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)

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)

The Uniform Determination of Death Act (UDDA) provides that “an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.” We show that the UDDA contains two conflicting interpretations of the phrase “cessation of functions.” By one interpretation, what matters for the determination of death is the cessation of spontaneous functions only, regardless of their generation by artificial means. By the (...) other, what matters is the cessation of both spontaneous and artificially supported functions. Because each UDDA criterion uses a different interpretation, the law is conceptually inconsistent. A single consistent interpretation would lead to the conclusion that conscious individuals whose respiratory and circulatory functions are artificially supported are actually dead, or that individuals whose brain is entirely and irreversibly destroyed may be alive. We explore solutions to mitigate the inconsistency. (shrink)

In his paper “The challenge of brain death for the sanctity of life ethic”, Peter Singer advocates two options for dealing with death criteria in a way that is compatible with efficient organ transplantation policy. He suggests that we should either redefine death as cortical death or go back to the old cardiopulmonary criterion and scrap the Dead Donor Rule. We welcome Singer’s line of argument but raise some concerns about the practicability of the two alternatives advocated by him. We (...) propose adding a third alternative that also – as the two previous alternatives – preserves and extends the possibility of organ transplantation without using anyone without their consent. Namely, we would like to draw readers’ attention to a proposal by Robert Veatch, formulated 42 years ago in his 1976 book “Death, dying, and the biological revolution” and developed further in his later publications. Veatch argues for a conscience clause for the definition of death that would permit people to pick from a reasonable range of definitional options. This autonomy-based option, we believe, is more likely to be practicable than the two options advocated by Singer. Furthermore, we present data from a study with Lithuanian participants that suggest that there is quite pronounced variation of preferences concerning death determination. (shrink)

In organ transplantation, there is a lack of ethical discussion about the recipient’s right not to receive a transplant. Using the current situation of living organ transplantation and deceased organ transplantation in Japan as an example, we prospectively discussed to what extent the recipient’s right not to receive a transplant is ethically acceptable. In directed transplantation from a living donor, a recipient may refuse organ donation from a particular donor. It is preferable that a recipient’s request for organ donation from (...) a donor occurs as part of a transparent process. In nondirected transplantation from a deceased donor, refusal of transplantation from a particular type of donor appears potentially justifiable. There are both moral and pragmatic considerations. Certain refusals based solely on belief are morally unacceptable, and refusal to transplant a recipient based on the donor’s age jeopardizes the entire transplant system. When religious beliefs affect mental and physical health, individualized measures are required for transplant rejection. We also deductively developed a prospective argument based on the current status of donor–recipient communication in living organ transplantation in Japan and the 2010 amendment of the law allowing relatives to be given priority in organ transplantation from deceased donors. (shrink)

BackgroundThis essay provides an ethical and conceptual argument for the use of informed consent prior to the diagnosis of brain death. It is meant to enable the family to make critical end-of-life decisions, particularly withdrawal of life support system and organ donation, before brain death is diagnosed, as opposed to the current practice of making such decisions after the diagnosis of death. The recent tragic case of a 13-year-old brain-dead patient in California who was maintained on a ventilator for over (...) 2 years illustrates how such a consent would have made a crucial difference.MethodsConceptual, philosophical, and ethical analysis.ResultsI first consider a conceptual justification for the use of consent for certain non-beneficial and unwanted medical diagnoses. I suggest that the diagnosis of brain death falls into this category for some patients. Because the diagnostic process of brain death lacks the transparency of traditional death determination, has a unique epistemic structure and a complex risk-benefit profile which differs markedly from case to case, and presents conflicts of interest for physicians and society, I argue that pre-diagnostic counseling and informed consent should be part of the diagnostic process. This approach can be termed as “allow cardiac death”, whose parallel logic with “allow natural death” is discussed. I also discuss potential negative impacts on organ donation and health care cost from this proposal and offer possible mitigation. I show that the pre-diagnostic counseling can improve the possibility for well-thought-out decisions regarding organ donation and terminating life-support system in cases of hopeless prognosis. This approach differs conceptually from the pluralism of the definition of death, such as those in New Jersey and Japan, and it upholds the Uniform Determination of Death Act.ConclusionsMy intention is not to provide an instant panacea for the ongoing impasse of the brain death debate, but to point to a novel conceptual ground for a more pragmatic, and more patient- and family-centered approach. By enabling the family to consent to or decline the diagnostic process of brain death, but not to choose the definition of death, it upholds the current legal definition of death. (shrink)

BackgroundThe increasing debate on financial incentives for organ donation raises concerns about a "commodification of the human body". Philosophical-ethical stances on this development depend on assumptions concerning the body and how people think about it. In our qualitative empirical study we analyze public attitudes towards organ donation in their specific relation to conceptions of the human body in four European countries (Cyprus, Germany, the Netherlands and Sweden). This approach aims at a more context-sensitive picture of what "commodification of the body" (...) can mean in concrete clinical decisions concerning organ donation.ResultsWe find that moral intuitions concerning organ donation are rooted in various conceptions of the human body and its relation to the self: a) the body as a mechanical object owned by the self, b) the body as a part of a higher order embodying the self, and c) the body as a hierarchy of organs constitutive of the self.ConclusionThe language of commodification is much too simple to capture what is at stake in everyday life intuitions about organ donation and organ sale. We discuss how the plurality of underlying body-self conceptions can be taken into account in the ethical debate, pointing out consequences for an anthropologically informed approach and for a liberal perspective. (shrink)

