This article was downloaded by: [University of Utah] On: 25 November 2014, At: 11:58 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Brain Dead Patients Are Still Whole Organisms a
Nicholas Sadovnikoff & Daniel Wikler a
b
Brigham and Women's Hospital
b
Harvard School of Public Health Published online: 21 Jul 2014.
To cite this article: Nicholas Sadovnikoff & Daniel Wikler (2014) Brain Dead Patients Are Still Whole Organisms, The American Journal of Bioethics, 14:8, 39-40, DOI: 10.1080/15265161.2014.925164 To link to this article: http://dx.doi.org/10.1080/15265161.2014.925164
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Brain Death
Journal of Medical Ethics, Published online 25 April 2014. doi: 10.1136/medethics-2013-101930. Truog, R. D., and F. G. Miller. 2014. Changing the conversation about brain death. American Journal of Bioethics 14(8): 9–14.
Wagner, E., and R. J. Jox. 2014. Patients torn in two directions: If advance directives and donor cards coexist. In G. J. Agich and S. Reiter-Theil, ed. 10th International conference on clinical ethics consultation, 71. Paris, France: Paris Descartes University.
Brain Dead Patients Are Still Whole Organisms
Downloaded by [University of Utah] at 11:58 25 November 2014
Nicholas Sadovnikoff, Brigham and Women’s Hospital Daniel Wikler, Harvard School of Public Health Bernat’s (2014) tenacious but unsatisfying defense of the view that brain-dead patients—even if stabilized and maintained in intensive care units (ICUs)—are dead concludes with his affirmation of the observation that the matter is “well settled yet still unresolved.” We concur with both judgments: The legal question was well settled decades ago in this country, by statutes enacted in every state, and he is correct, also, in noting that “opponents have been unsuccessful in catalyzing a public movement sufficient to change medical practices or public laws” and that “there has been no sustained public outcry to question or abandon the practice of brain death.”1 We also believe that the matter remains unresolved, by which we mean an adequate argument or basis for adopting this view has never been provided. Since Bernat concedes this, we are puzzled by Bernat’s commitment to its validity. We examine here the reasons he provides. The lack of resolution to which Bernat refers has to do with what he calls the “biophilosophical” justification of regarding brain death as death. Damaging critiques of this view were published as early as the mid-1970s, beginning with Ronald Becker’s “Human Being: The Boundaries of the Concept,” published in the prominent journal Philosophy and Public Affairs (Becker 1975); his argument was amplified and elaborated by others soon thereafter in the same journal (Green and Wikler 1980). The arguments advanced in those papers have never been refuted, and still remain a convincing and devastating rebuttal. Additional arguments, some of which stem from subsequent scientific research by Shewmon, are noted in the article by Truog and Miller (2014) in this issue. Space does not allow us to restate these arguments in detail, which ought to be familiar to anyone who contributes to this literature, but we will outline the strategy. The
first step is to gain agreement that what is at issue is not a decision (e.g., whether to withdraw life supports, or to remove a vital organ for transplantation) but rather to find the answer to a simple question: Is this patient—correctly diagnosed as brain dead, but continuing to breathe, circulate blood, maintain body temperature and blood pressure, digest, grow, and even gestate, for months on end—alive or dead? These functions are not characteristics of corpses. Why then regard this one as a corpse? There is, according to these critiques, no satisfactory answer to this question. It does no good to point to the patient’s permanent loss of consciousness, because the same is true of some patients whose brainstems are intact (and who breathe on their own), and they would be classified as alive under the brain death definition. Pointing to the dependence of the brain-dead patient on external life supports likewise fails to distinguish such a patient from those with intact brainstems—and hence alive, according to the brain-death definition—who require life supports (e.g., a quadriplegic who requires a ventilator). Conjoining these—almost always the next step taken by defenders of the brain death definition—is not only ad hoc (i.e., has no justification of its own) but is demonstrably inadequate: Consider the quadriplegic who falls into an irreversible coma but whose brainstem remains intact. This patient is (a) permanently unconscious and (b) machine-dependent, but according to the brain death definition, remains alive. Bernat’s confidence in the brain death definition would be justified only if he could rebut this critique, which he does not try to do. His favored defense centers on his concept of “the organism as a whole,” which remains alive only as long as the brainstem is intact. Life functions after brain death are, in this perspective, those of parts, akin to an isolated heart beating in a mechanical contraption or a
Address correspondence to Nicholas Sadovnikoff, Brigham and Women’s Hospital, Anesthesiology, Perioperative and Pain Medicine, 75 Francis Street, Boston, MA 02115, USA. E-mail: [email protected] 1. Oddly, Bernat observes (correctly, we believe) that “Brain death . . . remains poorly understood by the public and health professionals,” and “more work is necessary to establish its biophilosophical justification and to educate health professionals and the public” (3). What weight then should be given to the absence of public outcry by a public so poorly educated and ignorant of the real issues?
