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University of Southampton Faculty of Social Sciences Law In Need of Reappraisal? Examining the Defensibility of the Established Definition and Determination of Death Through its Implications for Persons with Prolonged Disorders of Consciousness by Elizabeth Catherine Redrup ORCID ID 0000-0002-3987-2872 Thesis for the degree of Doctor of Philosophy April 2020 University of Southampton Abstract Faculty of Social Sciences Law Thesis for the degree of Doctor of Philosophy In Need of Reappraisal? Examining the Defensibility of the Established Definition and Determination of Death Through its Implications for Persons with Prolonged Disorders of Consciousness by Elizabeth Catherine Redrup The practice of defining and determining ‘who is dead’ is no longer a medical or biological determination. It is instead a moral standpoint on what lives are not worth living; the traditional definition of death has been redefined and now retains merely a single foothold in biology. That single foothold seems to be the capacity to voluntarily respond above the level of reflex and may therefore explain how life support withdrawal is deemed defensible from living patients, even where their subsequent death is foreseen. Therefore, the practice impacts cognitive disability on the whole and not only those with prolonged disorders of consciousness, i.e., vegetative and minimally conscious state patients (PDOC patients). For example, how else could antibiotics be withdrawn from a dementia patient knowing that they will succumb to deadly infection? Nevertheless, this thesis explores the moral and legal justifiability of life support continuation decisions via a case study on PDOC patients. It seems that life support discontinuation from living patients who have lost the capacity to voluntarily respond also lose their personhood status: the recognition and endowment of equal moral and legal protection for those holding that inherently valuable characteristic of human life and may also demonstrate why the judgments’ often- noted moral inconsistency cannot be explained by intention or causation-based arguments alone. Therefore, the thesis argues that at the heart of best interests decision-making regarding life support continuation is a hidden war on personhood in which further skirmishes include: identifying the indicia of personhood, the justifiability of life support withdrawal from (living) PDOC patients and assessing whether best interests assessments are indirectly discriminatory to them. The answers to these questions are vital for exploring whether the definition and determination of death needs to be reappraised by legislators and medical regulatory bodies. The thesis’ core question asks: is the definition and determination of death in England and Wales defensible, given its implications for PDOC patients? That core question is set within a philosophical framework to enable fair assessment which may also help answer whether such judgments can be accurately described as dilemmatic cases that employ values-based decision-making. Accordingly, the relationship between death, cognitive impairment and personhood is explored to challenge the adopted theory of social justice and demonstrate why it is not enough to assume that they are persons, nor that death’s definition and determination does not impact PDOC patients in law and medicine. Table of Contents Table of Contents Table of Contents ....................................................................................................... i Table of Cases ............................................................................................................ v Table of Legislation ................................................................................................. ix Research Thesis: Declaration of Authorship ....................................................... xiii Acknowledgements ................................................................................................ xv Definitions and Abbreviations ............................................................................ xvii Thesis Introduction ................................................................................................... 1 Chapter 1 Indeterminacy in Moral Reasoning: Outlining Minimums and Recognising Inherent Limitations of an Applied Ethics Methodology ........................................................................................ 11 1.1 Chapter Introduction and Aims ..................................................................................... 11 1.2 How to Measure the Defensibility of a Purported Moral Requirement .......... 13 1.2.1 Section Introduction ................................................................................................. 13 1.2.2 Achieving Defensible Moral Requirements ...................................................... 13 1.2.3 Section Conclusion .................................................................................................... 16 1.3 Ensuring Consistency and Factual Accuracy in Medical Law Cases .................. 17 1.3.1 Section Introduction ................................................................................................. 17 1.3.2 Ensuring Consistency and Factual Accuracy in English and Welsh Medical Law ................................................................................................................. 17 1.3.3 Ensuring Consistency and Factual Accuracy in Medicine ............................ 26 1.3.4 Section Conclusion .................................................................................................... 31 1.4 Moral Dilemma or Moral Conflict? ............................................................................... 32 1.4.1 Section Introduction ................................................................................................. 32 1.4.2 Indicators of a Genuine Moral Dilemma ........................................................... 33 1.4.3 Mitigating Problems Faced in Adopting Moral Requirements in Law.... 38 1.4.4 Is Bland’s Cri de Coeur Indicative of a Moral Dilemma? .............................. 42 i Table of Contents 1.4.5 Section Conclusion .................................................................................................... 51 1.5 Conclusion ............................................................................................................................. 51 Chapter 2 Defining Death: “What’s in a Name?” Non-Conscious or Non- Responsive? ........................................................................................... 53 2.1 Chapter Introduction and Aims ..................................................................................... 53 2.1.1 Overview of Defining “Consciousness” and its Terminology ..................... 53 2.2 Defining Death is No Longer a Biological and Medical Prerogative ................ 59 2.2.1 Section Introduction ................................................................................................. 59 2.2.2 Pushing the Boundaries of Death: The Introduction of Transplantation and Ventilatory Technology ................................................................................... 59 2.2.3 Identifying the Vital “Biological” Factor in Defining Death ........................ 64 2.2.4 Section Conclusion .................................................................................................... 77 2.3 “What’s in a Name?” Consciousness or Responsivity? .......................................... 77 2.3.1 Section Introduction ................................................................................................. 77 2.3.2 Cortical Brain Damage and its Conceptual Ties to Consciousness .......... 78 2.3.3 Down the Rabbit Hole: Distinguishing Reflex from Voluntary Response ....................................................................................................................... 81 2.3.4 Section Conclusion .................................................................................................... 87 2.4 Consciousness and its Practical (Not Just Theoretical) Ties to Personhood . 89 2.4.1 Section Introduction ................................................................................................. 89 2.4.2 ‘Higher Brain Death’ or ‘Embodied Consciousness’: Implications for the ‘Hopelessly Conscious Patient’ ............................................................................. 89 2.4.3 Consciousness’ Conceptual Ties with Personhood ....................................... 97 2.4.4 Section Conclusion .................................................................................................. 106 2.5 Conclusion ........................................................................................................................... 107 Chapter 3 “Square Pegs in Round Holes”: Is “Best Interests” an Appropriate Standard for Delineating Personhood (Death)? ............................. 109 ii Table of Contents 3.1 Chapter Introduction and Aims ................................................................................... 109 3.2 Putting Morality Back into the ‘Morally and Intellectually Misshapen’ Law 110 3.2.1 Overview of the Moral and Legal Inconsistency in Bland ......................... 110 3.2.2 How Death is Defined and Determined in Bland and its Ties to Personhood ................................................................................................................ 119 3.2.3 Resolving Bland: Personhood,

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