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)

In this book, Douglas Walton examines the philosophical nature of two issues currently associated with medical ethics. In order to work towards an analysis of the concept of death that could function as a target towards which the medical criteria of death could be directed, he proposes the foundations for a theory free of logical contradictions, paradoxes, and other perplexities. This is the "superlimiting theory" which introduces the notion of a "possible person." The connection of these philosophical ideas (...) with medico-legal concerns like brain death and the Harvard criteria is discussed. Professor Walton then goes on to examine the difference between killing and letting die. Through a close study of the logic of action sentences, he develops a model that is discussed in the light of the ethical and jurisprudential realities of medical ethics to see if the distinction between bringing something about and letting something happen is one that makes a moral difference in the evaluation of actions. Numerous problematic conceptual snags are dealt with, and the author consistently supports the conceptual clarity and respectability of the distinction. Other relevant discriminations of an action-theoretic sort, such as that between "direct" and "indirect" euthanasia, are studied, and the concluding chapter applies the conceptual analysis to a philosophical discussion of attitudes towards death, asking, "Is it rational to fear death?". (shrink)

This paper discusses how alternative concepts of personhood affect the definition of death. I argue that parties in the debate over the definition of death have employed different concepts of personhood, and thus have been talking past each other by proposing definitions of death for different kinds of things. In particular, I show how critics of the consciousness-related, neurological formation of death have relied on concepts of personhood that would be rejected by proponents of that formulation. (...) These critics rest on treating persons as qualitative specifications of human organisms or as identical to human organisms. Since advocates of the consciousness-related, neurological formulation of death are not committed to either of these views of personhood, these critics commit the fallacy of attacking a straw man. I then clarify the substantive concept of personhood that may be invoked in the consciousness-related, neurological formulation of death, and argue that, on this view and contra Bernat, Culver, and Gert, persons have always been the kind of thing that can literally die. I conclude by suggesting that the discussion of defining death needs to focus on which approach to personhood makes the most sense metaphysically and morally. (shrink)

New Blackfriars, Volume 103, Issue 1107, Page 607-621, September 2022.

In this article I examine the question of how a liberal state should go about defining death. Plausible standards for a definition of death include a somatic one based on circulatory criteria, death by neurologic criteria (DNC), and higher brain death. I will argue that Rawlsian “burdens of judgment” apply in this process: that is, reasonable disagreement should be expected on important topics, and such disagreement ought not be resolved via the coercive powers of the (...) state. Nevertheless, the state must legislate a definition of death, and in doing so faces a “neutralist dilemma,” that is, when there are multiple reasonable ways to move forward, only one can be chosen. I will examine a possible way to exit this neutralist dilemma. Finally, I will argue for DNC as the normatively preferred default definition of death. To do this, I will employ the Rawlsian heuristic of the “original position” and offer public reasons in favor of using DNC as the preferred default definition of death. (shrink)

The recently published World Brain Death Project aims in alleviating inconsistencies in clinical guidelines and practice in the determination of death by neurologic criteria. However, critics have taken issue with a number of epistemic and metaphysical assertions that critics argue are either false, ad hoc, or confused. In this commentary, I discuss the nature of a definition of death; the plausibility of neurologic criteria as a sensible social, medical, and legal policy; and within a Rawlsian liberal framework, (...) reasons for personal choice or accommodation among neurologic and circulatory definitions. Declaration of human death cannot rest on contested metaphysics or unmeasurable standards, instead it should be regarded as a plausible and widely accepted social construct that conforms to best available and pragmatic medical science and practice. The definition(s) and criteria should be transparent, publicly justifiable, and potentially allow for the accommodation of reasonable choice. This is an approach that situates the definition of death as a political matter. The approach anticipates that no conceptualization of death can claim universal validity, since this is a question that cannot be settled solely on biologic or scientific grounds, rather it is a matter of normative preference, socially constructed and historically contingent. (shrink)

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the (...) brain, whether standard criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

