. This has a number of consequences for the debate about what we are. First, if animalism is true, individuals of our kind can be—and are—profoundly psychologically divided. Second, cephalopagus twinning does not divide animalism from its rivals, as has been claimed. Finally, animalists can reply to a vicious species of the ‘too many thinkers’ problem to which they are allegedly uniquely vulnerable. (shrink)

The purpose of this paper is methodological. I begin by showing the methodological frailties of both the heart and brain approach to the criteria of death used in connection with organ transplantation. I then clarify what a definition is. Finally, I propose to abandon the definition of death, and suggest a pragmatic definition of ‘explantability window’.

We discuss the meaning of “being alive” and “being dead.” Our primary aim is to pave the way for a sound and accurate ethical debate concerning these two concepts. In particular, we analyze a metabolic approach and a genetic one and discuss the reasons for their failure to constitute a good starting point for successive debates. We argue that any ethical or social discussion of topics involving life and death must introduce cultural constructs such as, on the one hand, the (...) concept of clinical death and, on the other hand, the concept of existence. We argue that these two cultural constructs, although consistent with biomedical knowledge, cannot be ontologically grounded in it. To conclude, we apply our findings to the case of human embryos. (shrink)

We discuss the meaning of “being alive” and “being dead.” Our primary aim is to pave the way for a sound and accurate ethical debate concerning these two concepts. In particular, we analyze a metabolic approach and a genetic one and discuss the reasons for their failure to constitute a good starting point for successive debates. We argue that any ethical or social discussion of topics involving life and death must introduce cultural constructs such as, on the one hand, the (...) concept of clinical death and, on the other hand, the concept of existence. We argue that these two cultural constructs, although consistent with biomedical knowledge, cannot be ontologically grounded in it. To conclude, we apply our findings to the case of human embryos. (shrink)

The publicity surrounding the recent McMath and Muñoz cases has rekindled public interest in brain death: the familiar term for human death determination by showing the irreversible cessation of clinical brain functions. The concept of brain death was developed decades ago to permit withdrawal of therapy in hopeless cases and to permit organ donation. It has become widely established medical practice, and laws permit it in all U.S. jurisdictions. Brain death has a biophilosophical justification as a standard for determining human (...) death but remains poorly understood by the public and by health professionals. The current controversies over brain death are largely restricted to the academy, but some practitioners express ambivalence over whether brain death is equivalent to human death. Brain death remains an accepted and sound concept, but more work is necessary to establish its biophilosophical justification and to educate health professionals and the public. (shrink)

The definition of death is one of the oldest and most enduring problems in biophilosophy and bioethics. Serious controversies over formally defining death began with the invention of the positive-pressure mechanical ventilator in the 1950s. For the first time, physicians could maintain ventilation and, hence, circulation on patients who had sustained what had been previously lethal brain damage. Prior to the development of mechanical ventilators, brain injuries severe enough to induce apnea quickly progressed to cardiac arrest from hypoxemia. Before the (...) 1950s, the loss of spontaneous breathing and heartbeat were perfect predictors of death because the functioning of the brain and of all other organs ceased rapidly and nearly simultaneously thereafter, producing a unitary death phenomenon. In the pretechnological era, physicians and philosophers did not have to consider whether a human being who had lost certain “vital functions” but had retained others was alive, because such cases were technically impossible. (shrink)

The distinction between the "permanent" (will not reverse) and "irreversible" (cannot reverse) cessation of functions is critical to understand the meaning of a determination of death using circulatory–respiratory tests. Physicians determining death test only for the permanent cessation of circulation and respiration because they know that irreversible cessation follows rapidly and inevitably once circulation no longer will restore itself spontaneously and will not be restored medically. Although most statutes of death stipulate irreversible cessation of circulatory and respiratory functions, the accepted (...) medical standard is their permanent cessation because permanence is a perfect surrogate indicator for irreversibility, and using it permits a more timely declaration. Therefore, patients properly declared dead in donation after circulatory death (DCD) protocols satisfy the requirements of death statutes and do not violate the dead donor rule. The acronym DCD should represent organ "donation after circulatory death" to clarify that the death standard is the permanent cessation of circulation, not heartbeat. Heart donation in DCD does not retroactively negate the donor's death determination because circulation has ceased permanently. (shrink)

