Brain Death

Thanks to Barton Palmer and John McMillan for these thoughtful commentaries. We found much to agree with and it is striking how so many of the issues relating to decision-making capacity assessment find resonances outside of an English jurisdiction. California and New Zealand are clearly grappling with a very similar set of issues and the commentaries speak to the international nature of these discussions.We will pick up on some main points the commentaries raise.As Palmer notes, DMC law is vulnerable to (...) the criticism that it does not attend to the authenticity of a decision. In ordinary language, this is the idea that someone is deciding while “not their self” or that it is the “illness speaking.” There is a... (shrink)

Here we respond to Shaw et al., and show why the application of Conscientious Objection cannot be dismissed from cases of organ donation, where the donor is presumed to be dead.

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 disorders as (...) compatible with organismic unity, then one equally ought to tolerate their 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 gave 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)

For hundreds of years, death had been defined by cardiopulmonary criteria. When heart and respiratory functions were permanently absent, doctors declared their patients dead. Three developments in intensive care medicine called into question these widely-accepted criteria, however: the advent of positive pressure ventilation and the promotion of cardiopulmonary resuscitation, both in the early 1950s, and the first successful heart transplantation in 1967. What had previously been diagnosed as the permanent absence of vital functions, suddenly became reversible. Not only could doctors (...) replace a defective heart with a functioning transplant; patients could also be kept oxygenated in the total absence of spontaneous respiratory function. The traditional boundaries between life and death became blurred. Patients for whom there was not the remotest possibility of regaining consciousness following massive brain damage continued to consume valuable medical resources. Moreover, their organs could not be procured for transplantation. Were those patients still alive or could the ventilators be switched off? A criterion suited to indicate a patient’s death despite the provision of external life support was needed. In 1968 an ad hoc committee of the Harvard Medical School published the first comprehensive definition of what would soon become the new clinical standard: brain death. The brain bears a special relation to other organs; it directs bodily functions without carrying them out. When the brain is destroyed, it was argued, this control mechanism is irreversibly dysfunctional, so that the organism becomes unable to maintain its vital functions, loses its somatic unity and, consequently, ceases to exist. This neurological criterion has been controversial ever since its introduction. Whether brain death is indeed death is what I shall be investigating in this thesis. I will be asking three main questions: What are we? Is brain death the death of an organism? Is brain death the death of a psychological being? The question of personal identity and the question of the appropriate definition of death are intimately related. Only when we have determined what kind of entity we essentially are can we specify what conditions must apply for this entity to persist or to cease to exist. I shall argue that we are essentially psychological beings, which entails that our death is distinct from the death of our organisms. Hence, we need two different criteria – one for the death of each entity. I shall try to establish whether brainstem death and whole-brain death correspond to the irreversible cessation of organismic functioning. I will then determine by which criterion the death of a psychological being can be diagnosed. (shrink)

Prolonged survival after the declaration of death by neurologic criteria creates ambiguity regarding the validity of this methodology. This ambiguity has perpetuated the debate among secular and nondissenting Catholic authors who question whether the neurologic standards are sufficient for the declaration of death of organ donors. Cardiopulmonary criteria are being increasingly used for organ donors who do not meet brain death standards. However, cardiopulmonary criteria are plagued by conflict of interest issues, arbitrary standards for candidacy, and the lack of standardized (...) protocols for organ procurement. Combining the neurological and cardiopulmonary standards into a single protocol would mitigate the weaknesses of both and provide greater biologic and moral certainty that a donor of unpaired vital organs is indeed dead. (shrink)

The biophilosophic justification for the idea that “brain death” (or total brain failure) is death needs to support two claims: (1) that what dies in human death is a human organism, not merely a psychological entity distinct from it; (2) that total brain failure signifies the end of the human organism as a whole. Defenders of brain death typically assume without argument 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 paper, 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)

A defense of the view that (i) to be alive is to be actively undergoing (not merely capable of undergoing) certain vital processes, that (ii) to die is cease to be capable of undergoing those processes (not to cease undergoing them), and that (iii) organisms in cryptobiosis (suspended animation) are not undergoing those processes but are capable of doing so, and are neither alive nor dead.

