Death, Brain Death, and Persistent Vegetative State Notes

The Concept of Brain Death and its Appeal

• Historically: Death was determined by the cessation of breathing and heartbeat. If someone wasn't breathing and their heart wasn't beating, they were considered dead.

• 20th Century Advances: New medical techniques emerged that could resuscitate individuals who had stopped breathing and whose heart had stopped beating. This meant people could be brought back from the brink of what was traditionally considered death.

• Mechanical Ventilation: This technology allowed oxygen to be forced into the lungs, maintaining bodily functions even if the person was unconscious. Patients could be kept alive through machines.

• Resource Strain: The rise in mechanically ventilated, unconscious patients strained medical resources. There were not enough resources to care for everyone, and it became a challenge to allocate them.

• Organ Transplant Demand: Simultaneously, there was an increasing demand for organs for transplants. People needed organs to survive, but there weren't enough available.

• Debate on Declaring Death: These factors led to a debate on when a patient could be declared dead. The goal was to determine when life support could be removed and organs could be made available for transplant.

• Shift to Brain Death: The traditional cardio-pulmonary criterion of death (breathing and heartbeat) shifted to the acceptance of brain death as a valid criterion.

• Definition of Brain Death: Brain death is defined as the irreversible cessation of functioning in the brain as a whole. This means the entire brain has permanently stopped working, though minor residual activity in certain areas might still be present.

• Practical Utility: Brain death's practical utility was clear. Patients on ventilators who tested positive for brain death could be declared dead and considered as potential organ sources.

• Somatic Functions: It was argued that somatic functions (bodily functions) could be sustained externally and were not constitutive of life itself. Life was more than just bodily functions.

• Ongoing Contestation: While medicine and law largely accept brain death as death, philosophers and some medical professionals continue to contest it. There is still disagreement on whether brain death should be considered true death.

Clarifying the Concept of Death

• Life Prerequisite: Only entities that have been alive can die. You can't die if you were never alive to begin with.

• Biological Phenomenon: Life is a biological phenomenon, leading most to view death as a biological phenomenon as well. Death is generally seen as a biological event.

• Orthodox View: Since the late 1960s, the orthodox view has been that death is a biological event involving the cessation of integrated functioning in an organism. When all parts of an organism stop working together, death occurs.

• Alternative Views: The claim attributed to Jesus that “whosoever liveth and believeth in me shall never die” (John 11:26) suggests death is not always biological; it can refer to the ceasing to exist of a person. Some believe death can be a spiritual or existential event.

• Amoeba Example: The ceasing to exist of a living entity is not always aptly describable as death. For example, amoebas undergo binary fission and cease to exist but do not die. They simply split into two new entities.

• Corpses: Corpses show that living beings can die biologically without ceasing to exist. A dead body still exists, even though the person is biologically dead.

• Distinction: The concepts of death and the ceasing to exist of a living entity are distinct, though overlapping. They are related but not identical.

Critique of Brain Death

• Two Concepts of Death: There are two concepts of death: the cessation of biological life processes and the ceasing to exist of a conscious being. One is about the body, and the other is about the mind.

• Arguments for Brain Death: Arguments for brain death as death imply both biological death and the ceasing to exist of the person. It suggests that when the brain dies, both the body and the mind have ceased to exist.

• Equivalence Claims: Brain death is seen as equivalent to the ceasing to exist of the person because the brain is the seat of consciousness. It is also seen as equivalent to biological death because there can no longer be integrated functioning in the organism.

• Challenging Equivalence: Brain death is not equivalent to either the irreversible loss of the capacity for consciousness or the irreversible cessation of integrated functioning in the organism as a whole. The brain can die without both of these things happening.

• Brain Regions: Consciousness is generated in the cerebral hemispheres (higher brain), while somatic functions are regulated in the brain stem (lower brain). Different parts of the brain control different functions.

• Vulnerability to Anoxia: Cerebral hemispheres are more vulnerable to anoxia (oxygen deprivation) than the brain stem. The higher brain is more easily damaged by lack of oxygen.

