Abstract
In this paper, I argue that brain death is death because, despite the appearance of genuine integration, the brain-dead body does not in fact possess the unity that is proper to a human organism. A brain-dead body is not a single entity, but a multitude of organs and tissues functioning in a coordinated manner with the help of artificial life support. In order to support this claim, I first lay out Hoffmann and Rosenkrantz’s ontological account of the requirements for organismal unity and summarize an earlier paper in which I apply this account to the brain death debate. I then further support this ontological argument by developing an analogy between the requirements for the unity of an organism and the requirements for the unity of an orchestra. To do so, I begin by examining the role that a conductor plays in unifying a traditional orchestra, and then go on to show that the human organism (at least in postnatal stages) functions like a traditional orchestra that relies upon a conductor (the brain) for its unity. Next, I consider the conditions required to achieve orchestral unity in conductorless orchestras and show that, in contrast to simpler organisms like plants, the postnatal human organism lacks those conditions. I argue, in other words, that although conductorless orchestras do exist, the human organism is not one of them. Like a traditional orchestra without a conductor, the brain-dead body is not a unified whole.
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Notes
For an ontological analysis and defense of this view, see [3].
I discuss Shewmon’s account at greater length later on.
This point is crucial for understanding why the brain-dead body is not analogous to the impaired (but still unified) traditional orchestra playing a piece it has already learned in the absence of a conductor. For unlike the orchestra’s members, the brain-dead body’s parts do not in any sense have a “vision of the whole” and thus lack an essential condition for unity, as I explain in more detail below.
Shewmon downplays the importance of centralized regulation, however, because he fails to appreciate the crucial significance of this regulatory role for human organismal unity.
The kidneys (and perhaps the gastrointestinal tract, according to one recent study [11]) also play a role in long-term blood pressure regulation, largely through the maintenance of sodium balance. However, renal blood pressure regulation mechanisms work more slowly than neural mechanisms both in sensing and in responding to unhealthy blood pressure levels; they are thus insufficient when an immediate adaptive response is required. It is therefore no surprise that some brain-dead bodies can maintain adequate blood pressure, given that renal blood pressure regulation mechanisms are still functioning (as they are even in living kidneys ex vivo) and that blood pressure maintenance is much easier in a body that always remains in a supine position. Even so, the capacity to maintain adequate blood pressure is severely impaired in brain-dead bodies, as shown by their reliance on vasopressors and on drugs like hydrocortisone and fludrocortisone, which help to raise blood pressure through their effect on sodium and fluid balance [11, 12].
On the basis of the claim, with which I agree, that all parts of the body contribute to its unity and that this unity is not itself localizable, Shewmon concludes—as though the two claims were effectively equivalent—that no single part (or set of parts) plays an irreplaceable role in the body’s unification. Yet the latter claim neither amounts to nor follows from the former. One can see the conflation of these two claims in the following passage:
The unity of a living organism … is a unity in the strict, “substantial” sense: the parts are not merely a set of entities in their own right that happen to be coordinated by some other entity external to the set; rather, they are only conceptually, not ontologically distinct, each existing not “in itself” but only virtually, as a component of a higher-level entity. Each part both contributes to and is subordinated to the transcendent unity, and the equality of ontological level of “part-hood” (as opposed to “entity” or “substance”) is not contravened by the evident multiplicity of ways of contributing to the higher unity. This unity-contributing, as distinct from unity-conferring, role is as true of the brain as it is of the little toenail, notwithstanding the fact that the brain’s contribution to the long-term maintenance of vitality is considerably more important than the toenail’s. [Note that Shewmon believes no organ or set of organs has a unity-conferring role.] Though much more precariously alive without brain-function than without toenail function, the body can remain alive without either (perhaps with medical assistance), precisely because its unity is truly “integrative” and therefore not intrinsically deriving from or dependent on any single part. [7, p. 472]
Up until the last sentence, everything Shewmon claims here is completely compatible with my account of organismal unity. The problem with Shewmon’s argument lies in the false inference (“and therefore not … dependent on any single part”) in this final sentence.
Obviously I am speaking metaphorically here. As I explain further below, the idea of “knowing” the functions of other parts of the body seems analogous to the pluripotency of many of the cells in relatively simple organisms with a decentralized master part. In organisms with a centralized master part, the master part’s “knowledge” of other parts seems to consist in a sense of the ranges within which the measures of each vital part’s activities should fall. And the idea of having a “vision” of the whole and the ability to communicate that vision seems to be analogous to the capacity to receive information from all of the other vital parts and regulate them so as to maintain the measures of their biological activities within a healthy range.
A pluripotent cell contains active genetic instructions for the others’ parts. It could thus be said to have access to (and be able to “read”) the whole musical score, as it were, in contrast to the players in a traditional orchestra who typically have a copy of only their own parts. I am not exactly sure how (or even if) the pluripotency—or, in some cases, totipotency—of the cells in organisms with decentralized master parts facilitates their unified functioning, but the pluripotency or totipotency of at least many of the organisms’ cells appears to be a common feature among them. It therefore strikes me as noteworthy that there is some parallel between the knowledge of the whole score possessed by members of a conductorless orchestra and the pluripotency or totipotency that is typical of at least many of the cells in organisms with decentralized master parts.
I used to think that a brain-dead body’s ability to continue performing some basic functions with artificial support was analogous to the ability of a traditional orchestra to continue to play pieces that they had already learned under the guidance of a conductor. I realize now, however, that this is not the case: the crucial unifying work of the conductor has already been done during rehearsals, such that the individual players have now also to a large extent made the conductor’s vision of the whole their own. This is possible because each of the players is capable of having a conductor-like vision of the whole, but the parts of the human body, other than the brain, do not have this capacity.
Here I have (using his own words) summarized Shewmon’s criterion for organismal unity. The complete criterion is as follows: “‘Integrative unity’ is possessed by a putative organism (i.e., it really is an organism) if the latter possesses at least one emergent, holistic-level property. A property of a composite is defined as ‘emergent’ if it derives from the mutual interaction of the parts, and as ‘holistic’ if it is not predicable of any part or subset of parts but only of the entire composite” [7, 460]. Shewmon later recognizes that this criterion is not sufficient for distinguishing organismal unity from other types of unity (such as social unity), and adds a second criterion: “living organisms topologically demarcate ‘self’ from ‘non-self’ by a continuous, closed membrane, across which matter is exchanged bidirectionally with the environment” [7, p. 461]. Even when taken together, however, these two criteria do not explain why the protozoans in the termite’s gut are distinct organisms and not parts of the termite or, to add another example, why dicephalus conjoined twins, which have two heads but share a number of vital organs within a continuous closed membrane, are not a single organism.
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Acknowledgements
I would like to thank Farr Curlin and Michael Gorman for their insightful comments on previous drafts of this article, as well as Daniel Sulmasy and the McDonald Agape Foundation for making possible the conference at which this paper was first presented.
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Moschella, M. The human organism is not a conductorless orchestra: a defense of brain death as true biological death. Theor Med Bioeth 40, 437–453 (2019). https://doi.org/10.1007/s11017-019-09501-z
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DOI: https://doi.org/10.1007/s11017-019-09501-z