The concept of whole‐brain death is under attack again. Scholars are arguing that the concept of brain death per se—regardless of the focus on “higher,” “stem” or “whole”—is fundamentally flawed. These scholars have identified what they believe are serious discrepancies between the definition and criterion of brain death, and have pointed out that medical professionals and lay persons remain confused about its meaning. Yet whole‐brain death remains the standard for determining death in much of the Western world and its defenders (...) believe this concept best maps onto our everyday conception of death. (shrink)

The definition of death is one of the oldest and most enduring problems in biophilosophy and bioethics. Serious controversies over formally defining death began with the invention of the positive-pressure mechanical ventilator in the 1950s. For the first time, physicians could maintain ventilation and, hence, circulation on patients who had sustained what had been previously lethal brain damage. Prior to the development of mechanical ventilators, brain injuries severe enough to induce apnea quickly progressed to cardiac arrest from hypoxemia. Before the (...) 1950s, the loss of spontaneous breathing and heartbeat were perfect predictors of death because the functioning of the brain and of all other organs ceased rapidly and nearly simultaneously thereafter, producing a unitary death phenomenon. In the pretechnological era, physicians and philosophers did not have to consider whether a human being who had lost certain “vital functions” but had retained others was alive, because such cases were technically impossible. (shrink)

The distinction between the "permanent" (will not reverse) and "irreversible" (cannot reverse) cessation of functions is critical to understand the meaning of a determination of death using circulatory–respiratory tests. Physicians determining death test only for the permanent cessation of circulation and respiration because they know that irreversible cessation follows rapidly and inevitably once circulation no longer will restore itself spontaneously and will not be restored medically. Although most statutes of death stipulate irreversible cessation of circulatory and respiratory functions, the accepted (...) medical standard is their permanent cessation because permanence is a perfect surrogate indicator for irreversibility, and using it permits a more timely declaration. Therefore, patients properly declared dead in donation after circulatory death (DCD) protocols satisfy the requirements of death statutes and do not violate the dead donor rule. The acronym DCD should represent organ "donation after circulatory death" to clarify that the death standard is the permanent cessation of circulation, not heartbeat. Heart donation in DCD does not retroactively negate the donor's death determination because circulation has ceased permanently. (shrink)

A combination of emerging life support technologies and entrenched organ donation practices are complicating the physician's task of determining death. On the one hand, technologies that support or replace ventilation and circulation may render the diagnosis of death ambiguous. On the other, transplantation of vital organs requires timely and accurate declaration of death of the donor to keep the organs as healthy as possible. These two factors have led to disagreements among physicians and scholars on the precise moment of death. (...) In this article, I suggest that the debate about exactly when a person dies can benefit from distinguishing the strict biological concept of death from the medical standards for determining human death, and I show how an appreciation of the difference between the permanent and irreversible cessation of circulation is helpful in understanding the reasons for the two approaches to determining when death should be declared. (shrink)

Abstract:Disturbing cases continue to be published of patients declared brain dead who later were found to have a few intact brain functions. We address the reasons for the mismatch between the whole-brain criterion and brain death tests, and suggest solutions. Many of the cases result from diagnostic errors in brain death determination. Others probably result from a tiny amount of residual blood flow to the brain despite intracranial circulatory arrest. Strategies to lessen the mismatch include improving brain death determination training (...) for physicians, mandating a test showing complete intracranial circulatory arrest, or revising the whole-brain criterion. (shrink)

The publicity surrounding the recent McMath and Muñoz cases has rekindled public interest in brain death: the familiar term for human death determination by showing the irreversible cessation of clinical brain functions. The concept of brain death was developed decades ago to permit withdrawal of therapy in hopeless cases and to permit organ donation. It has become widely established medical practice, and laws permit it in all U.S. jurisdictions. Brain death has a biophilosophical justification as a standard for determining human (...) death but remains poorly understood by the public and by health professionals. The current controversies over brain death are largely restricted to the academy, but some practitioners express ambivalence over whether brain death is equivalent to human death. Brain death remains an accepted and sound concept, but more work is necessary to establish its biophilosophical justification and to educate health professionals and the public. (shrink)

Ariane Lewis provided an insightful review of several controversial cases of death by neurologic criteria (“brain death”) in the UK, focusing on Archie Battersbee, a boy whose tragic illness provok...

