Abstract
This paper aims to determine whether it is necessary to propose the extreme of putrefaction as the only unmistakable sign in diagnosing the death of the human organism, as David Oderberg does in a recent paper. To that end, we compare Oderberg’s claims to those of other authors who align with him in espousing the so-called theory of hylomorphism but who defend either a neurological or a circulatory-respiratory criterion for death. We then establish which interpretation of biological phenomena is the most reasonable within the metaphysical framework of hylomorphism. In this regard, we hold that technology does not obscure the difference between life and death or confect metaphysically anomalous beings, such as living human bodies who are not organisms or animals of the human species who are informed by a vegetative soul, but instead demands a closer and more careful look at the “fuzzy area” between a healthy (living) organism and a decaying corpse. In the light of hylomorphism, we conclude that neurological and circulatory-respiratory criteria are not good instruments for diagnosing death, since they can offer only probabilistic prognoses of death. Of the two, brain death is further away from the moment of death as it merely predicts cardiac arrest that will likely result in death. Putrefaction, the criterion that Oderberg proposes, is at the opposite end of the fuzzy area. This is undoubtedly a true diagnosis of death, but it is not necessary to wait for putrefaction proper—a relatively late stage of decomposition—to be sure that death has already occurred. Rather, early cadaveric phenomena demonstrate that the matter composing a body is subject to the basic forces governing all matter in its environment and has thus succumbed to the universal current of entropy, meaning that the entropy-resisting activity has ceased to constitute an organismal unity. When this unity is lost, there is no possibility of return.
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Notes
The neurological criterion was quickly adopted in the legislative field—as early as 1981, the National Conference of Commissioners on Uniform State Laws included this criterion in the legal definition of death enacted in the Uniform Determination of Death Act [3]. However, its theoretical justification has been reformulated more than once and the number of detractors has increased. For a history of the neurological criterion, see [4, ch. 3; 5; 6].
Strictly speaking, putrefaction refers to a late cadaveric phenomenon. However, it seems unlikely that Oderberg is using the technical sense of this term. Rather, he appears to be referring to the entire decomposition process. In order to avoid confusion and ambiguity, we will use the term ‘decomposition’ to mean the breakdown of dead organic matter as a whole and ‘putrefaction’ to mean the specific postmortem process whereby cellular proteins are broken down by bacterial digestion [7, 8]. Terminological precision is a necessary tool to reach clarification on this complex topic.
His first assumption is that “the dead donor rule is ethically correct” [1, p. 360]. Given that the issue of transplantation is not of interest in this paper, we do not need to adopt that assumption here.
In particular, with respect to the neurological criterion, we will focus on the work of Jason Eberl [10], Maureen Condic [11, 12], and Melissa Moschella [13, 14], each of whom explicitly supports the hylomorphic doctrine. With respect to the circulatory-respiratory criterion, our focus will be on work by Alan Shewmon [5] and Franklin Miller and Robert Truog [4]. We do not include Patrick Lee and Germain Grisez [15, 16] among the former group of authors because, as we briefly argue, their interpretation of whole-brain death is not compatible with Oderberg’s Aristotelian assumptions.
In an eloquent expression, Oderberg says, “I am as much a human being in my little toe as in my whole body” [1, p. 371].
In fact, “permanent cessation of the functioning of the organism as a whole” is the very definition of death arrived at by James Bernat et al. when they first advanced a philosophical justification of the neurological criterion [19]. This later became the standard definition of death.
For Aristotle’s account of the four types of causes (material, formal, efficient, final), see Meta. 5.2.1013a24–1014a25 and Ph. II.3.194b23-195a3.
The soul is the first cause of all movements of the organism. The organs are secondary causes. Even where the organism performs multiple functions concurrently, the first cause of all of them is that single form. This point is relevant to the issue of brain death because even if an organ fails and a certain activity cannot be performed, as long as the organism is still alive, it will continue to be informed by the same soul that has the capacity to cause that operation. For example, dogs are animals that can see. A dog without eyes cannot see as it lacks the organ, the secondary cause, of sight; but it still has the radical capacity to see because it continues to have the form of a dog. Concerning this point, Oderberg is very clear: “I also understand the human being as an essentially rational animal—a being for whom the power of rational thought is present as long as it is a normal member of its kind, just as being winged is essential to birds as long as they are normal members of their kind” [1, p. 361]. Here the point at issue is whether a brainless human being can still be considered a human being.
