The Whole-Brain Concept of Death Remains Optimum Public Policy

The early history of “brain death” is discussed in Pernick M. S. , “Brain Death in a Cultural Context: The Reconstruction of Death 1967–1981,” in Youngner S. J. Arnold R. M. , and Schapiro R. , eds., The Definition of Death: Contemporary Controversies (Baltimore: Johns Hopkins University Press, 1999): 13–33; and Diringer M. N. and Wijdicks E. F. M. , “Brain Death in Historical Perspective,” in Wijdicks E. F. M. , ed., Brain Death (Philadelphia: Lippincott Williams & Wilkins, 2001): 5–27. Early reports from France described coma dépassé (a state beyond coma). See Mollaret P. and Goulon M. , “Le Coma Dépassé (Mémoire Préliminaire)” Revue Neurologique 101 (1959): 3–15. The Harvard Medical School report was the earliest widely publicized article to claim that such patients were dead. See “A Definition of Irreversible Coma: Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” JAMA 205 (1968): 337–340.

“Brain death” is the colloquial term for human death determination using tests of absent brain functions. But it is an unfortunate term because it is inherently misleading. It falsely implies that there are two types of death: brain death and ordinary death, instead of unitary death tested using two sets of tests. It also wrongly suggests that only the brain is dead in such patients. Robert Veatch stated that because of these shortcomings he uses the term only in quotation marks (personal communication November 4, 1995).

In 1970, Kansas became the first state to enact a death statute incorporating the new concept of brain death, a mere two years after the Harvard Medical School report. See Kennedy I. M. , “The Kansas Statute on Death – An Appraisal,” New England Journal of Medicine 285 (1971): 946–950, at 946.

See Belkin G. S. , “Brain Death and the Historical Understanding of Bioethics,” Bulletin of the History of Medical Allied Sciences 58 (2003): 325–361; Wijdicks E. F. M. , “The Neurologist and Harvard Criteria for Brain Death,” Neurology 61 (2003): 970–976; Giacomini M. , “A Change of Heart and a Change of Mind? Technology and the Redefinition of Death in 1968,” Social Science & Medicine 44 (1997): 1465–1482; and Pernick M. S. , supra note 1.

In nearly all states, brain death is incorporated into the statute of death. In a few jurisdictions, brain death is permitted in administrative regulations. See Beresford H. R. , “Brain Death,” Neurologic Clinics 17 (1999): 295–306. For international practices of brain death, see Wijdicks E. F. M. , “Brain Death Worldwide: Accepted Fact but No Global Consensus in Diagnostic Criteria,” Neurology 58 (2002): 20–25.

Youngner S. J. Arnold R. M. , and Schapiro R. , eds., The Definition of Death: Contemporary Controversies (Baltimore: Johns Hopkins University Press, 1999).

See, for example, Truog R. D. , “Is it Time to Abandon Brain Death?” Hastings Center Report 27, no. 1 (1997): 29–37; Taylor R. M. , “Re-examining the Definition and Criterion of Death,” Seminars in Neurology 17 (1997): 265–270; Byrne P. A. O'Reilly S. , and Quay P. M. , “Brain Death – An Opposing Viewpoint,” JAMA 242 (1979): 1985–1990; and Seifert J. , “Is Brain Death Actually Death? A Critique of Redefinition of Man's Death in Terms of ‘Brain Death,’” The Monist 76 (1993): 175–202.

Alan Shewmon's recent works on this topic include Shewmon D. A. , “The Brain and Somatic Integration: Insights into the Standard Biological Rationale for Equating ‘Brain Death’ with Death,” Journal of Medicine and Philosophy 26 (2001): 457–478; and Shewmon D. A. , “The ‘Critical Organ’ for the Organism as a Whole: Lessons from the Lowly Spinal Cord,” Advances in Experimental Medicine and Biology 550 (2004): 23–42. Other scholars agreeing with him also published works following his article in the Journal of Medicine and Philosophy.

Beecher H. K. , chairman of the landmark 1968 Harvard Medical School Committee report (see note 1), later warned: “Only a very bold man, I think, would attempt to define death.” See Beecher H. K. , “Definitions of ‘Life’ and ‘Death’ for Medical Science and Practice,” Annals of the New York Academy of Sciences 169 (1970): 471–474.