August, Volume 14, Number 8, 2014
ajob 39
Downloaded by [University of Utah] at 11:58 25 November 2014
The American Journal of Bioethics
dissected muscle induced to twitch by a substance in a Petri dish. This is a perfectly intelligible concept, but it does not refute the critique advanced by Becker and others unless accompanied by reasons to think that the well-maintained brain-dead patient falls short of constituting an “organism as a whole.” Such a patient’s principal organ systems are, after all, working in harmony and maintaining internal homeostasis. The beating heart pumps blood that is oxygenated by the breathing lungs and passed along to the body’s organs and cells, while the liver and kidneys perform their typical functions. Compare this to a laboratory of the future in which each of these organs is kept going in in isolation without interaction. Bernat admits that “the concept of the organism as a whole remains vague and would benefit from further biophilosophical analysis,” but refers us to a paper published recently in Psychiatria Danubina by Bonelli, Prat, and Bonelli (2009), who offer “an important step” toward making good on the “organism as a whole” thesis. Bonelli and colleagues offer a complex, elegant argument, setting forth several putative hallmarks of life in organisms of our sort and arguing that brain-dead patients do not meet these conditions. Bernat’s brief summary, while accurate, is too brief to make their argument fully intelligible, and we lack the space to do better. Here we only mention what we believe to be two flaws in their argument that deprive Bernat (and other defenders of the brain death definition of death) of the “biophilosophical support” that he concedes is needed. The interested reader should turn to Bonelli and colleagues to determine whether we have hit the mark. In Bernat’s words, Bonelli and colleagues argue that “with the irreversible cessation of all functions of the entire brain (brain death), the organism has permanently lost the capacity to function as a whole and therefore is dead.” But why is all that functioning—the digesting, the gestating, and so on—not functioning “as a whole”? Bernat approvingly quotes the authors as citing the brain-dead patient’s machine dependence. This is a mistake, in our view. What matters is whether the functioning continues, and is integrated—not what makes this happen. Fortunately, this is not their main argument, which instead is the claim about parts and wholes. Bonelli and colleagues note that parts (if they are nonessential, or if their functions can be supported by other means) can be removed from organisms without raising questions about the organism’s identity. Remove a gangrenous limb from a patient and the patient remains with us, while disposition of the limb is immaterial to the question. “Organisms as a whole” have parts, but cannot be parts. After brain death, according to Bonelli and colleagues, what remains is the organism’s parts, none of which have that organismic status; they “no longer belong to each other and no longer constitute a whole” (paraphrase by Bernat 2014, 6).
