Whole-Brain Death Reconsidered- Physiological Facts and Philosophy

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. siderations, The loss of the capacity for consciousness Would Dr Browne agree that a decapitated indi- and of the capacity to breathe relate to functional dis- vidual is dead (as an independent biological unit, ie as turbances at opposite ends ofthe brain stem, while the an 'organism as a whole') from the moment the head is former is also a meaningful alternative to 'the depar- severed, irrespective of the fact that the heart may go ture of the soul'. I believe the concept to be consonant on beating for some time? And if so, why? And what if both with modern developments in the fields of resus- the circulation had been closed prior to decapitation citation and intensive care, and with the endeavours of (the carotid arteries being joined to the jugular veins)? modern Man 'to secularise his philosophical under- Would the resulting preparation, after decapitation, be standing of his nature' (3). The concept itself will alive or dead? The identity of brain death with death almost certainly have to be amended in the light of has been very perceptively realised by people with little developing experience. But it provides, I hope, a or no knowledge of physiology: we have been hanging momentary locus of coherence in a rapidly evolving and decapitating for centuries. We have only to think 34 C Pallis J Med Ethics: first published as 10.1136/jme.9.1.32 on 1 March 1983. Downloaded from of 'whole-brain death' as physiological decapitation for evaded, on the ground that to face it would generate a the relationship to become crystal clear. 'conceptual crisis'. The known facts do indeed create What is it that is so important, anyway, about the such a crisis. In my opinion the challenge should be action of the heart? Only the hopelessly romantic met. would consider it an end in itself. Surely cardiac func- tion is only relevant if it results in irrigation of the brain? Is a frog alive, whose isolated heart is kept The vegetative state, whole-brain death, and beating in a test tube? Is a heart donor alive (even if death of the brain stem cremated) provided the heart he or she has donated is beating vigorously in its new host? Is the recipient Dr Browne is rightly concerned about what is ap- dead, because his own damaged heart has been propriate behaviour in different clinical circum- removed and discarded, to make room for the new one stances. But several ofhis proposals and concerns are, I he has just received? think, based on faulty physiological premises. These Dr Browne's assertion that 'it is not a biological fact undermine the temporal aspects of much of his argu- that one who has suffered whole-brain death is dead' ment. As a result the argument itself - at least for one can be taken in a different sense, however, and one familiar with the handling of such patients - has an air which is worth exploring. It could be taken to mean of unreality about it. He erects straw men - albeit that someone who is brain-dead (according to any of perplexed straw men, constantly tormenting them- several possible sets ofcriteria of brain death) will still selves with impossible questions. have a beating heart, kidneys that can form urine, or a It is important, at this stage, to be careful about the liver still able to conjugate bilirubin. Formulated in terms we use. Take the words 'irreversible coma' for this way, Dr Browne's statement is incontrovertibly instance. They have a venerable genealogy, but have true. come to denote quite different states. They were first The implicit (and unformulated) concept of death used in the title ofthe classical American description of underlying such a statement would be that a person can whole-brain death (the 1%8 report of the Harvard only be dead when such activities cease. Biological Committee) (4). The Boston workers had spoken death, according to this approach, is the death of 'the of 'irreversible coma' in an attempt to convey whole organism', the death of all of its component something of the flavour of 'coma d6passe' (literally a parts, the cessation offunction in each and every one of state beyond coma) which is how the French had origi- its cells. But even irreversible asystole is not immedi- nally described whole-brain death in I959 (5). The ately followed by biological death, defined in this way. state described by these various groups was not only Quite apart from the question of continued growth of total death of the brain, but total death of the whole the hair and nails, there is no doubt that cells with low nervous system (in that areflexia of spinal origin was http://jme.bmj.com/ oxygen requirements (in skin, arterial walls and the also demanded). Patients in 'coma depasse' had not only matrix of bone) may remain alive for variable periods lost all capacity to respond to external stimuli, they after the heart has permanently ceased to beat. Put- could not even cope with their internal milieu: they refaction would be the only criterion relevant to such a were poikilothermic, had diabetes insipidus, and could concept of biological death. not sustain their own blood pressure. The cardiac Neither doctors (too busy with practical decisions to prognosis of the condition was at most a few days, but