Nair-Collins and Joffe (2023) highlighted the noncongruence between the language of the Uniform Determination of Death Act (UDDA) and the accepted brain death bedside testing standard by showing th...

Notwithstanding these wise pronouncements, my project here is to characterize the biological phenomenon of death of the higher animal species, such as vertebrates. My claim is that the formulation of “whole- brain death ” provides the most congruent map for our correct understanding of the concept of death. This essay builds upon the foundation my colleagues and I have laid since 1981 to characterize the concept of death and refine when this event occurs. Although our society's well-accepted program of multiple (...) organ procurement for transplantation requires the organ donor first to be dead, the concept of brain death is not merely a social contrivance to permit us to obtain the benefits of organ procurement. Rather, the concept of whole- brain death stands independently as the most accurate biological representation of the demise of the human organism. (shrink)

Among the old and new controversies over brain death, none is more fundamental than whether brain death is equivalent to the biological phenomenon of human death. Here, I defend this equivalency by offering a brief conceptual justification for this view of brain death, a subject that Andrew Huang and I recently analyzed elsewhere in greater detail. My defense of the concept of brain death has evolved since Bernard Gert, Charles Culver, and I first addressed it in 1981, a development that (...) paralleled advances in intensive care unit treatment. The century‐old concept of the organism as a whole provides the fundamental justification for the equivalency of brain death and human death. In our technological age, in which increasing numbers of components and systems of an organism can be kept alive, and for longer intervals, the permanent cessation of functioning of the organism as a whole is the phenomenon that best corresponds to its death. (shrink)

The locked-in syndrome is a state of profound paralysis with preserved awareness of self and environment who typically results from a brain stem stroke. Although patients in LIS have great difficulty communicating, their consciousness, cognition, and language usually remain intact. Medical decision-making by LIS patients is compromised, not by cognitive impairment, but by severe communication impairment. Former systems of communication that permitted LIS patients to make only “yes” or “no” responses to questions was sufficient to validate their consent for simple (...) medical decisions but not for consequential medical decisions such as whether to refuse further life-sustaining therapy. Emerging technologies including computer-tracking assistance of retained partial motor function and brain-computer interfaces promise to improve the communication ability of LIS patients and, when better developed, will allow them to fully exercise their right to actively participate in consequential medical decisions about their own medical care. Although so-called “covert cognition” patients clinically diagnosed as vegetative state that are shown to be aware by functional neuroimaging maybe metaphorically considered locked-in, it is nosologically more coherent not to categorize them formally as LIS. (shrink)

Scepticism about ought simpliciter is the view that there is no such thing as what one ought simpliciter to do. Instead, practical deliberation is governed by a plurality of normative standpoints, each authoritative from their own perspective but none authoritative simpliciter. This paper aims to resist such scepticism. After setting out the challenge in general terms, I argue that scepticism can be resisted by rejecting a key assumption in the sceptic’s argument. This is the assumption that standpoint-relative ought judgments bring (...) with them a commitment to act in accordance with those judgments. Instead, I propose an alternative account of our normative concepts according to which only ought simpliciter judgments commit one to acting in accordance with those judgments. In addition to answering the sceptical challenge, the proposal offers an independently motivated account of what makes a concept normatively authoritative. (shrink)

Over the past quarter century, organ donation after the circulatory determination of death (DCD) has grown in acceptance and prevalence throughout the world (Domínguez-Gil et al. 2021). Notwithstan...

