Phase Two The Contours of a Statute

By 1979 four model statutes had been proposed in the United States; in addition to those from the American Bar Association (ABA), the American Medical Association (AMA), and the National Conference of Commissioners of Uniform State Laws (NCCUSL), the most widely adopted was the Capron-Kass proposal, which grew out of the work of a research group at the Hastings Center (U.S. President's Commission, 1981). Ironically, the major barrier to legislation became the very multiplicity of proposals; though they were consistent in their aims, their sponsors tended to lobby for their own bills, which in turn produced apprehension among legislators over the possible importance of the bills' verbal differences. Accordingly, the President's Commission worked with the three major sponsors—the ABA, the AMA, and the NCCUSL—to draft a single model bill that could be proposed for adoption in all jurisdictions. The resulting statute—the Uniform Determination of Death Act (UDDA)—was proposed in 1981 and is law in more than half of U.S. jurisdictions, while virtually all the rest have some other, essentially similar statute. In four states the law derives from a decision by the highest court recognizing cessation of all functions of the brain as one means of determining death (Cate and Capron).

The UDDA provides that an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards. This statute is guided by several principles. First, the phenomenon of interest to physicians, legislators, and the public alike is a human being's death, not the "death" of his or her cells, tissues, or organs. Indeed, one problem with the term "brain death" is that it wrongly suggests that an organ can die; organisms die, but organs cease functioning. Second, a statute on death will resolve the problem of whether to continue artificial support in only some of the cases of comatose patients. Additional guidance has been developed by courts and legislatures as well as by professional bodies concerning the cessation of treatment in patients who are alive by brain or heart-lung criteria, but for whom further treatment is considered (by the patients or by others) to be pointless or degrading. This question of "when to allow to die?" is distinct from "when to declare dead?"

Third, the merits of a legislative definition are judged by whether its purposes are properly defined and how well the legislation meets those purposes. In addition to its cultural and religious importance, a definition of death is needed to resolve a number of legal issues (besides deciding whether to terminate medical care or transplant organs) such as homicide, damages for the wrongful death of a person, property and wealth transmission, insurance, taxes, and marital status. While some commentators have argued that a single definition is inappropriate because different policy objectives might exist in different contexts, it has been generally agreed that a single definition of death is capable of being applied in a wide variety of contexts, as indeed was the traditional heart-lung definition. Having a single definition to be used for many purposes does not preclude relying on other events besides death as a trigger for some decisions. Most jurisdictions make provision, for example, for the distribution of property and the termination of marriage after a person has been absent without explanation for a period of years, even though a person "presumed dead"

under such a law could not be treated as a corpse were he or she actually still alive (Capron).

Fourth, although dying is a process (since not all parts of the body cease functioning equally and synchronously), a line can and must be drawn between those who are alive and those who are dead (Kass). The ability of modern biomedi-cine to extend the functioning of various organ systems may have made knowing which side of the line a patient is on more problematic, but it has not erased the line. The line drawn by the UDDA is an arbitrary one in the sense that it results from human choice among a number of possibilities, but not in the sense of having no acceptable, articulated rationale.

Fifth, legislated standards must be uniform for all persons. It is, to say the least, unseemly for a person's wealth or potential social utility as an organ donor to affect the way in which the moment of his or her death is determined. One jurisdiction, in an attempt to accommodate religious and cultural diversity, has departed from the general objective of uniformity in the standards for determining death. In 1991, New Jersey adopted a statute that allows people whose religious beliefs would be violated by the use of whole-brain criteria to have their deaths declared solely on the traditional cardiorespiratory basis (New Jersey Commission).

Sixth, the UDDA was framed on the premise that it is often beneficial for the law to move incrementally, particularly when matters of basic cultural and ethical values are implicated. Thus, the statute provides a modern restatement of the traditional understanding of death that ties together the accepted cardiopulmonary standard with a new brain-based standard that measures the same phenomenon.

Finally, in making law in a highly technological area, care is needed that the definition be at once sufficiently precise to determine behavior in the manner desired by the public and yet not so specific that it is tied to the details of contemporary technology. The UDDA achieves this flexible precision by confining itself to the general standards by which death is to be determined. It leaves to the developing judgment of biomedical practitioners the establishment and application of appropriate criteria and specific tests for determining that the standards have been met. To provide a contemporary statement of "accepted medical standards," the U.S. President's Commission assembled a group of leading neurologists, neurosurgeons, pediatricians, anesthesiologists, and other authorities on determination of death (Medical Consultants). Their guidelines, which provide the basis for the clinical methodology used in most American institutions, have since been supplemented by special guidance regarding children (Task Force).

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