In recent years physicians have used a variety of laboratory studies as confirmatory tests in the diagnosis of brain death. The most widely used test has been the EEG. However, with the development of newer technologies capable of measuring other parameters of brain functions, other laboratory studies are playing an increasingly important role in confirming brain death. In this article, we discuss the role of one of these newer tests, the radioactive brain scan, and compare its advantages and limitations with (...) the EEG. (shrink)

The esophageal obturator airway is a device used throughout the United States to facilitate artificial respiration of critically ill patients who are not hospitalized. Its use is restricted to persons who are over 15 years old because obturators for children are not available. A protocol submitted to an institutional review board intended to develop EOAs suitable for use in children. The investigators proposed to perform preliminary testing of these devices on children who had sustained irreversible loss of brain function. In (...) its review of this protocol, the IRB had to confront several vexing questions. (shrink)

The role of EEG in confirming the clinical diagnosis of isolated brain death has undergone evolutionary changes since the original recommendations concerning its use. Accumulated evidence now supports that approach that the EEG can be used not only as a confirmatory test for brain death, but one which considerably facilitates making the diagnosis. Using the EEG, brain death can often be identified with absolute certainty within just a few, rather than the previously recommended 24 or more hours after a known (...) precipitating event. Guidelines to this effect have now been established. (shrink)

The philosophical idea of the death of God has had various semantic operations within dominant modern positions on human empowerment. Beginning with the significance of this, the article aims to discuss the half-life of a God who has become a metaphor. In other words, it explores the reverberation of God and God's death in secularized philosophy as well as the consequences of this for ethics and the conception of the Good. Then, the article illustrates the complex connection of this aim (...) with the Occidental delimitation of human potentialities through gleanings from Murdoch, Arendt and Badiou´s ideas about the constellation ‘worldlessness, rupture, human frailty and everydayness’. It shows that such delimitation, operative in theories that share most of the assumptions surrounding the above constellation, re-sacralizes the justification of ethics as humanist programme. Finally, it indicates how this particular delimitation of human potentialities can be revisited through the revival of the dead metaphor of the angelic and the kind of ethics it can animate. (shrink)

Concepts, such as death, life and spirit cannot be known in their quintessential nature, but can be defined in accordance with their effects. In fact, those who think within the mode of pragmatism and Cartesian logic have ignored the metaphysical aspects of these terms. According to Islam, the entity that moves the body is named the soul. And the aliment of the soul is air. Cessation of breathing means leaving of the soul from the body. Those who agree on the (...) diagnosis of brain death may not able to agree unanimously on the rules that lay down such diagnosis. That is to say, there are a heap of suspicions regarding the diagnosis of brain death, and these suspicions are on the increase. In fact, Islamic jurisprudence does not put provisions, decisions on suspicious grounds. By virtue of these facts, it can be asserted that brain death is not absolute death according to Islamic sources; for in the patients diagnosed with brain death the soul still has not abandoned the body. Therefore, these patients suffer in every operation performed on them. (shrink)

This article criticizes a range of assumptions that proponents of brain death usually share. It argues that one of the main contentions made in defense of brain death – that the brain is necessary for integrated functioning in a human organism – is mistaken. It then sketches an alternative account of human death that distinguishes between the biological death of a human organism and the death or ceasing to exist of a person.

In Denmark, which alone in Western Europe has not accepted brain death as the criterion of death, the newly established Danish Council of Ethics has issued a report suggesting that in Denmark the criterion of death should still be the cessation of cardiac activity. The council bases its conclusion on the concept of death in everyday experience and its ethical implications.