It is inaccurate to say that death consists of the separation of the soul from the body (cf. [1, p. 362]), since the body is necessarily an “animated body,” which is to say it is constituted by the soul. After the soul is lost, the remains are mere matter: a corpse.
Material realities are extensive (spatial) and temporal (successive). Conversely, immaterial realities do not imply the existence of time or space, and so must be considered instantaneous—a notion that better captures the fact that, in temporal terms, they do not last, having a duration of zero.
The idea that identifies traits of personhood with sentience has a long philosophical tradition. For one of the latest relevant contributions in this area, see Alberto Giubilini and Francesca Minerva [22].
In a metaphysical analysis, it is important to elucidate what kind of entity that living thing is. Lee and Grisez are unfortunately not clear on this point. They agree with Shewmon that a totally brain-dead individual’s body maintains integrated functioning, but they say that it is not “a whole member of the human species” [15, p. 277]. In a later article, Lee explicitly allows that a brain-dead body may be some kind of organism, just not a human organism [16, p. 301]. However, within a hylomorphic metaphysical framework, which we are assuming for this discussion, it does not seem possible to make sense of a genetically human organism that is not a human being. We will discuss this further in our conclusion.
Lee and Grisez would not agree with this proposition, which is why we say that their position does not follow the metaphysical claims that we have assumed for this discussion. One of our assumptions is that “what makes an organism a living member of its kind is its functional unity and integrity” [1, p. 360]. Lee and Grisez do not deny the functional unity and integrity of a totally brain-dead individual, but they deny its humanity in that it has lost its radical capacity for sentience. This claim is not compatible with Oderberg’s assumptions. For him, the first cause of operations is the soul, not the specific organ (and Lee and Grisez deny the totally brain-dead individual’s radical capacity for sentience because of its destroyed brain), and it is for this reason that we do not discuss this article here.
Condic adds that in complex organisms it is even harder to determine the moment of death because at that moment the cells of the organism are still alive: “On a cellular and molecular level, nothing changes in the instant of death. Immediately following death, most of the cells in the body are still alive, and for a time at least, they continue to function normally” [12, p. 51].
Shewmon likewise refers to the living body as a “bubble of anti-entropy” [23].
It may be useful here to recall the distinction between the whole organism and the organism as a whole. A unitary whole, or complete organism, corresponds to the organism as a whole—however mutilated.
Despite their different starting points, the Jonasian description of a living being is perfectly compatible with hylomorphism (see [29]). In fact, Jonas maintains both the idea of the form as the final cause of the organism and the idea of the matter as the efficient cause [28, pp. 80–82], criticizing Cartesian dualism. In this way, his metabolic account succeeds in combining Aristotelian hylomorphism with cybernetics.
The absence of the reflex to breathe in individuals without cortical function explains why apnea testing is required in the clinical determination of whole-brain death.
High-cervical spinal cord injury disconnects the brainstem from the rest of the body, dispossessing these patients of their ability to breathe (inflate their lungs) spontaneously.
If the organism stays integrated (maintains anti-entropic movement), then it remains alive. Moreover, per our original assumptions, if the organism is alive, then the human person is alive.
Here we see an important difference between the position of these authors and that of Patrick Lee. Observing a distinction between permanent loss of consciousness and complete loss of the capacity for consciousness, Lee argues that people in persistent vegetative states should be considered alive on the basis of practical epistemic considerations: without a diagnosis of brain death, one cannot be reasonably certain that the radical capacity for consciousness has been lost, even where that capacity will never be realized [16, p. 311]. However, in principle, an individual could exist who has some level of brain functioning and yet lacks the radical capacity for consciousness—and, for Lee, that individual would have died. By contrast, neither the Eberl–Condic–Moschella camp nor Oderberg would claim that such a human organism is not a living human being. Whereas for Lee the quality that defines a human being is the radical capacity for rationality, for Eberl, Condic, and Moschella it is either the radical capacity for rationality or the radical capacity for self-integration (the biological manifestation of which is being a human organism), and for Oderberg it is the capacity for organismal integration. Oderberg—following Aristotle—holds that human substances are no different from other kinds of natural substances: if something is an organism of the human species, it is a human being.
