selected and reviewed by James Park,
evaluative comments and
responses appear in red.
The books are organized by quality beginning with the best.
Stuart Younger, Robert M. Arnold, & Renie Schapiro, editors
The Definition of Death:
MD: Johns Hopkins University Press,
(ISBN: 0-8018-5985-9; hardcover)
(Library of Congress call number: RA1063.D44 1999)
(Medical call number: W820D285 1999)
book was created from a conference in 1995.
Brain-death was well established by that time.
But some details were still being questioned.
And some people advocated higher-brain
definitions of death,
which would allow even earlier
declarations of death,
which is always better for harvesting donor-organs.
will deal selectively with the chapters indicated below.
Chapter 3: "How Much of the Brain
Must Be Dead?"
by Baruch A. Brody, PhD.
Many common definitions of brain-death
say that the integrative
functions of the brain have ceased.
And they cannot be restarted.
But one common integrative function
that remains in brain-dead cadavers is hormonal regulation.
Even when machines are needed to keep the heart and lungs functioning,
the brain-stem is sometimes still putting out hormones
that regulate various bodily functions.
On a literal
level, hormone regulation
is one remaining integrative function of the
But hair and nails keep growing too.
These are cell-activities that need no brain at all.
If all that my brain-stem can do on its own
is to produce hormonal regulators,
then I should be declared dead.
In fact, I prefer permanent unconsciousness
as the definition of death
that should be used at the end of my life.
I have no philosophical problems being declared brain-dead.
If others agree with Dr. Brody's objection,
we might need to modify the definition of brain-death
to say that most of
the integrative functions of the brain have been lost.
I do not think we should add any new tests
to see if the brain-stem is still producing hormones.
that biological death is a process
rather than a moment.
Various brain and body functions shut down at different times.
If we wait for each and every part of the process of dying to be
it could be 3 days later when death is finally declared,
which would usually mean that the organs would be useless for
But we do need a consistent and comprehensive
definition of death.
And we need good ways to convince the relatives of the dying patient
that death has really happened,
even tho some tests show continuing functions,
such as the production of the hormones that regulate some bodily
about laypersons with concerns and objections
is more serious than the technical questions of testing and
Some relatives will be quite conservative about the definition of death.
They will look only at the traditional concept of death
—when all bodily functions have
a permanent and irreversible
They want to be completely certain that death has occurred
before burial or cremation—or anything else happens to the body.
This reviewer thinks that the following will
The scientific definitions and tests will apply to most declarations of
And organ-transplants will follow some declarations of brain-death.
But there will be a minority of families who will never accept
They will insist on using their traditional definition of death.
At the end of
his chapter Brody raises the issue of anenchephalic infants.
These are infants born with most
of their brains simply missing.
They will never have even a single moment of conscious thought or
But their brain-stems can sometimes keep their bodies alive for a few
The American Medical Association now approves
of using babies born without brains
as organ-donors to save the lives of other babies.
According to the traditional definitions of death,
they would still be 'alive' when their organs are harvested.
situation could be clarified by certifying
that these babies were born
And they should be officially
declared to be dead by an independent physician
before any organs are
harvested for transplant into other infants.
Should such infants be officially declared brain-dead
before organ-donation is even considered?
This would avoid the very odd situation of declaring the time of death
to be when the first vital organ was removed.
Thus, this reviewer's answer to Dr. Brody's question:
"How much of the brain must be dead?" is:
Let the parents of infants decide for their babies.
And let adult decide for themselves.
My personal answer is that permanent
is a good definition of death.
And I should certainly be declared dead if I am brain-dead.
Chapter 4: "Refinements in the
Definition and Criterion of Death"
by James L. Bernat, MD
Dr. Bernat agrees with Dr. Brody that death is more
like a process than
But common-sense usage requires that we say of an organism
that is it either still alive
or that it has died.
We need a defined moment of
death for a variety of reasons:
organ-donation, life insurance, burial, etc.
And a declaration of death also leads to the removal of life-support
without asking for informed consent from anyone.
The family need no longer be asked
to approve any medical procedures
since a dead body does not warrant
any medical treatment.
Sometimes we can only be certain of the moment of
death in retrospect.
One such situation would be the failure to restart vital
When someone dies in a hospital, the 'crash team' is often called
whose job it is to restore any and all failing vital functions.
And they keep trying for a significant number of minutes.
If their efforts are successful, the patient was not really dead—only
If resuscitation does not
then we can say that the patient was doomed from the start of the CPR.
And death will be declared
after the failure of resuscitation.
In retrospect, we can say that for all practical purposes,
the patient died some minutes earlier.
But the official time of
death will be declared
as the moment when the resuscitation efforts were terminated.
The basic change
Dr. Bernat proposes
is adding the word "critical" to the following expression:
"Death occurs when the critical
functions of the whole brain have ceased."