Among the old and new controversies over brain death, none is more fundamental than whether brain death is equivalent to the biological phenomenon of human death. Here, I defend this equivalency by offering a brief conceptual justification for this view of brain death, a subject that Andrew Huang and I recently analyzed elsewhere in greater detail. My defense of the concept of brain death has evolved since Bernard Gert, Charles Culver, and I first addressed it in 1981, a development that (...) paralleled advances in intensive care unit treatment. The century‐old concept of the organism as a whole provides the fundamental justification for the equivalency of brain death and human death. In our technological age, in which increasing numbers of components and systems of an organism can be kept alive, and for longer intervals, the permanent cessation of functioning of the organism as a whole is the phenomenon that best corresponds to its death. (shrink)

Patrick Lee and Germain Grisez have argued that the total brain dead patient is still dead because the integrated entity that remains is not even an animal, not only because he is not sentient but also, and more importantly, because he has lost the radical capacity for sentience. In this essay, written from within and as a contribution to the Catholic philosophical tradition, I respond to Lee and Grisez’s argument by proposing that the brain dead patient is still sentient because (...) an animal with an intact but severed spinal cord can still perceive and respond to external stimuli. The brain dead patient is an unconscious sentient organism. (shrink)

A recent commentary defends 1) the concept of 'brain arrest' to explain what brain death is, and 2) the concept that death occurs at 2–5 minutes after absent circulation. I suggest that both these claims are flawed. Brain arrest is said to threaten life, and lead to death by causing a secondary respiratory then cardiac arrest. It is further claimed that ventilation only interrupts this way that brain arrest leads to death. These statements imply that brain arrest is not death (...) itself. Brain death is a devastating state that leads to death when intensive care, which replaces some of the brain's vital functions such as breathing, is withdrawn and circulation stops resulting in irreversible loss of integration of the organism. Circulatory death is said to occur at 2–5 minutes after absent circulation because, in the context of DCD, the intent is to not attempt reversal of the absent circulation. No defense of this weak construal of irreversible loss of circulation is given. This means that paents in identical physiologic states are dead (in the DCD context) or alive (in the resuscitation context); the current state of death (at 2–5 minutes) is contingent on a future event (whether there will be resuscitation) suggesting backward causation; and the commonly used meaning of irreversible as 'not capable of being reversed' is abandoned. The literature supporting the claim that autoresuscitation does not occur in the context of no cardiopulmonary resuscitation is shown to be very limited. Several cases of autoresuscitation are summarized, suggesting that the claim that these cases are not applicable to the current debate may be premature. I suggest that brain dead and DCD donors are not dead; whether organs can be harvested before death from these patients whose prognosis is death should be debated urgently. (shrink)

In The Human Animal I argued that we are animals, and that those animals do not persist by virtue of any sort of psychological continuity. Rather, personal identity in this sense consists in having the same biological life. And I said that a human life requires a functioning brainstem. Rina Tzinman takes this and other remarks to imply that personal identity consists in the continued functioning of the brainstem, which looks clearly false. I say it doesn’t follow. But Alan Shewmon (...) appears to have refuted my claim about the brainstem. (shrink)

Our approach to global bioethics will depend, among other things, on how we answer the questions whether global bioethics is possible and whether it, if it is possible, is desirable. Our approach to global bioethics will also vary depending on whether we believe that the required bioethical deliberation should take as its principal point of departure that which we have in common or that which we have in common and that on which we differ. The aim of this article is (...) to elaborate a theoretical underpinning for a bioethics that acknowledges the diversity of traditions and experiences without leading to relativism. The theoretical underpinning will be elaborated through an exploration of the concepts of sameness, otherness, self and other, and through a discussion of the conditions for understanding and critical reflection. Furthermore, the article discusses whether the principle of respect for the other as both the same and different can function as the normative core of this global bioethics. The article also discusses the New Jersey Death Definition Law and the Japanese Transplantation Law. These laws are helpful in order to highlight possible implications of the principle of respect for the other as both the same and different. Both of these laws open the door to more than one concept of death within one and the same legal system. Both of them relate preference for a particular concept of death to religious and/or cultural beliefs. (shrink)