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

During the past few months, the discussion over the physicians' “Right of Conscience” has been on the rise. The intervention of politics in this issue shifts the discussion to a very specific and narrow area, namely the “reproductive health laws” which bear well-known predisposing attitudes.In this article, the physician's ROC is discussed in the context in which it naturally belongs: the Patient Physician Relationship . I suggest that the physicians' rights demand is a comprehensible, predictable, and even inevitable step as (...) part of the “evolution” of the PPR. Thus, the most appropriate way to comprehend and tackle the demand for physicians' ROC is within the context of medical professionalism. While searching for practical solutions to the “reproductive health” problems, there is a need to recognize the ethical and practical implications of the change in the PPR and balance between patient and physician rights. (shrink)

Recently, the discussion regarding the physicians’ “Right of Conscience” has been on the rise. This issue is often confined to the “reproductive health” arena within the political context. The recent dispute of the Bush-Obama administrations regarding the legal protections of health workers who refuse to provide care that violates their personal beliefs is an example of the political aspects of this dispute. The involvement of the political system automatically shifts the discussion regarding physicians’ ROC into the narrow area of “reproductive (...) health laws.” Indeed, the immediate association that comes to mind when thinking about the practical implications of this dispute is related to the reproductive health arena. This is partly because of the historical context of the first “conscience clauses,” initially enacted by Congress and state legislatures in the mid-1970s; in fact, most of these clauses provided specific exemptions for abortion and few exempted sterilization as well. (shrink)

Expressing doubts about death criteria can serve healthy purposes, but can also cause a number of harms, including decreased organ donation rates and distress for donor families and health care staff. This paper explores the various causes of doubts about death criteria—including religious beliefs, misinformation, mistrust, and intellectual questions—and recommends responses to each of these. Some recommended responses are relatively simple and noncontroversial, such as providing accurate information. However, other responses would require significant changes to the way we currently do (...) business. Policymakers should establish minimum national standards for determining death to foster a trustworthy system; academics and publishers have a duty to publish only materials that substantially engage and advance the debate to minimize the harm caused by divided expert opinion; and opposition to the dead donor rule should be conceptually separated from doubts about death criteria. (shrink)

Several authors in bioethics literature have expressed the view that a whole brain conception of death is philosophically indefensible. If they are right, what are the alternatives? Some authors have suggested that we should go back to the old cardiopulmonary criterion of death and abandon the so-called Dead Donor Rule. Others argue for a pluralist solution. For example, Robert Veatch has defended a view that competent persons should be free to decide which criterion of death should be used to determine (...) their death. However, there is very little data on people’s preferences about death determination criteria. We conducted online vignette-based survey with Latvian participants (N = 1416). The data suggest that the pluralist solution fits best with the way our study participants think about death determination—widely differing preferences concerning death determination criteria were observed. Namely, most participants choose one of the three criteria discussed in the literature: whole brain, higher brain, and cardiopulmonary. Interestingly, our data also indicate that study participants tend to prefer less restrictive criteria for determination of their own deaths than for determination of deaths of their closest relatives. Finally, the preferences observed in our sample are largely in accord with the Dead Donor Rule for organ procurement for transplantation. (shrink)

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)

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)

Alireza Bagheri supports a policy on organ procurement where individuals could choose their own definition of death between two or more socially accepted alternatives. First, we claim that such a policy, without any criterion to distinguish accepted from acceptable definitions, easily leads to the slippery slope that Bagheri tries to avoid. Second, we suggest that a public discussion about the circumstances under which the dead donor rule could be violated is more productive of social trust than constantly moving the line (...) between life and death. (shrink)

Due to the worldwide shortage of organs for transplantation, there has been an increased use of organs obtained after circulatory death alone. A protocol for this procedure has recently been approved by a major transplant consortium. This development raises serious moral and ethical concerns. Two renowned theologians of the previous generation, Paul Ramsey and Moshe Feinstein, wrote extensively on the ethical issues relating to transplantation, and their work has much relevance to current moral dilemmas. Their writings relating to definition of (...) death, organ transplantation and the care of the terminally ill are briefly presented, and their potential application to the moral problem of organ donation after circulatory death is discussed. (shrink)

: Introduction : This review article is based on jurisprudential rulings, legal approaches, social aspects, medical and ethical approach perspectives, and clarifies decisions related to the issue of brain death. Correct understanding of the brain death phenomenon in terms of brain structure and functioning, and the attitude of the community towards this phenomenon, and in particular the understanding of the condition of a patient with brain death in the future, will modify the form and content of the type of decision (...) and process of the content. Human after the spirit insufflation will have been moral identity, and this identity remains with him until death and even after it.Brain death is a Neologism that hase propeled Experts in the fields of medicine, theology, law and even public to Try and Challenging the vague secret of death.Consistency Braindeath with absolute death Has serious pros and cons Which each other By resorting to Arguments desired, Try to Proving their alleged tendency views. Method: This research is a review article with Analytical descriptive and correlational method, by collecting information through the in which the resources include books, articles and electronic resources from the library of the Museum of History of Medicine and Central Library and Electronic Resources in the search engines google scholar, Pubmed, Direct Science, Ovid, SID, Iran medex and in If necessary, other databases have been searched by keywords. Discussion: Brain death is accepted in many countries as certain death. Sum Of the arguments seem to brain death is unequivalent exactly to certain death and don’t lapses human from humanity and At least the existence. the concepts of spirit, life and death,can be understood not by their quiddity but by their effect. according to Islamic thoughts, life and death is based on the presentation and separation soul from the body. It is seemed on the Islamic thought basis, Result : Brain death isnchrt realy equivalent with certain death because it has not broken relatinsheep between the spirit and body perfectly. From the perspective of medical ethics this is important that be accepted harvesting Vital organs from brain dead patients is cause of death them. Assuming the viability of brain dead patients, harvest any organ that led to his death is morally unacceptable Except with prior permission or substitute decision maker. (shrink)