When an individual is comatose while parts of her brain remain functional, the question arises as to whether any mental characteristics are still associated with this brain, that is, whether the person still exists. Settling this uncertainty requires that one becomes clear about two issues: the type of functional loss that is associated with the respective profile of brain damage and the persistence conditions of persons. Medical case studies can answer the former question, but they are not concerned with the (...) latter. Conversely, in the philosophical literature, various accounts of personal identity are discussed, but usually detached from any empirical basis. Only uniting the two debates and interpreting the real-life configurations of brain damage through the lens of the philosophical concepts enables one to make an informed judgment regarding the persistence of comatose persons. Especially challenging are cases in which three mental characteristics that normally occur together—wakefulness, awareness and memory storage—come apart. These shall be the focus of this paper. (shrink)

THE PRIMARY AIM OF THIS ESSAY is to advance discussion on how best to treat comatose patients. Its principal conclusion will be Some purportedly irreversibly comatose humans ought to be kept alive indefinitely. Of course, merely keeping such patients alive is not how best to treat them. How they are being treated while being kept alive is of paramount importance. Note that is compatible with the truth of All comatose humans ought to be kept alive indefinitely. I shall say nothing (...) more about. It will serve my present purpose if I can adequately defend, where "some" is to be understood in the usual manner, namely, as "at least one." The term "indefinitely," as one might surmise, is meant to convey some unspecified period of time. (shrink)

La clase de filosofía, desde la perspectiva del docente, no debe considerarse como una mera actividad transeúnte o predicamental. El presente estudio quiere examinarla, siguiendo la metafísica de la vida de Tomás de Aquino, como una obra vital, que requiere, por un lado, que el profesor se haga una sola cosa —una sola vida, podemos decir— con la doctrina que va a explicar y, por el otro, que esta intelección actual, sin movimiento alguno, dé lugar a la «concepción» y al (...) «parto» de lo entendido en una palabra del corazón, la cual, por su dinamismo intrínseco, tiende, a su vez, a manifestarse exteriormente en una palabra sonora, en un «verbum vocis». Esta exteriorización, por la cual aquella íntima operación que constituye la vida del que filosofa se corporeiza en forma de «diálogo», es, precisamente, la clase de filosofía. La técnica pedagógica debe tener en cuenta el orden intrínseco por el cual la vida humana, mediante la formación de una palabra del corazón, procede a su propia perfección, y no debe olvidar que el perfeccionamiento vital del profesor es causa (instrumental) del perfeccionamiento vital del alumno; es decir, quien no «produce», quien no «engendra», quien no «crea» interiormente lo que está explicando —independientemente de si se trata o no de una novedad— difícilmente ofrecerá unos medios adecuados para que el alumno conciba y dé a luz, en la intimidad de su mente, a un «verbum cordis». (shrink)

En este libro, que se titula «Sobre los nombres divinos [De divinis nominibus]», siguiendo la costumbre de aquellos que han transmitido la ciencia magistralmente [artificiose], Dionisio empieza, en primer lugar, presentando algunas consideraciones necesarias para todo el estudio sucesivo, y, en segundo lugar, prosigue exponiendo el objeto principal [de su tratado] en el capítulo tercero.

En contra de les aparences, la meva intenció és ridiculitzar i desactivar l’estratègic ús de referències a personatges de ficció per part dels mass media, els quals pretenen identificar el fundador de WikiLeaks amb tot aquest projecte —quelcom que facilita tant la deslegitimació com la mercantilització. Així, aquest article qüestiona la dominant personalització de la web de filtracions en Julian Assange, tot mostrant algunes de les més rellevants diferències i/o contradiccions entre el rerefons normatiu de WikiLeaks i la pseudo-filosofia política (...) de l’australià. La meva tesi és que la justificació de la il·legal revelació d’informació secreta i confidencial com a pràctica de desobediència civil es posa en perill per la contaminació de postulats utilitaristes i neoliberals. (shrink)

En este artículo se investigan los presupuestos ontológicos de aquellos nombres divinos que pueden predicarse de Dios y de las criaturas. En un primer momento, se destaca la anterioridad metafísica del ente como atributo de Dios. Después, al descubrir que el ente es un concepto análogo, se examinan las distintas modalidades de analogía confrontando dos textos: Summa contra Gentiles, I, cap. 34 y De Veritate, q.2, a.11. Finalmente, se muestra que la analogía de proporcionalidad es la que debe preferirse para (...) predicar algo acerca de Dios, y se pone de manifiesto en qué medida se funda sobre la cuarta vía «ex gradibus qui in rebus inveniuntur». (shrink)