Death concept, death definition, death criterion and death test pluralism has been described by some as a problematic approach. Others have claimed it to be a promising way forward within modern pluralistic societies. This article describes the New Jersey Death Definition Law and the Japanese Transplantation Law. Both of these laws allow for more than one death concept within a single legal system. The article discusses a philosophical basis for these laws starting from John Rawls' understanding of comprehensive doctrines, reasonable (...) pluralism and overlapping consensus. It argues for the view that a certain legal pluralism in areas of disputed metaphysical, philosophical and/or religious questions should be allowed, as long as the disputed questions concern the individual and the resulting policy, law or acts based on the policy/law, do not harm the lives of other individuals to an intolerable extent. However, while this death concept, death definition, death criterion and death test pluralism solves some problems, it creates others. (shrink)

Since the Harvard Committees bold and highly successful attempt to redefine death in 1968 (Harvard Ad Hoc committee, 1968), multiple controversies have arisen. Stimulated by several factors, including the inherent conceptual weakness of the Harvard Committees proposal, accumulated clinical experience, and the incessant push to expand the pool of potential organ donors, the lively debate about the definition of death has, for the most part, been confined to a relatively small group of academics who have created a large body of (...) literature of which this issue of the Journal of Medicine and Philosophy is an example. Law and public policy, however, have remained essentially unaffected. This paper will briefly review the multiple controversies about defining death in an attempt to explain why they have and will remain unresolved in the academic community and have even less chance of being understood and resolved by politicians, legislators, and the general public. Considering this, we will end by suggesting the probable course of public policy and clinical practice in the decades ahead. (shrink)

The concept of brain death as equivalent to cardiopulmonary death was initially conceived following developments in neuroscience, critical care, and transplant technology. It is now a routine part of medicine in Western countries, including the United States. In contrast, Eastern countries have been reluctant to incorporate brain death into legislation and medical practice. Several countries, most notably China, still lack laws recognizing brain death and national medical standards for making the diagnosis. The perception is that Asians are less likely to (...) approve of brain death or organ transplant from brain dead donors. Cultural and religious traditions have been referenced to explain this apparent difference. In the West, the status of the brain as home to the soul in Enlightenment philosophy, combined with pragmatism and utilitarianism, supports the concept of brain death. In the East, the integration of body with spirit and nature in Buddhist and folk beliefs, along with the Confucian social structure that builds upon interpersonal relationships, argues against brain death. However, it is unclear whether these reasoning strategies are explicitly used when families and medical providers are faced with acknowledging brain death. Their decisions are more likely to involve a prioritization of values and a rationalization of intuitive responses. Why and whether there might be differences between East and West in the acceptance of the brain death concept requires further empirical testing, which would help inform policy-making and facilitate communication between providers and patients from different cultural and ethnic backgrounds. (shrink)

In early 2017, Nevada amended its Uniform Determination of Death Act, in order to clarify the neurologic criteria for the determination of death. The amendments stipulate that a determination of death is a clinical decision that does not require familial consent and that the appropriate standard for determining neurologic death is the American Academy of Neurology’s guidelines. Once a physician makes such a determination of death, the Nevada amendments require the withdrawal of life-sustaining treatment within twenty-four hours with limited exceptions. (...) Neurologists have generally supported Nevada’s amendments for clarifying the diagnostic standard and limiting the ability of family members to challenge it. However, it is more appropriate to view the Nevada amendments with concern. Even though the primary purpose of the UDDA is to ensure that all functions of a person’s entire brain have ceased, the AAN guidelines do not accurately assess this. In addition, by characterizing the determination of death as solely a clinical decision, the Nevada legislature has improperly ignored the doctrine of informed consent, as well as the beliefs of particular faiths and cultures that reject brain death. Rather than resolving controversies regarding brain death determinations, the Nevada amendments may instead instigate numerous constitutional challenges. (shrink)