Metaethical expressivism is typically characterised as the view that normative statements express desire-like attitudes instead of beliefs. However, in this paper I argue that expressivists should claim that normative statements express beliefs in normative propositions, and not merely in some deflationary sense but in a theoretically robust sense explicated by a theory of propositional attitudes. I first argue that this can be achieved by combining an interpretationist understanding of belief with a nonfactualist view of normative belief content. This results in (...) a view I call ‘interpretative expressivism’. I then argue that traditional arguments employed by expressivists that normative statements express noncognitive attitudes can just as well support the claim that normative statements express nonfactual or nonrepresentational beliefs. Finally, I argue that this view has a number of advantages to versions of expressivism that deny that normative statements express non-deflationary normative beliefs. (shrink)

Despite the popularity, success, and growth of programs of organ donation after the circulatory determination of death (DCDD), a long‐standing controversy persists over whether the organ donor is truly dead at the moment physicians declare death, usually following five minutes of circulatory and respiratory arrest. Advocates of the prevailing death determination standard claim that the donor is dead when declared because of permanent cessation of respiration and circulation. Critics of this standard argue that while the cessation of respiration and circulation (...) may be permanent, it may not be irreversible at the moment death is declared because, if cardiopulmonary resuscitation were performed, it might succeed. And because irreversibility of cessation of respiration and circulation is required by both the statute and the biological concept of death, the donor must be alive. Who is correct?Making two related distinctions clarifies the cause of the disagreement over whether the DCDD donor is dead and points to a possible resolution. First, in a determination of death, there is an important distinction between the permanent and the irreversible cessation of circulation and respiration—two associated phenomena that are often confounded. Second, there is an important distinction between the medical practice standard for death determination, in which physicians certify the permanent cessation of vital functions as sufficient for death declaration, and the underlying biological concept of death that requires the irreversible cessation of vital functions because death, by definition, is an irreversible event. (shrink)

This paper examines the general prospects for conceptual role expressivism, expressivist theories that embrace conceptual role semantics. It has two main aims. The first aim is to provide a general characterisation of the view. The second aim is to raise a challenge for the general view. The challenge is to explain why normative concepts are not a species of defective concepts, where defective concepts are those that cannot meaningfully embed and participate in genuine inference. After rejecting existing attempts to answer (...) the challenge, I propose an alternative solution. However, the solution leaves conceptual role expressivism a far less distinctive and interesting position than its proponents claim. I conclude that we should be sceptical about how much expressivists gain by appealing to conceptual role semantics. (shrink)

Expressivists about normative thought and discourse traditionally deny that there are nondeflationary normative propositions. However, it has recently been suggested that expressivists might avoid a number of problems by providing a theory of normative propositions compatible with expressivism. This paper explores the prospects for developing an expressivist theory of propositions within the framework of cognitive act theories of propositions. First, I argue that the only extant expressivist theory of cognitive propositions—Michael Ridge's ‘ecumenical expressivist’ theory—fails to explain identity conditions for normative (...) propositions. Second, I argue that this failure motivates a general constraint—the ‘unity requirement’—that any expressivist theory of propositions must provide a unified nonrepresentational explanation of that in virtue of which propositional attitudes have the content that they have. Third, I argue that conceptual role accounts of content provide a promising framework in which to develop an expressivist theory of cognitive propositions. (shrink)

The overall purpose of this paper is to clarify the physical meaning and epistemological status of the term 'measurement' as used in quantum theory. After a review of the essential logical structure of quantum physics, Part I presents interpretive discussions contrasting the quantal concepts observable and ensemble with their classical ancestors along the lines of Margenau's latency theory. Against this background various popular ideas concerning the nature of quantum measurement are critically surveyed. The analysis reveals that, in addition to internal (...) mathematical difficulties, all the so-called quantum theories of measurement are grounded in unjustifiable, classical presuppositions. (shrink)

In a seminal 1977 article, Rumelhart argued that perception required the simultaneous use of multiple sources of information, allowing perceivers to optimally interpret sensory information at many levels of representation in real time as information arrives. Building on Rumelhart's arguments, we present the Interactive Activation hypothesis—the idea that the mechanism used in perception and comprehension to achieve these feats exploits an interactive activation process implemented through the bidirectional propagation of activation among simple processing units. We then examine the interactive activation (...) model of letter and word perception and the TRACE model of speech perception, as early attempts to explore this hypothesis, and review the experimental evidence relevant to their assumptions and predictions. We consider how well these models address the computational challenge posed by the problem of perception, and we consider how consistent they are with evidence from behavioral experiments. We examine empirical and theoretical controversies surrounding the idea of interactive processing, including a controversy that swirls around the relationship between interactive computation and optimal Bayesian inference. Some of the implementation details of early versions of interactive activation models caused deviation from optimality and from aspects of human performance data. More recent versions of these models, however, overcome these deficiencies. Among these is a model called the multinomial interactive activation model, which explicitly links interactive activation and Bayesian computations. We also review evidence from neurophysiological and neuroimaging studies supporting the view that interactive processing is a characteristic of the perceptual processing machinery in the brain. In sum, we argue that a computational analysis, as well as behavioral and neuroscience evidence, all support the Interactive Activation hypothesis. The evidence suggests that contemporary versions of models based on the idea of interactive activation continue to provide a basis for efforts to achieve a fuller understanding of the process of perception. (shrink)

