This stimulating and provocative paper by Professor Appel, Defining death: when physicians and families differ, asks us to consider (in the context of United States health care where, we are inclined to suppose, autonomy enjoys a primacy among moral considerations) “whether patients’ families should be permitted to opt out of widely accepted definitions of death in favour of their own standards”. This is a striking question in many ways. It reminds us that, as a simple description of fact, there are indeed different standards for human death in so far as different groups or communities (which can be professional as well as geographical or cultural) have accepted and continue to accept varying notions of what constitutes human death. The question’s reference to “opting out” suggests, perhaps reasonably, that it seems prima facie odd to think of adopting a definition of death as being a matter of individual choice. The reference to “permission” invites us to suppose limitations, primarily legal, upon the extent to which such a choice could be tolerated. Also, the question ascribes to certain “definitions of death” (note the plural) the authority of being widely accepted. The definitions thus favoured are, we learn, the various formulations of death referring to the state of the brain, chief among them “whole brain death” although the author is troublingly vague over whether all such formulations are morally, legally, or conceptually equivalent; and the relevant communities of acceptance turn out to consist of many—but, as the author admits, not all—physicians labouring under varying and inconsistent jurisdictions in the United States.

My preface to the criticisms that follow is a …