• Cardiac Arrest: Cardiac arrest can damage hemispheres while leaving the brain stem intact, resulting in a permanently non-conscious individual capable of bodily function with minimal support. The person can be unconscious but still have basic bodily functions.

• Early Advocates: Early advocates of brain death appealed to the intuition that the capacity for consciousness is essential to our existence. They believed that without consciousness, a person is no longer truly alive.

• Sufficiency but Not Necessity: Brain death is sufficient but not necessary for the irreversible loss of the capacity for consciousness. Brain death will cause loss of consciousness, but other things can also cause it.

• Persistent Vegetative State: Persistent vegetative state involves permanent non-consciousness, but the body continues to function with minimal life support. The person is unconscious, but their body is still working.

• Higher Brain Criterion: Some theorists suggest a “higher brain” criterion, such as cortical death, but this implies a persistently vegetative patient is biologically dead, which seems false. This idea suggests that only the higher brain needs to die for someone to be considered dead, but it has problems.

Integrated Functioning

• Brain Stem Destruction: A human organism could suffer the irreversible cessation of integrated functioning without the person ceasing to exist if the brain stem were destroyed while the cerebral hemispheres survived in a functional state. The body could stop working together even if the person is still conscious.

• Reticular Formation: The reticular formation, located in the brain stem, functions as an on-off switch for consciousness in the cortex. This part of the brain stem controls consciousness.

• Hypothetical Scenario: Consciousness could be preserved with a machine delivering oxygenated blood to the cortex even after the brain stem is destroyed, though it's unlikely. It might be possible to keep someone conscious even without a working brain stem.

• Real Examples: Real examples show that brain death can occur without the cessation of integrated functioning. The body can still function even when the brain is considered dead.

• Pregnant Women: Cases of pregnant women diagnosed as brain dead whose bodies were kept functional to allow fetal development show that corpses can support fetal gestation, maintain immune functions, metabolize nutrients, excrete wastes, and retain reproductive potential. The bodies of brain-dead women can still support a developing fetus.

• 4-Year-Old Boy: A 4-year-old boy diagnosed as brain dead grew, overcame infections, and healed wounds over 15 years despite having no blood flow within the cranium and a dissolved brain. This boy's body continued to function for many years despite being declared brain dead.

• Reinterpreting Cases: Those who hold that brain death is death describe these examples as cases in which corpses maintain immune functions and adjust them to the presence of a fetus. They try to explain these cases in a way that supports their view.

• Centralized Integration: They assume that internal integration of somatic functions has to be centralized in order for there to be life. They believe the brain must control everything for the body to be alive.

• Decentralized Integration: With minimal external support, the various organs and subsystems of a human organism can achieve decentralized integration, coordinating by sending, receiving, and processing signals among themselves. The body can coordinate itself without the brain.

• Brain's Role: People continue to assert that regulation by the brain is necessary for functioning in the organism to count as life. They insist that the brain must be in control.

• How Much Integration: The question arises: how much of the integration of somatic functions has to be done by the brain for the organism to count as alive? How much control does the brain need to have?

• Machine Assistance: If some functions are being regulated by machines while others are being regulated by the brain, that would seem to be sufficient for the presence of life, especially if consciousness is among those functions. Life can still exist if machines help the brain.

• Transition from Life to Death: If the regulation of one somatic function after another is taken over from the brain by a machine, the transition from life to death with the cessation of consciousness has nothing to do with the cessation of somatic regulation by the brain stem. The brain's control is not the deciding factor.

• Consciousness Matters: The cessation of consciousness alone is not the difference between biological life and death in the organism, as defenders of the brain death criterion themselves acknowledge when they refuse to consider a patient in a persistent vegetative state to be dead. Consciousness is important, but not the only factor.

• Spinal Cord and Swelling: Examples include cases in which the spinal cord is completely severed just below the brain stem (“high cervical transection”), and cases in which swelling and compression in the same area prevent the transmission of any signals between the brain and the rest of the body (as in some cases of Guillain-Barré syndrome). These conditions can separate the brain from the body.

• Brain Not Necessary: The truth seems to be that no degree of regulation by the brain is necessary for biological life in the organism. The brain may not be needed for the body to be alive.