Protocols for retrieving vital organs in consenting patients in cardiovascular arrest rest on the assumptions that irreversible asystole a) identifies the instant of biological death, and b) is clinically assessable at the time when retrieval of vital organs is possible. Unfortunately both assumptions are flawed. We argue that traditional life/death definitions could be actually inadequate to represent the reality of dying under intensive support, and we suggest redefining NHBD protocols on moral, social, and antrhopological criteria, admitting that irreversible (...) asystole can only equate a clinically determinable point of no return in the process of dying, where organ retrieval can be morally and socially accepted in previously consenting patients. (shrink)

Whether the law should permit individuals to opt out of accepted death standards is a question that must be faced and clarifiedWhile media coverage of the Terri Schiavo case in Florida has recently refocused public attention on end of life decision making, another end of life tragedy in Utah has raised equally challenging—and possibly more fundamental—questions about the roles of physicians and families in matters of death. The patient at the centre of this case was Jesse Koochin, a (...) six year old boy suffering from “inoperable and incurable” brain cancer. He had been undergoing care at Primary Children’s Medical Center in Salt Lake City since September 15, 2004 when “his tumor pushed his brain stem down through the skull”.1 Subsequently, two physicians independently determined that the child was “brain dead” and informed his parents that they would order life support removed within twenty four hours. Steve and Gayle Koochin overtly rejected the hospital’s definition of death. The couple, relying on traditional notions of cardiopulmonary death, obtained a restraining order to keep Jesse on a ventilator and ultimately removed the brain dead child from the hospital. The ongoing case raises the complex question of whether patients’ families should be permitted to opt out of widely accepted definitions of death in favour of their own standards.The definition of death has evolved rapidly in the United States over the past thirty five years. Until the middle of the twentieth century, the medical community, the legal system, and an overwhelming majority of the public understood death to …. (shrink)

In this book, Douglas Walton examines the philosophical nature of two issues currently associated with medical ethics. In order to work towards an analysis of the concept of death that could function as a target towards which the medical criteria of death could be directed, he proposes the foundations for a theory free of logical contradictions, paradoxes, and other perplexities. This is the "superlimiting theory" which introduces the notion of a "possible person." The connection of these philosophical ideas (...) with medico-legal concerns like brain death and the Harvard criteria is discussed. Professor Walton then goes on to examine the difference between killing and letting die. Through a close study of the logic of action sentences, he develops a model that is discussed in the light of the ethical and jurisprudential realities of medical ethics to see if the distinction between bringing something about and letting something happen is one that makes a moral difference in the evaluation of actions. Numerous problematic conceptual snags are dealt with, and the author consistently supports the conceptual clarity and respectability of the distinction. Other relevant discriminations of an action-theoretic sort, such as that between "direct" and "indirect" euthanasia, are studied, and the concluding chapter applies the conceptual analysis to a philosophical discussion of attitudes towards death, asking, "Is it rational to fear death?". (shrink)

Michael Nair-Collins and Franklin Miller are right to emphasise that, in order to deliberate responsibly about ethical and legal questions related to brain death and organ donation, it is crucial to answer the question of whether or not ‘brain death’i does indeed mark the biological death of the organism. Nonetheless, I disagree with the authors’ conclusion that brain death does not indicate the death of the human organism. Death can never be defined in merely (...) biological terms, because any biological conception of death relies on metaphysical presuppositions regarding what it means to be an ‘organism as a whole’, rather than an aggregate of cells and tissues. Death is a change in substance —that is, a change from one type of entity to another — not the cessation of all biological life. Organismal death occurs well before all of the organism’s parts irreversibly cease vital activity and decompose into inorganic matter. Biological life in some form can and usually does continue after organismal death at least for a time, with recent evidence indicating that animal cell networks continue to perform complex functions like stress response, immune response and inflammation response up to several days postmortem.1 With external support, many cells and tissues can continue to perform their functions ex vivo for long periods of time or even indefinitely.2 Henrietta Lax died in 1951, but cells derived from her cancerous cervical cells …. (shrink)

