It was the Greek philosopher, Epicurus who said that “Death does not concern us, because as long as we exist, death is not here. And when it does come, we no longer exist.” To many, defining the precise moment of death may appear to be an intellectual and academic exercise in comparison to the enormous emotional impact that is felt by family and friends of a loved one passing away. But defining death becomes extremely crucial when one begins to consider the matter of organ donation and transplantation.
Without an understanding of when someone is dead, there is the risk of removing organs from someone who could be still alive. Indeed it is this state of affairs which prompted the President’s Council on Bioethics in the USA to publish a white paper in December 2008 on this question and to offer a new philosophical explanation of how to recognise death.
Cardiac cessation and brain death
One may have thought that with developments and advances in science understanding the distinction between life and death would have become more distinct. Not so. In fact the very reverse has occurred. Up until the mid-20th century it was the widely held belief that someone died when their heart stopped beating. However, technological development has challenged this belief by providing the ability to allow a person’s heart to keep on beating and lungs to continue pumping despite severe brain failure.
Therefore, in response came arguments based upon neurological reasoning. If both high and low level brain activity ceased with no opportunity for recovery, there was no way the person could recover despite medical technology maintaining heart and lung functionality. Someone in this position is defined by medics as “ventilated, heart beating cadaver” and it is from such cadavers that most of the vital organs used for transplantation come from.
The term “brain death” has not been without its criticism. A number of doctors argue that some one who may well be defined as ‘brain death’ can still in fact perform some functions that can also be attributed to a living person. American paediatric neurologist, Alan Shewmon, for example points to the fact that wounds can heal, woman can sustain a healthy pregnancy and children can become sexually mature [1]. Acting on such an assumption would mean that organ donation would be seriously affected with a dramatic decline in available donors owing to the fact that a ‘brain dead’ person would be deemed to be still alive and not dead.
On the other hand, some doctors believe that nearly dead is dead enough. Despite the fact that someone may be able to breathe on their own, if they have irreversible brain damage then they are dead enough to permit the harvesting of organs from them.
As Keim notes, writing in his blog for Wired magazine [2], such a state of affairs present the medical profession with a number of choices; do they remove organs from someone who could be argued is still alive; loosen the standards of brain death or return to the former way of thinking of cardiac death.
Controversies in the determining death
In response to these issues, the President’s Council white paper, “Controversies in the determination of death”, attempts to bring some definition to this question. In so doing it has given support to the neurological standard that total brain failure is the standard upon which to assess whether an organism is dead. Adopting the term ‘engagement with the world’, the paper conjectures that an organism is dead when it no longer responds to and interacts with the environment.
However, from reading the white paper it is riddled with incoherency largely caused by the bizarre and ambiguous language used within in. For example, on p.3 of the report, it states that any form of life support machine “is, in essence, ventilating a corpse—albeit one that in many ways does not look like a corpse”. The paper proceeds to define a brain dead patient, as a “heart beating cadaver” (p.8). However as the reader proceeds through the paper, the language becomes more confusing and muddled. In laying out the basis for total brain failure, the Council acknowledge that in this state the body displays aspects of what is termed ‘somatic health’. In discussing this, the report states that “if the body is a cadaver, then, of course, it is no longer fitting to speak about its ‘health.’ Nonetheless, something like health is still present in the body of a patient with this diagnosis” (p. 39). So what is it? What is the paper trying to attempt to communicate here? As Miller acknowledges, is this simply characteristic of this particular debate that what appears to be true is in fact not the case? [3]
The Council acknowledge that “the apparent signs of life that remain – a beating heart, warm skin, and minimal, if any, signs of bodily decay – are a sort of mask that hides from plain sight the fact that the biological organism has ceased to function as such” (p. 3). Contrarily, considering the work of Shewmon et al, the question remains though just how can a corpse gestate a foetus. How can a corpse eliminate waste? If it is a case that when all vital functions of the organism cease to function then death occurs, then patients diagnosed with ‘total brain failure’ cannot be said to be dead.
Engagement with the world
At this juncture, the paper introduces the Council’s discussion of “the vital work of a living organism” (p.60). Gilbert Meilaender, one of the Council’s staff, comments that “We try to think of organisms as engaging in a work of self preservation. To be living is to be engaged in that work. To die is to cease to be engaged”.
According to the paper, such engagement takes place and its vital work satisfied when it exhibits (1) “receptivity to stimuli and signals from the surrounding environment,” (2) “the ability to act upon the world to obtain selectively what it needs,” and (3) “the basic felt need that drives the organism to act as it must, to obtain what it needs” (p. 61). Based upon such criteria, the paper states that patients with a diagnosis of total brain failure completely fail to meet these criteria. In contrast, a patient in a persistent vegetative state, breathing spontaneously but showing no signs of consciousness, completely fulfil these criteria.
As the criteria stands at the moment the detail is rather pithy making it difficult to reach any definite conclusion as to whether a patient who has been diagnosed with ‘total brain failure’ is actually dead. For example, surely possessing the ability to eliminate waste, or fight infection and see wounds heal is a demonstration of receptivity to stimuli and signals from the surrounding environment as well as the ability to act upon the world accordingly. It is the view of this author that the white paper does not appear to offer any substantial and coherent argument as to why a patient with total brain failure does not fulfil these criteria and consequently should be considered as dead.
Subsequently, rejecting total brain failure as constituting death means that two issues merge. It becomes unethical to remove organs from patients who are understood to be alive but have total brain failure. Obviously, this in turn significantly impacts upon the vital organ donation and transplantation process. The practice of “donation after cardiac death” could be one further option. However, reverting to the standard of cardiac death would mean that medical staff would have to wait for the heart to stop beating. It is now understood that even the shortest interruption of blood flow through the heart cause vital organs to be rendered unusable in another body.
Adding to the rather bizarre nature of the paper, Council member Arthur Caplan comments that “People are getting nervous that we're pushing the standard of death in order to get organs. The public is afraid that surgeons in search of organs for transplant will bend the definition of death to get them….This report keeps that bright line in place” [4]. But the paper has surely done just that? All that the white paper has done is accommodate the change in the definition and sought to give strength and support to it.
Theory vs practice
The fact that the Council’s white paper appears to be muddled and lacking coherency in its arguments can probably be explained by the paradox that clearly exists between theory and practice. The contemporary neurological standards for determining death appear not to stack up from a theoretical perspective and yet these standards help to support and promote vital organ donation. What can be done to overcome this conflict? Can the conflict between the two be appeased or will it continue? These are clearly questions which need to be addressed and once again brought into the public arena for discussion. In this regard, the Council’s white paper helps to initiate the discussion. It is a document which brings together contemporary current thinking and perspectives on the scientific, ethical and medical issues. The next step must surely be to expose this to careful rigorous debate and scrutiny amongst the science, science communication and public policy communities in order to work out and develop appropriate policy.
The President’s Council on Bioethics white paper, entitled “Controversies in the determination of death” can be downloaded at http://www.bioethics.gov/reports/death/index.html
[1] “Brain-death standard defended by bioethics council”, BioEdge news, http://www.bioedge.org/index.php/bioethics/bioethics_article/brain_death_standard_defended_by_bioethics_council/
[2] Keim, B. (2009), “Bioethicists Save Organ Donation by Tweaking the Definition of Death”, http://blog.wired.com/wiredscience/2009/01/braindeath.html
[3] Miller, F. (2009), “Muddling Through? A Commentary on Controversies in the Determination of Death”, http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=3148
[4] Keim, B. (2009), “Bioethicists Save Organ Donation by Tweaking the Definition of Death”, http://blog.wired.com/wiredscience/2009/01/braindeath.html
