The Linacre Quarterly

Volume 40 | Number 4 Article 3

November 1973 Definition and Criteria of Clinical Death Robert F. Rizzo

Joseph M. Yonder

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Recommended Citation Rizzo, Robert F. and Yonder, Joseph M. (1973) "Definition and Criteria of Clinical Death," The Linacre Quarterly: Vol. 40 : No. 4 , Article 3. Available at: http://epublications.marquette.edu/lnq/vol40/iss4/3 reach out and provide cart or sponse are rich and va ri ed. That those who have no "right" to i• 'ut we need to develop some empirical more concretely, as importa• as Definition and Criteria of Clinical Death rules of thumb to check our arbi­ criteria are to inform deci ns, trariness in some of the hard c ases Robert F. Rizzo, Ph .D . and Joseph M. Yonder occasioned by our increased tec h­ we cannot make them do a ~ he work of ethical judgment and JU­ nological skill is not in question. ment for all cases, since no l er­ As Eric Cassell suggests, "The func­ ion is going to relieve or s! Jld ti on o f mo rality in medicine is no longer simply to protect the weak make less troublesome the b· len and the sic k from indifference or of dec iding to operate to sa' the life of a severely retarded chi! To venality, but to protect them also Synopsis . and medical matters, they have im­ try to substitute " impe rson e~. cri­ from mercy grown overwhe lming Using the 1968 Journal of the medi ate bearing on the role of the teria" for what should be the lral • I • by technological advance.'' How­ American Medical Association arti­ physician in his relationship of / , . . ', agony of suc h decisions is alre 1 to ever, the de velopment of such rules cle on brain death by the Ad Hoc trust and service to the patient and sacrifice mo re of our human it" 1an o( thumb must be developed with Committee of the Harvard Medical community and on the quality care the kind o f e xactness that such we can stand. School and the 1972 lAMA report of the terminal patient. These are cases e nta il, rather than with the by the Task Force on Death and our major concerns in reexamining generality that opens them to the Dying of the Institute of Society. the definition and criteria of clini­ Finally. I think we shout, feel perversion of justifying our uncare Ethics and the Life Sciences on a cal death. more the oddness of trying to ter­ of those who do not fit our c urrent re-examination of brain death as Medical technology has chal­ mine this o r that as the criten hat standards of "full y human." SP_ringboards for a contemporary lenged the moral and medical cri­ makes us human. The con1 ons VIew of clinical death. the authors teria for determining death. Tech­ of being human form a far tO\ om· In this respect, I think a strong present the ambiguities and prob­ nical advances in health care have plex patte rn to be ever redu· I to cautionary note needs to be inter­ lems intrinsic to these articles and led some to put emphasis on "brain some thing like "criteria." r oo jected about developing c riteria concurrently propose an alternative death" rather than on heart and quick appeals to the myst • of of the human that will somehow re­ in I he form of a \\ 'O rkin~ hypo1hesis respiratory cessation as the criteria being human can be but ex cu ~ , for lieve us of the hard choices that we for clinical death as it re la tes 10 for diagnosing clinical death. The cloudy and sloppy thinki n ~ that are confro nting in modern care of the terminal palient. strain of moving from heart and m e di ~ attempts to evade some of th-. hard c ine. For c riteria that are suffi­ respiratory cessation to bra in death issues we are confronting, bt they cient for all the kinds of cases we reveals the inadequacy of present may also be profound respon ·s to confront will be· so vague tha t the ir medical and moral guidelines in the the huma n sense that ultimatt· v we Clinical Death concre te implications will be am­ face of an increasingly sophisticated are not our own creators. T1 ne a With technical progress in the biguous at best. Even if you try to technology. Deeply woven in the man is to be open to the call o ~.v ha t care of the sick and dying comes a make suc h c riteria more ope ra tion­ c ulture o f o ur society, the re we are not, and there is theref ·e no number of problems and a need to al for the doctor by tying the m to e merges the central question of the cha nce that our humanity \\ 'I be r~examine traditional presupposi­ empirical characteristics. it is by controve rsy. Are we really inter­ enhanced by excluding fror our tions, concepts and procedures. Ad­ no means clear that the mora l ques­ ested in the quality care of the pa­ ranks those who do not und t.: ,rand vances in chemical and mec hanical tions involved in many of these tient and partic ularly the te rminal as we. We must therefore app oach means for sustaining life have raised cases will be any more resolvable. questions concerning the clinical patie nt? the attempt to develo p crit\ ria of For eve n tho ugh suc h. criteria may definition of death and the tests for In the care of the dying, a rede­ the human with the humilit'- that help you dec ide that this life is not determining when clinical death has finition of clinical death and its cri­ recognizes tha t we would he less "fu lly human," the question o f occurred. Though these questions te ria would mean that docto rs than human if we did not recngnize whether c are should be given still have important relevance to a wide would withdraw extraordinary mea­ that there are limits to what can be remains, I suspect that we are hu­ range of legal as well as perso nal sures for sustaining life much soon- man exac tly to the extent we can bro ught under our control.