ABSTRACT Modern technology has made it uncertain as to when exactly death occurs, and this has put us in a quandary over when we can initiate behaviour traditionally deemed apt if and only if a patient is dead. In the light of this, there is general agreement that death should be redefined, but wide disagreement remains about how. I argue, against this, that it is a mistake to redefine death in any way: (1) redefining death will (...) not help to settle the question of when traditional death‐behaviour becomes appropriate, (2) any attempt to redefine death is attended with significant disutilities and no compensating utilities, and (3) the practical problems generated by the indeterminacy can be better handled in other ways. (shrink)

While there may be a place in some contexts for high handed, “blanket” legislative prohibitions on dissenting views of what constitutes death, the paper under consideration does not describe such a contextThis stimulating and provocative paper by Professor Appel, Defining death: when physicians and families differ, asks us to consider “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 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” 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 …. (shrink)

Offers objections to cognitive definitions of death. Death is a biological concept, and should have biological criteria for its definition.

Issues such as abortion, embryo research and euthanasia have been discussed exhaustively from the standpoint of Western philosophy and religion, but so far the voice of Buddhism has been little heard in the debate. Although widely respected for its benevolent and humanistic values, Buddhism has not so far shown how its ethical principles can be applied in a consistent manner to contemporary moral dilemmas. Drawing on both ancient and modern sources, this book sets out the basis of a Buddhist response (...) to the major ethical questions posed by modern medicine. (shrink)

This issue of the Journal of Medicine and Philosophy brings together fresh essays addressing three main genres of questions: questions about the nature of bioethical inquiry and the relevance of the humanities to medical practice; questions regarding the ethics of organ donation; questions bearing on the application of fairness to the distribution of medical resources.

In their manuscript, Nielsen Busch and Mjaaland (2023) argue that controlled donation after circulatory death (cDCD) is compatible with the dead donor rule (DDR) by describing the DDR and the incor...

To determine when the life of a human organism begins, Mark T. Brown has developed the somatic integration definition of life. Derived from diagnostic criteria for human death, Brown’s account requires the presence of a life‐regulation internal control system for an entity to be considered a living organism. According to Brown, the earliest point at which a developing human could satisfy this requirement is at the beginning of the fetal stage, and so the embryo is not regarded as a (...) living human organism. This, Brown claims, has significant bioethical implications for both abortion and embryo experimentation. Here, we dispute the cogency of Brown’s derivation. Diagnostic criteria for death are used to determine when an organism irreversibly ceases functioning as an integrated whole, and may vary significantly depending on how developed the organism is. Brown’s definition is derived from a specific definition of death applicable to postnatal human beings, which is insufficient for generating a general definition for human organismal life. We have also examined the bioethical implications of Brown’s view, and have concluded that they are not as significant as he believes. Whether the embryo is classified as a human organism is of peripheral interest—a far more morally relevant question is whether the embryo is a biological individual with an identity that is capable of persisting during development. (shrink)

We discuss the meaning of “being alive” and “being dead.” Our primary aim is to pave the way for a sound and accurate ethical debate concerning these two concepts. In particular, we analyze a metabolic approach and a genetic one and discuss the reasons for their failure to constitute a good starting point for successive debates. We argue that any ethical or social discussion of topics involving life and death must introduce cultural constructs such as, on the one hand, (...) the concept of clinical death and, on the other hand, the concept of existence. We argue that these two cultural constructs, although consistent with biomedical knowledge, cannot be ontologically grounded in it. To conclude, we apply our findings to the case of human embryos. (shrink)

This chapter explores what we actually mean by data donation after death, and what different types of data donation metadata are involved in the process. It then provides an analysis of the ethical ramifications of each of these different types of data, outlines the concepts of data advance directives and data donation guardians as one way of dealing with these issues, and considers alternative governance mechanisms. The degree of control given to the first data donors may need to be (...) high in order to maintain trust, but over time attitudes may evolve towards everyone giving “big consent” to data donation. (shrink)

Legally defining “death” in terms of brain death unacceptably obscures a value judgment that not all reasonable people would accept. This is disingenuous, and it results in serious moral flaws in the medical practices surrounding organ donation. Public policy that relies on the whole-brain concept of death is therefore morally flawed and in need of revision.