Si prescindiéramos de la composición acto-potencial entre «essentia» y «esse» en la línea del ente creado, necesariamente nos veríamos arrojados al monismo spinozista, esto es, a admitir que solamente hay una substancia (a) única, (b) infinita, (c) increada, (d) necesariamente existente, (e) acto puro, (f) identificada, en último término, con la misma substancia de Dios. En el capítulo LII del segundo libro de la Summa contra gentiles, Santo Tomás obtiene esos atributos divinos a partir de siete argumentos que tienen como (...) objetivo probar que, en el caso que no se aceptara la diferencia real entre essentia y esse en el ente finito —tanto material como inmaterial—, necesariamente deberíamos reconocer que sólo hay una substancia con los seis atributos anteriormente mencionados (cada argumento da lugar a un atributo distinto, exceptuando los dos primeros que desembocan en el mismo, a saber, el de la unicidad). En el artículo presente, siguiendo la interpretación de Norberto del Prado, nos proponemos exponer cómo puede refutarse el monismo spinozista desde la doctrina de Santo Tomás en dos etapas: la primera viene representada por el ya citado capítulo de la Summa contra gentes; la segunda, por la cuarta vía (Summa Theologiae, I, q.2, a.3). (shrink)

Este artículo transmite dos ideas destacadas: por un lado, defiende la justicia y la verdad de la democracia deliberativa; por el otro, denuncia el carácter ficticio del paradigma «westfaliano». Las dos hipótesis aparecen gracias a las filtraciones éticas de WikiLeaks. De cara a evaluarlas, previamente examino de forma crítica la evolución de la concepción política de Jürgen Habermas. Mi aportación es reinterpretar su deliberacionismo como una combinación entre una teoría del poder y una de la opinión pública.

En primer lugar, la presente comunicación describe brevemente un suceso un tanto insólito: el que una página web haya puesto en jaque al considerado gobierno nacional más poderoso del mundo. En segundo lugar, se ofrece una posible perspectiva teórica para interpretar tal acontecimiento: la teoría de la opinión pública, principalmente desde su articulación en el seno de la Teoría Crítica de Jürgen Habermas. En tercer lugar, se evalúan someramente las luces y las sombras tanto de WikiLeaks como de Habermas mediante (...) la comparación crítica. En general, este trabajo se propone iniciar el análisis de las potencialidades de internet como herramienta y espacio en favor de la democracia y la emancipación de una ciudadanía participativa y no encerrada en sus clásicos límites estatales. (shrink)

In 1968 the authors of the so-called Harvard Report, proposed the recognition of an irreversible coma as a new criterion for death. The proposal was accepted by the medical, legal, religious and political circles in spite of the lack of any explanation why the irreversible coma combined with the absence of brainstem reflexes, including the respiratory reflex might be equated to death. Such an explanation was formulated in the President’s Commission Report published in 1981. This document (...) stated, that the brain is the central integrator of the body, therefore the destruction of the brain results in the lack of that integration and the death of the organism. Therefore, according to that document, the so-called “brain dead” patients are really, biologically dead; strictly speaking they are not any more biological organisms but collections of organs and tissues. Their death was masked by the use of the medical equipment, but it was a real, biological death. Thus, the explanation given by the President’s Commission Report constituted a biological rationale for the new concept of death, known as “brain death.” However, after the long discussion, this rationale was refuted because of the evidence given by many medical authorities, that the bodies of the “brain dead” and “brainstem dead” patients are alive. In the context of the discussion about the neurological criteria for death, some authors follow the idea of Plato, that human being is the soul or mind, and the body does not belong to the human essence. Therefore, the loss of consciousness, which may be identified with the mind, constitutes the loss of personhood and may be interpreted as human death. The other group stresses the Aristotelian and Thomistic concept that the body belongs to the essence of every living creature, including human. Therefore, as long as the body is alive, the human being is alive and we cannot call the given patient dead even if he is deeply comatose. Moreover, in spite of the opinions dominating in the mass-media, these patients should be considered not only alive but also may be conscious to some degree and their state can be reversible. Their brains are lacking the electrical functions, but the neuronal tissue is alive and that state is reversible for at least first 48 hours since the onset of coma; this phenomenon is called “global ischemic penumbra” and is responsible for the regularly happening events interpreted as miracles, when some of the “brain dead” or “brainstem dead” patients turn to be alive and come back to normal life. Therefore, the neurological criteria of death are still lacking generally accepted scientific basis and should not be used in medicine and in the legal systems as a basis for diagnosing comatose/having no brainstem reflexes/apneic patients dead. (shrink)

At its inception, “brain death” was proposed not as a coherent concept but as a useful one. The 1968 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death gave no reason that “irreversible coma” should be death itself, but simply asserted that the time had come for it to be declared so. Subsequent writings by chairman Henry Beecher made clear that, to him at least, death was essentially a social construct, and society (...) could define it however it pleased. The first widely endorsed attempt at a philosophical justification appeared thirteen years later, with a report from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research and a seminal paper by James Bernat, Charles Culver, and Bernard Gert, which introduced the insightful tripartite scheme of concept, criterion, and tests for death. Their paper proposed that the correct concept of death is the “permanent cessation of functioning of the organism as a whole,” which tenuously remains the mainstream concept to this day. In this essay, I focus on this mainstream concept, arguing that equating brain death with death involves several levels of incoherence: between concept and criterion, between criterion and tests, between tests and concept, and between all of these and actual brain death praxis. (shrink)

: Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead and that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. (...) One strategy would be to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law—such as authorizing procuring surgeons to end the lives of patients by means of organ procurement—and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained. (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)

In lieu of an abstract, here is a brief excerpt of the content:The Incoherence of Determining Death by Neurological Criteria: A Commentary on Controversies in the Determination of Death, A White Paper by the President’s Council on Bioethics*Franklin G. Miller** (bio) and Robert D. Truog (bio)Traditionally the cessation of breathing and heart beat has marked the passage from life to death. Shortly after death was determined, the body became a cold corpse, suitable for burial or cremation. Two technological changes in (...) the second half of the twentieth century prompted calls for a new, or at least expanded, definition of death: the development of intensive care medicine, especially the use of mechanical ventilators, and the advent of successful transplantation of vital organs. Patients with profound neurological damage, leaving them incapable of breathing on their own and in an irreversible coma, could be maintained for some period of time with the aid of mechanical ventilation. The situation of these patients posed two ethical questions. Is it appropriate to stop life-sustaining treatment? If so, is it acceptable to retrieve vital organs for transplantation to save the lives of others before stopping treatment?In 1968, the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death proposed that death could be determined on the basis of neurological criteria, thus providing a positive answer to these two questions (Ad Hoc Committee 1968). According to the position of this committee, patients diagnosed with the cessation of brain function are dead, despite the fact that they breathe and circulate blood with the aid of mechanical ventilation. [End Page 185] Because they are dead, it is appropriate, indeed imperative, to stop mechanical ventilation. And because they are dead, it becomes ethical to procure vital organs for transplantation before stopping what otherwise would be life-sustaining treatment. Remarkably, this innovative neurological determination of death became, with little debate or controversy, the established position in medical ethics and the law throughout the United States.The Harvard Committee articulated the diagnosis of “irreversible coma,” but merely asserted that this condition constituted death. No explanatory rationale was provided. It fell to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research to provide an authoritative rationale in its 1981 report, Defining Death. The second paragraph of the report set the stage as follows: “The question addressed here is not inherently difficult or complicated. Simply, it is whether the law ought to recognize new means for establishing that the death of a human being has occurred” (President’s Commission 1981, p. 3). The Commission claimed that “death is a unitary phenomenon” (p. 7) and that the determination of death by neurological criteria, in terms of the absence of all brain function, is consistent with the traditional conception of death as the cessation of vital functioning of the organism as a whole. The key issue is the integrative functioning of the human organism, which ceases to exist, according to the Commission, when the whole brain, including higher cortical areas and the brain stem, fails to function. Although “brain-dead” patients do not appear to be dead—i.e., the reality of their death is “masked” by the activity of mechanical ventilation—the patient’s body has irreversibly lost all capacity for integrative functioning. In the words of the Commission: “When artificial means of support mask this loss of integration as measured by the old methods [cessation of respiration and heart beat], brain-oriented criteria and tests provide a new window on the same phenomenon” (p. 33). The President’s Commission was instrumental in developing and establishing “The Uniform Definition of Death Act”: “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” (p. 2).Although the question posed by the President’s Commission was easy to articulate, the answer, over time, has proved complicated and controversial. The coherence and cogency of determining death by neurological criteria has been challenged. Various experts have demonstrated that “brain-dead” patients maintained on mechanical ventilation display a range of vital, integrative, functioning, which conflicts with the judgment that they are dead (Truog and... (shrink)