November. 1973 223 Linacre Quarterly 222 er, allowing the patient to die with offset the pain, inconvenienct .tnd fied the dissolu tion of the integ rated respirator in spite of the eviden t d ignity and in peace. By "extra­ expe nse of the procedures. 'A !th­ organism we call huma n life. Clini­ breakdown of t he organic who le ord inary measures·· is meant all er a measure is e xtraordina or cal death has never been in theory and its own s uppo rt systems, the a rtificial life-sustaining procedures. ordinary canno t be d ecided 1 the or practice identical with complete rethinking of clinical death a nd biological death. For suc h a death W e are de fining "extraordinary" as abstract. The circumstanct of its tests needed o nly a prod from has been commonly understood by each case must be carefully 'lm- entails the death of all organ sys­ necessity, a facto r which techno l­ It many moralists. In Medico-Moral ined before a prudent judgmer .:an tems. is o bvio us the n that bio­ ogy provided. M o reover, the use Problems, G erald Ke lly, S. J., gives be made. According to a num r of logical death is a process more o r of the electroencephalograph ha s less gradual, depending o n the cir­ the traditional, moral definitio n as mo ralists, if a n artificial m~ .ure turned attentio n to the cessatio n cumstances. Even under the tradi­ of brain functio ns or brain death follows: offers no hope of substantial ·me­ tional criteria, after clinical death as a defini tive ind icatio n of clinical By these we mean all medicines, treat· fit in a particular clinical sitl tOn, ments, and operations, which cannot it is considered e xtraordinary ven was pronounced , some organs and death, despite the presence of ar­ be obtained or used without excessive tho ugh it may not be o f an < Jeri- tissues were still a live, continuing tificially mainta ined heartbeat a nd expense, pain or other inconvenience, me ntal nature.2 W e could late a metabolic function fo r ho wever respira tion. T he shift from heart or which, if used, wo uld not offer a the moral distinctio n betwe ex- brief a 'time. In practic e. this fac t death to brain death is a good exam­ reast•nahlc ho pe of benefit.1 ' • ' r · traordinary and ordinary me ~ to had little relevance. But the point ple of how technical progress ca n .. It should be noted that the phrase the general care of the te rmi ' pa­ that bears re peating is that practi­ open new ho ri zons and thinking but ' ..· .•' " reasonable hope of benefi t" means cally and theoretically clinical death also create a set o f problems and ' ' I tient and the rights · o f the 1 ie nl ~ . traditionally reasona ble hope of . ·~ ~. to decide for o r against ext •rdi­ and biological death are not iden­ new opportunities for decision. .. '. substantial or real benefit. It signi­ : .. nary meas ures as mo rall y d, ned. tical even under the ~ rad it i o n a l pro­ .. . fies reasonable prognosis of even­ cedures. As regards theological The lsoelectric EEG ; He re we limit o urselves to 1 king tual recovery from a debilita ting ill­ For those who have kept abreast .. . the obvio us conclus io n that li ag­ death, it is defined as the mo ment . • ness or of carrying the patient over o f the discussio n surrounding the : nosis of clinical de ath baseL ln a the soul leaves the body. Catholic ,. .. a te mpo rary crisis , factors whic h theology theorized tha t the soul did reevaluatio n o f clinical death, the re new set o f crite ri a wo uld me • t h ~: •. withdrawal o f a ll artifi cia life­ not leave the body immed iately are certain gene ral points tha t . upon clinical death but lingered fo r e merge fro m writings o f the subject . '· sustainers at an earlier st . ~ of ;,. Dr. Robert Rizzo received his a short time. T he obvio us uncer­ The eli minating o f heartbeat as a te rminal care. ' .. PhD. in R eligion f rom the Catho­ tainty o f such speculation elimi­ de finitive sign o f huma n life is gen­ . lic University of America, Washing­ The fundamental questio con­ nates the possibility o f using the erally accepted by those who focus ... ton, D.C. in May, 1971. Dr. Rizzo fro nting us in the redefi nit n of concept of theological death as a o n brain death. The isoelectric has been teaching at Canisius Col­ clinical death is whe ther de <• 1 is a i : . relevant tool in reexamining medi­ EEG is regarde d as a confirming : ·. lege, Buffalo, N. Y., f or