By activation we mean the “activation of the integrative processes.” We are grateful to José Luis Irarrázaval for this important insight.
For the sake of simplicity, we focus on gases only, though other nutrients are naturally also required for biological life.
We are not claiming that all patients with brain death are alive, but we reject the idea that those diagnosed with brain death who ostensibly survive for a significant time while past their diagnosis do so with a life that is “artificial.” Their life is natural, although technically assisted (see [5, 36]).
According to Moschella, the soul is the internal principle of unity insofar as it accounts for “the root capacity for internally-directed integration or self-integration” [13, p. 287]. As such, if integration is achieved by means of another (external) principle, the integrated matter would not be an organism, even if it performed the exact same operations in the exact same way as a natural organism. We reject this point by drawing a distinction between activation and integration. The integration (of the unitary whole) is still ongoing as an effect of the soul. The only difference is that in some cases, or during some stages of development (such as in utero), integration is not activated by the brainstem.
Strictly speaking, one can destroy or incapacitate the apt matter for organismal life, but technology has never been able to generate (build up or capacitate) living matter from inert matter. No matter how much one ventilates a corpse, it will not recover life.
In such cases, self-regulation restarts after a period of acute instability, one that often eventuates in the rapid onset of asystole, during which much support is required so that the patient does not die [4, 5]. During this period, the symptoms of both kinds of patients—which Shewmon brackets under “spinal shock” [37]—are almost the same. Those who manage to overcome spinal shock tend to spontaneously begin self-regulating again (to the extent possible).
Recall that for Lee and Grisez, for instance, these are living remains of a human being but are not “a whole member of the human species” [16, p. 277].
By “holistic” property, Shewmon means one that cannot be predicated on any part or subset of parts alone, but must be predicated on the entire composite; and by “emergent” property, he means one that is derived from the mutual interaction of the composite’s parts [32, p. 460]. Finally, he adds the continuous membrane condition to distinguish organisms from other kinds of integrated unities, such as societies or forests [32, p. 461].
In that way, strictly speaking, an organ separated from the organism is no longer the specific organ represented by its shape (say, a kidney) [10, p. 52].
Oderberg refutes this argument. According to him, the closer researchers try to simulate organic functions, the more processes there are that must be substituted or imitated: “In other words, by mimicking organismic behaviour in order to have a reliable model, they tacitly admit that in vivo healing is a holistic process attributable to the organism rather than any of its parts. It invokes, as Shewmon puts it, ‘multiple bodily systems distant from the wound’” [1, p. 369].
As is well known, David Hume presented a different view of causality. For him, if there is a habitual association between A and B, if B always precedes A, and if there is a spatiotemporal connection between A and B, then it can be said that B causes A. In this case, the relationship between A and B is weaker and does not imply dependence, only a (fallible) prediction: if B, then probably (given the limits of observation) A.
As explained above, the form actualizes the matter and thus constitutes the substance. In living beings, the soul actualizes the matter constituting the body or organism. That act of actualization brings the body into existence (it is its act of existence) and integrates it (it is the act of integration). We are grateful to a blind referee who urged us to explain this metaphysical claim. For further reflection on this topic, see David Jones [42].
Oderberg explicitly distinguishes the “process of dying” (or gradual dying) from death, which must be instantaneous [1, p. 363]. Later, when he talks about “loss of integration as a biological phenomenon,” he dismisses the intercommunication model proposed by Tonti-Filippini and others because it would entail “gradual death” [1, pp. 365–366]. The problem is that he does not clarify what he means by loss of integration as a biological phenomenon. It is precisely this notion that we intend to illuminate with the hylomorphic doctrine.