We discuss the meaning of “being alive” and “being dead.” Our primary aim is to pave the way for a sound and accurate ethical debate concerning these two concepts. In particular, we analyze a metabolic approach and a genetic one and discuss the reasons for their failure to constitute a good starting point for successive debates. We argue that any ethical or social discussion of topics involving life and death must introduce cultural constructs such as, on the one hand, (...) the concept of clinical death and, on the other hand, the concept of existence. We argue that these two cultural constructs, although consistent with biomedical knowledge, cannot be ontologically grounded in it. To conclude, we apply our findings to the case of human embryos. (shrink)

Looking to Scripture through the eyes of contemporary medical experience, I analyze the meaning of the criteria used for determining death, specifically in the light of Jesus’ final moments and the resurrection of the Shunammite’s son in 2 Kings, chapter 4. I argue that four theses are consistent with, and informed by, these passages that can help guide Christian belief and decision-making about how death is determined in the clinical context: (1) death is neither permanent nor irreversible; (...) (2) something like the “brain dead” state is, at best, a confounding state that requires one to “pace and pray” or let go; (3) that the case for determining death by neurologic criteria depends on the “working togetherness” of the body's parts for the sake of impacting its environment; and (4) that the practice of neurologically-based death determination is a response to the problem of disaggregation of the human form into its organ systems that modern critical care medicine makes possible. I end with advice about how Christians might approach the debates over the law and practice even if they cannot come to a consensus. (shrink)

This article is about the recognition of personhood when death occurs in early life. Drawing from anthropological perspectives on personhood at the beginnings and ends of life, it examines the implications of competing religious and customary definitions of personhood for a small sample of young British Pakistani Muslim women who experienced miscarriage and stillbirth. It suggests that these women's concerns about the lack of recognition given to the personhood of their fetus or baby constitute a challenge to customary practices (...) surrounding burial as a Muslim. The article suggests that these women's concerns cannot be adequately glossed as a clash of Islamic belief versus Western medicine. Rather, they represent a renegotiation of Islamic opinion and customary practices within the broader context of changes in the medical and social norms surrounding pregnancy loss and infant death in multi-ethnic British society. (shrink)

This article is in a larger textbook of articles in Medical Ethics.

This special report is published in commemoration of the fiftieth anniversary of the “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of (...) the organism to maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades. (shrink)

In Peter Singer’s article “The Challenge of Brain Death for the Sanctity of Life Ethic”, he articulates that ethics has always played an important role in defining death. He claims that the demand for redefining death spreads rather from new ethical challenges than from a new, scientifically improved understanding of the nature of death. As thorough as his plea for dismissal of the brain-death definition is, he does not avoid the depiction of the complementary (...) relationship between science and ethics. Quite the opposite, he tends to formulate a stronger, philosophically more consistent argument to help science and medical practitioners to define life, death, and the quality of life. In my commentary, I would like to focus on two issues presented in Singer’s study. Firstly, I will critically analyze the relationship between science and ethics. Secondly, I will follow on from Singer’s arguments differentiating between end of life as an organism and end of life as a person. The latter case is necessarily linked with man’s participation in her/his life, setting life goals, and fulfilling her/his idea of good life. Through the consequential definition of the dignity in ethics of social consequences, I will try to support Singer’s idea. (shrink)

More than 50 years after the publication of the Harvard Committee Report that sought to define death according to whole-brain function criteria, this document continues to generate a diversity of o...

Reflection on death gives rise to a variety of philosophical questions. One of the deepest of these is a question about the nature of death. Typically, philosophers interpret this question as a call for an analysis, or definition, of the concept of death. Plato proposed to define death as the separation of soul from body. This definition is not acceptable to materialists, who think that there are no souls. It is also unacceptable to anyone who thinks (...) that plants and lower animals have no souls, but can die. Others have defined death simply as the cessation of life. This too is problematic, since an organism that goes into suspended animation ceases to live, but may not die. (shrink)

In 1968, the Harvard criteria equated irreversible coma and apnea with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism, minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. Brain (...) death does not disrupt somatic integrative unity and coordinated biological functioning of a living organism. Neurological criteria of human death fail to determine the precise moment of an organism’s death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. Brain -based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs. (shrink)