question, as they should, the philosophical implica- sometimes as little as a few hours. on September 26, 2021 by guest. Protected copyright. tions ofwhat they are doing) nor philosophers (usually Unfortunately, the words 'irreversible coma' were too concerned with conceptual problems to find time to later used (quite inappropriately) to describe some- ascertain what is real and unreal in their speculations) thing very different, namely the vegetative state (and it have ever demanded putrefaction as a criterion of is as a synonym for this condition that Dr Browne uses death. Rightly, both are more concerned with cessa- the words). The vegetative state was clearly described tion of function of the 'organism as a whole' than with by Jennett and Plum in I972 (6). For many years it had cessation offunction of'the whole organism'. And here been 'a syndrome in search of a name'. (The condition brain-stem death begins to assert its relevance. When is also known as 'neocortical death', the 'apallic state', the human organism has irreversibly lost the crucial or 'cerebral death'.) The vegetative state has a potential capacity for consciousness and the ability to breathe prognosis of months or years. It usually results from (and thereby to maintain a spontaneous heart beat), either cerebral anoxia (which may devastate the cortical and when moreover it has lost such important mantle of the brain while sparing the brain stem) or responses to its environment as the homeostatic main- from impact injury to the head (which may massively tenance of temperature and blood pressure (which are shear the subcortical white matter, disconnecting the mediated through or by the brain stem), in what sense cortex from underlying structures). Other pathological can it be said to be an independent biological unit? processes may, on occasion, be responsible. Chronic Technological developments (such as cardiac trans- care units all over the world are full of such patients. plantation and our capacity, for a while, to maintain a Affected individuals open their eyes, and show al- heart-lung pteparation) make a redefinition of death ternating sleep-wake sequences. By definition they imperative. And it helps no one when the issue is cannot be described as comatose, for coma is a state of Whole-brain death reconsidered - physiologicalfacts and philosophy 35 J Med Ethics: first published as 10.1136/jme.9.1.32 on 1 March 1983. Downloaded from

sleep-like unresponsiveness, from which the patient ignore some further fundamental differences between cannot be roused. (Empirical evidence is now over- whole-brain death and the vegetative state. The latter is whelming that coma, so defined, never lasts more than easier to describe than to define physiologically. In fact about three weeks. Comatose patients either develop it is doubtful whether it will ever be possible to define it asystole during this period, or they open their eyes and with the physiological rigour needed if practical steps pass into a vegetative state). (and behavioural patterns) are to flow from the defini- Although intermittently awake, patients in a vegeta- tion. The loss ofcognition and affect (in the vegetative tive state exhibit no behavioural evidence ofawareness. state) cannot be quantitated in the way absent brain- Conjugate roving movements ofthe eyes are common, stem reflexes can (in whole-brain death). The loss of orienting movements rare. The patients do not speak awareness (including self awareness) in the vegetative or initiate purposeful movement of their limbs. Ab- state cannot be recognised as readily as a respiratory normal motor responses to stimulation may often be centre incapable of responding to an arterial carbon produced. The patients grimace, swallow and breathe dioxide tension of 6.65 kPa. A second year medical spontaneously, and their pupillary and corneal reflexes student could diagnose whole-brain death - but even are usually preserved. They clearly have a working an experienced neurologist has difficulties in assessing brain stem, but no evidence offunction above the level the various deficits in the vegative state. In a nutshell it ofthe tentorium. The words 'irreversible coma' should is easier to test pupils than to be certain about senti- clearly be dropped when what ismeant is the