Thus we do not need to concern ourselves
with the random firing of groups of neurons in the brain
such activity makes no difference
to the critical function of the brain as integrator of bodily functions.
Likewise, the secretion of hormones and continuing auditory-pathway
do not count in the determination of death.
distinctions will be lost on most laypersons.
We simply want to know: Is the patient alive or dead?
And we will normally not object to the declaration of death by a
—using acceptable criteria and tests for
separating life from death.
Chapter 8: "The Conscience Clause:
How Much Individual Choice in Defining Death Can Our Society Tolerate?"
by Robert M. Veatch, PhD.
Most laypersons have given no thought to the
definition of death.
So they just follow what seems most comfortable and familiar to them.
This will often be colored by their religious background or cultural
And the more religious they are,
the more traditional their definition of death will probably be.
Some religious groups refuse to acknowledge that someone is dead
if the heart is still beating
and the lungs are still
But the medical profession and the law has moved
Some states now permit physicians to declare death
based solely on brain functions.
Veatch proposes that the default definition of death
be the whole-brain criterion:
If all the functions of the whole brain have ceased,
the patient may be declared dead.
If the patient or the family have not expressed any views,
then this definition of death can be used without any further question.
But patients and/or families ought to be permitted
from this default definition of death in either direction:
Conservatives could insist that heart and lungs must have stopped.
Liberals could deviate toward higher-brain definitions of death.
For example, when all
consciousness is over forever,
such permanent unconsciousness
could be defined as death.
There must be
We will not tolerate relatives declaring the merely-disabled to be dead.
At the other end, we will not tolerate our hospitals keeping corpses
because the relatives refused to allow death to be declared
until the very last cell in that body is obviously dead.
In most human deaths, the differences in definitions
will have no practical effect.
Opting for the more conservative definitions
will mean that the doctor will wait a few more minutes
before declaring death based on signs obvious to all present.
If the patient or corpse is not yet dead according to everyone's
it will be completely dead within a short period of time.
difficult cases will involve life-support machinery:
When the heart and lungs are being
kept going by life-supports,
then the follow-on stages of
that clearly indicate death to
everyone would be missing.
In such cases, the conservative
relatives might be convinced
by having the life-supports
to see if the patient lives or
Philosophically we might all agree
that death is a process
rather than an event.
But we nevertheless need a date
in order to know when to start other behavior related to death:
When will we have the funeral or memorial service?
When with health-care coverage end?
When will life-insurance death-benefits be paid?
When will any marriage of the patient be over?
Veatch suggests some individual choice about the
ending of marriage.
Perhaps the surviving spouse should be permitted to declare the
when the patient has become permanently unconscious,
even if the patient is maintained on life-supports for some reason.
If it has been confirmed that the
patient will never have
another conscious thought or
then every form of interpersonal
interaction is over.
Veatch suggests that spouses of individuals in PVS
should be allowed to establish new marriages.
Socially the PVS spouse is dead,
even if the unconscious body is maintained by feeding-tubes, etc.
will have philosophical and/or religious reasons
for staying married to a spouse in
persistent vegetative state.
The loving commitment to that former person can be maintained
while the spouse who is still a full person moves on in life.
This is what Michael Schiavo did after his wife Terri Schiavo
had been in PVS for some years:
He started a new marriage-like relationship
and even had children with his new 'spouse'
while he was still officially married to Terri.
When Terri was finally disconnected from life-supports,
Michael married his second wife.
(Michael Schiavo's book, Terri,
The Truth, is reviewed in another bibliography:
Books on the Right-to-Die:
Veatch points out that having different
definitions of death
in different states might create the following nightmare scenario:
What if the patient/corpse is taken by ambulance to another state,
where different criteria of death are in force?
If a patient is declared dead in one state,
does this status also apply in all other states?
under any permissive set of optional definitions,
there would be only one declaration of death for each individual.
Once death is declared by a physician at the bedside,
all changes that normally follow death will begin:
Health-care for preserving the life of the patient will cease.
Life-support systems will be disconnected,
unless they are needed to preserve organs in good condition for
Life-insurance benefits will be paid.
Marriage will be over.
Social security and other pension benefits will end—or shift to a spouse.
raise the possibility that some individuals might be kept 'alive'
so that their relatives will
continue to receive generous pension benefits.
There are no such reports, but it is a theoretical possibility.
If the family is receiving
thousands of dollars a month
from some form of annuity,
pension, or social security,
they do not want to kill the goose
that is laying the golden eggs,
even if there are no other reasons
for keeping the patient on life-supports.
Does this sort of thinking actually take place?
Exactly when should pension-benefits terminate for the not-quite-dead?
On the other
hand, inheritance is a benefit
that takes place only after death is declared.
Assets would pass to the heirs at an earlier date
if higher-brain criteria were used to declare death.