40 ajob
But saying this doesn’t make it so. Again, the problem is that in the well-maintained brain-dead patient, these “parts”—the heart, the lungs, the liver, the kidneys, the mitochondria, and so on—do constitute a single functioning life system. To be sure, it is machine dependent— though once stabilized, this may consist of little more than a ventilator and a feeding tube, the same as would be needed by a vent-dependent (but not brain-dead) quadriplegic who fell into a persistent vegetative state. This brain-dead patient has parts, but isn’t him- or herself a part. If we were to transplant a functioning kidney into this patient, the kidney would become a part of the whole in precisely the same sense as it would if the patient were not brain dead. Bonelli and colleagues would have to be able to point to some difference between well-maintained brain-dead patients and permanently unconscious (and perhaps machine-dependent) non-brain-dead patients in virtue of which the part-whole relationships of the two differ, and differ on account of brain death. They do not, and there isn’t any. Unless Bernat can come to their rescue, he will have to give up relying on Bonelli and colleagues to turn the “organism as a whole” idea into an adequate defense of the brain death definition of death. Bernat wants to be able to claim that when a braindead patient is declared dead (on account of being brain dead), the declaration is a true statement of fact. This seems patently incorrect, but all can be made right again if we return to the distinction mentioned earlier between statements of fact and decisions to act. When a brain-dead patient is declared dead, we should understand this as a sanctioned, sincere, and judicious statement of futility, one that provides a justification for removing life-supporting therapies and/or removing organs for transplantation. The statutes defining brain death as death should be interpreted similarly. To be fully honest and transparent, we would simply announce these decisions as such, instead of claiming, against logic and evidence, that these breathing, digesting, growing, and even gestating human organisms are already dead. & REFERENCES Becker, L. 1975. Human being: The boundaries of the concept. Philosophy and Public Affairs 4(4): 334–359. Bernat, J. L. 2014. Whither brain death? American Journal of Bioethics 14(8): 3–8. Bonelli, R. M., E. H. Prat, and J. Bonelli. 2009. Philosophical considerations on brain death and the concept of the organism as a whole. Psychiatria Danubina 21(1): 3–8. Green, M., and D. Wikler. 1980. Brain death and personal identity. Philosophy and Public Affairs 9(2): 105–133. Truog, R. D., and F. G. Miller. 2014. Changing the conversation about brain death. American Journal of Bioethics 14(8): 9–14.
August, Volume 14, Number 8, 2014
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Brain Dead Patients Are Still Whole Organisms a
Nicholas Sadovnikoff & Daniel Wikler a
b
Brigham and Women's Hospital
b
Harvard School of Public Health Published online: 21 Jul 2014.
To cite this article: Nicholas Sadovnikoff & Daniel Wikler (2014) Brain Dead Patients Are Still Whole Organisms, The American Journal of Bioethics, 14:8, 39-40, DOI: 10.1080/15265161.2014.925164 To link to this article: http://dx.doi.org/10.1080/15265161.2014.925164
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Brain Death
Journal of Medical Ethics, Published online 25 April 2014. doi: 10.1136/medethics-2013-101930. Truog, R. D., and F. G. Miller. 2014. Changing the conversation about brain death. American Journal of Bioethics 14(8): 9–14.
Wagner, E., and R. J. Jox. 2014. Patients torn in two directions: If advance directives and donor cards coexist. In G. J. Agich and S. Reiter-Theil, ed. 10th International conference on clinical ethics consultation, 71. Paris, France: Paris Descartes University.