It is not our intention to suggest that Oderberg implies that systemic failure means material disintegration (decomposition). In fact, he actually proposes a third concept of disintegration as “the literal physical separation of parts of an organism,” which better accounts for biological disintegration [1, p. 366]. Yet the three concepts he proposes—loss of integrity, systemic failure, and physical separation—are somewhat hazy. For example, as mentioned above, Oderberg says that systemic failure must occur prior to true metaphysical death. However, if systemic failure is understood as the process by which biological systems stop working, then it can occur before or after metaphysical death, as many subsystems take some time to completely cease or shut down. Oderberg also says that “physical separation can occur either prior to or subsequently to true metaphysical death” [1, p. 366]. However, we think this is equivocal: if by physical separation he means the severance of a particular part of the organism, such as the amputation of a limb, the extraction of a kidney, or decapitation, then it can indeed occur before or after metaphysical death; but if he means material disintegration or decomposition, as suggested above, then it can occur only after metaphysical death. We thank the referees for having us clarify our differences with Oderberg’s position here.
The central problem with the concept of irreversibility is that it is not empirically verifiable. That is, irreversibility can only be known retrospectively [24].
In this regard, it is worth considering Jonas’s above-mentioned metabolic theory.
As Mark Spencer explains, “For the hylomorphic interpretation of this situation … some activity of the body must be able to be attributed to an internal source; there must be some activity of the whole organism that cannot be entirely explained in terms of external forces, such as the operations of a machine, if the organism is to be considered alive and still informed by the same soul it had when it was uncontroversially alive” [46, p. 866].
It is not our goal (and is probably not feasible) to identify which physical phenomena commence immediately after death. We are looking for signs of death. Our discussion thus pertains to the manifestation of changes after death, and not the changes in and of themselves [47].
Oderberg defines putrefaction as “the physical decomposition of the body” [1, p. 374], indicating that it is a multistage process that begins with algor mortis (temperature change), followed by rigor mortis (muscular stiffening) and livor mortis (pooling of the blood). This is not accurate. As we point out in footnote 2 above, technically speaking, putrefaction is the specific late cadaveric process by which cellular proteins are broken down into their biochemical components by aerobic and anaerobic bacteria [7, 8]. It proceeds in four phases: discoloration (starting with abdominal greening), gas accumulation (bloating), liquefaction (tissue reduction), and skeletonization [8, pp. 30–33; 48; 49]. Moreover, it is worth noting that the whole process of decomposition is not as linear as Oderberg suggests. Empirical studies in forensic medicine have found that both livor mortis and rigor mortis of the facial muscles start to become visible as soon as one hour after death, while algor mortis is actually more variable given that temperature is highly dependent on the particular environment [50].
Spencer defends the circulatory-respiratory criterion defined as the “loss of the capacity for the circulation of oxygenated blood or its functional equivalent” [46, p. 868]. This definition is interesting because by talking about the capacity for circulating oxygenated blood, the criterion avoids engendering false negatives in thought experiments involving suspended animation or cryogenic freezing, in which circulation is actually stopped but could be restarted.
Truog and Miller document this claim with articles from the’70 s and’80 s, particularly an article by Julius Korein [51].
Metaphysically these claims are difficult to explain. If the head and the body form an indiscernible unity, the spinal cord-injured patient would be a unitary living entity informed by two souls. This situation runs counter to the hylomorphic doctrine.
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Acknowledgements
We acknowledge Katelyn MacDougald for her outstanding final revision of the paper and relevant suggestions on a previous version of the paper. Furthermore, we acknowledge the team of neurologists at Pontificia Universidad Católica de Chile (Patricio Mellado, Jorge Tapia, Jaime Godoy, Max Andresen, Rommy von Bernhardi, and Patricio Sandoval) for their high-level insights on brain death.
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Carrasco, M.A., Valera, L. Diagnosing death: the “fuzzy area” between life and decomposition. Theor Med Bioeth 42, 1–24 (2021). https://doi.org/10.1007/s11017-021-09541-4
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DOI: https://doi.org/10.1007/s11017-021-09541-4