But the same kind of abuse by greedy relatives could occur
when the rich individual is being supported by machinery.
Premature withdrawal of life-supports could happen.
So far no such cases have been established.
But we need to be alert for the
possibility that some life-ending decisions
are being taken to achieve an
earlier pay-out of some kind of benefits.
[Here are some safeguards for protecting patients from greedy relatives:
such as the Pope, the President, or the king
remain in that office until death is declared.
But now that we can keep individuals 'alive' by means of life-supports
even after they become permanently unconscious,
we need ways to replace such individuals if they enter PVS.
Sometimes care-givers such as nurses and doctors
might be troubled by more liberal definitions of death.
They might not agree to 'pull the plug' for a patient in a coma
even if that patient has been officially declared dead.
But this problem is not unique to the definition of death.
Terminating medical treatment is also a lawful choice,
even if the doctors and nurses do not agree with this course of action.
If the patient dies as the result
of withdrawing life-supports
or terminating other forms of
death will not be declared until
after the body shows the accepted signs of death.
Veatch suggests that the initiative for adopting an
unusual concept of death
should belong to the family or the proxies.
Whenever they have unusual medical ethics,
it is their responsibility to make those views known.
Directive for Medical Care is the most logical and convenient place
for the patient and/or the proxies
to make any such wishes known.
See this reviewer's Question 19
for comprehensive Advance Directives:
"Which definition for death should
apply to you?":
Chapter 9: "The Unimportance of Death"
by Norman Fost, MD, MPH
This author suggests that we give up trying to
but go ahead with organ-donation from bodies that will be known as
He does not think that we will ever have a single definition of death
that will be suitable for all purposes.
Fost cites the practice of organ transplantation in
before that state
created its brain-death law.
For 10 years, transplant surgeons took the donor to the operating room,
turned off the life-support systems,
waited a few minutes for the heart and lungs to stop,
declared death using the heart-lung criteria,
restarted the life-support machines,
& proceeded to harvest and transplant the reusable organs.
of proving death by the traditional criteria
is still practiced where brain-death laws are in effect.
This might be more for the benefit of the family than anyone else.
The family is supposed to be reassured that the donor was really dead
because the heart and lungs stopped working.
But, as others have argued,
if the vital functions of the body could be restored by the
then the patient was not
really dead after all.
This reviewer believes that it would be easier on
for the death to be declared on the basis of brain-functions.
This could take place, not in the operating room
just before the organs are harvested,
but in the normal hospital bed
where the patient received his or her
And it could take place hours or even days
before any cutting for transplantation begins.
The process of proving and certifying that
brain-death has occurred
would not be rushed
by the necessity of operating immediately
in order for the organs to be as fresh as possible.
Second opinions can be sought to make sure
that the first doctor was not mistaken
about the present and future state of the brain
of the patient who will become the donor.
Once death has been officially declared
and the death-certificate completed and signed,
then the family will proceed with the next steps in their grieving
notifying all family and friends of the death,
proceeding with funeral or memorial service plans, etc.
There will be no further need for the family members to stay by the
The costs of terminal medical care will end with the declaration of
After the patient has been declared dead,
the costs of maintaining the body for possible organ-transplants, etc.
will be billed as a small part of the cost of the transplants that will
The delay made possible by declaring death using
will allow the transplant system to locate and prepare
the very best recipients
of the organs to be harvested.
The organs will be removed from a body that has been officially dead
for a few hours or even a few days,
even tho all of the vital functions of that body
are being maintained by artificial means.
Fost points out
that even in France,
which has a presumed-consent law for organ-transplantation,
in actual practice the doctors still ask for the organs from the
And if the grieving family declines, the organs are not used.
This means that
presumed consent is not working.
If that law were working as
then the organs would
automatically be available for transplant.
The family would be informed but there would be no process of asking.
In most of the USA, we have required request laws.
This means that the medical personnel are required to ask for organs
from the usually-traumatized family.
But this has made little difference in practice
because there are no consequences for not asking.
Since there is no enforcement
the medical staff will simply
following their own feelings,
which often means that they do not
ask the grieving family
for the organs of their soon-to-be-dead or newly-dead relative.
Changing the law
to allow more liberal definitions of death
will not make more organs available for transplant
unless those laws actually change
what happens at the bedside of the dead (or nearly-dead) patient.
Fost points out that where
laws have been changed,
organ-donation has not increased.
Also, new definitions of death create confusion
among doctors and laypersons alike.
It used to be easier to 'pull the plug' without worrying about the law.
But now lawyers might have to be brought into the process
to make sure that death was properly declared according to the new law.
Fost thinks that everything was easier for doctors
before the laws were changed to permit brain-criteria to be used in
Fost says that the legislatures should resist the temptation
to resolve philosophical and religious issues by creating new laws.
