Journal ofmedical ethics, 1983, 9, 32-37 J Med Ethics: first published as 10.1136/jme.9.1.32 on 1 March 1983. Downloaded from Commentary Whole-brain death reconsidered- physiological facts and philosophy C Pallis Reader Emeritus, Royal Postgraduate Medical School, Consultant Neurologist, Hammersmith Hospital Author's abstract the recognition ofthe important clinical, physiological, pathological and prognostic differences between the Four main areas generating confusion in discussion on vegetative state, whole-brain death and death of the brain death are identified as a) the relation ofcriteria of brain stem. Unless agreed definitions are reached con- death to concepts ofdeath, b) the argument about whether cerning these states, terminological problems soon death is an event or a process, c) the inadequate render meaningful communication impossible; differentiation ofdifferent neurological entities having The difference between 'identifying death' and different cardiac prognoses, and d) insufficient 'allowing to die'. Discussions about what have been awareness ofthe separate issues of'determining death' called the 'uncomfortable dimensions ofthe care ofthe and 'allowing to die'. It is argued that ifby death we mean dying'(i) have nothing to do with identifying a dead the dissolution ofthe human 'organism as a whole', then brain stem. whole-brain death is death. Behavioural patterns, legitimate in thepresence ofa cadaver, should be legitimate from the time whole-brain death is diagnosed. Concepts and criteria Discussions between philosophers and neurologists on the subject of death require a double commitment. As Two boys were walking in a field, arguing fiercely. One to differentiate their patients more was carrying a butterfly net, the other a mousetrap. neurologists begin Each was claiming that his was 'the better' instrument. carefully, philosophers will have to ask their questions http://jme.bmj.com/ more precisely. And as philosophers probe deeper into They almost came to blows. A third boy (an obvious what it really means to be alive, physicians will have to candidate for a First in philosophy) came up and asked abandon some of their more traditional attitudes. the necessary question: 'Better for what?'. Neither philosophers nor neurologists can any longer This apocryphal tale emphasises that all talk about accept death as a brute empirical fact, the recognition the criteria of death - and ipso facto about 'better' of which is just a technical problem. Whether we real- criteria or 'new' criteria - must be related to some ise it or not there are philosophical implications to both overall concept of what death means. Dr Browne our acts, and our failures to act. There is no harm in rightly stresses that important behavioural conse- on September 26, 2021 by guest. Protected copyright. seeking to make our assumptions explicit. In fact quences flow from the recognition that a person is recent developments in the fields of resuscitation and dead. But we cannot argue about whether a neuro- intensive care render the task imperative. And if logical or a cardio-respiratory approach is 'better' for their skills to this recognising such a state, unless we are agreed on what philosophers wish help endeavour, we are to When we rather than hinder it, they will have to familiarise exactly it is that seeking identify. themselves with these developments. consider death, the tests we carry out and the decisions Four main areas of confusion bedevil most discus- we make should be logically derived from agreed con- sions about brain death. They concern: ceptual and philosophical premises. of I find it a novel experience to have to argue with a the kind of relation necessary between concepts philosopher who asserts that 'even granting that ... death and criteria of death; important legal, moral and medical consequences flow what is meant by the 'biological fact' of death? Inti- from the determination of death . it still does not mately related to this are the twin questions as to to the definition ofdeath'. event or a and whether follow that we ought precise whether death is an process, Even more surprising is his statement that 'we can what is ofclinical significance is 'death ofthe organism remove any uncertainty in practical affairs without as a whole' or 'death of the whole organism'; fiddling with the definition of death'. Dr Browne seems here to be donning the garb of the pragmatic, Key words unreflecting physician. It is not reassuring when Brain death; whole-brain death; death; philosophy; medical philosophers, ofall people, tell us that we can leave the ethics. concept of death in. its present 'indeterminate' state, Whole-brain death reconsidered - physiologicalfacts and philosophy 33 J Med Ethics: first published as 10.1136/jme.9.1.32 on 1 March 1983. Downloaded from and that we should get on with the job of specifying situation. Dr