The Whole BrainDeath Formulation Concept and Criterion

When the Harvard Committee recommended that a whole-brain-death criterion be used to determine death in respirator-dependent patients, thus creating an exception to the use of the traditional cardio-pulmonary criteria for a specific category of patients, controversy arose over whether the adoption of this criterion constituted a departure from the concept of death implicit in the use of the traditional cardio-pulmonary criteria for the determination of death.

Some saw the use of the brain-death criterion to be a blatantly utilitarian maneuver to increase the availability of transplantable organs. Some opposed it because it was inconsistent with their view of the human self and/or failed to protect and respect dying patients. While others agreed that the neurological focus represented an alternative understanding of the self, they saw the move to be eminently logical: What argument could one have with the notion that someone whose whole brain is dead, is dead? Others continued to affirm that life was essentially a heart-centered reality rather than a brain-centered reality: They saw the shift to a neurological focus on the human to be a discounting of the relevance of the spontaneous beating of the heart and the mechanically sustained functioning of the lungs. So, representatives of some cultures and faith traditions opposed the shift to the brain-death criterion, suggesting that it was a radically unacceptable way of understanding and determining the death of a human being.

The Harvard Committee report was a clinical recommendation, not a philosophical argument. It made recommendations at levels two and three (the criteriological and the diagnostic), and prompted but did not answer a number of level one definitional questions. What is death, such that either the traditional criteria or the whole-brain-death criterion may be used to determine its occurrence? Do the traditional criteria and the brain-death criterion presuppose the same definition of death? If not, should human death be redefined in response to technological change? It gave rise to a philosophical debate that is ongoing on the question, What is so essentially significant to the nature of a human being that its irreversible loss should be considered human death?

The literature has been replete with answers to this question, including the irreversible loss of the flow of vital fluids, the irreversible departure of the soul from the body, the irreversible loss of the capacity for bodily integration, the irreversible cessation of integrative unity (i.e., of the anti-entropic mutual interaction of all of the body's cells and tissues), the irreversible loss of the integrated functioning of the organism as a whole, and the irreversible loss of the capacity for consciousness or social interaction. Without such an account of what is essentially significant, the criterion used as a basis for determining death lacks an explicit foundation. However, the plurality of thoughtful answers to this fundamental conceptual question raises the issues of whether a consensus view can be fashioned, whether to tolerate diverse understandings of human death, and of how to assure societal stability concerning the determination of death.

While the Harvard Committee provided no philosophical defense of its position, adherents of the whole-brain formulation have continued to argue over the years that the traditional criteria and the whole-brain-death criterion share a common concept of death—the irreversible loss of the capacity for integrated functioning of the organism as a whole. Not everyone has agreed with this position, however. Some resist the adoption of the brain-death criterion for this reason, considering the shift to a new understanding of human death to be philosophically unjustifiable. However, others have welcomed the change: Reflecting on the contingency of the definition of death under circumstances of technological change, some have argued in favor of redefining death even further. In their view, the philosophical concept of death said to underlie the whole-brain-death criterion inadequately reflects the essentially significant characteristic of human existence: existence as an embodied consciousness. A more adequate concept of human death, they contend, would center on the permanent cessation of consciousness (requiring a higher-brain-death criterion), not on the permanent cessation of the integrated functioning of the organism. Advocates of the higher-brain formulation of death oppose the whole-brain formulation on the ground that the latter unjustifiably defers to the characteristics biological organisms have in common and ignores the relevance of the distinctively human characteristics associated with life as a person.

If the whole-brain formulation is essentially an organismically-based concept, and the higher-brain formulation is essentially a person-based concept, the controversy between whole- and higher-brain formulations suggests that in order to answer the question, What is human death? another layer of philosophical reflection is required. The central normative question concerning what is essentially significant to the nature of the human being requires a prior account of the nature of the human being. In philosophical terms, such an account of the nature of a being is referred to as an ontological account. One's view of the nature of the human being is informed by philosophical, theological and/or cultural perspectives on the nature of human existence, its essentially significant characteristics, and the nature of its boundary events. In the case of the human, there appear to be two logically distinct choices concerning the nature of the human being: one either sees it as one organism among others, for which meanings-in-common of life and death should be sought; or one sees the human being as distinctive among organisms for the purpose of characterizing its life and death, in ways we signify by the term person. In short we need to make and defend a decision concerning the way we look at the human—as organism or as person— for the purpose of determining what constitutes human death.

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