- Stuart J. Younger, Robert M. Arnold, and Renie D. Schapiro have recently described the “deconstruction of what seemed to be a scientific, philosophical, and even public consensus about the definition and determination of death“ (Youngner, Arnold, & Schapiro, 1999, p. xv). Perhaps at no other time since Henry K. Beecher chaired the Ad Hoc Committee of the Harvard Medical School and formulated a “A Definition of Irreversible Coma “ (Ad Hoc Committee of the Harvard Medical School, 1968) has there been so much ferment over the theoretical understanding of death and its clinical implications. Based on current discontents in bioethics writing, such a deconstruction would not be entirely unwelcome. In recent years, it has seemed that this collapse would be the outcome either of efforts to render a more philosophically sound definition of death, such as a higher-brain standard, or at a more practical, clinical level, by efforts to increase organ procurement. However, the books under consideration in this review, Beyond Brain Death1, and Brain Death2, would welcome a retreat not only from the philosophical argumentation in support of higher-brain death3, but to a large extent, from any brain-based concept of death. Their critique of current approaches and call to move to a non-brain, biologically validated definition of death holds, of course, very significant (some would say disastrous) implications for organ transplantation4. But on the view of most authors contributing to this perspective, the demise of organ transplantation5 at least on the scale in which it is currently conducted is needed to maintain professional moral integrity and public credibility. Organ transplantation6 is seen as so dominant a factor in the timing and determination of death that professionals are inevitably faced with conflicting interests, in particular, putting social welfare ahead of patient care. Meanwhile, the authors portray the public as both confused and somewhat fearful that persons will be declared dead prematurely to facilitate earlier organ recovery.
- In the context of these critiques, it is worth recalling why some form of brain-based concept, whether whole brain in the U.S. or brain stem in the U.K., eventually seemed to have constructed a consensus in the late 1960s and through the 1970s. The report of the Harvard committee was quite direct about the necessity to revise the standard and concept of death: A brain-based conception was affirmed in order to address problems generated by the advent of new technologies of life extension, including technologies that sustained bodily, non-conscious human life, and technologies that preserved life through organ transplantation7. Reliance on the traditional vital signs criteria for death, it was argued, would lead to hospital wards filled with comatose persons kept alive only by machines, at great expense, and to missed opportunities to save life because of organ scarcity. It is a question of some importance as to whether these objectives are inextricably intertwined or can be addressed independent of each other.
- That is to say, practical questions seemed to drive the initial moves toward a brain-based conception for death, rather than theoretical or philosophical argumentation (Pernick, 1999, pp. 10-11). Legal codification and philosophical justification for whole brain death8 evolved as social constructs on the assumption that the irreversible loss of all functions of the entire brain was the physiological equivalent of determining death through irreversible loss of respiratory and circulatory functions (President's Commission, 1981). A brain death9 standard thus seemed to offer considerable advantages over traditional criteria: it allowed the termination of futile and expensive medical treatments, facilitated organ transplants10, and provided a philosophically sound basis for legal and professional immunity for professionals who might otherwise be thought to have ended life prematurely. Moreover, such a standard could be responsive and adaptive to new technological developments, including technologies that permit more precise diagnostic measurements to determine the occurrence of death.
- The support for brain-based criteria seems to have been broad but not terribly deep. It has undergone critical commentary and deconstruction from both medical and philosophical perspectives. Equally significant, both professionals and the public have expressed confusion about what constitutes brain death11 and what circumstances justified its application. Indeed, whereas in 1992, Youngner referred to a “fragile consensus “on brain death12 (Youngner, 1992), he seems now to have conceded the “deconstruction“ of this consensus. The twelve essays collected in the anthology Beyond Brain Death13 capitalize on both conceptual and practical problems with brain death14 standards to mount a collective critique that moves less “beyond “ brain death15 as much as it makes a case “against“ brain death16. While the essays “blow the whistle“ on perceived abuses, such revelations do not suggest a philosophical or policy trajectory for the future.
Reviews the books Beyond Brain Death17: The Case Against Brain Based Criteria for Human Death, by Michael Potts, Paul A. Byrne, and Richard G. Nilges and Brain Death18: Philosophical Concepts and Problems, by Tom Russell.
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