Further Arguments Against Brain Death

• Brain Functioning Level: Brain death implies that we remain alive as long as the brain maintains a certain level of functioning but die when it loses that level of functioning. Life depends on a certain level of brain activity.

• Embryo Consideration: This implies a certain account of when we begin to be alive: we cannot begin to be alive until that same level of function is initially achieved. We can't be alive until our brain reaches a certain level of development.

• Embryo Argument: No one claims that a human embryo in which the brain is forming but has not yet become active is an inanimate entity. Even without a working brain, an embryo is considered alive.

• Inconsistency: If a human embryo one month after conception is a living human organism even though none of its functions is regulated by its brain because it has no brain, why then is a brain-dead but fully functional human organism sustained by a ventilator not also alive? If an embryo is alive without a brain, why isn't a brain-dead person on life support also alive?

• Defenders' Rationale: Those who defend the notion of brain death do so because they think it indicates when a human organism is no longer biologically alive. They believe brain death shows when the body is no longer alive.

• Not Necessary for Consciousness Loss: The death of the brain as a whole is not necessary for the irreversible loss of the capacity for consciousness. You can lose consciousness without the whole brain dying.

What Kind of Entity Are We?

• Body Identity: The biological death of a human organism is necessarily the death of a person only if we are (in the sense of being identical with) human organisms. Death of the body only means death of the person if we are our bodies.

• Survival After Death: Those who believe that we survive the biological death and decomposition of our bodies cannot consistently believe that we are biological organisms. If we survive death, we can't just be our bodies.

• Anomalous Conditions: Various anomalous conditions show that we cannot be organisms. Unusual cases prove we are more than just our bodies.

• Dicephalic Twinning: Dicephalic twinning is a radically incomplete form of conjoined twinning in which two heads sit atop a single body. In these cases, there are two persons but only one human organism. Two people can share one body.

• Craniothoracopagus: Craniothoracopagus, in which there is one brain and one head, below which there appear to be two bodies, each with its own set of organs, either of which could in principle be separated from the other and from the head, leaving a complete living organism behind. One head can have two bodies, and either body can be separated and live on its own.

• Craniopagus Parasiticus: Craniopagus parasiticus, in which one conjoined twin is fully developed but the other has failed to develop a body.

• Rarity: There are only 11 recorded cases of this phenomenon, but two have occurred in the twenty-first century. This is a very rare condition.

The Soul

• Precarious Foundation: The idea that we are souls is a highly precarious foundation for our beliefs about the nature of death. Basing our beliefs about death on the idea of the soul is uncertain.

• Animal Souls: Do animals have souls, and, if not, how can one detect the presence of the soul in a human embryo while being confident of its absence in a chimpanzee? If only humans have souls, how can we tell when they appear?

• All-or-Nothing: Assuming that souls do not come in degrees, so that the possession of a soul is all-or-nothing, when in the course of evolution did our ancestors begin to be endowed with souls? When did our ancestors start having souls?

• Detectable Difference: Was there a detectable difference between the parent who lacked a soul and the child who had one? Could you tell if someone had a soul or not?

• Impact on the Brain: If the soul can survive the death of the human organism and retain its full psychological capacities in a disembodied state, why are one’s psychological capacities or states affected at all by what happens to one’s brain? If the soul is separate from the body, why does brain damage affect our minds?

• Embryo Division: What happens to the soul of an embryo that divides and is replaced by two new embryos? What happens to the soul when an embryo splits into twins?

• Severed Hemispheres: What happens to the soul when the tissues connecting a person’s cerebral hemispheres are surgically severed, creating two separate centers of consciousness, each capable of experiences inaccessible to the other? What happens to the soul when the brain is split into two?

• Departure Timing: What reason is there to suppose that the soul departs from the body at brain death rather than, for example, at the onset of persistent vegetative state? Why would the soul leave at brain death and not at another time?

Minds and Consciousness

• Ceasing to Exist: I think we should conclude that you ceased to exist along with the capacity for consciousness. We stop existing when we lose consciousness.