the past process o r an e vent. Techno •gical cal procedures and establi shing a rather than a dete rmining sign. Fo r five years and is presently A ssis­ advances have provoked a l!con­ working clinical definitio n of death . example. Franc is D. Moore writes: tant Professor in the Department of sid eratio n of the traditional 'efini- Biological and theological death A fla t EEG is no t e no ugh. There musl Religious Studies at Canisius. tio n and tests. C linical de< 1 has must be regarded in theory a nd be somelh ing tha t can be seen by the unaided eye whic h tells the observer customarily been d efined in terms practice as distinct fro m clinical Mr. Joseph Yonder is a candidate thai the brain is damaged. extruded. o f cessation o f heartbeat, ' •<; pira­ death. divided. or destroyed. Then. with 1he for the Master of Art degree at tio n and reflexes. Canisius College in Religious Stud­ total cessation of neural activity of As Vincent J. Collins point'i out. Sophisticated techno logica l care the brain. the state o f the other organs ies. His area of concentration is can be whateve r sui ts the recipient of the patient is the major cause in medical ethics. For the past five there are three possible ~ .t ys of best. Even if lhe heart is slill bealing. yean Mr. Yonder has worked in lo oking at death: clinical, Piologi­ the reexaminatio n of traditio nal cri­ there is no questio n for the coroner or Western New York hospitals and cal and theological.3 C linical death teria. Since the heartbeat and res­ the lawyer. T he dono r is dead.4 is presently an Inhalation Therapy has been customa rily ide ntifi ed by piration can be a rtific ially ma in­ T he Report o f the Ad Hoc C ommit­ Technician at the Buffalo Colum­ the cessation o f the functioning of tained for a time by che mical stimu­ tee of the Harvard Medical School bus Hospital. certain organs, a fact which signi- lants and mechanical devices as the says essentially the same but more

November. 1973 224 Linacre QuarterlY 225 :'

Repo rt offers these crite ria n mg· specifi cally by laying down de· · vard Committee Report, the Task linked to mere vegetative existence. tail ed criteria and mode of proce· gested guidelines whic h a l :tor Force on Death and Dying of the and hence. to· the function ing o f the dure in the definition of brain death. could follow in diagnosing c ical Institute o f ·society, Ethics, a nd circulatory system and the heart.9 A patient in this state appears to be death . the Life Sciences makes the fo llow· T his analysis adds to the ambiguity in deep coma. T he condition can be ing observation : . by ascribing the higher functions or satisfactorily diagnosed by points I , 2 T he fl at EEG is therefor· pre· human functi o ns to the CNS a nd and 3 to follow . The electr oencepha· T he new criteria are meant to be cerebral cortex in the sa me breath. logram (point 4) provides confirma· sented as confirmatory rathe han necessary for only that small percen· tory data, and when available should a dete rminative indication o t lini· For part of the brain or part o f the tage of cases where there is irrevers· be utilized.5 cal death within the conte J< pro· CNS is largely involved in control· ible coma w ith permanent brain dam­ ·. Briefl y the well-known criteria are posed by the Report. It is ·this age, and w here the traditional signs ling vegetative functio ns in a ll verte­ the fo llowing:6 po int that our problem begir We of death are obscured because o f the brates. C. U. M. Smith in The Brain. are a ttempting to establish ~ eria inter vention of resuscitaiion machin· fo r exa mple. describes th e functi o ns I. U nreceptivity and unrespo nsivity ery. The p roposal is meant to comple· for clinical death, while rc< ~ n i z· of the med ulla in this fashio n: to even the most painful stimuli. ment not to replace. the tradi tional ing biological death as a proct not 2. No spontaneous muscular move· criteria of determining death .a The medulla i tself. although rela­ who lly identical with clinical ath. ments o r spontaneous respiration Perhaps the elimination of heart· ri,·ely undifferentiated - it st ill sho ws In this context, we must ask ,eth· the four functional columns of the or respo nse to stimuli suc h as beat as a d e fi nitive sign of li fe in • .•t. er the death of the cerebral rtex sp inal cord - is of considerable im· \ . .· . : pain, touch, sound o r light, veri­ certain cases might seem to some a , .