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Whole-brain death and integration: realigning the ontological concept with clinical diagnostic tests

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Abstract

For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. However, a series of recent cases in which individuals were declared brain dead yet physiologically maintained for prolonged periods of time has challenged the status quo. This signals a need for deeper reflection and reexamination of the underlying philosophical, scientific, and clinical issues at stake in defining death. In this paper, I consider four levels of philosophical inquiry regarding death: the ontological basis, actual states of affairs, epistemological standards, and clinical criteria for brain death. I outline several candidates for the states of affairs that may constitute death, arguing that we should strive for a single, unified ontological definition of death as a loss of integrated functioning as a unified organism, while acknowledging that two states of affairs (cardiopulmonary death and whole-brain death) may satisfy this concept. I argue that the clinical criteria for determining whole-brain death should be bolstered to meet the epistemic demand of sufficient certainty in defining death by adding indicators of cerebro-somatic dis-integration to the traditional triad of loss of consciousness, loss of brainstem function, and absence of confounding explanations.

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  • 17 December 2020

    My article, “Whole-brain death and integration: Realigning the ontological concept with clinical diagnostic tests”.

Notes

  1. This idea of different levels of inquiry builds upon the pioneering work of Alexander Capron and Leon Kass [6], who distinguish between the concept, the physiological standards, the operational criteria, and the tests or procedures, and of James Bernat, Charles Culver, and Bernard Gert [7], who distinguish between the definition and criterion of death. The levels of inquiry proposed here differ from these earlier attempts to parse death-related concerns, at least in part because recent developments have surfaced new types of underlying questions.

  2. This observation is not undermined by the sorites paradox. One could argue that the possibility of creating a chimera by adding cat genes to a giraffe means that kinds are continuous. Yet one would need to concede that at some point the resulting animal would become a cat, not a giraffe. Just as one cannot say with certainty which additional grain of sand makes a pile, so one could not say with certainty which additional gene would make a giraffe a cat. But at some point it becomes a cat. And saying that something is a cat is a kind sortal, a fact about the world, not a social construction.

  3. Elizabeth Anscombe attributes this idea to Johnson without citation [24], and neither I nor my research assistant, MaryKate Brueck, have been able to find a source in Johnson’s writings.

  4. Or perhaps it does not. Perhaps pet owners could also decide whether their dogs were dead. Or, to the extent that certain higher apes can exercise primitive autonomy, one would need to ask them whether they were dead too.

  5. There is no requirement that one continue life support for such individuals if one judges that the burdens of support outweigh the benefits in a particular case, but clinicians would not be empowered to refuse requests for such treatment solely on the grounds that the patient is dead.

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  1. Kennedy Institute of Ethics, Georgetown University, Healy 419, 3700 O Street NW, Washington, DC, 20057, USA

    Daniel P. Sulmasy

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Sulmasy, D.P. Whole-brain death and integration: realigning the ontological concept with clinical diagnostic tests. Theor Med Bioeth 40, 455–481 (2019). https://doi.org/10.1007/s11017-019-09504-w

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