To give another example,
legislators should not attempt to define when human life begins.
brain-based definitions of death
have initially created more confusion than clarity,
this reviewer believes that we can only go forward
toward more freedom in defining death
rather than going back
to relying only on the traditional criteria.
And we should even welcome as liberal a test
as permanent unconsciousness
to be chosen as a definition of death
by those patients and families who see the advantages of such a
Dr. Fost here
raises the issue of babies born without any upper brains.
He does believe that
such anencephalic infants
should be used as organ donors
to save the lives of other infants.
But they should not
be defined as born dead.
He would prefer to think of these bodies without upper brains as living donors.
The parents would be told that
their babies died when their organs were harvested.
This reviewer suggests that it would be easier for
to prove that these infants were born permanently unconscious.
Because the parts of the human brain that are the seat of consciousness
are completely missing from these infants,
they will never have a conscious thought or feeling.
Their lives will never be more than the reflexes controlled by their
If we ourselves were ever to decline into such a state
of biological life without the possibility of conscious thinking or
we would probably prefer that the last vestiges of 'life' be terminated.
But when the organs of permanently unconscious human bodies
can be used to extend the lives of babies and adults
who can live full human lives,
then it seems wiser to harvest the organs
than to allow those organs to die with their original owners.
Dr. Fost wants
to resolve this problems in a different way:
Instead of redefining death using brain-criteria,
he wants infants and adults without higher-brain functions
to be considered alive
until the moment their bodies die
because vital organs were removed for transplant.
this understanding, most organ-donors would be living
Their date and time of death would be when the heart (for example) is
It seems to me this would create more problems than it solves.
wants to operate on living
who will be declared dead only when their organs are removed?
What family would
consent to 'killing' their loved ones for their
The dead-donor rule
is now universally accepted:
Organs are only harvested from cadavers.
The transplant-team should not begin the process of harvesting
until after death has been officially declared by an independent doctor.
Dr. Fost is
quite liberal in practice,
even tho he takes a different
philosophical point of view.
He even favors organ 'donation' from patients in persistent vegetative
When PVS patients are going to be disconnected from life-supports
they have no further interests or rights
that will be violated by harvesting their organs.
But his understanding would define PVS donors as living donors.
And, again, death would be declared after the vital organs are
Even more radical, Dr. Fost would permit
to donate their organs to save other lives.
Under present law and practice,
living donors are only allowed to
donate paired-organs or parts of organs,
when such donations will not result in their own
Under Dr. Fost's proposal, the law
would have to be modified
to make certain that the transplant surgeon could never be charged with
for removing vital organs that resulted in the donor's death.
The donor might be alive and fully-functioning in every sense.
He or she might be able to give fully-informed consent
for the removal of his or her organs
with full knowledge that death would result from such harvesting.
extreme conclusion might seem to follow from Dr. Fost's premises,
it does not seem likely to this reviewer
that any such practice would ever be condoned.
The main worry would be that terminally-ill patients
were being killed for their
Even with the best safeguards to
prevent mistakes and abuses,
the general public would not agree
to allow terminally-ill patients to 'donate' their organs.
There will always be the doubt that the donor might have been saved.
The option of a liberal definition of death
(such as permanent unconsciousness)
would allow this altruistic terminally-ill patient
to donate his or her organs so that others might live:
After all are satisfied that the safeguards have been fulfilled
so that no premature death will be involved,
the donor could be made
by the most appropriate medical means.
Then the donor could be declared
officially and permanently dead
on the basis of the final loss of consciousness
—without the possibility of
consciousness ever returning.
If it seems wise, this donor could be certified to be brain-dead
before any consideration of organ-donation is begun.
Only some time after official death has been certified,
after the death-certificate has been completed and signed,
would any cutting for transplant begin.
This would not violate the dead-donor
The donor would be a cadaver
at the time of the donation.
This is how I would like to donate my own remains.
After I am finished with my body,
I want it to be used as a 'living cadaver'.
And if my body and/or organs are used in this way after my death,
I will have become a dead-donor.
Thus, it is critical that permanent
be accepted as a new (perhaps optional) definition of death.
Or perhaps it would be appropriate to insist
that brain-death be
officially determined and declared.
But we can still extend our thanks to Dr. Fost
for his creative attempts to solve the same dilemma in a different
There are several other chapters not reviewed here.
If interested, check the Internet for a complete table of contents.
This collection has presented several different points of view,
from different professions, countries, religions, & generations.
More such conferences should
continue the discussion
of the definitions of death.
2. Richard Zander, editor
Death: Beyond Whole-Brain Criteria
NL: Kluwer Academic Publishers,
(Library of Congress call number: not given)
(Medical call number: W820D2853 1984)
on a conference in 1984, the contributors to this volume
definitions of death
and others advocating higher-brain
or even the death of the
As of the time of this conference,
no clear consensus among the experts had yet emerged.