The paper comments on Scott Dunbar's "An obstructed death and medical ethics," arguing contra Dunbar that we should not view truth-telling to the terminally ill as primarily governed by principles of veracity and respect for autonomy. All such rules are of limited value in medical ethics. We should instead turn to an ethics deriving from the centrality of moral relationships and virtues. A brief analysis of the connections between moral relationships and moral rules is offered. Such an ethics would lower (...) the value that philosophical fashion places on truth-telling and autonomy and leave decisions about truth-telling and the terminally ill more dependent on the circumstances of particular cases. (shrink)

Four main areas generating confusion in discussion on brain death are identified as a) the relation of criteria of death to concepts of death, b) the argument about whether death is an event or a process, c) the inadequate differentiation of different neurological entities having different cardiac prognoses, and d) insufficient awareness of the separate issues of 'determining death' and 'allowing to die'. It is argued that if by death we mean the dissolution of the human 'organism as a whole', (...) then whole-brain death is death. Behavioural patterns, legitimate in the presence of a cadaver, should be legitimate from the time whole-brain death is diagnosed. (shrink)

Karen Quinlan, the American girl who has lain in deep coma for many months, is still 'alive', that is to say, her heart is still beating and brain death has not occurred. However, several other cases have raised difficult issues about the time of death. Dr Skegg argues that there is a case for a legal definition of death enshrined in statutory form. He suggests that many of the objections to a statutory provision on death are misplaced, and that a (...) statute concerning the occurrence of death could remove all doubts in the minds of both doctors and public as to whether a 'beating heart cadaver' was dead or alive for legal purposes. (shrink)

The dilemma of whether or not a doctor should tell a patient dying of cancer the truth remains a difficult one, as the disagreement between the two previous writers shows. One favours giving priority to patient autonomy, the other feels the doctor's duty of beneficence should be the overriding principle governing such decisions. To this contributor it seems both approaches have something to offer. By being sensitive to what and how much the patient wishes to know and by learning from (...) the insights provided by the study of medical ethics, doctors can learn how to make better moral decisions in this and in other areas. Both lying and truth-telling carry risks of harm to the patient. Learning to work with and balance these risks is part of clinical practice. So is minimising risks by clear thinking. (shrink)

John Lizza says that to define death well, we must go beyond biological considerations. Death is the absence of life in an entity that was once alive. Biology is the study of life. Therefore, the definition of death should not involve non-biological concerns.

John P. Lizza has long been a major figure in the scholarly literature on criteria for death. His searching and penetrating critiques of the dominant biological paradigm, and his defense of a theory of death of the person as a psychophysical entity, have both significantly advanced the literature. In this special issue, Lizza reinforces his critiques of a strictly biological approach. In my commentary, I take up Lizza’s challenge regarding a biological concept of death. He is certainly right to point (...) out that science is not value-free; however, this does not imply that there cannot be a characterization of biological death that can be shown to be superior to other concepts. After characterizing and justifying such a theory of biological death, I show that patients who meet the diagnostic criteria for brain death are unequivocally biologically alive. However, with respect to concepts of personhood and related ideas, I urge the acceptance of a pluralism of such concepts for matters of public policy. (shrink)

In his article, “Defining Death: Beyond Biology,” John Lizza argues in favor of a civil definition of death, according to which the potential for consciousness and social interaction marks us as the “kind of being that we are.” In this commentary, I critically discuss this approach to the bioethical debate on the definition of death. I question whether Lizza’s account is based on a full recognition of the “practical, moral, religious, philosophical, and cultural considerations” at play in this debate. I (...) further propose that a truly ethical debate on definitions of death ought to concentrate on how different definitions of death are used in diverse contexts – what definitions of death do – and focus less on who has the right definition of death for all situations. (shrink)

In the ongoing ‘brain death’ controversy, there has been a constant push for the use of the ‘higher brain’ formulation as the criterion for the determination of death on the grounds that brain-dead individuals are no longer human beings because of their irreversible loss of consciousness and mental functions. This essay demonstrates that such a position flows from a Lockean view of human persons. Compared to the ‘consciousness-related definition of death,’ the substance view is superior, especially because it provides a (...) holistic vision of the human person, and coheres with the perennial axiom about the ‘whole and parts.’. (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)

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)

Review of the book: Człowiek na granicy istnienia. Dyskusje o śmierci mózgowej i innych aspektach umierania, Grzegorz Hołub, Piotr Duchliński, Akademia Ignatianum w Krakowie, Wydawnictwo WAM, Kraków 2017.

