Whole-brain death and integration: realigning the ontological concept with clinical diagnostic tests
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Whole‑brain death and integration: realigning the ontological concept with clinical diagnostic tests Daniel P. Sulmasy1
© Springer Nature B.V. 2019
Abstract For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. However, a series of recent cases in which individuals were declared brain dead yet physiologically maintained for prolonged periods of time has challenged the status quo. This signals a need for deeper reflection and reexamination of the underlying philosophical, scientific, and clinical issues at stake in defining death. In this paper, I consider four levels of philosophical inquiry regarding death: the ontological basis, actual states of affairs, epistemological standards, and clinical criteria for brain death. I outline several candidates for the states of affairs that may constitute death, arguing that we should strive for a single, unified ontological definition of death as a loss of integrated functioning as a unified organism, while acknowledging that two states of affairs (cardiopulmonary death and whole-brain death) may satisfy this concept. I argue that the clinical criteria for determining whole-brain death should be bolstered to meet the epistemic demand of sufficient certainty in defining death by adding indicators of cerebro-somatic disintegration to the traditional triad of loss of consciousness, loss of brainstem function, and absence of confounding explanations. Keywords Brain death · Ethics · Medical ethics · Epistemology · Diagnosis For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. Yet it has now become problematic. Widely publicized cases, in which individuals who were pronounced brain dead continued pregnancies for months and even delivered live babies at term, seem to undermine the idea that such individuals are dead [1]. The fact that some individuals have been pronounced brain dead but supported physiologically with ventilators and feeding tubes for years has prompted the use of ironic terminology such as “chronic brain * Daniel P. Sulmasy [email protected] 1
Kennedy Institute of Ethics, Georgetown University, Healy 419, 3700 O Street NW, Washington, DC 20057, USA
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death” [2]. Theoretical worries that were raised decades ago are resurfacing. While some observers seem merely to be insisting on the status quo [3–5], a reexamination of the underlying philosophical, scientific, and clinical issues at stake seems warranted. From a philosophical point of view, one may distinguish four levels of inquiry regarding death: (1) the ontological concept of death, (2) the actual states of affairs that are consistent with the concept, (3) the epistemological standards for judging that such a state of affairs can be affirmed for a particular entity, and (4) the clinical criteria that a profession or society sets forth for affirming death—criteria that meet the epistemological standards and correctly identify the actual sta
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