vegetative ence. state. Although the condition is usually irreversible, Death behaviour is eschewed by relatives confronted the patients are not comatose. with the more severe forms of the vegetative state No culture has ever considered patients in the veg- because open eyes, grimacing, swallowing and spon- etative state as dead, or suitable subjects for organ taneous breathing are, rightly or wrongly, associated in donation. No physician would be authorised, any- their mind with the capacity for awareness. Death where in the world, to use the bodies of such patients behaviour is eschewed by doctors, in similar circum- for what Dr Browne calls 'certain experimental or stances, because it is widely felt that such behaviour instructional purposes'. No doctor would be prepared would be the first step along a very slippery slope. If to perform an autopsy on such a case, or to 'initiate the 'irreversible loss ofhigher functions' (or the 'loss of burial procedures', or to do any of the other things personal identity') were equated with death, then which Dr Browne lists as appropriate death-behaviour. which higher functions? Damage to one hemisphere or Against whom then is he arguing when he repeatedly to both? If to one hemisphere, to the 'verbalising' raises the issue of such patients? For instance when he dominant one, or to the 'attentive' non-dominant one? states that according to the 'cerebral-death definition To the frontal lobes or to the parietal lobes? In next to of death [by which he means the vegetative state] a no time leading politicians all over the world would be http://jme.bmj.com/ person is dead as soon as he is in irreversible coma'? declared brain-dead. 'Whose cerebral-death definition of death?' one may ask. I described the vegetative state in some detail so that That of philosophers? Idiosyncratic viewpoints aside, it should not be confused withwhole-brain death, which no authoritative medical or legal body has, to my know- is something very different. Brain-dead individuals ledge, ever defined the vegetative state as death. In the exhibit no signs of neural function above the level of real world, there is no socially significant acceptance of the foramen magnum. Brain-stem death is the physio- a 'cerebral-death definition ofdeath'. Has Dr Browne, logical kernel of brain death, the anatomical sub- on September 26, 2021 by guest. Protected copyright. at times, confused whole-brain death with the vegeta- stratum ofthe physical signs encountered in the condi- tive state? I suspect he may have. For instance to what tion (apnoeic coma with absent brain-stem reflexes) condition precisely is he referring when he talks (p 30) and the main determinant of its invariable cardiac about patients who are 'irreversibly comatose [ie in prognosis: asystole within hours or days. the vegetative state] but have artificially supported Dr Browne conjures up visions of whole-brain dead respiration and heart beat'. Patients in the vegetative individuals, maintained on ventilators, being used as 'a state breathe spontaneously, so that it cannot be about self-replenishing blood or skin bank, a reservoir of them that he is thinking. And patients who are transplantable organs in the freshest possible condi- 'whole-brain' dead - and who require artificial respira- tion, a plant for manufacturing biomedical compounds tion - are not in 'irreversible coma' . . . at least not in and so on'. In this he seems to be under a misappre- the sense in which Dr Browne repeatedly uses the hension as to how long the heart may continue to beat term. In his whole discussion ofthe vegetative state he when the brain stem is dead. I have summarised else- seems to be tilting at windmills with very blurred where (7) the published evidence concerning what edges. happens when brain-dead patients are maintained on There is, admittedly, a substantial body of medical ventilators. Asystole invariably develops. For (and lay) opinion which holds that patients in a persis- instance, ofthe 63 patients diagnosed as brain-dead in a tent vegetative state should be allowed to di,:. But even large Danish series (8) (and maintained on the ven- to envisage that the persistent vegetative state could be tilator) 29 developed asystole within 12 hours, io be- equated with death is both to confuse the issues of tween 12 and 24 hours, i6 in 24-72 hours, and the 'allowing to die' and 'determining death' - and to remaining 8 in 72-21I hours. Experience in Great 36 C Pallis J Med Ethics: first published as 10.1136/jme.9.1.32 on 1 March 1983. Downloaded from

