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Death: Beyond Whole-Brain Criteria (Philosophy and Medicine)

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Richard Zander, editor
Death: Beyond Whole-Brain Criteria

(Dordrecht, NL: Kluwer Academic Publishers, 1988)
(ISBN: )
(Library of Congress call number: not given)
(Medical call number: W820D2853 1984)

Based on a conference in 1984, the contributors to this volume
are divided--some advocating whole-brain definitions of death
and others advocating higher-brain definitions
or even the death of the person.
As of the time of this conference,
no clear consensus among the experts had yet emerged.
And they knew that the general public would take even longer
to comprehend the higher-brain definitions of death.

But if we call it the death of the person or the end of conscious life,
then lay people should be able to grasp that easily and quickly.
This reviewer believes that each individual
should be empowered to specify in advance
which definition of death should be applied to him or her.
In some cases, this would permit an earlier declaration of death,
which would be very important for organ-donation
and other possible uses of a brain-dead body.

The first chapter gives a good history of concern for defining death.
In the past, the worry was mostly that patients would be wrongly declared dead.
Early medicine discovered how to resuscitate people who seemed to have died.
And medicine discovered how to keep tissue alive without its original host-body.
Premature burial was a wide-spread worry in the 19th century
--even tho no modern cases of being buried alive were ever proven.

In recent years, however, the main problem has been keeping the body 'alive'
even after the death of the person.
We now worry about being wrongly declared alive.

Whole-brain-death became the standard in medical practice in 1968,
because a wide consensus could be achieved about that definition.
But from the beginning, some experts advocated a higher-brain standard.
However, there were no reliable tests to prove permanent unconsciousness.
And it had become increasingly easy to keep a body 'alive'
without any of the higher functions of the human brain.

Part of the difficulty in defining death is the assumed need
for an either/or definition of death:
Either this body is alive or this body is dead.
But this reviewer would be content with descriptions of the various stages of dying.
And the permanent loss of personhood should be a permissible definition of death.
A human person has: consciousness, memory, language, & autonomy.
These are phenomena that every layperson can evaluate.
We do not need high technology to determine whether an individual is awake.
But we do need professional opinions to evaluate the possibility
that the patient might awaken at some time in the future.

The second chapter argues forcefully
that once the upper surface of the brain (the gray matter) is dead,
that person is forever dead,
even if the brain-stem can keep the heart beating and the lungs breathing.
After the upper brain tissue is definitely dead, it never regenerates.
And consciousness has never been known to return to such a brain.
Thus, it seems wise and compassionate the stop the heart and the lungs,
to declare death, and to proceed with all of the other activities that follow death.

The law has special reasons for requiring a sharp line between life and death.
A spouse of a patient in persistent vegetative state
would not be permitted to remarry until the patient is declared dead.
Inheritance does not pass until the grantor is legally dead.
Homicide is no longer possible if the patient was already dead.

In general, the legal profession and the state laws
have left it to the medical profession to decided when to declare death.
And brain-death statutes grant legal permission
to use whole-brain criteria as sufficient for declaring death.
In the future, it might be better to leave all determination of death to the medical profession
(presumably using criteria and tests doctors generally accept)
rather than changing the state laws
every time there is a new advance in medical practice.
A good-faith declaration of death by a licensed physician
following accepted medical practice
should be sufficient to certify that a person is dead.

David Smith recommends neocortical death as the definition.
When certain criteria are met, the person would be declared dead.
Smith would depend on a PET scan to decide when a patient's neocortex is dead.
But additional methods have probably been developed since this writing,
which answer with ever greater confidence this question:
"Will this patient ever regain consciousness?"

Once the patient has been declared dead,
the family or the estate could keep the biological functions going at their own expense.
But the public should not be expected to pay for such maintenance.
This would be parallel to the practice of freezing a body after death,
in the remote hope that a cure for the cause of death would be discovered
and the body could be brought back to life.
Any such freezing takes place after the declaration of death.
And the cost of keeping the body in the freezer is paid by the estate or the family,
just as the cost of burial or cremation would be borne by the family.