And they knew that the general public would take even longer
to comprehend the higher-brain definitions of death.
But if we call
it the death
of the person or the end of
then lay people should be able to
grasp that easily and quickly.
This reviewer believes that each individual
should be empowered to
specify in advance
which definition of death
should be applied to him or her.
In some cases, this would permit an earlier declaration of death,
which would be very important for organ-donation
and other possible uses of a brain-dead body.
chapter gives a good history of concern for defining death.
In the past, the worry was mostly that patients would be wrongly declared dead.
Early medicine discovered how to resuscitate people who seemed to have
And medicine discovered how to keep tissue alive without its original
Premature burial was a wide-spread worry in the 19th century
tho no modern cases of being buried alive were ever proven.
In recent years, however, the main problem has been
keeping the body 'alive'
even after the death of the person.
We now worry about being wrongly
Whole-brain-death became the standard in medical
practice in 1968,
because a wide consensus could be achieved about that definition.
But from the beginning, some experts advocated a higher-brain standard.
However, there were no reliable tests to prove permanent
And it had become increasingly easy to keep a body 'alive'
without any of the higher functions of the human brain.
Part of the
difficulty in defining death is the assumed need
for an either/or definition
Either this body is alive
or this body is dead.
But this reviewer would be content with descriptions of the various stages of dying.
And the permanent loss of personhood should be a permissible definition
A human person
has: consciousness, memory, language, & autonomy.
These are phenomena that every layperson can evaluate.
We do not need high technology to determine whether an individual is
But we do need
professional opinions to evaluate the possibility
that the patient might awaken
at some time in the future.
chapter argues forcefully
that once the upper surface of the brain (the gray matter) is dead,
that person is forever dead,
even if the brain-stem can keep the heart beating and the lungs
After the upper brain tissue is definitely dead, it never regenerates.
And consciousness has never been known to return to such a brain.
Thus, it seems wise and compassionate the stop the heart and the lungs,
to declare death, and to proceed with all of the other activities that
The law has special reasons for requiring a sharp
line between life and death.
A spouse of a patient in persistent vegetative state
would not be permitted to remarry until the patient is declared dead.
Inheritance does not pass until the grantor is legally dead.
Homicide is no longer possible if the patient was already dead.
In general, the legal profession and the state laws
have left it to the medical profession to decided when to declare death.
And brain-death statutes grant
to use whole-brain criteria as sufficient for declaring death.
In the future, it might be better to leave all determination of death
to the medical profession
(presumably using criteria and tests doctors generally accept)
rather than changing the state laws
every time there is a new advance
in medical practice.
A good-faith declaration of death
by a licensed physician
following accepted medical practice
should be sufficient to certify that a person is dead.
recommends neocortical death as the definition.
When certain criteria are met, the person would be declared dead.
Smith would depend on a PET scan to decide when a patient's neocortex
But additional methods have
probably been developed since this writing,
which answer with ever greater
confidence this question:
"Will this patient ever regain
Once the patient
has been declared dead,
the family or the estate could keep the biological functions going at
their own expense.
But the public should not be expected to pay for such maintenance.
This would be parallel to the
practice of freezing
a body after death,
in the remote hope that a cure for the cause of death would be
and the body could be brought back to life.
Any such freezing takes place after
the declaration of death.
And the cost of keeping the body in the freezer is paid by the estate
or the family,
just as the cost of burial or cremation would be borne by the family.
In the donation-plans of this reviewer,
after the declaration of death based on permanent unconsciousness,
my body would become the property
of the medical institution,
which could use it for any medical, scientific, or educational purposes.
This would be much better than keeping my body 'alive'
as a 'living memorial' to the person I once was.
These views are explored more fully in an on-line essay entitled:
"The Living Cadaver: Medical Uses of Brain-Dead Bodies":
A chapter entitled:
"Human Death and the Destruction of the Neocortex"
by Edward T. Bartlett & Stuart J. Younger
In creating a new definition of death, we need three
a concept, medical criteria, & objective tests.
The first formulation of whole-brain death
did not separate these elements very well.
In fact, much of their informal presentation
really referred to the higher-brain
functions such as:
sentience, memory, personality, conscious life, uniqueness,
judging, reasoning, acting, enjoying, & worrying.
However, their formal definitions refer to the integrating functions of the
such as regulating heart-beat, breathing, body-termperature, &
These are all functions that continue while we are asleep.
But the distinctively human and personal functions
only happen while we are awake.
definitions of death would also apply to all animals.
But our higher-brains provide the functions that make us persons
—which is more than mere living
From the human and personal point of view,
we care more about the disintegration of ourselves as persons.
The deaths of our human selves or persons take place
before the final deaths of our bodies as biological organisms.
We might want to draw the line between living persons and dead persons.
And we might add a new category: former persons.
