Questioning the Whole Brain Formulation

The whole-brain formulation has been attacked at the conceptual level, and on the ground that the answers at each level collectively provide an incoherent account of concept, criterion and clinical tests for determining death. The President's Commission's concept or definition of death has been objected to by those who favor one centered on the essential features of a personal life, as well as by those who favor a circulatory concept and consider that only the irreversible cessation of circulation adequately signals death.

In addition, since 1981, clinical findings have confirmed that what has come to be called whole-brain death is not in fact synonymous with the death of the brain in all of its parts. There are instances of isolated continued functioning in the brain-dead brain. Those wishing to support the established consensus around the use of the brain-death criterion argue that such residual functioning in the brain-dead brain is insignificant to the determination of death. Specifically, then, they refuse to allow that these kinds of residual brain functioning have significance: (i) persistent cortical functioning as evidenced by electroencephalograph (EEG) activity, and in rare cases a sleep/wake pattern; (ii) ongoing brainstem functioning as evidenced by auditory or visual evoked potential recording; and (iii) preserved anti-diuretic neurohormonal functioning. Such instances of residual functioning suggest that brain death, as customarily diagnosed, does not include the hypothalamus and the posterior pituitary. Most importantly, the third instance of residual functioning just cited actually plays an integrative role in the life of the organism as a whole. Hence, one of the residual functions fulfills the concept of life implicit in the definition of death underlying the whole-brain formulation.

So, the clinical tests used to establish the death of the entire brain have been shown to reflect a pervasive but nonetheless partial death of the brain only, opening wide the question, If brain death is to remain a reasonable basis upon which to declare death, which brain functions are so essentially significant that their irreversible loss should be counted as brain death? Why?

Both philosophically and clinically speaking, then, many feel that a rethinking of the U.S. societal adherence to the brain-death criterion is warranted. It rests on a contested understanding of what human death is, raising the issue of whether the brain-death criterion should be used to declare someone dead who holds philosophical/theological/cultural objections to it. It lacks coherence among its levels because (1) the brain-death criterion does not correlate with the irreversible loss of the integrated functioning of the organism as a whole; and (2) because the clinical tests for brain death fail to reflect the death of the entire brain. No important societally established practice can be imagined to be so highly problematic as this one.

The supporters of the whole-brain formulation have nonetheless stood their ground, claiming that the instances of residual cellular and subcellular activities occurring in the brain are irrelevant to the determination of the life/death status of the patient. In their view, the brain-death criterion should continue to be used, despite that it really reflects a pervasive albeit partial brain death.

The basic challenge to the whole-brain formulation has been that its defenders need to provide criteria for distinguishing between brain activity that is relevant and irrelevant for the purpose of determining death. Some have argued that the only bright line that could be drawn in this regard is between the brain functions essential for consciousness and those that are not; others have argued that the brain should be abandoned entirely as a locus for establishing that a human being has died. In point of fact then, advocates of the whole-brain formulation have embraced a partial-brain-death criterion but have failed to provide a non-question-begging, principled basis for it.

Another aspect of the whole-brain formulation that has been challenged concerns its reliance on the non-spontaneous function of the lungs to support the claim that the irreversible cessation of the integrated functioning of the organism as a whole has occurred. They claim that the integrated functioning continues, and that the manner of its support is irrelevant. Their point is that as long as the respirator is functioning, it seems something of a word game to say that the organism is not functioning as an integrated whole.

While in brain death the brain stem is no longer playing its linking role in the triangle of function along with lungs and heart, the respirator is standing in for the brain stem, just as it might if there were partial brain destruction in the area of the brain stem. If the patient were conscious, but just as dependent on the respirator in order to continue functioning as an organism, there would be no inclination to pronounce the patient dead. Hence, it would seem that even the brain-dead patient is exhibiting integrated organismic functioning until the respirator is turned off, the lungs stop, and the heart eventually stops beating. The phenomenon of a mechanically-sustained brain-dead pregnant woman producing a healthy newborn certainly seems to bear out their insight: Whatever the sort of organismic disintegration possessed in such a case, it seems most unfitting to call it death. Integrated organismic functioning is present in brain death, so if brain death should be considered the death of the human being, it is not because brain death signals the irreversible loss of the integrated functioning of the organism as a whole.

As this last point makes clear, the real reason so many people are inclined to agree that the brain-dead patient is dead has much more to do with the fact that the brain-dead patient is permanently unconscious than with the facts of brain stem destruction and respirator dependency. It is this loss of the self, the loss of consciousness and thus of embodiment as a self, that is for many of us a good reason to consider the brain-dead patient dead. This suggests that the concept of human death underlying people's willingness to adopt the brain-death criterion may have more to do with the loss of the capacity for embodied consciousness than with the loss of the capacity for integrated organismic functioning.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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