~ , or neocortex signals human ath, revolutiona ry step. But in practi ce porta nee in the body's economy . It fi ed over at least an ho ur. is from th is part of the brain that even tho ug h othe r parts of thl rain ,•' \. 3. Absence of cere bral and spinal the proposals of the Harvard Com­ many o f the vital automatic activities may still be functioning for , tme. re fl exes. mittee do not amount to a real o f the viscera are controlled. For ex­ We a re posing this questio n 1 re· 4. T he fl a t EEG verified by compe· change in the evaluatio n of death. ample. nerve centers in this structure gard to the quality of te rmina :are. regulate the activity of the heart. tent specialist. In contrast, we would propose the The Repo rt does not he lp us • an· question whethe r there is h uman lungs and alimentary canal : the cali· In the case of a patie nt on a me· ber of the arterioles in many parts swe r the above questio n dire <.. v be· life in the event of the death of c h a nica) respira to r , the R e po rt o f the body; the metabolism o f carbo· cause it introduces criteria hich states precisely the procedure as the neocortex as indicated by ne u­ hydrates: the osmo tic pressure of the rela te to the functioning o t •ther rophysiolog ical signs. blood. These nerve centers are. how· fo llows: parts o f the brain and o f the ntral In this area, the re is sufficie nt am­ ever. themselves often governed by liS tS centers fu rther forward in th e brain.IO The total absence of spontaneous nervo us system in general. biguity and Jack of clarity. For ex­ breathing may be established by turn· evi dent in its focus o n spo nt•· leous ample, the Task Force (mentio ned T he CNS, therefore. is too broad a ing off the respirator for thr.ee min· breathing, cerebral and spir t1 re· above), in a ttempting to clear up phrase to designate what controls utes and observing whether there is fl exes, and respo nse to stim :li. It ambiguities surrounding the mean­ higher h uman functi ons. We offer any effort on the part o f the subject is clear then tha t brain death neans ing of death, notes that we are the hypothesis that human death to breathe spontaneously. (The res· shoul d be related to the cessati on pirator may be turned off for this time for the H arvard Committe( total talking of "the death of the human provided that at the start o f the trial cessation of brain func tions ,. "to· organism." It the n goes o n to state: of functi o ns d istinc tly human since per iod the patient's carbon dioxide tal bra in death" and no t simr ces· breathing, heartbeat and circulatio n tension is within the normal range. satio n of the neocortical fu n tions. It may make a considerable difrcr· are vegetati ve processes shared by and provided also that the patient had T he Committee has reintrc luced ent.:e whic h of tht: two terms " hu· othe r animals. been breathing room air for at l ea.~t man" or "organism " - is given prior· 7 all the traditional criteria w. h the 10 minutes prior to the tria1. ity. Emphasis on the former might Fro m the evidence accumul ated With the exception of two condi· exceptio n of heartbeat in a patient mean that t he concepts o f life and from a battery of psychological. tio ns, hypothermia . (temperature on a mechanical respirator. In the death would be most lin ked to the neurological and physiological tests. below 90 F o r 32.2 C) and coma re­ case of suc h a patient who L1i ls all higher human func tions. and h c n~·e . Ale ksand r Luria in High Cortical sulting fro m central nervous system the above tests, heartbeat ts not to the f u ~ c ti on ing o f the ce ntral ncr· Fu nctions states that ''the cerebral regarded as a definiti ve sign uf hu· vous system (CNS). and ultimately. de pressants, the failure of these of the cerebral cortex. Emphasis on cortex, the most highly organized tests, repeated at least 24 hours man life since it is artific ially main· the latter might mean that the con· part of the e ntire central nervo us later, indicates brain death. The taine d . Comme nting o n the Har· cepts of life and death wou ld he most system. has come to be regarded as