These would be individuals who have permanently lost
most of the capacities that constitute personhood:
consciousness, memory, language, & autonomy.
How would we want to
be treated if we become former persons?
These four criteria of personhood
are explored more deeply in a small book by the present reviewer:
When Is a Person? Pre-Persons
and Former Persons:
This book contains about 200 questions that can be asked by laypersons
in evaluating the levels of personhood in someone they know.
definition of death was proposed
because it would be acceptable by various groups in the public,
even if they have different philosophical concepts of life and death.
But there are
some very conservative religious groups
that will be very slow to accept any changes in the concept of death.
Whole-brain death was acceptable because without mechanical support,
the body would soon be completely dead
by the traditional criteria of the loss of breathing and heart-beat
—which have been the definition of death
for thousands of years.
When religions are founded on texts
written hundreds or even thousands of years ago,
it will be difficult for the present believers to make adjustments
for advances in medical science and technology.
But the following is one possible direction for new
Religious people are very concerned about the spiritual condition
of the patient whose death is being determined.
Religions sometimes speak of the departure of the soul or spirit.
Perhaps modern thinkers based in ancient religious
will be able to notice that spirituality
was usually found in living
When thinking has ended permanently,
perhaps all spiritual
activities of that person are also at an end.
When the final death of the body followed immediately after the death
of the brain,
there was little reason to wonder about the departure of the soul.
When the breathing stopped, the soul departed:
Spiritual life within this earthly body was over.
But what about a body in persistent vegetative state?
Does the soul or spirit still exist within a body in a coma?
Or has the spiritual life of that living person come to an end?
The present reviewer believes that we do have
important spiritual capacities,
such as self-transcendence, freedom, creativity, & love.
But all of these capacities of our human spirits depend on consciousness.
See a series of cyber-sermons entitled
WHAT IS SPIRITUALITY?:
Other persons who believe in the human spirit take
different points of
For some, spirit means primarily the capacity to exist beyond death.
But all who think about spiritual matters should ask themselves:
What is the spiritual condition of a former person in a coma?
Some authors in
this collection have begun the process
of re-thinking death as the death
of the person,
which would anatomically be associated with the death of the neocortex.
If we are certain that the upper
parts of the brain are permanently
then we can be confident in declaring that person dead.
But it might be some decades before this concept is accepted by the
Laypersons are more familiar with consciousness
and the end of consciousness.
Each of us experiences the temporary loss of consciousness
every night when we go to sleep.
We know that sleep was temporary when we awake in the morning.
And when we observe others who have lost consciousness,
we can keep hoping that they will wake up again.
But after a reasonable time, if consciousness does not return on its
we should consult neurologists to discover
the causes of what appears to be permanent unconsciousness.
If medical science tells us that consciousness will
never return to this brain,
then we should consider what to do next.
The most conservative choice would be
to keep the body 'alive' for as long as possible,
using whatever life-support systems are
The course suggested by standard medical care
is to wait for an agreed-upon length of time
to see if any efforts can
bring this upper brain back to life.
And if nothing helps, then the life-supports are disconnected,
allowing the patient to die a natural death.
The most liberal (and still controversial) choice
would be to declare the patient to be dead
when it has been well-established that consciousness will never return.
the neocortex or death
of the person
would allow the body to be used for organ transplant
and other medical procedures and education.
But all medical personnel involved in such further use
of the permanently unconscious body
will have to be convinced in
their own minds that this patient is
If death has been officially
declared and accepted
by all concerned,
then the remains can be treated as dead bodies have been treated
as far back as history and anthropology can discover.
The public will be slow to accept
the death of the upper brain
as the death of the person.
For example, there are more than 10,000 patients in persistent
who are being kept 'alive' by various means of life-support.
The public will not easily allow these patients to be declared dead.
The case of Terri Schiavo amply illustrates this:
Most public opinion (including most of the US Congress)
did not believe that Terri should be disconnected from life-supports,
which in her case was mainly a feeding-tube.
We need careful discussion of the most appropriate
options of care for patients in PVS.
Should they be described as "former persons"?
Should we automatically keep all PVS patients on life-supports as long
Should other options be accepted by the medical profession
as well as the general public?
How will resistance to 'pulling the plug' be
It might take decades of discussion and re-thinking.
Perhaps other high-profile cases will galvanize new dialog.
The ever-increasing number of patients in PVS
will mean that more families will become personally involved in this
And some individuals will make their own decisions
about how death should be defined in their own cases,
which will stimulated others who know about such choices
to reconsider how they would like to be treated at the end
of their lives,
especially if they might have a long period of unconsciousness at the
This reviewer recommends that all patients in PVS
be evaluated at least once every month.