Brain Dead Patients Are Still Whole Organisms
Downloaded by [University of Utah] at 11:58 25 November 2014
Nicholas Sadovnikoff, Brigham and Women’s Hospital Daniel Wikler, Harvard School of Public Health Bernat’s (2014) tenacious but unsatisfying defense of the view that brain-dead patients—even if stabilized and maintained in intensive care units (ICUs)—are dead concludes with his affirmation of the observation that the matter is “well settled yet still unresolved.” We concur with both judgments: The legal question was well settled decades ago in this country, by statutes enacted in every state, and he is correct, also, in noting that “opponents have been unsuccessful in catalyzing a public movement sufficient to change medical practices or public laws” and that “there has been no sustained public outcry to question or abandon the practice of brain death.”1 We also believe that the matter remains unresolved, by which we mean an adequate argument or basis for adopting this view has never been provided. Since Bernat concedes this, we are puzzled by Bernat’s commitment to its validity. We examine here the reasons he provides. The lack of resolution to which Bernat refers has to do with what he calls the “biophilosophical” justification of regarding brain death as death. Damaging critiques of this view were published as early as the mid-1970s, beginning with Ronald Becker’s “Human Being: The Boundaries of the Concept,” published in the prominent journal Philosophy and Public Affairs (Becker 1975); his argument was amplified and elaborated by others soon thereafter in the same journal (Green and Wikler 1980). The arguments advanced in those papers have never been refuted, and still remain a convincing and devastating rebuttal. Additional arguments, some of which stem from subsequent scientific research by Shewmon, are noted in the article by Truog and Miller (2014) in this issue. Space does not allow us to restate these arguments in detail, which ought to be familiar to anyone who contributes to this literature, but we will outline the strategy. The
first step is to gain agreement that what is at issue is not a decision (e.g., whether to withdraw life supports, or to remove a vital organ for transplantation) but rather to find the answer to a simple question: Is this patient—correctly diagnosed as brain dead, but continuing to breathe, circulate blood, maintain body temperature and blood pressure, digest, grow, and even gestate, for months on end—alive or dead? These functions are not characteristics of corpses. Why then regard this one as a corpse? There is, according to these critiques, no satisfactory answer to this question. It does no good to point to the patient’s permanent loss of consciousness, because the same is true of some patients whose brainstems are intact (and who breathe on their own), and they would be classified as alive under the brain death definition. Pointing to the dependence of the brain-dead patient on external life supports likewise fails to distinguish such a patient from those with intact brainstems—and hence alive, according to the brain-death definition—who require life supports (e.g., a quadriplegic who requires a ventilator). Conjoining these—almost always the next step taken by defenders of the brain death definition—is not only ad hoc (i.e., has no justification of its own) but is demonstrably inadequate: Consider the quadriplegic who falls into an irreversible coma but whose brainstem remains intact. This patient is (a) permanently unconscious and (b) machine-dependent, but according to the brain death definition, remains alive. Bernat’s confidence in the brain death definition would be justified only if he could rebut this critique, which he does not try to do. His favored defense centers on his concept of “the organism as a whole,” which remains alive only as long as the brainstem is intact. Life functions after brain death are, in this perspective, those of parts, akin to an isolated heart beating in a mechanical contraption or a
Address correspondence to Nicholas Sadovnikoff, Brigham and Women’s Hospital, Anesthesiology, Perioperative and Pain Medicine, 75 Francis Street, Boston, MA 02115, USA. E-mail: [email protected] 1. Oddly, Bernat observes (correctly, we believe) that “Brain death . . . remains poorly understood by the public and health professionals,” and “more work is necessary to establish its biophilosophical justification and to educate health professionals and the public” (3). What weight then should be given to the absence of public outcry by a public so poorly educated and ignorant of the real issues?
