Phase One Framing Definitions

A MEDICAL MATTER? A number of routes were advanced for arriving at what was often termed a new definition of death that would encompass the neurological understanding of the phenomenon of death that emerged in the 1960s and has since been further refined. (The common shorthand phrase "definition of death" is misleading since "definition" suggests an explanation of a fact whereas the task at hand is specifying the significance of particular facts for the process of determining whether, and when, a person has died.) Early commentators proposed that the task should be left to physicians, because the subject is technical and because the law might set the definition prematurely, leading to conflicts with developments that will inevitably occur in medical techniques (Kennedy). Yet the belief that defining death is wholly a medical matter misapprehends the undertaking. At issue is not a biological understanding of the inherent nature of cells or organ systems but a social formulation of humanhood. It is largely through its declaration of the points at which life begins and ends that a society determines who is a full human being, with the resulting rights and responsibilities.

Since physicians have no special competence on the philosophical issue of the nature of human beings and no special authority to arrogate the choice among definitions to themselves, their role is properly one of elucidating the significance of various vital signs. By the 1970s, it became apparent that a new definition should be forthcoming, not simply to accommodate biomedical practitioners' wishes but as a result of perceived social need and of evidence that tests for brain function were as reliable as the traditional heart-lung tests.

JUDICIAL DECISIONS? If not physicians, then who should frame the definition? One answer was, "Let the courts decide." In the United States and other common-law countries, law is to be found not only on the statute books but in the rules enunciated by judges as they resolve disputes in individual civil and criminal cases. Facing a factual situation that does not fit comfortably within the existing legal rules, a court may choose to formulate a new rule in order to more accurately reflect current scientific understanding and social viewpoints.

Nonetheless, problems of principle and practicality emerged in placing primary reliance on the courts for a redefinition of death. Like the medical profession, the judiciary may be too narrowly based for the task. While the judiciary is an organ of the state with recognized authority in public matters, it still has no means for actively involving the public in its decision-making processes. Judge-made law has been most successful in factual settings embedded in well-defined social and economic practices, with the guidance of past decisions and commentary. Courts operate within a limited compass—the facts and contentions of a particular case—and with limited expertise; they have neither the staff nor the authority to investigate or to conduct hearings in order to explore such issues as public opinion or the scientific merits of competing "definitions." Consequently, a judge's decision may be merely a rubber-stamping of the opinions expressed by the medical experts who appeared in court. Moreover, testimony in an adversary proceeding is usually restricted to the "two sides" of a particular issue and may not fairly represent the spectrum of opinion held by authorities in the field.

Furthermore, in the U.S. cases in which parties first argued for a redefinition, the courts were unwilling to disturb the existing legal definition. Such deference to precedent is understandable, because people need to be able to rely on predictable legal rules in managing their affairs. As late as 1968, a California appellate tribunal, in a case involving an inheritorship issue, declined to redefine death in terms of brain functioning despite the admittedly anachronistic nature of an exclusively heart-lung definition (Cate and Capron).

The unfortunate consequences for physicians and patients of the unsettled state of the common-law definition of death in the 1970s is illustrated by several cases. In the first, Tucker v. Lower, which came to trial in Virginia in 1972, the brother of a man whose heart was taken in an early transplant operation sued the physicians, alleging that the operation was begun before the donor had died. The evidence showed that the donor's pulse, blood pressure, respiration, and other vital signs were normal but that he had been declared dead when the physicians decided these signs resulted solely from medical efforts and not from his own functioning, since his brain functions had ceased. At the start of the trial, the judge indicated that he would adhere to the traditional definition of death, but when charging the jury, he permitted them to find that death had occurred when the brain ceased functioning irreversibly. Although a verdict was returned for the defendants, the law was not clarified since the court did not explain its action.

The other two cases arose in California in 1974, when two transplant operations were performed using hearts removed from the victims of alleged crimes. The defendant in each case, charged with homicide, attempted to interpose the action of the surgeons in removing the victim's still-beating heart as a complete defense to the charge. One trial judge accepted this argument as being compelled by the existing definition of death, but his ruling was reversed on appeal, and both defendants were eventually convicted. This graphic illustration of legal confusion and uncertainty led California to join several other jurisdictions in the United States, Canada, and Australia that, beginning in 1970, followed a third route to redefining death, the adoption of a statutory definition.

STATUTORY STANDARDS? The legislative process allows a wider range of information to enter into the framing of standards for determining death, as well as offering an avenue for participation of the public. That is important because basic and perhaps controversial choices among alternative definitions must be made. Because they provide prospective guidance, statutory standards have the additional advantage of dispelling public and professional doubt, thereby reducing both the fear and the likelihood of cases against physicians for malpractice or homicide.

Not all countries have adopted legislation. In Great Britain, for example, the standards for determining death reside not in a statute but in medically promulgated codes of practice, which have been indirectly accepted in several judicial decisions (Kennedy and Grubb). Yet in the United States and among most commentators internationally, the first period in policymaking on a new definition of death produced wide agreement that an official response was necessary in light of the changes wrought by medical science, and that this response ought to be statutory.

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