226 Linacre Q uarterly November. 1973 227 a high-level center for analysis and is gene ra lly acce pted that a 1 ent neocortex, together with the re­ we a nswer it. will affect the contin­ integra ti on o f signals received by with severe brain damage re ling sumption o f spontaneous respiration uation of intensive care for the and o f certa.in brainste m re fl exes."l5 the organism from its internal and fro m head injuries, cerebra\ . ular patie nt with respect to h is rights to The autho rs distinguish " neocortical external environment."11 T he highe r accident or cardiac arrest pro· die with dignity. It is obvious to mental functions are dependent o n no unced dead in the presenc f an death" fro m "brair. death'' o r "total th e m as well as to us that the Har­ the integrated functioning of vari­ isoelectric EEG (strictly dt ed), brain death" in which insta nce there vard Committee Report is concern­ o us centers of the cerebral cortex lack of re fl ex reactio n a nd m tani· is no reflex activity a nd no spon­ ed about criteria for establishing o r neocortex.12 The functio ning of cally sustained respiration a car· taneous breathing along with an iso­ total brain death with its particular the cortical centers cover a wide diac functions. They go on pre· elec tric EEG. In each case, the focus o n reflex responses and spo n­ with. range of phenomena from the pro­ sent the cases of two patien neuropathological evidence con­ taneous breathing whic h a re indi­ cesses of perception a nd move ment irreversible brain damage al car· firmed the neurophysio logical data cative of cerebral functio ns carried to complex systems of speech and diac a rrest who were e xcept1 al in which indicated the d eath o f the on in spite of neocortical death. in tellectual activity. Since the brain their surviving fo r five mont with neocortex with the continua tio n of Thus, the Harva rd Commi ttee operates as an integrated who le a flat EEG. certain brainste m and spinal func­ ma kes clinical death dependent no t with its systems neurally interre­ tions for five months. This confir­ o n the cessation o f the highe r human In case one. eye-opening. ya' tg. la ted, the neocortex certainly does mation prompted the authors to functions or o n the death of the wit h associated movements. SP<'' ne· propose that " it is likely that a physiological bases for these func­ no t pe rform its higher tasks inde­ ex ous respiration and certain systematic study of sensory evoked tions but on the cessation o f vege­ pendently from othe r parts of the activities at brainstem and spin;., •rei tative functions shared by other central ne rvous system. However, levels were present; while in ca wo cortical potentials and the EEG as tty a nimals. It is this feature which we with its death, it is equally certain the resumed central nervous a soon as possible afte r cardiac arrest was restricted to spontaneous r 1ra· find inadequate. that the remaining systems canno t could identify the existence of neo­ tion and certain brainstem and 1al· cortical death earlier than was pos­ substitute for the neocortex to ef­ cord reflexes. In both cases ro· sible in the present cases. ''16 As in We must not only deal with the fect the integrated operations that physiological investigations led the other cases of isoelectric EEG, the state o f the art as it i~ now but as it result in the higher mental func tio ns conclusion that the neocorte vas md will progress. T herefore, the event­ associated with human pe rceptio n. dead while certain brainsten presence of depressant drugs in spinal centres remained intact uo· the system must be take n in to con­ ual problems of defining brain death unde rstanding and judgment. From sequent detailed neuropathot ical sideratio n in evaluating the tests. could easily threaten the quali ty of all clinical evidence, the death of analysis confirmed this predict 1 in li fe for the patients with terminal 13 To remove a ny doubts, " neocortical the neocortex marks the e nd of the each case. conditio ns. From the Lancet article, physiological basis for human con­ death could be confirmed by the appro priate neuropatho logical ex­ the re is the prospect of countless sciousness, that is, a consciousness Witho ut going into all the dt ails of amination o f a biopsy specime n (a individuals being maintained after unique in its powers of reflectio n. the cases and o f the test g. we 1-1-5 em. cube) taken fro m the their neocortex is dead . As tech­ It signals the end of the brain as a would like to po int up o bse1> ations poste rior half o f a cerebral hemi- niquesand instrumentatio n improve, dynamic integrated whole and