Britain (g) and elsewhere is in line with these observa- heart had been allowed to stop would probably be tions. The reasons why the heart stops within a short guilty ofmalpractice. In other parts ofthe world, such while when the brain-stem-mediated baroceptor as Poland and Sweden, brain death is recognised and reflexes are disrupted, and when the vasomotor centre disconnection from ventilators is permissible, al- is destroyed, are complex but the empirical fact is though surgeons have to wait some 20 minutes until the established beyond all doubt. heart has stopped before they can remove organs. This The twin pillars of Dr Browne's whole argument state of conceptual schizophrenia cannot be expected have now been shown to be shaky. The categorisation to last. It is striking how readily the relatives of brain- of what is or is not appropriate death-behaviour is dead patients already accept the diagnosis. I recently irrelevant in the context of patients in the vegetative informed the nephews of a brain-dead patient that I state (whom no one would consider dead). It is unreal, had just diagnosed their uncle as brain-dead. 'That's in practical terms, in the context of whole-brain death strange', one of them said, 'I thought he died last (because as soon as this state is diagnosed doctors Tuesday'. usually withdraw ventilatory support and the heart Those who think that 'weighty moral arguments' are stops). Even if physicians did not act in this way, the necessary seem to doubt that whole-brain-dead indi- repertoire of potential behaviour patterns possible viduals, maintained on ventilators, are 'really dead'. between the two events (the irreversible cessation of They imply (although seldom say so explicitly) that brain function and the irreversible cessation of heart such individuals are not really dead, and that whatever function) would be strictly limited, for reasons oftime. is done to them is somehow being done to 'persons'. And what if the heart could be permanently replaced The very use ofsuch terms as 'maintaining life-support by some mechanical device? It is impossible to predict systems' and 'the administration of health care' (when how prevailing attitudes would, by then, have evolved. applied to the brain-dead) are examples of termino- But it will certainly be a meaningless question to ask, logical sleight of hand. Playing on atavistic anxieties for those who still accept the framework of Black's generated by the presence ofa still beating heart, those Law Dictionary. who reject the whole-brain concept of death seek to lure their opponents into terminological quagmires. The trap is easy to avoid ifrecognised. The best way to Death .. . and appropriate 'death-behaviour' avoid it is to ask those who refuse a whole-brain defmi- tion ofdeath to come out in the open, and give us their We are told that 'it has not been characteristic for own concept ofdeath. To seek refuge behind legalistic advocates [of a whole-brain concept of death] to ac- dictionary 'definitions' that predate the development knowledge, let alone defend' its implications, and that

ofmodern intensive care facilities - and which often are http://jme.bmj.com/ 'some weighty moral arguments' are needed before not definitions at all - is just not good enough. those who accept such a concept can justify 'death- behaviour' such as the harvesting of organs. There is finally something offensive - and not a little I do not see the need for special pleading when paranoid - in the suggestion that those who want to confronted with what I have called a 'beating heart redefine death (some would say, who want to define it cadaver', that is a dead patient in whom only a machine adequately for the first time) are seeking a 'death jus- (maintaining ventilation) ensures a transient continua- tification' to legitimise their practices. It is implied that tion of the heart beat. If one is sincere and physicians are seeking to change the definition ofdeath convinced, on September 26, 2021 by guest. Protected copyright. logical about one's conviction that whole-brain death so that they may continue to do what they want, with- equals death, what one considers to be permissible out being accused of practising euthanasia. There is no flows simply and without fuss. A death certificate may, foundation for this view. Brain death has a sound for instance, be issued. And with proper respect for the physiological basis, in its own right. It had been identi- susceptibilities and wishes of the relatives all classical fied before renal transplantation got under way. And if cadaver-related behaviour becomes acceptable (dissec- better methods were discovered for treating end-stage tion, the removal of organs, the teaching of' anatomy, renal failure, well run intensive care units would still be etc). No intellectual contortions are needed. The whole producing whole-brain-dead patients, in increasing matter centres on the acceptability of the conceptual numbers all over the world. premise, and on confidence that the clinical assessment Modern