In the donation-plans of this reviewer,
after the declaration of death based on permanent unconsciousness,
my body would become the property of the medical institution,
which could use it for any medical, scientific, or educational purposes.
This would be much better than keeping my body 'alive'
as a 'living memorial' to the person I once was.
These views are explored more fully in an on-line essay entitled:
"The Living Cadaver: Medical Uses of Brain-Dead Bodies".
You can find this essay by searching the Internet for the following exact expression:
"the living cadaver".

~~~~~~~

A chapter entitled:
"Human Death and the Destruction of the Neocortex"
by Edward T. Bartlett & Stuart J. Younger

In creating a new definition of death, we need three elements:
a concept, medical criteria, & objective tests.
The first formulation of whole-brain death
did not separate these elements very well.

In fact, much of their informal presentation
really referred to the higher-brain functions such as:
sentience, memory, personality, conscious life, uniqueness,
judging, reasoning, acting, enjoying, & worrying.

However, their formal definitions refer to the integrating functions of the brain-stem:
such as regulating heart-beat, breathing, body-termperature, & blood-pressure.
These are all functions that continue while we are asleep.
But the distinctively human and personal functions
only happen while we are awake.

Whole-brain definitions of death would also apply to all animals.
But our higher-brains provide the functions that make us persons
--which is more than mere living biological organisms.
From the human and personal point of view,
we care more about the disintegration of ourselves as persons.

The deaths of our human selves or persons take place some time
before the final deaths of our bodies as biological organisms.
We might want to draw the line between living persons and dead persons.
And we might add a new category: former persons.
These would be individuals who have permanently lost
most of the capacities that constitute personhood:
consciousness, memory, language, & autonomy.
How would we want to be treated if we become former persons?
These four criteria of personhood
are explored more deeply in a small book by the present reviewer:
When Is a Person? Pre-Persons and Former Persons:
You can find this book on the Internet by searching its exact title:
"When Is a Person? Pre-Persons and Former Persons".
This book contains about 200 questions that can be asked by laypersons
in evaluating the levels of personhood in someone they know.

The whole-brain definition of death was proposed
because it would be acceptable by various groups in the public,
even if they have different philosophical concepts of life and death.

But there are some very conservative religious groups
that will be very slow to accept any changes in the concept of death.
Whole-brain death was acceptable because without mechanical support,
the body would soon be completely dead
by the traditional criteria of the loss of breathing and heart-beat
--which have been the definition of death for thousands of years.
When religions are founded on texts
written hundreds or even thousands of years ago,
it will be difficult for the present believers to make adjustments
for advances in medical science and technology.

But the following is one possible direction for new religious thinking:
Religious people are very concerned about the spiritual condition
of the patient whose death is being determined.
Religions sometimes speak of the departure of the soul or spirit.

Perhaps modern thinkers based in ancient religious traditions
will be able to notice that spirituality was usually found in living minds.
When thinking has ended permanently,
perhaps all spiritual activities of that person are also at an end.
When the final death of the body followed immediately after the death of the brain,
there was little reason to wonder about the departure of the soul.
When the breathing stopped, the soul departed:
Spiritual life within this earthly body was over.
But what about a body in persistent vegetative state?
Does the soul or spirit still exist within a body in a coma?
Or has the spiritual life of that living person come to an end?

The present reviewer believes that we do have important spiritual capacities,
such as self-transcendence, freedom, creativity, & love.
But all of these capacities of our human spirits depend on consciousness.

Other persons who believe in the human spirit take different points of view.
For some, spirit means primarily the capacity to exist beyond death.
But all who think about spiritual matters should ask themselves:
What is the spiritual condition of a former person in a coma?

Some authors in this collection have begun the process
of re-thinking death as the death of the person,
which would anatomically be associated with the death of the neocortex.
If we are certain that the upper parts of the brain are permanently dead,
then we can be confident in declaring that person dead.
But it might be some decades before this concept is accepted by the general public.

Laypersons are more familiar with consciousness
and the end of consciousness.
Each of us experiences the temporary loss of consciousness
every night when we go to sleep.
We know that sleep was temporary when we awake in the morning.
And when we observe others who have lost consciousness,
we can keep hoping that they will wake up again.
But after a reasonable time, if consciousness does not return on its own,
we should consult neurologists to discover
the causes of what appears to be permanent unconsciousness.

If medical science tells us that consciousness will never return to this brain,
then we should consider what to do next.
The most conservative choice would be
to keep the body 'alive' for as long as possible,
using whatever life-support systems are appropriate.
