Questioning the Irreversibility of Death

Still laboring under the power of the Dead Donor Rule and a concern to increase the supply of transplantable organs, a 1990s effort to update the clinical tests associated with the cardiac-centered traditional criteria occurred. Several transplant centers began the practice, in the case of a dying patient who had consented in advance to be an organ donor and to forego both life-sustaining treatment and resuscitative efforts, of declaring death two minutes after the patient's last heartbeat, as the measure of the patient's irreversible loss of cardiopulmonary function. This approach to assessing the irreversible loss of cardiopulmonary function challenged people to accept a particular and unprecedented definition of irreversibility in relation to declaring patients dead. Both common understanding and the Uniform Determination of Death Act were understood to require irreversibility of functional loss in the stronger sense that the functional loss could in no way be recovered or restored.

If death is declared two minutes after the loss of cardiopulmonary function, when, conceivably, the heart could resume functioning on its own (auto-resuscitation) or resuscitation could successfully restart the heart, in what sense is the loss of function irreversible? It appears that irreversibility is only a function of a morally valid decision on the part of a patient or perhaps a surrogate to forego resuscitation. Is this change in the association of death with the irreversible loss of function ethically acceptable?

The interest in declaring death as close to the cessation of cardiopulmonary function as possible arises from the need to remove organs before warm ischemia destroys their viability for transplantation. But what sense of the concept of irreversibility should be required to assess a loss of critical function sufficient to ground a declaration of death? In the weak moral sense indicated above, two minutes after the last heartbeat when resuscitation has been refused? In the relatively stronger sense that auto-resuscitation of the heart has become physiologically impossible? Or in the strongest sense, that the heart cannot be restarted by any means?

While many hold the religious belief that the self survives the death of the body, the commonly held view is that the death of the body is a finished, non-reversible condition. The Uniform Determination of Death Act requires that the cessation of brain function be irreversible in the sense that all function throughout the entire brain is permanently absent, or it requires that cardiopulmonary function has ceased in the sense that the patient can never again exhibit respiration or heartbeat. Clearly, then, because it entails a novel understanding of the conceptual connections between death and irreversibility, the variation in the application of the cardiopulmonary criterion adopted by many transplant centers after 1992 requires philosophical justification.

In addition this new strategy for determining death raises interesting issues about the overall consistency of alternative approaches to determining death. It has always been the case that a patient declared brain-dead could not be declared dead using the traditional criteria, since the respirator was maintaining lung and heart functions. Those functions were effectively ruled out as signs of life. Yet after only two minutes of cardiac cessation, the patient is arguably not yet brain-dead, raising a question: Is the non-heart beating donor (NHBD) whose heart has stopped for two minutes but whose brain retains some functional capacity really dead? In order to be declared dead, should a patient be required to fulfill at least one but not necessarily all extant criteria and their associated clinical tests for the determination of death? Which way of being determined dead is more morally appropriate when surgery to procure organs is to be undertaken?

In sum, the definition-of-death debate goes on. The deep and disturbing irony in this debate surrounds the disagreement among ethicists as to whether the public should be informed about the degree of dissension on the conceptual, clinical, and policy issues central to the debate. Despite the rather stable practice in the United States of using the brain-death criterion to determine death, the definition-of-death debate is at loggerheads. The situation is such that, some have argued, parties to the debate should share none of this dissension with the public lest they disturb the acceptance of the brain-death criterion and the improved access to transplantable organs it allows over the traditional criteria for determining death. Others argue that every question in this debate, including the question of the kind of irreversibility that should ground the determination of deaths, is still an open question, and that the public should be informed and polled for its views. Yet others have suggested that one of the prime movers in the definitional debate, the Dead Donor Rule, should be rethought, and the practices of declaring death, discontinuing life-sustaining treatment, and removing organs for transplantation should be decided independently of one another.

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