Duquesne University Duquesne Scholarship Collection Electronic Theses and Dissertations Fall 2006 An Examination of the Bio-Philosophical Literature on the Definition and Criteria of Death: When is Dead Dead and Why Some Donation After Cardiac Death Donors Are Not Leslie Whetstine Follow this and additional works at: https://dsc.duq.edu/etd Recommended Citation Whetstine, L. (2006). An Examination of the Bio-Philosophical Literature on the Definition and Criteria of Death: When is Dead Dead and Why Some Donation After Cardiac Death Donors Are Not (Doctoral dissertation, Duquesne University). Retrieved from https://dsc.duq.edu/etd/1359 This Immediate Access is brought to you for free and open access by Duquesne Scholarship Collection. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of Duquesne Scholarship Collection. For more information, please contact [email protected]. An Examination of the Bio-Philosophical Literature on the Definition and Criteria of Death: When is Dead Dead and Why Some Donation After Cardiac Death Donors Are Not A Dissertation Presented to the Faculty of the McAnulty College and Graduate School of Liberal Arts Duquesne University in partial fulfillment of the requirements for the degree of Doctor of Philosophy by Leslie Mary Whetstine iii For my grandparents, Marguerite and Joseph Tantalo iv Acknowledgements I share this accomplishment with many individuals who supported me throughout this endeavor. First and foremost, I wish to express my deepest gratitude to my parents, George Edward and Candace Ellen Whetstine. I hold my father in the greatest esteem for cultivating my appreciation of the humanities and for showing me the elegance of the written word. I am beholden to my mother for instilling in me the value of education and for providing me every opportunity to pursue it. I am indebted to my committee members, David F. Kelly, Aaron L. Mackler, and John W. Hoyt for their guidance and insights throughout this process, with special thanks to Dr. Kelly for directing this work. To the many friends and family members who lent their encouragement, I cannot give enough thanks. In particular, I am grateful to Joseph A. Nelson, for providing unconditional emotional encouragement and for his enduring patience. My deep appreciation also goes to my colleagues, especially to Laurie Balog for her unique perspective and sensitivity and to Matthew Butkus for helping me to hone my analytical skills. The Gumberg Library Reference staff at Duquesne University was also instrumental in enabling this work. With special thanks to Valerie C. Sweeney, a consummate researcher and the most dedicated librarian I have had the pleasure of working with over the years. I consider myself lucky to have interacted with medical experts through the International Critical Care Medicine Group CCM-L, especially Thomas P. Bleck and Michael G. Darwin, who routinely shared ideas and criticisms throughout this process. I sincerely appreciate the support provided by Robert A. Fink, who devoted much time to cultivating the ideas contained herein. I am also particularly grateful to James L. Bernat, a leading expert in the definition of death debate, who was especially generous with his time and expertise. In addition I wish to thank Leda Heidenreich from Mercy Health System, Greg Burke from Geisinger Medical Center and Michael A. DeVita from the University of Pittsburgh Medical Center for providing me with their insights as well as access to their Donation After Cardiac Death Protocols for my scrutiny. Finally, I am indebted to David W. Crippen who introduced me to the international medical community, mentored my career development, and became a dear friend. If I faltered over the years or thought that I could go no farther he was there to pick me up, confident that I would persevere. I am eternally grateful for his motivation and guidance throughout my graduate studies. v Preface Human fascination with transplantation has been portrayed in mythology and legend as well as in art and literature throughout history. It has both horrified and captivated our collective conscience and has progressed, in a relatively short time period, from science fiction to a modern accomplishment that can improve longevity and enhance quality of life. The primary obstacle for transplantation is no longer scientific in nature but is predominantly one of supply and demand and carries with it attendant ethical concerns. Specific to this work is the question of whether a particular method of organ procurement known as Donation After Cardiac Death procures organs from the newly dead or from the imminently dying. Since the normative rules that guide transplantation require that one may not be killed for or by the removal of one’s organs determining the nature of death is of paramount importance. Accordingly, the primary question concerned herein is whether Donation After Cardiac Death donors are dead at the moment of organ recovery. This work focuses on the conceptual underpinnings