The course suggested by standard medical care
is to wait for an agreed-upon length of time
to see if any efforts can bring this upper brain back to life.
And if nothing helps, then the life-supports are disconnected,
allowing the patient to die a natural death.
The most liberal (and still controversial) choice
would be to declare the patient to be dead
when it has been well-established that consciousness will never return.

Death of the neocortex or death of the person
would allow the body to be used for organ transplant
and other medical procedures and education.
But all medical personnel involved in such further use
of the permanently unconscious body
will have to be convinced in their own minds that this patient is really dead.
If death has been officially declared and accepted by all concerned,
then the remains can be treated as dead bodies have been treated
as far back as history and anthropology can discover.

The public will be slow to accept
the death of the upper brain as the death of the person.
For example, there are more than 10,000 patients in persistent vegetative state,
who are being kept 'alive' by various means of life-support.
The public will not easily allow these patients to be declared dead.
The case of Terri Schiavo amply illustrates this:
Most public opinion (including most of the US Congress)
did not believe that Terri should be disconnected from life-supports,
which in her case was mainly a feeding-tube.

We need careful discussion of the most appropriate
options of care for patients in PVS.
Should they be described as "former persons"?
Should we automatically keep all PVS patients on life-supports as long as possible?
Should other options be accepted by the medical profession
as well as the general public?

How will resistance to 'pulling the plug' be overcome?
It might take decades of discussion and re-thinking.
Perhaps other high-profile cases will galvanize new dialog.
The ever-increasing number of patients in PVS
will mean that more families will become personally involved in this problem.
And some individuals will make their own decisions
about how death should be defined in their own cases,
which will stimulated others who know about such choices
to reconsider how they would like to be treated at the end of their lives,
especially if they might have a long period of unconsciousness at the end.

This reviewer recommends that all patients in PVS
be evaluated at least once every month.
And just because a decision was once made to put them on life-supports
should not prevent changing that decision
after a longer period of time without the return of consciousness has elapsed.

Permanent unconsciousness might become an optional definition of death:
New laws could be written that would allow a physician qualified in neurology
to declare a former person dead
if that patient has been unconscious for a year or more
and is never likely to regain consciousness.
And if the patient has given permission for such a definition
in an Advance Directive for Medical Care,
this will make such a declaration easier.
The family and the proxies might also agree with such a determination.
If the patient has received neurological care and evaluation for one year,
there can be a high degree of confidence
if all the neurological tests say that this upper brain
will never again have another moment of consciousness.

Similar laws allow a missing person to be declared legally dead
if he or she has been missing for seven years.

Death: Beyond Whole Brain Criteria was one of the earliest attempts
to go beyond the whole-brain-death definitions of death.
What was basically lacking when it was written
(and might still be basically absent)
is a clear set of tests for 'neocortical death'.
Only after medical science has reached a good consensus
about the end of consciousness and the death of the person
can the general public be expected to follow suit.

Using higher-brain criteria for death
will allow patients to be declared dead
when they become permanently unconscious.
When our conscious lives have irreversibly come to an end,
we should permit a declaration of death,
which would then allow all the after-death events to begin.

This is the choice I make for myself now.
Even if my body still has a heart-beat and is still breathing,
I grant my permission to be declared dead
if I will never again have a moment of conscious thought or feeling.
I would like to donate my body as a 'living cadaver'.
This is a new concept for medicine and for the general public.
But such an intermediate state might become more common.
For all purposes (medical, social, legal, etc), such a body is dead.
These views are explored more fully in an on-line essay entitled:
"The Living Cadaver: Medical Uses of Brain-Dead Bodies".
Search the Internet for this expression: "the living cadaver".

Many of the authors in this book also raised the question
of the defining what it means to be a person,
but none offered very elaborate definitions and tests for personhood.
They merely referred to such common-sense activities as
thinking, feeling, acting, communicating, relating, etc.
This reviewer thinks that we need more careful criteria
to decide just when a certain individual might have stopped being a person.
One book that offers about 200 questions that can be asked by laypersons
who wish to discuss the degree of mental decline in a loved one
is called "When Is a Person? Pre-Persons and Former Persons".
Search the Internet for this exact title.

Even tho this book, Death: Beyond Whole-Brain Criteria, is a few decades old,
the issues have still not been resolved.
And new books along this line are definitely needed.

If you would like to read other books about defining death,
search the Internet for the following exact expression:
"death--proof and certification".

James Leonard Park, existential philosopher
and advocate of higher-brain criteria for defining death.