One reason why the Biological Approach to personal identity is attractive is that it doesn’t make its advocates deny that they were each once a mindless fetus.[i] According to the Biological Approach, we are essentially organisms and exist as long as certain life processes continue. Since the Psychological Account of personal identity posits some mental traits as essential to our persistence, not only does it follow that we could not survive in a permanently vegetative state or irreversible coma, (...) but it would appear that none of us was ever a mindless fetus. But what happens to the organism that was a mindless fetus when the _person_ arrives on the scene?[ii] Can the acquisition of thought destroy an organism? That would certainly be news to biologists. Does one organism cease to exist with the emergence of thought and another organism, one identical to the person, take its place? (Burke,1994) That doesn’t seem much more plausible than the previous move. Should identity and Leibniz. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Incoherence of Determining Death by Neurological Criteria: A Commentary on Controversies in the Determination of Death, A White Paper by the President’s Council on Bioethics*Franklin G. Miller** (bio) and Robert D. Truog (bio)Traditionally the cessation of breathing and heart beat has marked the passage from life to death. Shortly after death was determined, the body became a cold corpse, suitable for burial or cremation. Two technological changes in (...) the second half of the twentieth century prompted calls for a new, or at least expanded, definition of death: the development of intensive care medicine, especially the use of mechanical ventilators, and the advent of successful transplantation of vital organs. Patients with profound neurological damage, leaving them incapable of breathing on their own and in an irreversible coma, could be maintained for some period of time with the aid of mechanical ventilation. The situation of these patients posed two ethical questions. Is it appropriate to stop life-sustaining treatment? If so, is it acceptable to retrieve vital organs for transplantation to save the lives of others before stopping treatment?In 1968, the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death proposed that death could be determined on the basis of neurological criteria, thus providing a positive answer to these two questions (Ad Hoc Committee 1968). According to the position of this committee, patients diagnosed with the cessation of brain function are dead, despite the fact that they breathe and circulate blood with the aid of mechanical ventilation. [End Page 185] Because they are dead, it is appropriate, indeed imperative, to stop mechanical ventilation. And because they are dead, it becomes ethical to procure vital organs for transplantation before stopping what otherwise would be life-sustaining treatment. Remarkably, this innovative neurological determination of death became, with little debate or controversy, the established position in medical ethics and the law throughout the United States.The Harvard Committee articulated the diagnosis of “irreversible coma,” but merely asserted that this condition constituted death. No explanatory rationale was provided. It fell to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research to provide an authoritative rationale in its 1981 report, Defining Death. The second paragraph of the report set the stage as follows: “The question addressed here is not inherently difficult or complicated. Simply, it is whether the law ought to recognize new means for establishing that the death of a human being has occurred” (President’s Commission 1981, p. 3). The Commission claimed that “death is a unitary phenomenon” (p. 7) and that the determination of death by neurological criteria, in terms of the absence of all brain function, is consistent with the traditional conception of death as the cessation of vital functioning of the organism as a whole. The key issue is the integrative functioning of the human organism, which ceases to exist, according to the Commission, when the whole brain, including higher cortical areas and the brain stem, fails to function. Although “brain-dead” patients do not appear to be dead—i.e., the reality of their death is “masked” by the activity of mechanical ventilation—the patient’s body has irreversibly lost all capacity for integrative functioning. In the words of the Commission: “When artificial means of support mask this loss of integration as measured by the old methods [cessation of respiration and heart beat], brain-oriented criteria and tests provide a new window on the same phenomenon” (p. 33). The President’s Commission was instrumental in developing and establishing “The Uniform Definition of Death Act”: “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” (p. 2).Although the question posed by the President’s Commission was easy to articulate, the answer, over time, has proved complicated and controversial. The coherence and cogency of determining death by neurological criteria has been challenged. Various experts have demonstrated that “brain-dead” patients maintained on mechanical ventilation display a range of vital, integrative, functioning, which conflicts with the judgment that they are dead (Truog and... (shrink)

It is worthwhile comparing Hylomorphic and Animalistic accounts of personal identity since they both identify the human animal and the human person.The topics of comparison will be three: The first is accounting for our intuitions in cerebrum transplant and irreversible coma cases. Hylomorphism, unlike animalism, appears to capture “commonsense” beliefs here, preserves the maxim that identity matters, and does not run afoul of the Only x and y rule. The next topic of comparison reveals how the rival explanations (...) of transplants and comas are both at odds with some compelling biological assumptions. The third issue deals with our practical concerns, most notably, the possibility of an afterlife. It turns out that the hylomorphic treatment of Purgatory raises the spectra of the “too many thinkers” problem and some considerable unfairness. Contrary to expectations, an animalist insistence on uninterrupted bodily continuity between this life and the next does not involve deceptive body snatching. (shrink)

Given the long‐standing controversy about whether the brain‐dead should be considered alive in an irreversible coma or dead despite displaying apparent signs of life, the ethical and policy issues posed when family members insist on continued treatment are not as simple as commentators have claimed. In this article, we consider the kind of policy that should be adopted to manage a family's insistence that their brain‐dead loved one continues to receive supportive care. We argue that while it would (...) be ethically inappropriate to continue to devote scarce acute care resources to such patients in a hospital setting, it may not be ethically inappropriate for patients to receive these resources in certain other settings. Thus, if a family insists on continuing to care for their brain‐dead loved at their home, we should not, from a policy perspective, interfere with the family's wishes. We also argue that healthcare professionals should make some effort to facilitate the transfer of brain‐dead patients to these other settings when families insist on continued treatment despite being informed about the lack of any potential for recovery of consciousness. Our arguments are strengthened by the fact that patients in a persistent vegetative state, who, when correctly diagnosed, also have no potential for recovery of consciousness, are routinely transferred from hospitals to nursing homes or long‐term care facilities where they continue to be ventilated, tube fed and to receive other supportive care. We also briefly explore the question of who should be responsible for the costs of such treatment at the long‐term care facility. (shrink)

Introduction: Decisions to withdraw or withhold curative or life-sustaining treatment can have a huge impact on the symptoms which the palliative-care team has to control. Palliative-care patients and their relatives may also turn to palliative-care physicians and nurses for advice regarding these treatments. We wanted to assess Indian palliative-care nurses and physicians’ attitudes towards withholding and withdrawal of curative or life-sustaining treatment. Method: From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programmes in (...) New Delhi, using a semi-structured questionnaire. For the interviews and analysis of the data we followed Grounded-Theory methodology. Results: Withholding a curative or life-sustaining treatment which may prolong a terminal cancer patient’s life with a few weeks but also has severe side-effects was generally considered acceptable by the interviewees. The majority of the interviewees agreed that life-sustaining treatments can be withdrawn in a patient who is in an irreversible coma. The palliative-care physicians and nurses were of the opinion that a patient has the right to refuse life-saving curative treatment. While reflecting upon the ethical acceptability of withholding or withdrawal of curative or life-sustaining treatment, the physicians and nurses were concerned about the whole patient and other people who may be affected by the decision. They were convinced they can play an important advisory role in the decision-making process. Conclusion: While deciding about the ethical issues, the physicians and nurses do not restrict their considerations to the physical aspects of the disease, but also reflect upon the complex wider consequences of the treatment decisions. (shrink)