pre­ a nd conclusio ns relevant o ou r sphe re."t7 the patient without higher neocorti­ sages in most cases the imminent d iscussio n. cal functions will be maintained for death of other cerebral systems. Case o ne and two were c 1 nically lo nger periods and with greater fre­ The study of these two cases ide ntical except fo r the fact that in quency.18 Because of the Harvard brings the authors to ask the fu nda­ Two Exceptions case o ne brainstem and spina l reflex Committee Report's focus on spon­ menta l question we have raised. In o rder to point up the rele­ acti vity was not in evidence until namely, whethe r wit h the evidence taneous breathing and reflexes as vance of our hypothesis and line of the second day after the arrest and definitive signs of h uman life, it is dea th o f the neocortex a nd conse­ reasoning, we would like to cite respiration was sustained by me· in fact relegating a neocortically 14 quent irreversible loss o f consc ious­ some findings and conclusions pre­ chanica! ventilation for 17 days. dead pa ti ent to a ''vegetative" ex­ ness a nd accompanying hig he r me n­ sented in an article e ntitled "Neo­ The diagnosis of " neocortical death" iste nce promoted by machinery and tal func ti ons there is still huma n life. cortical Death After Cardiac Ar­ was made from a " persiste ntly iso· drugs. They ask this q uestion fo r the same rest," which appeared in Lancet. At electric E. E.G. and the absence of reasons indicated above. The way We feel there are three reasons the o utset, the autho rs no te tha t it sensory evoked respo nses in th e

November, 1973 229 228 Linacre QuarterlY for upgrading the criteria for clinical should not be absolutely requir in express. But it does seem sa fe to Now with modern techniques, there death: ( 1) the patient's right to die determining clinical death iP 1e propose. that when the capacity or can be a n e \~ situation and order of with dignity and the attendant care face o f neocortical death. W it 1e potentiality ·for higher mental fu nc­ procedure. The physician can start death o f the neocortex, huma. fe of the terminal patient; (2) the hard­ tions, fo r reflec tive consciousness, with the neocortex and proceed to . . . ships imposed upon the family and is ended because the potent ty ceases. then human life ceases. the realiza tion that with its death ,. workers surrounding the patient: to reflect consciously is eradi' cd Physicians must rely on neurophysi­ the biological wholeness which is and (3) the unfairness of withhold­ in the organism . There is en gh ological signs of cessa tion, am ong human life and makes possible hu­ ing organs from those who need evidence to call this a pract lly which is the persistent isoelec tric man consciousness and personhood them desperately. The primary and certain conclusion. If we are lo ng EEG. They cannot and should not is irrevocably gone. H ence human ·. majo r reason o f dignity really invol­ for absolute certitude that thL · lUI involve themselves in the unanswer­ death has occurred even in the pres­ ves both care of the terminal patient or con sciousness has departed 1m able question w hether or not the ence o f some heartbeat, breathing and clinical death. If we have no the body, we would never pr' ed soul or spirit consciousness leaves and reflexes. suitable criteria for clinical death as to declare the person dead 1til the body at a particular point in the Safeguards indicated in terms of neocortical every organ is orga nically ' nt. biological process o f death. Now But is there not the danger o f / , ... ·, ·,. death, then patients o f the type des­ We would not follow the H < trd that the heartbeat has been removed making a rash diagnosis at the ex­ ... Committee Report. The pr;; cal cribed above could become even at least theoretically as a definitive pense o f the patient? There is al­ ·,' ·. \ . more prevalent as medical techni­ decision is based on practical rti· sign of l ife in the certain cases, ways the danger that every se t o f ques pro long their vegetative exis­ tude that human life has c· ed. breathing as well as heartbeat must principles and procedures will be ... \ tence. At the sam e time. their Practical certitude m eans ' ply be seen in its proper context. Cultu­ misused. So there is need for safe­ families will suffer not only the ex­ that one is confident that, aft e. tre­ rally this will be diffic ult. For just