And just because a decision was once made to put them on life-supports
should not prevent changing that decision
after a longer period of time without the return of consciousness has
Permanent unconsciousness might become an optional definition of death:
New laws could be written that would allow a physician qualified in
to declare a former person dead
if that patient has been
unconscious for a year or more
and is never likely to regain
And if the patient has given permission for such a definition
in an Advance Directive for Medical Care,
this will make such a declaration easier.
The family and the proxies might also agree with such a determination.
If the patient has received neurological care and evaluation for one
there can be a high degree of confidence
if all the neurological tests say that this upper brain
will never again have another
moment of consciousness.
Similar laws allow a missing person to be
if he or she has been missing for seven years.
Whole Brain Criteria was one of the earliest attempts
to go beyond the whole-brain-death definitions of death.
What was basically lacking when it was written
(and might still be basically absent)
is a clear set of tests for 'neocortical death'.
Only after medical science has reached a good consensus
about the end of
consciousness and the death
of the person
can the general public be expected to follow suit.
Using higher-brain criteria for death
will allow patients to be declared dead
when they become permanently unconscious.
When our conscious lives have irreversibly come to an end,
we should permit a declaration of death,
which would then allow all the after-death events to begin.
This is the choice I make for myself now.
Even if my body still has a heart-beat and is still breathing,
I grant my permission to be declared dead
if I will never again have a
moment of conscious thought or feeling.
I would like to donate my body as a 'living cadaver'.
This is a new concept for medicine and for the general public.
But such an intermediate state might become more common.
For all purposes (medical, social, legal, etc), such a body is dead.
(As linked earlier, these views are explored more fully in an
on-line essay entitled:
"The Living Cadaver: Medical Uses of Brain-Dead Bodies":
Many of the
authors in this book also raised the question
of the defining what it means to be a person,
but none offered very elaborate definitions and tests for
They merely referred to such common-sense activities as
thinking, feeling, acting, communicating, relating, etc.
This reviewer thinks that we need
more careful criteria
to decide just when a certain individual might have stopped being a
See When Is a Person?
Pre-Persons and Former Persons:
Even tho this book, Death:
Beyond Whole-Brain Criteria, is a few decades old,
the issues have still not been resolved.
And new books along this line are definitely needed.
Michael Potts, Paul A. Byrne, & Richard G. Nilges, editors
Beyond Brain Death:
The Case Against Brain Based
Criteria for Human Death
NL: Kluwer Academic Publishers,
2000) 270 pages
(ISBN: 0-7923-6578-X; hardcover)
(Library of Congress call number: not given)
(Medical call number: W820P871b 2000)
Brain death has been widely accepted in the
developed world since the 1980s.
But this group of doctors and philosophers raise doubts about this
Most of them come from Roman Catholic backgrounds,
but their objections are still based in science more than metaphysics.
The definition of brain death was developed mainly
to facilitate organ transplantation.
But are we sometimes declaring
people death too soon
in order to have the organs in the best possible condition for their
Laypersons will always have problems with declaring
their relatives dead
when they can see their bodies still breathing (perhaps with the aid of
their hearts still beating, & their bodies still warm to the touch.
Even if they are told that all brain functions have ceased
without the possibility of ever returning,
laypersons sometimes hold to the common-sense notion that this body is
And before the 20th century,
all doctors would have agreed that such bodies are still alive.
But almost all states in the United States now permit a new definition
If all functions of the
whole brain have ceased, the person may be
if there are still some vestiges of
consciousness in the upper brain
when the brain-stem has ceased to function
and its functions have been taken over by machines?
If we take organs from such a body,
are we removing them while the donor is still alive?
the way towards death is not the same as being dead.
Fatal diseases or conditions are not sufficient to declare death.
Drugs can sometimes cause all functions of the brain to cease.
And if these bodies are not supported by medical technology,
all functions of those bodies will soon stop.
But in such cases, the loss of brain-function does not equal death.
Some people can be brought back from drug overdoses.
This is the
reason that there must be a
followed by re-testing before
brain-death can be declared.
Drowning or drugs might have
caused a temporary loss of brain-function.
beliefs about the soul inside the body
create some problems for the brain-death criteria.
According to most religious beliefs,
as long as the body is breathing, the soul is still there.
beliefs might have to be adjusted for the new reality
of bodies being supported by
When these beliefs emerged, breathing bodies were always alive.
And the departure of the soul was identified with the last breath.
People who believe in a soul will have to re-examine their beliefs
with respect to bodies sustained by life-support machinery:
If the patient is brain-dead,
—excluding the possibility of
consciousness ever returning to this
has the soul already departed?
Can there be spiritual
functions in a body
after consciousness is no
What about a patient who spends years in persistent
Is the soul of such a patient still waiting within the body?
Will the soul go to heaven or hell only after the life-supports are
This reviewer believes that all
spiritual functions depend on
After my consciousness is over forever, so are all my spiritual
But other kinds of belief might reach different conclusions.
