PHI 227 Biomedical Ethics

Death And Dying

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  1. Background information
    1. The brain has three general anatomic/functional divisions:
      1. the cerebrum ("higher brain"), with its outer shell called the cortex. The cerebrum has primary control of consciousness, thought, memory and feeling.
      2. the cerebellum, which coordinates voluntary movements and maintains bodily equilibrium.
      3. the brain stem ("lower brain"). The brain stem has control of spontaneous vegetative functions such as swallowing, yawning, and sleep-wake cycles. It controls respiration, which maintains the correct levels of carbon dioxide and oxygen.
    2. Life-support machines, such as those supporting heart-lung operation, were developed in 1950s and 1960s.
      1. An artificial respirator is used to compensate for the inability of the thoracic muscles to fill the lungs with air.
      2. The heart can pump blood without external control from the brain. An intact heart can continue to beat despite loss of brain function. This can continue for only a limited time (2-10 days for adults, longer for babies) when the brain has entirely ceased functioning. At present, no machine can take place of the heart except for a limited time and in limited circumstances.
    3. Other relevant medical terms
      1. CPR: Cardiopulmonary Resuscitation
      2. Dialysis
      3. Nutrition/Hydration

  2. Traditional Conception of Death:
    1. Criterion Permanent absence of respiration and heartbeat
    2. Tests:
      1. Feeling for a pulse
      2. Listening for heartbeat and breathing using a sthetoscope
      3. Holding a mirror to nose to see if there is condensation which indicate breathing.
      4. Checking if pupils are fixed.

  3. Necessity of Revising the Traditional Criterion of Death
    1. Cases
      1. Brain-dead patients
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        1. The entire brain has ceased functioning, cerebral and brain stem.
        2. The patient is irreversibly unconscious.
        3. The heart and the lung cannot function without a respirator and other machines.
        4. Patient can be kept alive for up to three months.
        5. No brain-dead patient has ever recovered.
        6. No sleep-wake cycles
      2. Patients in Persistent Vegetative State
        1. The cerebral cortex is damaged but the brain stem function remains sufficient to sustain respiration and blood circulation.
        2. As a result of the damage to the cerebral cortex, consciousness and cognition are irreversibly lost.
        3. Patient has no awareness of his environment
        4. Patients can survive for years in this condition without a respirator.
        5. Few patients recovered.
        6. Reflexes but no spontaneous movements

    2. Problems Are brain-dead patients and people in persistent vegetative state dead or alive?
      1. Removing patient from respirator and/or stopping treatment.
        If the patient is dead then removing him from the respirator and/or stopping treatment do not pose any moral problem but if the patient is still alive the caregiver is hastening his death and this is morally problematic.
      2. Harvesting organs for transplantation
        If the patient is dead, there is no problem, provided that the patient or his family has consented to it. If, on the other hand, the patient is still alive, there is a problem.

  4. The Whole Brain Criterion of Death
  5. To deal with these problems, some physicians and ethicists suggested replacing the traditional criterion of death with the criterion of brain death. A person is brain dead when he has suffered irreversible and total brain damage even if he has a normal heartbeat and normal respiration. According to this new criterion, if a patient is "brain dead," removing life-support equipment or stopping treatment does not constitute either allowing someone to die or euthanasia.
    1. The Harvard Criteria In 1968, an ad hoc committee at Harvard Medical School developed the Harvard Criteria of brain death.
      1. Unreceptivity and unresponsiveness, no stimulus evokes any response
      2. No spontaneous movements or breathing (if patient is supported by a respirator, turn it off for three minutes)
      3. No reflexes
      4. A flat EEG. No brain activity.
      5. Repeat all tests after 24 hours
      6. exceptions:
        1. no hypothermia (<90o F.)
        2. no central nervous system depressants
      7. safeguards:
        The decision to declare a patient dead should not be made by physicians involved in later efforts to transplant tissue or organs. Declare patient dead before turning off respirator.

    2. President's Commission for the Study of Ethical Problems In 1981, the President's Commission for the Study of Ethical Problems wrote a report on criteria for death. The Commission regards only irreversible cessation of the functions of the whole brain -- including the brain stem -- as meeting the criteria of death. According to this criterion, a person who is in a persistent vegetative state is not dead but a person who can breath and have a heartbeat only through artificial means is dead.

  6. Higher Brain Criterion
    1. Some doctors and ethicists believe that someone who is in a persistent vegetative state but has suffered irreversible damage to the cerebrum or higher brain lacks and will permanently lack the minimum that makes life human, i.e., thinking, reasoning, feeling and human interaction. These patients are no longer persons. The whole brain criterion of death ought to be replaced with the higher brain criterion of death. Robert Veatch: Death is "irreversible loss of that which is essentially significant to the nature of man...[the] irreversible loss of embodied capacity for social interaction." Death, Dying, and the Biological Revolution (1976).
    2. Problems with the higher brain criterion
      1. severely senile patients and the severely retarded were no longer persons.
      2. Scientists are not certain where cognition and consciousness reside.

  7. Questions on the readings
    1. Veatch, "The Impending Collapse of the Whole-Brain Definition of Death
      1. What qualifications, according to Veatch, have undermined the whole-brain definition?
      2. What are the consequences of the collapse of the whole-brain definition of death for the assessment of significant brain activity?
      3. What does Veatch reply to the charge that the higher-brain approach can be undermined by a slippery slope argument?
      4. Even though Veatch favors a higher-brain definition of death, he advocates the incorporation of a "conscience clause" in any law that defines death. What does "conscience clause" mean?

    2. Truog, "Is It Time to Abandon Brain Death?"
      1. Give examples of how, according to Truog, the concept of "brain death" remains "incoherent in theory and confused in practice."
      2. For Truog, Definitions of death are irrelevant to issues of withdrawal of life support and organ transplantation, how does he suggest solving these problems?

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Last updated: April, 2001