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death: Medical, Legal and Ethical Issues in the Determination of Death (Washington, DC: U.S. Government Printing Office, 1981): at 31–43.

Bernat J. L. Culver C. M. and Gert B. , “On the Definition and Criterion of Death,” Annals of Internal Medicine 94 (1981): 389–394.

Alan and Elisabeth Shewmon recently claimed that my approach is futile because language constrains our capacity to conceptualize life and death. They regard death as an “ur-phenomenon” that is “…conceptually fundamental in its class; no more basic concepts exist to which it can be reduced. It can only be intuited from our experience of it…” See Shewmon D. A. and Shewmon E. S. , “The Semiotics of Death and its Medical Implications,” Advances in Experimental Medicine and Biology 550 (2004): 89–114. Winston Chiong also rejected my analytic approach claiming that there can be no unified definition of death. Yet, he agreed that the whole-brain criterion of death is the most coherent concept of death. See Chiong W. , “Brain Death Without Definitions,” Hastings Center Report 35 (2005): 20–30.

I have discussed these conditions in greater detail in Bernat J. L. , “The Biophilosophical Basis of Whole-Brain Death,” Social Philosophy & Policy 19, no. 2 (2002): 324–342.

Robert Veatch exemplifies a scholar who has attempted to redefine death for the purpose of considering patients in persistent vegetative states as dead, despite the fact that all societies consider them alive. See, for example, Veatch R. M. , “The Impending Collapse of the Whole-Brain Definition of Death,” Hastings Center Report 23, no. 4 (1993): 18–24. Linda Emanuel abstracted death to a clinically unhelpful metaphysical level: “there is no state of death…to say ‘she is dead’ is meaningless because ‘she’ is not compatible with ‘dead.’” See Emanuel L. L. , “Reexamining Death: The Asymptotic Model and a Bounded Zone Definition,” Hastings Center Report 25, no. 4 (1995): 27–35.

For a scholar who argues that the definition of death is largely a normative social matter, see Veatch R. M. , “The Conscience Clause: How Much Individual Choice in Defining Death Can Our Society Tolerate?” in Youngner S. J. Arnold R. M. , and Schapiro R. , eds., The Definition of Death: Contemporary Controversies (Baltimore: Johns Hopkins University Press, 1999): 137–160.

In this regard, I disagree with Jeff McMahon that there are two types of death: death of the organism and death of the person. See McMahon J. , “The Metaphysics of Brain Death,” Bioethics 9 (1995): 91–126.

Halevy A. and Brody B. , “Brain Death: Reconciling Definitions, Criteria, and Tests,” Annals of Internal Medicine 119 (1993): 519–525.

Morison R. S. , “Death: Process or Event?” Science 173 (1971): 694–698 and Kass L. , “Death as an Event: A Commentary on Robert Morison,” Science 173 (1971): 698–702. The Shewmons (see note 12) recently described the process vs. event argument as “tiresome” because, as a consequence of linguistic constraints, death can be understood only as an event.

Bernat J. L. Culver C. M. , and Gert B. , “On the Definition and Criterion of Death,” Annals of Internal Medicine 94 (1981): 389–394.

Parnia S. Waller D. G. Yeates R. , and Fenwick P. , “A Qualitative and Quantitative Study of the Incidence, Features, and Etiology of Near Death Experiences in Cardiac Arrest Survivors,” Resuscitation 48 (2001): 149–156.

Veatch R. M. , “The Whole Brain-Oriented Concept of Death: An Outmoded Philosophical Formulation,” Journal of Thanatology 3 (1975): 13–30; Veatch R. M. , “Brain Death and Slippery Slopes,” Journal of Clinical Ethics 3 (1992): 181–187; and Veatch R. M. , “The Impending Collapse of the Whole-Brain Definition of Death,” Hastings Center Report 23, no. 4 (1993): 18–24.

Veatch R. M. , supra note 21, at 23.

See, for example, Green M. B. and Wikler D. , “Brain Death and Personal Identity,” Philosophy and Public Affairs 9 (1980): 105–133; Youngner S. J. and Bartlett E. T. , “Human Death and High Technology: The Failure of the Whole Brain Formulation,” Annals of Internal Medicine 99 (1983): 252–258; and Gervais K. G. , Redefining Death (New Haven: Yale University Press, 1986).