Given the long-standing controversy about whether the brain-dead should be considered alive in an irreversible coma or dead despite displaying apparent signs of life, the ethical and policy issues posed when family members insist on continued treatment are not as simple as commentators have claimed. In this article, we consider the kind of policy that should be adopted to manage a family's insistence that their brain-dead loved one continues to receive supportive care. We argue that while it would (...) be ethically inappropriate to continue to devote scarce acute care resources to such patients in a hospital setting, it may not be ethically inappropriate for patients to receive these resources in certain other settings. Thus, if a family insists on continuing to care for their brain-dead loved at their home, we should not, from a policy perspective, interfere with the family's wishes. We also argue that healthcare professionals should make some effort to facilitate the transfer of brain-dead patients to these other settings when families insist on continued treatment despite being informed about the lack of any potential for recovery of consciousness. Our arguments are strengthened by the fact that patients in a persistent vegetative state, who, when correctly diagnosed, also have no potential for recovery of consciousness, are routinely transferred from hospitals to nursing homes or long-term care facilities where they continue to be ventilated, tube fed and to receive other supportive care. We also briefly explore the question of who should be responsible for the costs of such treatment at the long-term care facility. (shrink)

According to the International Register of Organ Donation and Transplantation, Japan is one of the countries with the lowest number of registered deceased donors. In 2019, Japan was ranked 61st out of 70 countries. The authors of this article have decided to explore the reasons for this phenomenon. In the first part of the work, religious influences (Shinto and Buddhism), the tradition of gotai manzoku, the importance of altruism and the family in the perception of death and organ transplantation by (...) the Japanese are considered. The second part of the article presents the arguments of Alan Shewmon, who believes that brain death is not death in the biological sense. Undermining the brain’s death criterion raises doubts concerning death of patients in irreversible coma, what in result discourages transplantology in Japan. In the third part, the authors compare the results of JOTN, IRODaT and the Fact Book of Organ Transplantation 2018 in Japan from 2010 to 2018. The aim of the article is to explain the cultural determinants of transplantology in Japan, taking into account the influence of philosophical and bioethical aspects of human death. (shrink)

It has been fifty years since a report by an ad hoc committee of Harvard Medical School ushered in the widespread adoption of brain death as a definition of death. Yet brain death remains disputed as an acceptable definition within bioethics. The continuous debate among bioethicists has had three key recurring features: first and foremost, argument over alleged flaws in the conceptual logic and consistency of the “whole‐brain” approach as a description of the meaning of death; second, efforts to fix (...) perceived limitations of brain death‐based practices to optimize transplantation, especially given that transplantation was the presumed original intended purpose of the definition; and third, a basic unease provoked by the experience of using the criteria and managing a body in this state of “irreversible coma.”The third feature is the one I find the most compelling, though it is less explored, and it persists because of the failures of the prior two. Brain death remains strange—to medical personnel, families, philosophers. That is not because it hasn’t yet been logically argued well enough or conceptually framed adequately, but because those things don’t matter as much to resolving this strangeness as the bioethical approach to brain death over the last fifty years has assumed it does. It is necessary to look to other things that can anchor the aims of medicine in the midst of this strangeness. (shrink)

The definition of death as “irreversible coma” was introduced in 1968 by the Harvard University Medical School. It was developed largely in diagnostic terms as the “irreversible cessation of all functions of the entire brain, including the brainstem.” In its review of brain death in 1981, The President’s Commission for the Study of Ethical Problems in Medicine argued that brain death is consonant with circulatory death because the loss of certain brain functions results in the “loss of (...) integrative unity of the organism,” leading to cardiac arrest. This picture of a unified conception of death was challenged by subsequent clinical evidence suggesting that, with proper treatment, circulatory death is not the inevitable result of brain death. Here, it is argued that, if death, in the morally relevant sense, is defined as irreversible loss of consciousness, a unitary conception of death can be maintained. However, significant theoretical and methodological obstacles remain in diagnosing irreversible loss of consciousness. (shrink)

The author, a philosopher, suggests that the concept of death should be left as it is 'in its present indeterminate state', and that we ought to reject attempts to define death in terms of whole-brain death or any other type of brain death, including cerebral death and 'irreversible coma'. Instead of 'fiddling with the definition of death' clear rules should be established specifying 'what can be appropriately done to whom when'.