BackgroundThe brain death standard allowing a declaration of death based on neurological criteria is legally endorsed and routinely practiced in the West but not in Asia. In China, attempts to legalize the brain death standard have occurred several times without success. Cultural, religious, and philosophical factors have been proposed to explain this difference, but there is a lack of empirical studies to support this hypothesis.Methods476 medical providers from three academic hospitals in Hunan, China, completed a selfadministered survey including a 12-question (...) brain death clinical knowledge assessment and hypothetical vignettes describing brain dead patients.ResultsThe response rate was 95.2 %. Almost all of the providers had heard of the term “brain death.” More than half have encountered presumed brain dead patients. Two-thirds accepted brain death as an ethical standard to determine human death. The mean knowledge score was 8.50 ± 1.83 out of 12. When given the description of a brain dead patient, 50.7 % considered the patient dead, 51.9 % would withdraw life support, and 40.6 % would allow organ procurement. Both provider and patient characteristics contributed to the providers’ decisions. Ethical acceptance was the most important independent predictor for brain death acknowledgement, followed by high knowledge scores, and the belief that the soul lives in the brain. Religious faith and associated beliefs did not have a significant effect.ConclusionsNotwithstanding scarce official accounts, recognition of the brain death standard is not uncommon in China. Chinese medical providers can adequately define the medical characteristics of brain death and accept it in theory, but hesitate to apply it to practice in the vignettes. Legalization is paramount in providing the protection providers need to comfortably declare brain death. However the medical decision-making surrounding brain death is complex and the provider's past experiences and emotions may also influence the process. (shrink)

Depending on our mode of reasoning—moral, prudential, instrumental, empirical, dialectical, and so on—we may come to vastly different conclusions on the nature of death and the appropriate orientation toward matters such as euthanasia or procuring organs from brain-dead patients. These differing orientations have resulted in some of the most enduring conflicts in biomedical decision-making with roots in the earliest strands of philosophical discourse. Through continually grappling with questions over matters of death, we continually step closer to clarity, even if certainty (...) on these matters remains necessarily as elusive as death itself. (shrink)

In early 2017, Nevada amended its Uniform Determination of Death Act, in order to clarify the neurologic criteria for the determination of death. The amendments stipulate that a determination of death is a clinical decision that does not require familial consent and that the appropriate standard for determining neurologic death is the American Academy of Neurology’s guidelines. Once a physician makes such a determination of death, the Nevada amendments require the withdrawal of life-sustaining treatment within twenty-four hours with limited exceptions. (...) Neurologists have generally supported Nevada’s amendments for clarifying the diagnostic standard and limiting the ability of family members to challenge it. However, it is more appropriate to view the Nevada amendments with concern. Even though the primary purpose of the UDDA is to ensure that all functions of a person’s entire brain have ceased, the AAN guidelines do not accurately assess this. In addition, by characterizing the determination of death as solely a clinical decision, the Nevada legislature has improperly ignored the doctrine of informed consent, as well as the beliefs of particular faiths and cultures that reject brain death. Rather than resolving controversies regarding brain death determinations, the Nevada amendments may instead instigate numerous constitutional challenges. (shrink)

Since the introduction of the concept of brain death by the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death in 1968, the validity of this concept has been challenged by medical scientists, as well as by legal, philosophical, and religious scholars. In light of increased criticism of the concept of brain death, Stephen Napier, a staff ethicist at the National Catholic Bioethics Center, set out to prove that the whole-brain death criterion serves as (...) good evidence for death in the Catholic bioethical framework, on the grounds that when whole-brain death has occurred the soul has already departed from the body. Opponents have argued that (1) brain death does not disrupt the somatic integrative unity and coordinated biological functioning of a living organism and (2) clinical tests outlined in the practice guidelines for determining brain death lack sufficient power to exclude persisting function and fail to detect elements of the brain that, although currently functionless, may retain potential for recovery under conditions of optimal medical care. It is therefore possible that heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of active euthanasia and physician-assisted death, both of which, either concealed or overt, the Catholic Church opposes. (shrink)

In 1968, the Harvard criteria equated irreversible coma and apnea with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism, minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. Brain death does not disrupt somatic (...) integrative unity and coordinated biological functioning of a living organism. Neurological criteria of human death fail to determine the precise moment of an organism’s death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. Brain -based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs. (shrink)