Bernat J. L. Culver C. M. , and Gert B. , “On the Definition and Criterion of Death,” Annals of Internal Medicine 94 (1981): 389–394. I later refined the definition to require only the permanent loss of the critical functions of the organism as a whole, in response to exceptional cases raised, but this is mostly quibbling. See Bernat J. L. , “Refinements in the Definition and Criterion of Death,” in Youngner S. J. Arnold R. M. , and Schapiro R. , eds., The Definition of Death: Contemporary Controversies (Baltimore: Johns Hopkins University Press, 1999): 83–92.

Loeb J. , The Organism as a Whole (New York: G. P. Putnam's Sons, 1916).

See, for example, the explanation of emergent functions in Mahner M. and Bunge M. , Foundations of Biophilosophy (Berlin: Springer-Verlag, 1997): at 29–30.

Korein J. , “The Problem of Brain Death: Development and History,” Annals of the New York Academy of Sciences 315 (1978): 19–38. For the most recent refinement of Korein's argument, see Korein J. and Machado C. , “Brain Death: Updating a Valid Concept for 2004,” Advances in Experimental Medicine and Biology 550 (2004): 1–14.

I have discussed these three formulations in greater detail in Bernat J. L. , “How Much of the Brain Must Die in Brain Death?” Journal of Clinical Ethics 3 (1992): 21–26.

The text of Defining Death makes clear that the President's Commission found an important distinction between brain clinical functions and brain activities. See President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death: Medical, Legal and Ethical Issues in the Determination of Death (Washington, DC: U.S. Government Printing Office, 1981): at 28–29.

Residual EEG activity seen on unequivocally brain dead patients has been described by Grigg M. M. Kelly M. A. Celesia G. G. Ghobrial M. W. , and Ross E. R. , “Electroencephalographic Activity after Brain Death,” Archives of Neurology 44 (1987): 948–954.

Plum F. and Posner J. B. , The Diagnosis of Stupor and Coma, 3rd ed., (Philadelphia: F. A. Davis, 1980): at 88–101.

These are the most common causes of brain death. See Staworn D. Lewison L. Marks J. Turner G. , and Levin D. , “Brain Death in Pediatric Intensive Care Unit Patients: Incidence, Primary Diagnosis, and the Clinical Occurrence of Turner's Triad,” Critical Care Medicine 22 (1994): 1301–1305.

Kinney H. C. and Samuels M. A. , “Neuropathology of the Persistent Vegetative State: A Review,” Journal of Neuropathology and Experimental Neurology 53 (1994): 548–558.

Multi-Society Task Force on PVS, “Medical Aspects of the Persistent Vegetative State. Parts I and II,” New England Journal of Medicine 330 (1994): 1499–1508, 1572–1579.

Conference of Medical Royal Colleges and their Faculties in the United Kingdom, “Diagnosis of Brain Death,” British Medical Journal 2 (1976): 1187–1188; and Pallis C. , ABC of Brainstem Death (London: British Medical Journal Publishers, 1983).

I have provided more extensive arguments with examples to support this claim in Bernat J. L. , “A Defense of the Whole-Brain Concept of Death,” Hastings Center Report 28, no. 2 (1998): 14–23 at 18–19.

The Quality Standards Subcommittee of the American Academy of Neurology, “Practice Parameters for Determining Brain Death in Adults [Summary Statement],” Neurology 45 (1995): 1012–1014. The tests accepted in various European countries are described and compared in Haupt W. F. and Rudolf J. , “European Brain Death Codes: A Comparison of National Guidelines,” Journal of Neurology 246 (1999): 432–437.

The clinical and confirmatory tests for brain death are described in detail in Wijdicks E. F. M. , “The Diagnosis of Brain Death,” New England Journal of Medicine 344 (2001): 1215–1221.

See, for example, Mejia R. E. and Pollack M. M. , “Variability in Brain Death Determination Practices in Children,” JAMA 274 (1995): 550–553; and Wang M. Y. Wallace P. , and Gruen J. B. , “Brain Death Documentation: Analysis and Issues,” Neurosurgery 51 (2002): 731–735.