And medical ethics should allow all forms of
unless there is a serious conflict between scientific medicine and
Some people might want to consult their religious advisors
before deciding which definition of death should be used in a
Brain-death has been accepted by the scientific community,
but it might be a long time before all religious authorities accept
And this book has collected the views of a few people
who do not agree that a
brain-dead patient is really dead.
countries have been slow to adopt brain-death,
a patient might be declared dead in one country but not in another.
differences will gradually be resolved
as universal standards and tests
for defining brain-death
everywhere on the Earth.
If we are going
to harvest the organs of donors kept 'alive' by life-supports,
we must first define
them as dead.
Death must be officially declared by a doctor
before any transplant surgeon will begin the operation
to remove reusable organs from the donor.
From this perspective, the potential donor must be either alive or dead.
If brain-death criteria and tests are to be used,
the family members must be brought along with this process.
Some religious family members might object to declaring death
when all functions of the brain have ceased.
can be resolved in advance by having the patient decide
(while still a fully-functioning
exactly which definition of death
should be applied to him or her.
And such a practice would permit
very liberal potential patients
to select even more controversial
definitions of death,
such as the permanent loss of
Such permissions could be embodied
comprehensive Advance Directives
for Medical Care.
For example, Your Last
Year by the present reviewer
asks the following open-ended
definition of death should apply to you?"
One author included in this volume, David Albert
objects to all
heart-transplants for the following reason:
Being almost dead is
not the same as being completely
If the heart can be re-started, then the donor was not dead after all.
Even if the heart was observed not beating for two minutes
required by some protocols—
the fact that it could be re-started in the body that receives the
shows that the heart was not really dead.
Thus the donor was
not dead because the heart could be re-started.
In Jones' view this donor is a living donor
because the heart was still beating
before it was stopped by removing the life-support systems.
And we do not permit living patients to donate vital organs such as
We do not want even the suspicion
that living donors have been
killed for their organs.
This raises the
very valid question of just
when to declare death.
If the patient has given
permission in advance
for a liberal definition of death,
then there should be no reluctance
on the part of the declaring doctor
to certify that this patient is
Brain-death is the most common
All functions of the whole brain
have permanently ceased.
A doctor—not part of the
transplant team—declares the donor dead.
Then the dead body may be used for
But if the patient has given
even something as liberal as permanent
could be accepted as a definition
This would be required for using
the body as a 'living cadaver'.
points out that some people who oppose abortions
nevertheless permit brain-death
criteria to be used for declaring death.
Some claim that a fetus is a human person even tho it has no
So why do they not maintain that an individual who is brain-dead
has a similar status to a
fetus before consciousness emerges?
Some thinkers place the beginning of personhood
when a fetus can live outside its mother's womb.
Some say that personhood depends on being a unified organism,
controlled by a brain.
reviewer defines personhood as having
(1) consciousness, (2) memory, (3)
language, & (4) autonomy.
Under this definition, neither a
nor an adult who is permanently
would qualify as a human person.
A fetus would be a pre-person.
And a permanently-unconscious adult would be a former person.
Two chapters deal
where brain-death has been slow to
The basic worry is that a donor will
be declared dead
before he or she is really dead
in order to harvest his or her
organs for another individual.
real status of the donor is in doubt,
more and better testing is
And this will often require more
than simple, bedside tests
that can be performed by any
Neurologists with special
equipment should be employed
for doubtful cases of brain-death.
Some authors represented in this book
believe that we should always err on the side of caution:
Instead of allowing bodies to be declared dead
when all functions of the brain have ceased forever,
we should wait for all signs
of death to be present,
including the end of heart-beat and breathing.
We would not do an autopsy on a warm, breathing body.
At least one author says that the soul is present in
from the moment of conception.
And he does not know exactly when the soul leaves the body.
Therefore he will insist on the centuries-old definition of death.
valid religious beliefs.
And those who embrace such
statements of faith should say so
in their Advance Directives for
Also they might explicitly
rule out organ-donation
because of the remote possibility
that they might be declared dead
Since this book was published in 2000,
there does not seem to have been any movement to overturn
the practice of declaring death using the brain-death criteria.
But the cautions embodied in this book
do need to be taken into account.
And laypersons, especially, need to be 'brought up to speed'
with current practices so that they will not hesitate of donate organs
if and when a sudden tragedy strikes the family.
11-2-2007; 11-7-2007; Revised and expanded 12-8-2007; 12-15-2007;
12-18-2007; 2-26-2009; 4-18-2009; 5-30-2010; 9-11-2010
Here is the complete list of bibliographies related to death:
Books on Terminal Care (from the Doctor's Point of View)
D. Books on
Directives for Medical Care
G. Books Opposing
H. Safeguards for
I. Definitions of
on Voluntary Death
K. Helping People to
L. Books Describing
M. Best Books on Cancer
There Life After Death?—Best Books