guards as well as for som e concrete­ pense but also the anguish o f the ful investigation, there is non. mal as the heart has been associated ness in es tablishing criteria. There •, . long wait until a cardiac arrest or reason to fear error. It is PL aps is the obvious need to verify w ith with the seat o f life and emotions. .. ' super infection destroys the vege­ here that m any physicians are luc­ so breathing has become synony­ practical certitude the death o f the tative drives. T here is also the possi­ tant to d efine clinical de<• in mous with life. There is no intention neocortex through anatomical and .. bility that care of the patient w ill terms of neocortical death bt tuse to say that heartbea t, breathing and neurophysio logical data. As regards be le£t to the efficiency o f mac hines of their uncertainty as to th re li­ reflexes are unimportant. But th ey the use of the EEG, it is well to note: and therefore depersonalized. M ore­ ability of neurophysiological ests must be seen in their biological con­ over, those in need of transplants in indicating irreversible ces tion text, in their relationship to the or­ However. a greal deal o f caution and will necessarily ha ve to wait, even o f neocortical functio ns: H o 1 ·ver, ganic whole we call human life. no little expertise is required to con· elude I hat a record is indeed .. isoelec· tho ugh this could be a de·ath knell as progress is made in thi -.. area When the essential prerequisite for thro ugh the refinement of ech­ tric ... The number and placemenl of for many. Thus these three reasons human consciousness no longer electrodes. length of the recording present strong evidence for th e niques, as for example prese• ·d in exists, that is, when the neocortex and st:nsilivity as well as filter sett ings need to re-evaluate the traditional The Lancet article. confidenl · will is dead, then heartbeat, breathing all are crucial in making this diagnosis. criteria. even as updated by the grow in the methods o f testin neo­ and reflexes sho uld not be regarded EKG and EMG monitori ng channels are very helpful in determining arti· Harva rd Committee. and then the cortical death. Our proposal 1.., that. as signs of hum an life but rather fa ctual po1en1ials. Even aft er deter· when physicians have practi ~ I cer­ need to establish new c riteria for signs of biological life which has mining that .. electrocerebral silence .. clinical death. titude of the reliability of t h ~ tests. lost the organic wholeness that is present. its significance must be the incontrovertible indicati1 n ~ of makes it human life and which is determined. Repeated tracings at neocortical dea th suffice as L riteria variable intervals have been recom· Neocortical Death in the process of dying o rgan by for d etermining clinical deat h. organ. mended. Massive overdoses of CNS Therefore. we propose as an hy­ depressanls and hypothermia may po thesis that, when there is incon­ Perhaps w hat is needed is a philo­ erroneously lead to a premature diag­ trovertible evidence of neocortica l sophical definition o f hum an life Customarily doctors move fro m nosis of "cerebral death." 19 death. then human life has ceased. and death. Admittedly an adequa te the cessation of vital signs to the T here must . therefore, be incontro­ It appears then that cessation of and universally accepted C\1 11Cept realization that the neocortex and vertible evidence of neocortical spontaneous breathing and reflexes would be difficult to formulat..: and then the rest of the brain are dead. death. But such evidence would

230 Linacre Quarterly November, 1973 23 1 suffice to declare the patient clini­ this is accomplished not in isol •n clinical death is more imperative teria for the Determination of Dea th: An Appraisal."' 1AM,4,. 221: 48-53 (J uly 3. 