technology, in its desperate attempts to save has been meticulously carried out. human life, has produced the entity we call brain Dr Browne and I would agree, I suspect, that what is death. The conceptual problems this creates will not go considered acceptable is culturally determined. We are away, just because we choose to ignore them. The now in a state of transition in these matters. In many redefmiing ofdeath has become one ofthe more impor- countries brain death has achieved legal status and is tant challenges of modern medicine. In accepting the synonymous with death (io). In some parts of the challenge physicians need the creative help of world the concept ofa 'beating heart cadaver' is widely philosophers, not proclamations of conceptual established, and not only among doctors. In California, agnosticism. for instance, a surgeon who transplanted the anoxic Dr Browne's arguments have been directed against and discoloured kidneys of a brain-dead donor whose both a specific target of 'whole-brain death', and Whole-brain death reconsidered - physiologicalfacts and philosophy 37 J Med Ethics: first published as 10.1136/jme.9.1.32 on 1 March 1983. Downloaded from

against the more general target of any definition of philosophical and policy confusion. Annals ofthe New death in terms of brain function. I have attempted to York Academy ofScience I978; 315: 307-321. show why his arguments fail against each of these (4) Ad Hoc Committee of the Harvard Medical School. A targets. I have suggested elsewhere, however, that just definition of irreversible coma. Journal ofthe American as brain death is the necessary and sufficient com- MedicalAssociation 1964; 205: 85-88. ponent of human death so is brain-stem death the (5) Mollaret P, Goulon M. Le coma depasse (memoire pre- necessary and sufficient component of brain death liminaire). Revue neurologique I959; 101: 3-15. (i i). Brain stem death can moreover readily be iden- (6) Jennett B, Plum F. Persistent vegetative state after tified clinically. But that is another brain damage: a syndrome in search of a name. Lancet issue. 1972; I: 734-737. (7) Pallis C. An ABC of brain stem death. British medical journal i983; 286: 123-124. References (8) J0rgensen E 0. Spinal man after brain death. Acta neurochirurgica 1973; 28-: 259-273. (g) Jennett Gleave Wilson P. (i) Beresford B, J, Brain death in three H R. Cognitive death: differential problems neurosurgical units. British medical journal 282: and legal overtones. Annals ofthe New York Academy of I98I; Science I978; 315: 533-539. 339-348. (io) Pallis C. An ABC of brain stem death. British medical (2) Pallis C. An ABC of brain stem death. British medical journal I983; 286: 209-2IO. journal I982; 285: 1409-1412. (iI) Pallis C. An ABC of brain stem death. London: (3) Veatch R M. The definition of death: ethical British medical journal, I983.

Contributors to this issue

Alan G Johnson is Professor of Surgery at the Univer- C Pallis is Reader Emeritus at the Royal Postgraduate sity of Sheffield. Medical School and Consultant Neurologist at Ham- mersmith Hospital, London. David Belgum is Professor ofreligion in the University of Iowa's School of Religion and Head of Pastoral Mark S Komrad is a Services at University of Iowa Hospitals and Clinics. senior medical student at Duke http://jme.bmj.com/ University School of Medicine, Durham, North Carolina. Diana Brahams is a barrister practising in Lincoln's Inn London. Brendan Caliaghan, sJ, (Society ofJesus), is a Clinical Malcolm Brahams is a solicitor practising in London. Psychologist and Lecturer in Pastoral Theology at Heythrop College. Peter Ferguson is an undergraduate in his final year of Honours in Scots Law at the University ofEdinburgh. Gregory Stone is a barrister. on September 26, 2021 by guest. Protected copyright. John Havard the is Secretary of the British Medical Luke Zander is a General Practitioner and Senior Lec- Association. turer in the Department of General Practice, St Thomas's Hospital, London. The Right Revd John Habgood is the Bishop of Durham and has for nine years been Chairman of a Alastair working group which has published a series of studies Campbell is Senior Lecturer, Department of Christian Ethics and Practical Theology, University of on various problems in medical ethics. Edinburgh. Kenneth M Boyd is Scottish Director of the Society for the Study of Medical Ethics. Case conference editor Roger Higgs, 8i Brixton Water Lane, London SW2 Alister Browne is an Instructor in Philosophy at the iPH. University of British Columbia, Capilano College and Douglas College. He has published in the areas of American correspondent philosophy of mind, social philosophy and medical Bernard Towers,Department ofPediatrics, University of ethics (his current research interest). California at Los Angeles.