On 5 August 1968, publication of the Harvard Committee’s report on the subject of “irreversible coma” established a standard for diagnosing death on neurological grounds. On the same day, the 22nd World Medical Assembly met in Sydney, Australia, and announced the Declaration of Sydney, a pronouncement on death, which is less often quoted because it was overshadowed by the impact of the Harvard Report. To put those events into present-day perspective, the authors reviewed all papers published on this (...) subject and the World Medical Association web page and documents, and corresponded with Dr A G Romualdez, the son of Dr A Z Romualdez. There was vast neurological expertise among some of the Harvard Committee members, leading to a comprehensible and practical clinical description of the brain death syndrome and the way to diagnose it. This landmark account had a global medical and social impact on the issue of human death, which simultaneously lessened reception of the Declaration of Sydney. Nonetheless, the Declaration of Sydney faced the main conceptual and philosophical issues on human death in a bold and forthright manner. This statement differentiated the meaning of death at the cellular and tissue levels from the death of the person. This was a pioneering view on the discussion of human death, published as early as in 1968, that should be recognised by current and future generations. (shrink)

Definition of the problem:Truog’s critique of the ”brain death” concept outlines inconsistencies well understood in the U.S. ethical debate, while he is one of the first to suggest returning to the traditional, coherent concept of death, thus breaking with the ”dead-donorrule.” The German transplantation law of 1996 endorses equating ”brain death” with death. A defeated draft, however, had acknowledged that irreversible total brain failure is a death-near state with a zero prognosis; organ harvesting, then, was to be allowed only (...) in case of prior personal consent. The politically effective objection against this concept was its admitted violation of the dead-donorrule and thus its (incorrectly) alleged precedent potential for legalising active euthanasia. Truog’s suggestion to justify organ explantation on the grounds of ”consent and nonmaleficence” would have fuelled German counter-critics had they known it. The problem is how to justify organ harvesting after breaking the dead-donorrule. Arguments: With the allegation that ”imminent death” and ”irreversible coma” allow concluding that there is ”no harm,” Truog ironically returns to the weak arguments traditionally used to support the ”brain death” concept. His suggestion opens the door to a wide array of eligible organ donors (and, indeed, to a precedential case for active euthanasia). The euphemistic tradition of the ”brain death” concept, perhaps a prominent reason for public scepticism towards transplantation, will be perpetuated unless it is acknowledged that the interference of organ explantation with the donor’s dying process does as such constitute ”harm” to this individual. Organ harvesting, then, requires prior personal consent and needs to be clearly differentiable from any act of ”killing” if it is to be compatible with the law, acceptable to surgeons and not a precedent for active euthanasia. A close look at the actual procedure reveals that consent has invariably the effect of prolonging, not shortening the factual life span of the person in whom irreversible total brain failure has been diagnosed. This peculiarity distinguishes organ explantation from all other forms of terminating a person’s life and is not congruent with the ethical and legal notion of ”killing”. Conclusion: Breaking the dead-donorrule by allowing for the donor to give prior personal consent to organ explantation as a procedure that is going to interfere with his or her dying can be justified, informed consent provided, without setting foot on a slippery slope. (shrink)