1972). cally dead. There may still be signs but in dialogue with other p ·s- in view of technological advances in intensive care which i ncrease the 50. o f biological life, that is, of life pro­ sions and the general comm y. 9. Ibid.. 49. cesses of organs and tissues. H ow­ But the responsibility bears h. ly chances o f patient's ··survivar· for 10. C.U.M. Smith. The Brain: Toll'ards ever. as stated above, in regard to upo n the medical pro fession 1 e- extended periods wirh·out a func­ an Underslanding (New Y ork : G. P. Put­ human death. the foc us should be velo p standards for prolongin fe tioning neocortex. nam's Sons. 19701. p. 202. I I . A leksandr Romanovich Luria. Higher o n w hat constitutes human life and and determining death. As thl tr- Conical Funaions in Man. trans. Basil Haigh makes possible human conscious­ vard Committee Report s tat e ~ (New York: Basic Books. I nc .. Publishers. ness and personhood. If the neo­ No statutory change in the law slH 1966), p. 42. be necessary since the law treats cortex is the physiological prere­ REFERENCES: 12. I bid.. pp. 30ff. question essentially as one of fat:' l. Gerald K elly. S.J .. Medico-Moral Prob­ 13. J. B. Brierley, D . I. Graham. J. H . quisite for human consciousness, be determined by physicians. The lems (St. Louis: T he Catholic H ospital Adams. J. A. Si mpsom. "Neoconical Death for the ability to associate, reflec t . circumstance in which it woult1 Association. 1958). p. 129. After Cardiac Arrest."' Lance/. 2: 560-65 necessary that legislation be off, judge, appreciate and evaluate, then 2. Sec ibid., pp. 128-4 1. Cf. John J. Lynch. (September II. 1971). 560. in the various states to define ''de; the total cessatio n of its func tions, SJ., "No tes on Moral Theology:· Theo lo~i­ 14. Ibid.. 564. by law would be in the event that!! once deemed irrevocable. o ffers cal Studies. 22 (June. 1961). 246-48. I 5. Ibid. controversy were engendered 3. Vincent J. Collins. "'Limits of M edical 16. Ibid. practically certain gro unds for the rounding the subj ect and physit Responsibility in Prolonging L ife... lAMA. 17 . Ibid.. 565. diagnosis o f clinical deat h. were unable to agree on the 206: 389-92 (October 7. 1968). 391. 18. Ibid. medical criteria.21 19. Gary D . Vanderark and Ludwig G. Another safeguard would be the 4. Francis D . Moore. "'Medical Responsi­ bility for the Prolongation of Life:· lAMA. Kempe. Primer of Eleclroencephalowaphy se tting up o f a hospital board to re­ George P. Fletcher, prof es~ of 206: 384·86 (October 7. 19681. 386. I eurosurgery Service. W alter Red General veiw the decisio ns. especially in law, concurs that physicians th tgh 5. Report of the Ad Hoc Committee of the Hospital : Hoffmann-LaRoche I nc .. 1970l. cases o f potential donors. T his commonly accepted practice· '> La­ Harvard M edical School. "'A Definition of p. 46. 20. Report of the Ad H oc Commiuee of would help to refine procedures and blish the criteria for dec i sion ~ re­ Brain Death."' lAMA. 205: 85-88 (August 5. 1968). 85. lhe Harvard M edical School. 339. eliminate anxiety in the team caring gard to prolonging life and dt ·ing 6. Ibid.. 85-86. 21. Report of the Ad Hue Commiucc .... fo r the patient and the transplant death. 7. Ibid. JJ9. team . A s suggested by th e Harvard 22. George P. Fletcher . "' Legal A spects o f By establish ing customary stand. 8. A Report by the Task Force on Death the D ecision Not to Prolong Life ... lAMA. Committee, one precaution would they may determine the expectat and Dying of the Institute of Society. Ethics. and the Life Sciences. "' Refinements in Cri- 203: 11 9-22 (January I. 1968), 122. be the distinction between the team of their patients and thus regulatt <: o f physicians that cares for the understanding and relationship .:· patient and thus has the responsi­ tween doctor and patient. . And )' regulating that relationship, they •Y bility to declare clinical dea th and control their legal obligations to n· the team w hich may be involved in der aid to dll0111cd patients.22 the transplant operation.20 Natural­ Phys ic ians should see tht re- ly, the rights of the next o f kin must be respected and consent for trans­ spo nsibility in its many dimen tms: plant procedures received after the first and foremost , toward tl pa­ details o f the case are given. tient with his right to die in ~ ace and with dignity: secondly. It ward In establishing new criteria fo r the next of kin, w ho could be snared clinical death, medic ine should no t the ordeal of witnessing the dying look to law for a set o f guidelines. of a loved one prolonged b) artifi­ It is intrinsic to the m edica l profes­ cial measures beyond the hope of sion that it se t the criteria for deter­ substantial benefit to the patient: mining death . Thus the law and the thirdly. toward the potential re­ public look to m edic ine to define c ipient of a transplant. The urgency and protect the criteria. Of course, of re-examining the criteria for

232 Linacre Quarterly November, 1973 233