• Mind as Essence: That suggests that you are essentially an entity with the capacity for consciousness – a mind. We are, at our core, minds.

• Sustaining Brain: Each of us is a mind, a subject of consciousness, which is sustained by the functioning of his or her brain, which is in turn sustained by the functioning of his or her organism. Our minds are supported by our brains, which are supported by our bodies.

• Irreversible Loss: We cease to exist when we irreversibly lose the capacity for consciousness. We die when we can no longer be conscious.

• Higher Brain Criterion: The best criterion for when this happens is some form of “higher brain” criterion. The best way to tell when this happens is to look at the higher brain.

Persistent Vegetative State

• Higher Brain Criterion: A higher brain criterion is the correct criterion for determining when we cease to exist. Looking at the higher brain is the right way to determine when we die.

• Person vs. Organism: The death or ceasing to exist of a person is not equivalent to the biological death of a human organism. The death of a person is not the same as the death of the body.

• Distinguishing: We must distinguish between the person and the organism and thus between the death or ceasing to exist of the person and the biological death of the organism. We need to separate the person from the body.

• Vegetative State: Persistent vegetative state involves the ceasing to exist of the person but not the biological death of the organism. In a vegetative state, the person is gone, but the body is still alive.

• No Rights: A human organism that does not and cannot support the existence of a person does not have interests or rights. A body without a person has no rights.

• Only Difference: The only difference between a genuinely persistently vegetative patient and a fully functional but brain-dead organism is that some of the former’s functions are regulated by the brain stem whereas those same functions in the latter are triggered by the combination of the ventilator and the decentralized action of other body parts. The only difference is how the body's functions are controlled.

• Moral Status: A living human organism in which all possibility of consciousness has been lost has much the same moral status as a human corpse. A body that can't be conscious has the same moral status as a dead body.

Organ Transplantation

• Respect for Corpses: We do not think that corpses have interests or rights, but we recognize that there are ways in which it would be disrespectful to treat them. Corpses don't have rights, but we should still respect them.

• Vegetative Organism: Precisely the same is true of a persistently vegetative human organism: there are various forms of respect that it is owed by virtue of its association with the person who once animated it. We should also respect vegetative bodies.

• Permissible Use: It can be permissible to use a corpse’s organs for transplantation, provided that this is not done against the will of the person whose body it was, so we should conclude that it is not disrespectful of a person to take organs from his persistently vegetative organism, even though that involves killing the organism, provided that it is not done against his will. It's okay to use organs from corpses and vegetative bodies if the person agreed to it.

• Advance Consent: People should be allowed to forbid the taking of their organs for transplantation after they lapse into a persistent vegetative state. People should be able to say they don't want their organs taken.

Uncertainties and Research

• Moral Objection: The most serious moral objection to taking organs from persistently vegetative patients, even with their advance consent, is that at present there is often uncertainty about their condition. We are often unsure about the condition of vegetative patients.

• Possibility of Recovery: The two most important forms of uncertainty concern the possibility of recovery and the possibility of consciousness of which external observers are unaware. We don't know if they might recover or be conscious in some way we can't detect.

• Recent Research: Recent research has demonstrated that some people who had satisfied the clinical criteria for persistent vegetative state had not in fact lost the capacity for consciousness. Some people who seemed vegetative were actually still conscious.

• Neuroimaging Techniques: One of the problems is that the sophisticated new neuroimaging techniques that have made these discoveries possible are quite expensive and are often not covered by medical insurance. The technology to detect consciousness is expensive.

• Informed Decisions: Unless such technologies are used and show that this is the case, it could be wrong to kill a patient diagnosed as persistently vegetative in order to remove her organs for transplantation, even with her advance consent. We need to use these technologies to make informed decisions.

• Treatment and Organ Use: We could then treat those who would be determined to have some chance of recovery and use the organs of those beyond the possibility of recovery to save the lives of others. We can treat those who might recover and use the organs of those who won't.

• Brain Stem Consciousness: We cannot yet entirely rule out the possibility that even in patients whose cortex is wholly dead there might be some dim, flickering, primitive form of consciousness in the brain stem. There might be some consciousness in the brain stem