The Brain Death Reconsidered – Is It a Tenable Concept? Since 1968 it has been recognized in the medical practice that irreversible coma connected with apnea can serve as a criterion of human death. This approach was first introduced in the so called Harvard Protocol. As a result of the work of this commission, the brain-based criteria of human death were quickly legally introduced in America and in most countries in the world. The only symptom on which death (...) can be pronounced is, according to this new definition, the absence of spontaneous brain function. However, the acceptance of the new definition of death did not eliminate the old one completely. In many states both old and new definitions of death are legally valid. Practically, in these countries the alternative definition of death functions alongside the old one and diagnosis of death can be based both on the cardiac/respiratory and brain symptoms. One of the few exceptions proved to be Japan. The law in this country does not provide a uniform answer to the question of what human death is. Instead, it allows people to choose between traditional death and brain death. The law states that if a person wants to be an organ donor after brain death has occurred, he or she must record that intention on a donor card or label beforehand. Those who object to brain death and transplantation do not need donor cards. They are considered to be alive until the heart stops beating. In this way the Japanese law respects the opinion of 20-40% of the society who do not believe in the brain death. The opinion of the same percentage of people in Western societies who oppose BD is ignored by their legal systems. Initially the concept of BD did not cause a lot of controversy but this situation changed in the nineties of the last century. Since then many authors have criticized the validity of the brain-based criteria of death. They maintain that it is impossible to declare the absence of all the functions of the whole brain on the basis of the clinical tests supposed to detect it. There may be present some level of consciousness in brain death (BD) patients and therefore, they may feel pain. It is significant that 27% of the members of the teams which perform the excision of the heart for transplantation think that they are killing a living person and that in many countries during this operation a normal general anesthesia is required because of the vivid reaction of the body of the patient. The opponents of the brain death theory stress that the accurate examination of the so-called brain dead persons shows the persistence of the functions of significant parts of their brains. There are EEG waves recorded in 20-40% of BD patients. Event related potentials (ERP) show the reaction to verbal and non-verbal stimuli and the hormone production by the brain tissue can be detected in many BD people. The proper treatment could not only significantly prolong lives of the BD patients, but around 60% of possible donors with the lowest result of 3 in Glasgow Coma Scale could be restored to normal life if their brain edema is properly treated. This treatment should be based on the therapeutic hypothermia connected with the application of the thyroid hormones, whose level is usually too low in the patients with the brain injury. There is a growing lack of consensus regarding the issue of brain death, especially among physicians. Some regard brain death as a biological one, some as the death of the person but not of the human body, and the rest, as a definition accepted by the society, which doesn’t require other legitimacy than the freely chosen criteria. The brain death concept is also criticized from the philosophical point of view. The strength of the brain death theory was based on the premise that the brain is the integrating center of the body. According to this argument, the death of the brain means that the organism ceases to exist for it is no longer a functioning whole. To this argument the opponents of the brain death concept say that this question is not a question a priori but an empirical one and that the empirical data validate the opposite opinion, which says that the bodies of brain dead patients are alive. Some widely known cases show that even the real death of the entire brain means the death of the body and, therefore, may not signify the death of a human person. The integration of the body is the function of the organism as a whole and not of a single organ, even if this organ is the brain. This point of view can be confirmed by the opinion of St. Thomas Aquinas who says that the soul is primarily and per se connected with the body as a whole as the proportionate perfectible and only secondarily with the parts of the body, according to their ordination to the whole. So, the death of any single organ does not preclude the union of the soul with the rest of the body as a living whole. Moreover, the terms such as “consciousness” and “person” should not be identified. The term such as “human living nonpersons”, proposed by some bioethicists and referring to the people without consciousness has not been accepted in the official documents concerning BD. Bodies of the BD people are alive, therefore, it is not right to use the term “brain death” to describe the state of these patients, but rather the term “brain failure” should be used. As the result, according to some authors, the dead donor rule should be abolished. The Catholic Church stresses the sacredness of the human life from the beginning to the end. Therefore She requires that there be no doubts that the donor in BD is really dead. Because of the lack of consensus among physicians, philosophers and theologians, the popes John Paul II and Benedict XVI decided to continue the scientific research and discussion concerning BD between the representatives of various disciplines. Keywords: brain death, brain edema, global ischemic penumbra, therapeutic hypothermia, consciousness, person, substantial form. (shrink)

Not long ago I was called by my brother’s doctor. He wanted to know if I would accept his judgment that the respirator for my brother should be turned off. Vince, age 81, had contracted West Nile virus, normally treated successfully in 99% of cases, but often lethal in 1%. My brother was in that 1%, with a fast onset of the disease and a no less rapid decline into a coma, all in one day. There was no pain (...) or suffering. His doctor called me one month later for my decision. I had no hesitation in agreeing with him—despite knowing that some patients do come out of seemingly irreversible comas later, even much later, than that—a low probability, but not a certainty. But my brother had lived a long and... (shrink)

BackgroundSocio-cultural perceptions surrounding death have profoundly changed since the 1950s with development of modern intensive care and progress in solid organ transplantation. Despite broad support for organ transplantation, many fundamental concepts and practices including brain death, organ donation after circulatory death, and some antemortem interventions to prepare for transplantation continue to be challenged. Attitudes toward the ethical issues surrounding death and organ donation may influence support for and participation in organ donation but differences between and among diverse populations have not (...) been studied.ObjectivesIn order to clarify attitudes toward brain death, organ donation after circulatory death and antemortem interventions in the context of organ donation, we conducted a scoping review of international English-language quantitative surveys in various populations.Study appraisalA search of literature up to October 2020 was performed, using multiple databases. After screening, 45 studies were found to meet pre-specified inclusion criteria.Results32 studies examined attitudes to brain death, predominantly in healthcare professionals. In most, around 75% of respondents accepted brain death as equivalent to death of the person. Less common perspectives included equating death with irreversible coma and willingness to undertake organ donation even if it caused death. 14 studies examined attitudes to organ donation following circulatory death. Around half of respondents in most studies accepted that death could be confidently diagnosed after only 5 min of cardiorespiratory arrest. The predominant reason was lack of confidence in doctors or diagnostic procedures. Only 6 studies examined attitudes towards antemortem interventions in prospective organ donors. Most respondents supported minimally invasive procedures and only where specific consent was obtained.ConclusionsOur review suggests a considerable proportion of people, including healthcare professionals, have doubts about the medical and ethical validity of modern determinations of death. The prognosis of brain injury was a more common concern in the context of organ donation decision-making than certainty of death. (shrink)

Hawley begins by answering the question of why we ought to care about how things persist. We care about the persistence of many things, such as ourselves, our relatives and friends, and our possessions. The inquiry should be metaphysical and not, say, legal, because the law assumes, without inquiry, answers to metaphysical questions. Could one survive entering irreversible coma? Although the law may consider biological facts, the question is about a relation, if any, between those facts and personhood. (...) Impatient people, intuiting that such questions have no answers, insist they must be resolved by convention. But Hawley doubts that a mind possesses magical powers enabling it to create or destroy physical things with words or thoughts. To raise the issue of mind-independent objects is to enter metaphysics. (shrink)

