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)

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

Since its inception in 1968, the concept of whole-brain death has been contentious, and four decades on, controversy concerning the validity and coherence of whole-brain death continues unabated. Although whole-brain death is legally recognized and medically entrenched in the United States and elsewhere, there is reasonable disagreement among physicians, philosophers, and the public concerning whether brain death is really equivalent to death as it has been traditionally understood. A handful of states have acknowledged this plurality of viewpoints and enacted “conscience (...) clauses” that require “reasonable accommodation” of religious and moral objections to the determination of death by neurological criteria. This paper argues for the universal adoption of “reasonable accommodation” policies using the New Jersey statute as a model, in light of both the ongoing controversy and the recent case of Jahi McMath, a child whose family raised religious objections to a declaration of brain death. Public policies that accommodate reasonable, divergent viewpoints concerning death provide a practical and compassionate way to resolve those conflicts that are the most urgent, painful, and difficult to reconcile. (shrink)

For many years a debate has raged over what constitutes futile medical care, if patients have a right to demand what doctors label as futile, and whether physicians should be obliged to provide treatments that they think are inappropriate. More recently, the argument has shifted away from the difficult project of definitions, to outlining institutional policies and procedures that take a measured and patient-by-patient approach to deciding if an existing or desired intervention is futile. The prototype is the Texas Advance (...) Directives Act, but similar procedures have been widely implemented both with and without the protection of the law. While this method has much to recommend it, there are inherent moral flaws that have not received as much discussion as warranted. Because these strategies adopt a semblance of procedural justice, it is assumed that the outcomes of such proceedings will be both correct and fair. In this paper, I argue that there are three main irremediable defects in the policy approach: there is the potential for arbitrary decision-making about futility in specific cases; there are structural, pre-ordained consequences for ethnic minorities who would be disproportionately affected by the use of these procedures; and the use of rationing justifications to support the use of these policies. These flaws detract so much from any benefit that could be derived that they make such strategies more harmful than helpful. (shrink)

Transplantation of vital organs has been premised ethically and legally on "the dead donor rule" (DDR)—the requirement that donors are determined to be dead before these organs are procured. Nevertheless, scholars have argued cogently that donors of vital organs, including those diagnosed as "brain dead" and those declared dead according to cardiopulmonary criteria, are not in fact dead at the time that vital organs are being procured. In this article, we challenge the normative rationale for the DDR by rejecting the (...) underlying premise that it is necessarily wrong for physicians to cause the death of patients and the claim that abandoning this rule would exploit vulnerable patients. We contend that it is ethical to procure vital organs from living patients sustained on life support prior to treatment withdrawal, provided that there is valid consent for both withdrawing treatment and organ donation. However, the conservatism of medical ethics and practical concerns make it doubtful that the DDR will be abandoned in the near future. This leaves the current practice of organ transplantation based on the "moral fiction" that donors are dead when vital organs are procured. (shrink)

Bioethics is a hybrid discipline. As a theoretical enterprise it stands for untrammeled inquiry and argument. Yet it aims to influence medical practice and policy. In this article we explore tensions between these two dimensions of bioethics and examine the merits and perils of a “Socratic” approach to bioethics that challenges “the conventional wisdom.”.

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)

The American Journal of Bioethics, Volume 12, Issue 2, Page 42-44, February 2012.

Based on the fieldwork at two Norwegian Intensive Care Units, we wish to discuss the sometimes inconsistent manner in which death is handled, determined and made real by nurses and other healthcare personnel in high‐tech hospital situations. These discrepancies draw our attention towards different ways of attending to the dying and dead and views about appropriate or inappropriate codes of professional behaviour. As we will argue below, the analytical tools developed by Annemarie Mol are useful for sharpening our understanding of (...) the enactment of multiple ontologies of death as they are enacted within the ICU. Annemarie Mol and John Law’s notion of ‘ontological politics’ increases our awareness about the non‐arbitrary way some but not other practices are considered self‐evident whereas others are denigrated as muddled and illogical. (shrink)

Islam and End-of-Life Practices in Organ Donation for Transplantation: New Questions and Serious Sociocultural Consequences Content Type Journal Article Pages 175-205 DOI 10.1007/s10730-009-9095-8 Authors Mohamed Y. Rady, Mayo Clinic Hospital in Phoenix 5777 East Mayo Boulevard Phoenix Arizona USA 85054 Joseph L. Verheijde, Mayo Clinic College of Medicine 5777 East Mayo Boulevard Phoenix Arizona USA 85054 Muna S. Ali, Arizona State University Phoenix Arizona USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume (...) 21, Number 2. (shrink)

The current practice of organ transplantation has been criticized on several fronts. The philosophical and scientific foundations for brain death criteria have been crumbling. In addition, donation after cardiac death, or non-heartbeating-organ donation (NHBD) has been attacked on grounds that it mistreats the dying patient and uses that patient only as a means to an end for someone else's benefit.

Ethical problems surrounding organ donation have been discussed since before technologies supported the procedure. In addition to issues on a societal level (e.g. brain-stem death, resource allocation), ethical concerns permeate the clinical practice of health care staff. These latter have been little studied. Using qualitative methods, this study, focused on transplant co-ordinators and their descriptions of dilemmas, ethical concerns and actions in response to them. Interviews with three co-ordinators in Japan and two in the UK revealed five areas in which (...) dilemmas occurred: aspects of discrimination; conditions placed on who should be the recipient and the related issues of directed donation; respect for a person's right to make a decision and the extent of information provided and understood by donors and recipients; potential issues of coercion, compensation and rewards in live-related and live-unrelated donations; and potential conflicts in duties. This study describes the dilemma areas revealed. Their meaning for co-ordinators will be presented in a subsequent report. (shrink)

Based on the fieldwork at two Norwegian Intensive Care Units, we wish to discuss the sometimes inconsistent manner in which death is handled, determined and made real by nurses and other healthcare personnel in high‐tech hospital situations. These discrepancies draw our attention towards different ways of attending to the dying and dead and views about appropriate or inappropriate codes of professional behaviour. As we will argue below, the analytical tools developed by Annemarie Mol are useful for sharpening our understanding of (...) the enactment of multiple ontologies of death as they are enacted within the ICU. Annemarie Mol and John Law’s notion of ‘ontological politics’ increases our awareness about the non‐arbitrary way some but not other practices are considered self‐evident whereas others are denigrated as muddled and illogical. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 40-42, February 2012.