The article provides a critical overview of the Polish bioethics literature concerning the shortage of organs for transplantation. Problems related to this issue bear, to a considerable degree, on the attempt to answer the question how to increase the number of organs available in ethically acceptable ways. Polish authors have focused, in this respect, on the analysis and assessment of two solutions: an opt out system of acquiring organs and a system that allows the aquisition of organs on a “free (...) market”. Both solutions have been almost unanimously negatively assessed. Apart from the presentation and critique of the positions of Polish bioethicists on this matter, an important part of the text is constituted by a report from a debate, held at the national level, on the criteria and definition of death: for it is only from the deceased donors that unpaired bodily organs, such as heart, can be taken. (shrink)

In this paper, I would like to argue that brain-dead small children have a natural right not to be invaded by other people even if their organs can save the lives of other suffering patients. My basic idea is that growing human beings have the right to grow in the form of wholeness, and dying human beings also have the right to die in the form of wholeness; in other words, they have the right to be protected from outside invasion, (...) unless they have declared their wish to abandon that right beforehand. I call this the principle of wholeness. Natural rights, which were discussed by Hobbes and Locke in the 17th century, have to be extended to include the right to grow and die in the form of wholeness in the age of scientific civilization, where peripheral human lives are being threatened by aggressive biomedicine and other advanced technologies. (shrink)

Prisoners sometimes die in prison, either due to natural illness, violence, suicide, or a result of imprisonment. The purpose of this study is to understand deaths in custody using qualitative methodology and to argue for a comprehensive definition of death in custody that acknowledges deaths related to the prison environment. Interviews were conducted with 33 experts, who primarily work as lawyers or forensic doctors with national and/or international organisations. Responses were coded and analysed qualitatively. Defining deaths in custody according to (...) the place of death was deemed problematic. Experts favoured a dynamic approach emphasising the link between the detention environment and occurrence of death rather than the actual place of death. Causes of deaths and different patterns of deaths were discussed, indicating that many of these deaths are preventable. Lack of an internationally recognised standard definition of death in custody is a major concern. Key aspects such as place, time, and causes of death as well as relation to the prison environment should be debated and incorporated into the definition. Systematic identification of violence within prison institutions is critical and efforts are needed to prevent unnecessary deaths in prison and to protect vulnerable prisoners. (shrink)

This article discusses the conceptual ambiguities in relation to the current definitions of ‘death’. It addresses the need for an essentially pluralistic approach that probes the limits of epistemic singularity and perceives death as an open concept. Despite the views dependent upon the irrevocable termination of existence, I assume the opposite: first, that there are manifold ways to respond philosophically to the issue, without giving priority to any sovereign or prescribed position; second, that the plurality of unequally convincing positions opens (...) up the ‘democratic’ space of negotiations about life and death as a political space par excellence, privileged by philosophy. Finally, my thesis about the thanatological pluralism gets closer to what I shall call the ‘political philosophy of death’ in the future studies of the issue, here insufficiently explored. (shrink)

McGovern, Kevin How might we prepare well for death? And how might we help other people also to prepare well for death? Spiritual guide Henri Nouwen suggests that we should strive to recognise that we are children of God, brothers and sisters of one another, and parents of the generations to come. This article explores what he means.

The Death of Art evaluates the philosopher Theodor W. Adorno's ideas on music, visual arts, and literature and their relevance to today's mass culture. This book is a comprehensive and clear overview of Adorno's cultural theories and their impact.