Browne, on the other hand, does not 'what can appropriately be done to whom' - and define death at all. This makes it very difficult to get to 'when'. Dr Browne questions the desire to solve practi- grips with what he writes. He seems opposed both to a cal problems by making definitions more precise. He 'whole-brain' definition of death (p 3I) and to the iden- calls it a temptation (implying it should be resisted). I tification of the vegetative state with death. He quotes believe a more positive approach would be to accept the definition ofdeath given inBlack's Law Dictionary Oscar Wilde's suggestion that 'the only way to get rid and states he is against the redefmiition ofdeath 'in any of a temptation is to yield to it'. I cannot endorse Dr other way'. Does he then endorse the traditional defini- Browne's view that in discussing death 'we should first tion? He is nowhere explicit enough for this confi- settle the question of what behaviour becomes appro- dently to be asserted. The problem with the traditional priate when' - and even less his conclusion that 'this definition he quotes is that it is not really a definition at can be settled independently ofthe question ofwhen a all, or at least not one that encompasses some of the person is dead'. more macabre by-products ofmodern technology. It is Dr Browne seems to be arguing for an ad hoc patch- my beliefthat ifthe concept ofdeath is left 'indetermi- work of practices, of unspecified relationship to one nate' - as Dr Browne advocates - one will not even need another, and certainly unrelated to any overall to invoke the principle ofindeterminacy to foretell that philosophical concept. I don't know if any school of some ofthe decisions reached will prove irrational and philosophy exists whose main aim is to purge harmful as well as arbitrary. philosophical awareness from the minds of human beings. If it does neurologists should caution their philosopher colleagues against it, for the only real al- Death as an event or death as a process? ternative to an overall philosophical concept ofdeath is a set of arbitrarily assembled rules of conduct. Who Dr Browne claims that 'it is not a biological fact that would issue such rules? On what basis? And would not one who has suffered whole-brain death is dead'. Is the issuing of edicts, unrelated to a widely discussed that correct? And what exactly does it mean? and generally accepted concept ofdeath, constitute the The statement is ambiguous: it can be interpreted in very 'medical paternalism' Dr Browne so rightly two different ways. Is the 'biological fact' of death, to decries? History tends to show that when prescribed which - according to Dr Browne - brain death does not observances and practices have no roots in generally relate, the 'death of the organism as a whole'? Or is it accepted conceptual frameworks they face one of two the 'death of the whole organism', that is the death of fates: they are either abandoned (and sooner rather each and every one of its cells? Both are legitimate than later) - or they are only sustained by the imposi- interpretations ofthe 'biological fact' ofdeath, but they http://jme.bmj.com/ tion offorce. Is the latter what Dr Browne means when lead to very different conclusions. he quotes proposed empirical rules that threaten those If we accept the first interpretation (namely that the who transgress them with 'the most severe sanction 'biological fact' ofdeath relates to the dissolution ofthe available' to particular jurisdictions? 'organism as a whole') Dr Browne's statement (that it is I have elsewhere sought to argue against what I have not a biological fact that brain death is death) is self- called 'free floating criteria ofdeath' and to show how, evidently untenable. The very opposite would seem to historically, different concepts of death have necessi- be nearer the truth, namely that only when the brain is tated the adoption of different criteria of can death (2). In dead the individual (the 'organism as a whole') be on September 26, 2021 by guest. Protected copyright. this context I have outlined my own concept ofhuman considered dead. Whereas the functions of lungs and death (to which criteria assessing brain stem function heart can (for a while) be taken over by a machine, those are central). The full argument for defining human of the brain cannot. In this perspective the classical death as the 'irreversible loss of the capacity for con- criteria of death (arrest of the heart beat and circula- sciousness, combined with the irreversible loss of the tion) are only indicative of death when they have per- capacity to breathe' cannot be recapitulated here. sisted for long enough for the brain to die. All human Briefly, this admittedly hybrid definition seeks to death, according to this view, is (and always has been) combine philosophical and physiological con- brain death. That is the position I hold.