In its October 2001 issue, this journal published a series of articles questioning the Whole-Brain-based definition of death. Much of the concern focused on whether somatic integration - a commonly understood basis for the whole-brain death view - can survive the brain's death. The present article accepts that there are insurmountable problems with whole-brain death views, but challenges the assumption that loss of somatic integration is the proper basis for pronouncing death. It examines three major themes. First, it accepts the (...) claim of the "disaggregators" that some behaviors traditionally associated with death can be unbundled, but argues that other behaviors (including organ procurement) must continue to be associated. Second, it rejects the claims of the "somaticists," that the integration of the body is critical, arguing instead for equating death with the irreversible loss of "embodied consciousness," that is, the loss of integration of bodily and mental function. Third, it defends higher-brain views against the charge that they are necessarily "mentalist," that is, that they equate death with losing some mental function such as consciousness or personhood. It argues, instead, for the integration of bodily and mental function as the critical feature of human life and that its irreversible loss constitutes death. (shrink)

The current definition of death used for donation after cardiac death relies on a determination of the irreversible cessation of the cardiac function. Although this criterion can be compatible with transplantation of most organs, it is not compatible with heart transplantation since heart transplants by definition involve the resuscitation of the supposedly "irreversibly" stopped heart. Subsequently, the definition of "irreversible" has been altered so as to permit heart transplantation in some circumstances, but this is unsatisfactory. There are three available strategies (...) for solving this "irreversibility problem": altering the definition of death so as to rely on circulatory irreversibility, rather than cardiac; defining death strictly on the basis of brain death (either whole-brain or more pragmatically some higher brain criteria); or redefining death in traditional terms and simultaneously legalizing some limited instances of medical killing to procure viable hearts. The first two strategies are the most ethically justifiable and practical. (shrink)

The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing (...) treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a “legal fiction.” Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement. (shrink)

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard (...) criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

According to a prominent view of organism persistence, organisms cease to exist at death. According to a rival view, organisms can continue to exist as dead organisms. Most of the arguments in favor of the latter view rely on linguistic and common sense intuitions. I propose a new argument for somaticism by appealing to two other sources that have thus far not figured in the debate: the concept of naturalness, and biological descriptions of organisms, in particular in ethology and ecology. (...) I show that if we hone in on the relevant notion of naturalness, we can show that organisms can continue to instantiate the natural property being an organism after death. (shrink)

We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between “legally dead” and “legally blind” (...) demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike. (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)

For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. However, a series of recent cases in which individuals were declared brain dead yet physiologically maintained for prolonged periods of time has challenged the status quo. This signals a need for deeper reflection and reexamination of the underlying philosophical, scientific, and clinical issues at stake in defining death. In this paper, I consider four levels of philosophical inquiry regarding death: the ontological basis, actual states of (...) affairs, epistemological standards, and clinical criteria for brain death. I outline several candidates for the states of affairs that may constitute death, arguing that we should strive for a single, unified ontological definition of death as a loss of integrated functioning as a unified organism, while acknowledging that two states of affairs may satisfy this concept. I argue that the clinical criteria for determining whole-brain death should be bolstered to meet the epistemic demand of sufficient certainty in defining death by adding indicators of cerebro-somatic dis-integration to the traditional triad of loss of consciousness, loss of brainstem function, and absence of confounding explanations. (shrink)

Fifteen years ago I was the ethicist involved in a case of a 20-year-old woman who had a stroke, and who was discovered in the emergency room to be 16 weeks pregnant on the same day she was declare...

What makes an act of killing morally wrong is not that the act causes loss of life or consciousness but rather that the act causes loss of all remaining abilities. This account implies that it is not even pro tanto morally wrong to kill patients who are universally and irreversibly disabled, because they have no abilities to lose. Applied to vital organ transplantation, this account undermines the dead donor rule and shows how current practices are compatible with morality.

For more than thirty years, in most of the world, the irreversible cessation of all brain function, more commonly known as brain death, has been accepted as a criterion of death. Yet the philosophical basis on which this understanding of death was originally grounded has been undermined by the long-term maintenance of bodily functions in brain dead patients. More recently, the American case of Jahi McMath has cast doubt on whether the standard tests for diagnosing brain death exclude a condition (...) in which the patient is not dead, but in a minimally conscious state. I argue that the evidence now clearly shows that brain death is not equivalent to the death of the human organism. We therefore face a choice: either we stop removing vital organs from brain dead patients, or we accept that it is not wrong to kill an innocent human who has irreversibly lost consciousness. (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)

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)