Hawley begins by answering the question of why we ought to care about how things persist. We care about the persistence of many things, such as ourselves, our relatives and friends, and our possessions. The inquiry should be metaphysical and not, say, legal, because the law assumes, without inquiry, answers to metaphysical questions. Could one survive entering irreversible coma? Although the law may consider biological facts, the question is about a relation, if any, between those facts and personhood. (...) Impatient people, intuiting that such questions have no answers, insist they must be resolved by convention. But Hawley doubts that a mind possesses magical powers enabling it to create or destroy physical things with words or thoughts. To raise the issue of mind-independent objects is to enter metaphysics. (shrink)

Lockean views of personal identity maintain that we are essentially persons who persist diachronically by virtue of being psychologically continuous with our former selves. In this article, I present a novel objection to this variant of psychological accounts, which is based on neurophysiological characteristics of the brain. While the mental states that constitute said psychological continuity reside in the cerebral hemispheres, so that for the former to persist only the upper brain must remain intact, being conscious additionally requires that a (...) structure originating in the brainstem—the ascending reticular activating system—be functional. Hence, there can be situations in which even small brainstem lesions render individuals irreversibly comatose and thus forever preclude access to their mental states, while the neural correlates of the states themselves are retained. In these situations, Lockeans are forced to regard as fulfilled their criterion of diachronic persistence since psychological continuity, as they construe it, is not disrupted. Deeming an entity that is never again going to have any mental experiences to be a person, however, is an untenable position for a psychological account to adopt. In their current form, Lockean views of personal identity are therefore incompatible with human neurophysiology. (shrink)

Defenders of the Psychological Approach to Personal Identity (PAPI) insist that the possession of some kind of mind is essential to us. We are essentially thinking beings, not living creatures. We would cease to exist if our capacity for thought was irreversibly lost due to a coma or permanent vegetative state. However, the onset of such conditions would not mean the death of an organism. It would survive in a mindless state. But this would appear to mean that before (...) the loss of cognition and the destruction of the person, the organism and the person were spatially coincident entities – two beings composed of the same matter at the same time and place. Perhaps the most problematic aspect of positing spatially coincident material entities is that it would seem to result in there being one too many thinkers. Since the person can obviously think, the organism should also have such a capacity as a result of possessing the same brain as well as every other atom of the person. This means that there now exist two thinking beings under the reader’s clothes! (shrink)

I, along with others, have been critical of the social construction of brain death and the various social factors that led to redefining death from cardiopulmonary failure to irreversible loss of brain functioning, or brain death. Yet this does not mean that brain death is not the best threshold to permit organ harvesting—or, as people today prefer to call it, organ procurement. Here I defend whole-brain death as a morally legitimate line that, once crossed, is grounds for families to (...) give permission for organ donation. I do so in five moves. First, I make the case that whole-brain death is a social construction that transformed one thing, coma dépassé, into another thing, brain death, as a result of social pressures. Second, I explore the way that the 1981 President’s Commission tried to establish the epistemological certainty of brain death, hoping to avoid making arcane metaphysical claims and yet still utilizing metaphysical claims about human beings. Third, I explore the moral meaning of the social construction of a definition that cannot offer metaphysical certainty about the point at which somebody becomes just some body. Fourth, I describe how two moral communities—Jewish and Catholic—actually ground their metaphysical positions with regard to brain death in the normativity of prior social relations. Finally, I conclude with a reflection on the aesthetic-moral enterprise of the metaphysical-epistemological apparatus of brain death, concluding that only such an aesthetic-moral approach is sufficiently strong to stave off the utility-maximizing tendencies of late-modern Western cultures. (shrink)

In the early days of organ transplantation from deceased donors, the surgical team would bring the donor into the operating room with the recipient, the respirator would be stopped, and the team would wait for the donor’s heart to cease beating. This type of organ donation has been defined as donation after cardiac death, also referred to as non-heart-beating donation. These donors were not declared dead using neurological criteria, but rather using conventional cardiorespiratory criteria. In 1959, Mollaret and Goulon coined (...) the term “coma dépassé” for the patients with an irreversible state of coma and apnea. Jean Morelle and Guy Alexandre of the Catholic University of Louvain, Belgium, were the first to introduce a set of brain death criteria based on the description of coma dépassé, and carried out, in 1963, the first transplants from a brain dead donor in their country and in the world. (shrink)

Explores the extraordinary states of expanded consciousness that arise during comas, both positive and negative.

All-encompassing text examines every aspect of coma from neurochemistry, monitoring, and treatments to prognostic factors.

This paper explores a distinction among causal relationships that has yet to receive attention in the philosophical literature, namely, whether causal relationships are reversible or irreversible. We provide an analysis of this distinction and show how it has important implications for causal inference and modeling. This work also clarifies how various familiar puzzles involving preemption and over-determination play out differently depending on whether the causation involved is reversible.