PHIL103: Moral and Political Philosophy

With the development of mechanical ventilators, new drugs, and other forms of treatment, it became possible to artificially maintain circulatory and respiratory functions, even after the brain had stopped functioning. In the past four decades many countries amended their death statutes to include a definition of death by the complete and irreversible cessation of all brain functions. Since that time almost all cadaveric organs have been recovered from patients who have been declared "brain dead". Veatch has never been comfortable with the term "brain death," preferring instead "brain-oriented definition of death". Since the 1970s he has argued that the entire brain does not have to be dead for the individual as a whole to be dead. Instead, he advocates a "'higher-brain-oriented definition' of death ­– in other words, one is dead when there is irreversible loss of all 'higher' brain functions" he further proposes creating a new definition of death law that incorporates the notion that one need only have an irreversible loss of consciousness as opposed to an irreversible loss of all brain functions. Veatch's proposal is clearly controversial. It suggests a violation of an ethical boundary most clinicians are currently unwilling to cross. Perhaps he is correct that such a change is inevitable and that the "definition of death at the conceptual level is a religious/philosophical/social policy choice rather than a question of medical science". There was clear leadership from individuals such as pioneering transplant surgeon, Dr. David Hume; Dr. Hume wrote "there is only one definition of death, irreversible brain damage. Cessation of heart beat does not constitute death unless it has caused irreversible brain damage there must be no spontaneous respirations". These observations were later corroborated by Dr. William Sweet published in the New England of Medicine when he wrote "it is clear that a person is not dead unless his brain is dead. The time-honored criteria of stoppage of heart beat in circulation are long enough for the brain to die". Dr. Sam Shemie has clarified the paradigm for donation and death by emphasizing on the "required absence of circulation" and by underscoring the vital functions of the brain as an essential criterion of life. "Where the extracorporeal machines of transplantation can support or replace the function of organs such as the heart, lung, liver or kidney, the brain is the only organ that cannot be supported by medical technology". On the other hand Byrne and others have rejected brain death as constituting death of the person contending the "cessation of the entire brain function, whether irreversible or not, is not necessarily linked to total destruction of the brain or the death of the person". Byrne, apparently, bases his opinion regarding death as philosophically constituting a separation of the soul from the body. However, applying that personal philosophy to the diagnosis of death defies a legal and medical standard, and an ethical and practical sensibility. No one knows when the soul may separate from the body at the time of death. However, the legal and medical definition of death is clear in terms of neurological and circulatory function. It becomes unethical to impose futile clinical treatments to a comatose individual, if the function of the entire brain is irreversibly lost. What would opponents of the brain death determination do with a patient on a ventilator with such a clinical condition have them maintained indefinitely in such a state? To propose the brain death criteria as constituting death was the central issue that confronted the Harvard Committee in 1967. No one knows when the soul separates from the body, but a precise time of death must be specified for obvious legal, medical and social reasons, so that futile treatment can be concluded (without further obligation or responsibility to provide resuscitative or supportive technologies) and proper disposition of the body with burial and estate and property transfer, etc can be exercised. For many years, Truog has also objected to the determination of death by neurologic evaluation and by circulatory function. He wrote in the New England Journal of Medicine that "arguments about why these patients should be considered dead have never been fully convincing. The definition of brain death requires a complete absence of all functions of the entire brain yet many of these patients retaining essential neurologic function, such as regulated secretion of hypothalamic hormones". The rebuttal to this assertion has been given by Shemie who claimed that "the release of antidiuretic hormone (ADH) from the hypothalamus is not considered to be essential neurologic function. Brain death is determined by an absence of consciousness, receptivity and responsiveness, spontaneous movement, spontaneous breathing and absence of brainstem reflexes". Brain death does not require every brain cell to be nonviable but the criteria require an irreversible loss of neurologic function of a patient interminably supported by a mechanical respirator. For Truog and others however, these patients are not considered dead because they indeed can be supported indefinitely beyond the acute phase of their illness. It is well known however that despite the irreversible loss of brain function the remainder of the body can be maintained by mechanical support; for example, even by patients who become brain-dead during pregnancy yet successfully have their fetuses brought to term. The clinical condition still constitutes the death of the mother and a viable fetus buys continued mechanical support until birth. Again in the New England Journal of Medicine. Truog and Veatch have asserted the donation after cardiac death (DCD) is not acceptable; that is, the recovery of organs after the determination of death by circulatory and respiratory criteria. Troug suggests that recovery of the heart following DCD is "paradoxical" because the hearts of patients who have been declared dead on the basis of the irreversible loss of cardiac function have in fact been transplanted and successfully functioned in the chest of another". Veatch is similarly not convinced that the donor is dead and stated that "if someone is pronounced dead on the basis of irreversible loss of heart function, after all. It would not be possible for heart function to be restored in another body. Both Veatch and Truog misinterpret the uniform declaration of death act UDDA which precisely stated that it applies to an individual who had sustained irreversible cessation of circulatory and respiratory functions. It is not a matter of the cessation of heartbeat or cardiac function per se but an irreversible cessation of circulation in the donor. The consequence of the absence of circulation is upon the function of the brain results in an irreversible loss or neurologic function – the UDDA definition of death.

Bernat has written that circulation – not heartbeat – is the critical function that must be lost using circulatory-respiratory tests to determine death. For example, we do not declare patients dead who are on heart lung machines during cardiac surgery, on ECMO awaiting heart transplantation (even if they never receive a heart), or carrying artificial hearts because, despite absence of heartbeat, their circulation remains continuously maintained. That is why the death standard requires absence of circulation. "Whether the asystolic heart is subsequently left alone, removed and not restarted or removed and restarted in another patient is irrelevant to the circulatory status of the just-declared dead patient. Removing and restarting the heart elsewhere simply has no impact on the previous death determination because that patient remains permanently without circulation in exactly the same way as if the non-beating had been left in place". And as an everyday example after slaughtering the rooster it jumps higher and stronger as never than done in its life, this movement doesn't indicate that he is still alive and it continues bleeding strongly indicating that the heart is still functioning, and on the opposite side the heart beating may stop spontaneously, known as cardiac arrest and attempts of rescue continue, in many cases the restitution succeed. The heart start beating again and life gets back to its normal state, moreover doctors can stop the heart for hours during the operation of the open heart, however the blood circulation does not stop, not even for seconds, therefore the heart beating does not mean life and the stoppage of heart beating does not necessarily mean death. Irreversible loss of consciousness may be due to partial or total brain injury. For the determination of brain death, irreversible coma must be due to injury to the brain so severe as to cause loss of brain functions

Death is when blood stop reaching the brain causing a permanent harm to the brain and leading to a permanent loss of all its functions including the brainstem functions and to diagnose death it is necessary to prove the cessation of the functions of the brain, and then brain commences disintegration and its known that many cells from a dead person remain alive after the declaration of his death. Therefore we find that the muscular cells responds to electrical stimulations and some cells within the liver continue transforming the glucose to glycogen, so cells do not die all at once, however they differ in their timing of death and perish after death of the person. We can extend the life of these cells if they are put in saline solution, especially with the flow by means of a pump hence allowing the use of organs and cell of the dead person for another patient needing them, the death is a process and not an event.

Brain death can be defined as follows: When the brain is damaged, and its activities completely cease, brain death is present, even if it is possible for the patient to be kept breathing and his heart is beating with artificial respiration and medications; even if the heart and liver are functioning that is not live it is just artificial. The consideration of legality of brain death as "true death" was first considered in the early 1960's; with the 1968 Harvard report becoming the "standard" definition of brain death. the majority of countries and international professional associations have accepted it.