- In "Chiong (Winston) - Brain Death without Definitions" (HCR, Nov-Dec 2005), Winston Chiong argues that the three-part framework, definitions-criteria-tests, that James Bernat, Charles M. Culver, and I put forward twenty-five years ago should be given up because there is no adequate definition of death. Chiong seems to hold this view because he thinks of definitions as stating the essence of a term. But in our book, Bioethics: A Return to Fundamentals, which Chiong cites, we make clear that we are trying to describe the ordinary use of the word "death" and point out that "death" is not a technical medical or scientific term.
- Originally, we did think that we could arrive at a definition of death that would explain the ordinary use of the word "death" by mentioning only a single biological feature, "permanent cessation of the integrated function of the organism as a whole." But by the time we wrote the book referred to above, we realized that this single biological feature would not account for all of the ordinary uses of the term "death" and added that, in addition to the cessation of integrated function, there must be also be "the permanent absence of consciousness in the organism as a whole and in any part of that organism."
- Winston Chiong does an excellent job in his article of applying the insights of Wittgenstein, Kripke, and Putnam to challenge the idea that there is a single, unified definition of death – some set of necessary and sufficient conditions that must be met for anything to die. Following them, Chiong proposes that "death" refers to a cluster of properties that tend to be co-instantiated in paradigm cases.
- However, when an individual possesses some but not all of the properties in the cluster, as in cases of whole-brain death1 and persistent vegetative state2 (PVS), Chiong suggests that we need to "sharpen" our distinction between life and death. Chiong defends the whole-brain criterion3 for determining death on grounds that it is consistent with "sharpening," rather than "revising," our distinction between life and death. However, he rejects declaring an individual in PVS4 or a still-conscious victim of irreversible cardiopulmonary failure dead because this would involve a "revision" of the ordinary meaning of death. The individual in PVS5 retains so many properties in the cluster of what it means to be alive, such as spontaneous circulatory and respiratory functions, that it would be a misuse or revision of language to regard this individual as "dead." Similarly, because the victim of irreversible cardiopulmonary failure may retain consciousness, albeit for a short time, it would be incorrect to say that the individual had died before consciousness was irreversibly lost.
- Chiong's distinction between "revision" and "sharpening," however, is unclear. Moreover, clarification of the distinction may not be possible due to problems of "framing bias." Framing bias refers to the interests, values, and related ontological assumptions behind our classificatory schemes. …
- Youngner (Full Text)
- Winston Chiong proposes an interesting model for understanding life and death. His "cluster of attributes" model for explaining life and death, introduced by Borkin and Post in 1992, is explained using the work of Wittgenstein and others. This philosophic discussion is compelling in many ways, but it is beyond my critical expertise. However. I do have concerns about empirical assumptions that he makes.
- Chiong claims to intuit what "any [emphasis mine] ordinary understanding of life or death is," and that this ordinary understanding is, among other things, that PVS6 patients are alive and that the integrating capacity of the brain stem is not essential. In their seminal paper, On the Definition and Criterion of Death7, Bernat, Culver, and Gert also claimed knowledge of the ordinary meaning of death ("the definition of death must encompass the common usage of the term") — only in their case death "ordinarily" meant the loss of integrating function. These are two very different claims about the ordinary meaning of death. On what do Chiong and Bernat base their claims of knowledge? On wisdom? Personal experience? Or projection? Shouldn't such claims be based on empirical data about what real people "ordinarily" mean by death? Studies that have attempted, however imperfectly, to answer these questions find a wide variety of answers about how people understand death, including many who do believe PVS8 patients are dead and others who think of brain-dead patients as alive. Philosophic arguments that are partly dependent on what people ordinarily mean by death would be much stronger if they were developed with efforts to gather actual evidence to support their intuitions.
- In this brief space, I could not hope to do justice to the many interesting points raised in these responses to my article. Therefore, I limit myself here to a single issue that all three respondents touch upon.
- In "Chiong (Winston) - Brain Death without Definitions", I defend a realist account of life and death, on which the biological facts that determine whether something is alive or dead are (at least in determinate cases) independent of our linguistic and classificatory practices. Given this independence, on the realist position9 we always run the risk that our practices are mistaken—for instance, that some category that we employ doesn't match up with any "real" or causally relevant kind out in the world.
- Contrast this with what I'll call a nominalist position, on which the question of whether something is alive or dead is entirely settled10 by how we choose to use the English words "alive" and "dead," without invoking any further commitments about how the world is arranged. Nominalism thereby avoids the worry about whether our categories correspond to a reality independent of them.
Three letters to the Editor concerning "Chiong (Winston) - Brain Death without Definitions", with a reply.
- Annals of Internal Medicine. March 1981, 94 (3):389-94.
- Abstract: The permanent cessation of functioning of the organism as a whole is the definition underlying the traditional understanding of death. We suggest the total and irreversible loss of functioning of the whole brain as the sole criterion of death; this has always been an implicit criterion of death. If artificial ventilation is present, only completely validated brain dysfunction tests should be used to show that this criterion of death is satisfied. In most cases without artificial ventilation, permanent loss of cardiopulmonary function is sufficient. We propose a statutory definition of death based on the criterion of total and irreversible cessation of whole brain functions but allowing physicians to declare death according to their customary practices in most cases.
Footnote 10: Does anyone adopt this extreme nominalist position?
- I agree with this realist approach to a degree, in that it is not just “up to us” to decide who is alive and who dead.
- But death is an event with vague boundaries, so there will always be disputes.
- Also, someone might be technically alive, but not have a life worth having – or (worse – and these are the critical cases) have a life worth not having, and maybe ultimately a life that’s so expensive to maintain that society cannot (any longer) afford its maintenance.
- The definition of life – even on the realist view – and the duty to preserve it – may not be perfectly aligned, so a precise definition of “death” may not be as important as we imagine.
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