The most controversial issue in organ donation after the circulatory determination of death is whether the donor was truly dead at the moment death is declared. My colleagues and I further analyzed this issue by showing the relevance of the distinction between the “permanent” and the “irreversible” loss of circulatory functions. Permanent cessation means that circulatory function will not return because it will not be restored spontaneously and medical attempts to restore it will not be conducted. By contrast, irreversible cessation (...) means that circulatory function cannot be restored using currently available technology. In this issue of the Report, Kevin Munjal and colleagues criticize the unjustified application of the permanent‐irreversible distinction, which my colleagues and I developed for cDCDD, to their well‐designed and carefully conducted experimental protocol of uncontrolled DCDD (uDCDD) in New York City, for which our analysis was not targeted. They claimed that to determine a donor's death in uDCDD, it is unnecessary to show that permanence is a valid surrogate indicator of irreversibility because the unsuccessful attempt to resuscitate the patient comprises prima facie evidence of circulatory irreversibility. Ironically, that potent justification defending death determination in uDCDD yields limitations that are similar to those created when our permanent‐irreversible distinction is applied to death determination in cDCDD. (shrink)

I consider the role of cognitive modeling in cognitive science. Modeling, and the computers that enable it, are central to the field, but the role of modeling is often misunderstood. Models are not intended to capture fully the processes they attempt to elucidate. Rather, they are explorations of ideas about the nature of cognitive processes. In these explorations, simplification is essential—through simplification, the implications of the central ideas become more transparent. This is not to say that simplification has no downsides; (...) it does, and these are discussed. I then consider several contemporary frameworks for cognitive modeling, stressing the idea that each framework is useful in its own particular ways. Increases in computer power (by a factor of about 4 million) since 1958 have enabled new modeling paradigms to emerge, but these also depend on new ways of thinking. Will new paradigms emerge again with the next 1,000‐fold increase? (shrink)

This book supports the emerging field of vascularized composite allotransplantation for face and upper-limb transplants by providing a revised, ethically appropriate consent model which takes into account what is actually required of facial and upper extremity transplant recipients. In place of consent as permission-giving, waiver, or autonomous authorization, this book imagines consent as an ongoing mutual commitment, i.e. as covenant consent. The covenant consent model highlights the need for a durable personal relationship between the patient/subject and the care provider/researcher. Such (...) a relationship is crucial given the recovery period of 5 years or more for VCA recipients. The case for covenant consent is made by first examining the field of vascularized composite allotransplantation, the history and present understandings of consent in health care, and the history and use of the covenant concept from its origins through its applications to health care ethics today. This book explains how standard approaches to consent are inadequate in light of the particular features of facial and upper limb transplantation. In contrast, use of the covenant concept creates a consent model that is more appropriate ethically for these very complex surgeries and long-term recoveries. (shrink)

The shape of a life hypothesis holds that the temporal sequence of good or bad times in a life can itself be a valuable feature of that life. This is generally thought to be incompatible with additivism about lifetime well-being, which holds that lifetime well-being is fully determined by momentary well-being. This discussion examines Dale Dorsey’s recent argument that these views are in fact compatible. I argue that accepting the conjunction of these views requires stronger commitments than Dorsey recognizes. After (...) arguing that these commitments are problematic, I conclude that we should reject the compatibility claim. (shrink)

It[is] unlikely that the main question concerning Paul in Romans is how can an individual sinner become a righteous man in God's sight. Rather, Paul seems chiefly concerned to answer another, more fundamental question: Under whose dominion is the world?