of why a person is said to be dead according to particular definitions and when specific criteria and tests are fulfilled. Much attention is devoted to exploring why the irreversible loss of cardio- respiratory functions or the irreversible cessation of all functions of the entire brain signifies death and whether these two criteria represent distinct types of death or if they instantiate the same overarching definition. The first two chapters of this work are structured as a chronology demonstrating how our conception of death was intimately tied to the ability to test for certain bodily functions. These notions would quickly change when medicine developed technologies that could substitute for such functions and when transplantation demonstrated that the brain, not the heart, was of primary importance in determining life from death. The third chapter focuses on clinical and theoretical arguments with the discussion of the traditional biological definition of death and the whole brain death criterion. Chapter four continues by challenging the biological definition of death as internally inconsistent and advances an ontological position while retaining the neurologic criterion. The dissertation concludes by drawing on the arguments established throughout to ultimately claim that some Donation After Cardiac Death Donors are not yet dead at organ procurement according to either a traditional or an ontological definition of death. Transplantation saves lives and is a social good that society ought to continue to support. The aim of this dissertation is not to denigrate the field. On the contrary, if donation is to thrive we must ensure that our definition and criteria for death are coherent and that the methods for procurement operate accordingly. vi An Examination of the Bio-Philosophical Literature on the Definition and Criteria of Death: When is Dead Dead and Why Some Donation After Cardiac Death Donors Are Not Table of Contents Acknowledgments iv Preface v Chapter One: The History of the Definition of Death 18th Century to the 20th Century 1 The Cardio-Respiratory Standard 2 Premature Burial 7 Safeguards to Prevent Premature Burial 13 Medical Advancement 24 Chapter Two: The History of Organ Transplantation 29 Mythology and Legend 29 Early Experimentation 33 Phenomenon of Rejection 35 Overview of Immune System 39 Modern Era of Transplantation 41 Cardio Pulmonary Resuscitation 45 Logistics of Organ Transplantation 51 Historical Shift 55 Chapter Three: On the Legitimacy of Whole Brain Death 66 The Relationship Between Transplantation and Death 67 The Concept of Whole Brain Death 72 The Brain as the Primary Integrator of the Organism as a Whole 84 Diagnosis of Whole Brain Death 94 Debate and Reevaluation of the Definition of Death 105 Chapter Four: Evaluating a Higher Brain Death Definition 111 and Criterion for Death Revisiting the Problem of Whole Brain Death 114 vii Approaches to Define Death 116 Competing Concepts of Death 124 A New Definition of Death 131 Conceptual and Clinical Difficulties with the Higher Brain Death Criterion 145 A Hybrid Approach 154 Chapter Five: On the Legitimacy of Donation After Cardiac 160 Death Background: Defining Donation After Cardiac Death 165 DCD and the Institute of Medicine 171 Auto-Resuscitation and Manual Resuscitation 176 Defining Irreversibility 192 Heart-dead Versus Brain-dead 203 Additional Procedural Concerns 211 Conclusion 221 Appendix A 226 Appendix B 227 Appendix C 228 Appendix D 229 Bibliography 230 1 Chapter 1 The History of the Definition(s) of Death 18th century to the 20th century A person is dead when a physician says so.1 This dissertation will argue that some Donation After Cardiac Death (DCD) donors are not dead at the moment of organ recovery because the practice uses a criterion of death that prognosticates death rather than diagnoses it. The analysis of DCD is reserved for the final chapter, with each prior chapter addressing a particular issue that contributes to the foundation of that claim. This first chapter is not concerned with a conceptual exploration of what death “is” but focuses instead on when death occurs (determination of death) and the operational criteria used to confirm it (tests). The question of why death is said to occur when particular criteria are met will be more fully examined in chapter three during the discussion of cardio-respiratory death versus brain death. The purpose here is to chronicle when and how death has been determined beginning in the 18th century until the mid 20th century. An interesting dynamic will be shown across these time periods. Physicians in the 18th century were certain that death occurred when the heart and lungs ceased but lacked adequate tests to certify it. In the 20th century the moment of death became less clear, and for that reason the tests physicians had finally perfected proved insufficient. This chapter lays the foundation for this dissertation 1 Kenneth V. Iserson, Death to Dust (Tuscon: Galen Press Ltd., 1994) 19.