Bangladesh, a Muslim-majority country, has a national organ donation law that was passed in 1999 and revised in 2018. The law allows living-related and brain-dead donor organ transplantation. There are no legal barriers to these two types of organ donations, but there is no legislation providing necessary costs and incentive measures associated with successful organ transplants. However, many governments across the globe provide different types of incentives for motivating living donors and families of deceased donors. This study assesses the merits (...) and demerits of incentive measures already in use around the world and proposes ethical measures that can promote organ donation in Bangladesh. The primary focus of this paper is to present an ethical analysis of the comparison of incentive measures on organ donation between Bangladesh and the Islamic Republic of Iran as two Muslim countries that operate organ donation for transplantation practices according to Islamic principles. In this paper, I mainly argue that providing a fixed bare minimum financial incentive measure to distantly related living donors and families of deceased donors will encourage Bangladeshis to donate organs in a manner that is ethically justifiable, morally permissible, and socio-economically appropriate. The government of Bangladesh should revise the existing biomedical law to include a provision related to incentive measures and set a strict policy to properly regulate these measures as key stewardship that can ethically promote organ donation for transplantation. (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)

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)

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)

In many ways, grief is thought to be outside the realm of bioethics and clinical ethics, and grieving patients or family members may be passed off to grief counselors or therapists. Yet grief can play a particularly poignant role in the ethical encounter, especially in cases of brain death, where the line between life and death has been blurred. Although brain death is legally and medically recognized as death in the United States and elsewhere, the concept has been contentious since (...) its inception in 1968. Yet in most cases, families are not allowed to reject the determination of brain death. Apart from religious exemptions, families have no recourse to reject this controversial determination of death. This paper explores the role of grief in brain death determinations and argues that bioethics has failed to address the complexity of grief in determinations of brain death. Grief ought to have epistemological weight in brain death determinations because of the contested nature of the diagnosis and the unique ways in which grief informs the situation. Thus, I argue that, in some rare cases, reasonable accommodation policies should be expanded to allow for refusals of brain death determinations based on the emotional and moral force of grief. By drawing on ethnographic accounts of grief in other cultures, I problematize the current procedural and linear understandings of grief in brain death determinations, and I conclude by offering a new way in which to understand the case of Jahi McMath. (shrink)

Brain death or determination of death based on the neurological criterion has been an enduring source of controversy in academic and clinical circles. The controversy chiefly concerns how death is defined, and it also bears on the justification of the proposed criteria for death determination and their interpretation. Part of the controversy on brain death and death determination stems from disputed crucial medical facts, but in this paper I formulate another hypothesis about the nature of ongoing controversies. At stake is (...) a misunderstood relationship between, on the one hand, the nature of our lay views about death and, on the other hand, the nature of scientific insights into death and its determination. The misunderstanding of this relationship has partly anchored the controversy and continues to fuel it. Based on a perspective inspired by pragmatism, which stresses the positive contribution of science to ethical and policy debates but also challenges different forms of scientism in science and philosophy found in foundationalist interpretations, I scrutinize three different stances regarding the relationship between lay and scientific perspectives about the definition of death: foundational lay views, foundational expert views, and co-evolving views. I argue that only the latter is sustainable given recent challenges to foundationalist interpretations. (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)

Despite continuing controversies regarding the vital status of both brain-dead donors and individuals who undergo donation after circulatory death (DCD), respecting the dead donor rule (DDR) remains the standard moral framework for organ procurement. The DDR increases organ supply without jeopardizing trust in transplantation systems, reassuring society that donors will not experience harm during organ procurement. While the assumption that individuals cannot be harmed once they are dead is reasonable in the case of brain-dead protocols, we argue that the DDR (...) is not an acceptable strategy to protect donors from harm in DCD protocols. We propose a threefold alternative to justify organ procurement practices: (1) ensuring that donors are sufficiently protected from harm; (2) ensuring that they are respected through informed consent; and (3) ensuring that society is fully informed of the inherently debatable nature of any criterion to declare death. (shrink)

This paper argues that competing ethical positions in the Terri Schiavo debate—calls to “err on the side of life” or to “err on the side of liberty”—aim to regulate life and not to defend its sanctity or freedom. Advancing analyses of the “biopolitics” of the case, I show how Terri Schiavo’s status as a speaking-being is an important question for both positions. Informed by feminist concerns about the marginalization and ventriloquization of voices, I argue that bioethicists should “lend an ear” (...) to the voices of Terri Schiavo. (shrink)

Whole brain failure constitutes the diagnostic criterion for death determination in most clinical settings across the globe. Yet the conceptual foundation for its adoption was slow to emerge, has evoked extensive scientific debate since inception, underwent policy revision, and remains contentious in praxis even today. Complications result from the need to relate a unitary construal of the death event with an adequate account of organismal integration and that of the human organism in particular. Advances in the neuroscience of higher human (...) faculties, such as the self, personal identity, and consciousness, and dynamical philosophy of science accounts, however, are yielding a portrait of higher order global integration shared between body and brain. Such conceptual models of integration challenge a praxis relying exclusively on a neurological criterion for death. (shrink)