Shewmon D. A. , “Chronic ‘Brain Death’: Meta-analysis and Conceptual Consequences,” Neurology 51 (1998): 1538–1545.

Wijdicks E. F. M. and Bernat J. L. , “Chronic ‘Brain Death’: Meta-analysis and Conceptual Consequences,” (letter to the editor) Neurology 53 (1999): 1639–1640.

I defend this claim in Bernat J. L. , “On Irreversibility as a Prerequisite for Brain Death Determination,” Advances in Experimental Medicine and Biology 550 (2004): 161–167.

This conclusion was reached by Alexander Capron, the former Executive Director of the President's Commission (see note 10), in Capron A. M. , “Brain Death – Well Settled Yet Still Unresolved,” New England Journal of Medicine 344 (2001): 1244–1246.

Wijdicks E. F. M. , “Brain Death Worldwide: Accepted Fact but No Global Consensus in Diagnostic Criteria,” Neurology 58 (2002): 20–25.

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death: Medical, Legal and Ethical Issues in the Determination of Death (Washington, DC: U.S. Government Printing Office, 1981): at 72–84.

Law Reform Commission of Canada, Criteria for the Determination of Death (Ottawa: Law Reform Commission of Canada, 1981).

Burt R. A. , “Where Do We Go from Here?” in Youngner S. J. Arnold R. M. , and Schapiro R. , eds., The Definition of Death: Contemporary Controversies (Baltimore: Johns Hopkins University Press, 1999): 332–339.

See Wijdicks E. F. M. , supra note 5, at 22–23.

In the early brain death era, commentators asserted that brain death was compatible with the world's principal religions. See Veith F. J. Fein J. M. Tendler M. D. Veatch R. M. Kleiman M. A. , and Kalkines G. , “Brain Death: I. A Status Report of Medical and Ethical Considerations,” JAMA 238 (1977): 1651–1655.

Campbell C. S. , “Fundamentals of Life and Death: Christian Fundamentalism and Medical Science,” in Youngner S. J. Arnold R. M. , and Schapiro R. , eds., The Definition of Death: Contemporary Controversies (Baltimore: Johns Hopkins University Press, 1999): 194–209.

Some Catholic commentators had long claimed that brain death violated Catholic teachings. See Byrne P. A. , supra note 7. But in August, 2000, in an address to the 18th Congress of the International Transplantation Society meeting in Rome, the Pope asserted that brain death was fully consistent with Catholic doctrine. For a detailed historical discussion of earlier statements on brain death from Vatican academies, an account of the process of Vatican decision making, and an explanation of the Pope's recent statement, see Furton E. J. , “Brain Death, the Soul, and Organic Life,” The National Catholic Bioethics Quarterly 2 (2002): 455–470.

The rabbinic debate is explained in Rosner F. , “The Definition of Death in Jewish Law,” in Youngner S. J. Arnold R. M. , and Schapiro R. , eds., The Definition of Death: Contemporary Controversies (Baltimore: Johns Hopkins University Press, 1999): 210–221.

Saudi Arabia represents a conservative interpretation of Islam and brain death is accepted there. See Yaqub B. A. and Al-Deeb S. M. , “Brain Death: Current Status in Saudi Arabia,” Saudi Medical Journal 17 (1996): 5–10.

Jain S. and Maheshawari M. C. , “Brain Death – The Indian Perspective,” in Machado C. , ed., Brain Death (Amsterdam: Elsevier, 1995): 261–263.

Lock M. , “Contesting the Natural in Japan: Moral Dilemmas and Technologies of Dying,” Culture, Medicine and Psychiatry 19 (1995): 1–38.

See Shewmon , supra note 8.

See Shewmon , supra note 40.

Taylor R. M. , “Re-examining the Definition and Criterion of Death,” Seminars in Neurology 17 (1997): 265–270.

I made this point in a review of a pre-publication draft of the Institute of Medicine report. See, Institute of Medicine, Non-Heart-Beating Organ Transplantation: Practice and Protocols (Washington DC: National Academy Press, 2000): at 22–24. The same point was made in reference to an earlier publication of the Institute of Medicine in Menikoff J. , “Doubts about Death: The Silence of the Institute of Medicine,” Journal of Law, Medicine & Ethics 26 (1998): 157–165.