August, Volume 14, Number 8, 2014
ajob 39
Downloaded by [University of Utah] at 11:58 25 November 2014
The American Journal of Bioethics
dissected muscle induced to twitch by a substance in a Petri dish. This is a perfectly intelligible concept, but it does not refute the critique advanced by Becker and others unless accompanied by reasons to think that the well-maintained brain-dead patient falls short of constituting an “organism as a whole.” Such a patient’s principal organ systems are, after all, working in harmony and maintaining internal homeostasis. The beating heart pumps blood that is oxygenated by the breathing lungs and passed along to the body’s organs and cells, while the liver and kidneys perform their typical functions. Compare this to a laboratory of the future in which each of these organs is kept going in in isolation without interaction. Bernat admits that “the concept of the organism as a whole remains vague and would benefit from further biophilosophical analysis,” but refers us to a paper published recently in Psychiatria Danubina by Bonelli, Prat, and Bonelli (2009), who offer “an important step” toward making good on the “organism as a whole” thesis. Bonelli and colleagues offer a complex, elegant argument, setting forth several putative hallmarks of life in organisms of our sort and arguing that brain-dead patients do not meet these conditions. Bernat’s brief summary, while accurate, is too brief to make their argument fully intelligible, and we lack the space to do better. Here we only mention what we believe to be two flaws in their argument that deprive Bernat (and other defenders of the brain death definition of death) of the “biophilosophical support” that he concedes is needed. The interested reader should turn to Bonelli and colleagues to determine whether we have hit the mark. In Bernat’s words, Bonelli and colleagues argue that “with the irreversible cessation of all functions of the entire brain (brain death), the organism has permanently lost the capacity to function as a whole and therefore is dead.” But why is all that functioning—the digesting, the gestating, and so on—not functioning “as a whole”? Bernat approvingly quotes the authors as citing the brain-dead patient’s machine dependence. This is a mistake, in our view. What matters is whether the functioning continues, and is integrated—not what makes this happen. Fortunately, this is not their main argument, which instead is the claim about parts and wholes. Bonelli and colleagues note that parts (if they are nonessential, or if their functions can be supported by other means) can be removed from organisms without raising questions about the organism’s identity. Remove a gangrenous limb from a patient and the patient remains with us, while disposition of the limb is immaterial to the question. “Organisms as a whole” have parts, but cannot be parts. After brain death, according to Bonelli and colleagues, what remains is the organism’s parts, none of which have that organismic status; they “no longer belong to each other and no longer constitute a whole” (paraphrase by Bernat 2014, 6).
40 ajob
But saying this doesn’t make it so. Again, the problem is that in the well-maintained brain-dead patient, these “parts”—the heart, the lungs, the liver, the kidneys, the mitochondria, and so on—do constitute a single functioning life system. To be sure, it is machine dependent— though once stabilized, this may consist of little more than a ventilator and a feeding tube, the same as would be needed by a vent-dependent (but not brain-dead) quadriplegic who fell into a persistent vegetative state. This brain-dead patient has parts, but isn’t him- or herself a part. If we were to transplant a functioning kidney into this patient, the kidney would become a part of the whole in precisely the same sense as it would if the patient were not brain dead. Bonelli and colleagues would have to be able to point to some difference between well-maintained brain-dead patients and permanently unconscious (and perhaps machine-dependent) non-brain-dead patients in virtue of which the part-whole relationships of the two differ, and differ on account of brain death. They do not, and there isn’t any. Unless Bernat can come to their rescue, he will have to give up relying on Bonelli and colleagues to turn the “organism as a whole” idea into an adequate defense of the brain death definition of death. Bernat wants to be able to claim that when a braindead patient is declared dead (on account of being brain dead), the declaration is a true statement of fact. This seems patently incorrect, but all can be made right again if we return to the distinction mentioned earlier between statements of fact and decisions to act. When a brain-dead patient is declared dead, we should understand this as a sanctioned, sincere, and judicious statement of futility, one that provides a justification for removing life-supporting therapies and/or removing organs for transplantation. The statutes defining brain death as death should be interpreted similarly. To be fully honest and transparent, we would simply announce these decisions as such, instead of claiming, against logic and evidence, that these breathing, digesting, growing, and even gestating human organisms are already dead. & REFERENCES Becker, L. 1975. Human being: The boundaries of the concept. Philosophy and Public Affairs 4(4): 334–359. Bernat, J. L. 2014. Whither brain death? American Journal of Bioethics 14(8): 3–8. Bonelli, R. M., E. H. Prat, and J. Bonelli. 2009. Philosophical considerations on brain death and the concept of the organism as a whole. Psychiatria Danubina 21(1): 3–8. Green, M., and D. Wikler. 1980. Brain death and personal identity. Philosophy and Public Affairs 9(2): 105–133. Truog, R. D., and F. G. Miller. 2014. Changing the conversation about brain death. American Journal of Bioethics 14(8): 9–14.
August, Volume 14, Number 8, 2014
