From Discussions VOL. 9 NO. 2
"Irreversibility" and the Modern Understanding of Death
IRREVERSIBILITY: AN ETHICALLY DEPENDENT TERM
Not surprisingly, there are many critics of Cole’s theory. Tom Tomlinson, of Michigan State University, believes that Cole’s new definition of death and its use of the “ordinary concept” is flawed. What does Cole mean when he says that death happens when “life processes cease”? Do they cease irreversibly? If so, Cole contradicts himself (Tomlinson, 1993).
Furthermore, Tomlinson states that Cole’s refutation of irreversibility is insubstantial. He points out that “if we can never really know whether the condition of death is reversible – then we can never really know whether we’ve made the condition less reversible or more reversible” by removing organs or doing experiments. Cole allows “sheer logical possibility” to carry heavy moral weight. By this logic, which says that we should not remove organs from the brain-dead because of the possibility of a medical breakthrough, Tomlinson contends that Cole should also “be loathe to turn on the light switch for fear that they are wired to someone’s bath tub” (Tomlinson, 1993).
Tomlinson proposes that irreversibility should remain in the definition of death. However, “irreversible” should not be taken to mean “logically impossible,” because that definition would lead us to a conclusion similar to Cole’s. Rather, it should be understood to mean that “the possibility for reversal is not ethically significant.” Let us say, for example, that an organ donor under the Pittsburgh protocol decides that he would not like to be resuscitated in the event of cardiac arrest. Thus, should he undergo cardiac arrest, it would be unethical to resuscitate him, and therefore, once his heart stops, he is “irreversibly” dead due to ethical obligation, despite the possibility of medical resuscitation (Tomlinson, 1993).
PERMANENCE: CIRCULATORY AND RESPIRATORY TESTS FOR DEATH
James Bernat makes a similar argument to Tomlinson’s after applying the concepts to cardiopulmonary death criteria. Bernat argues that “permanence” is more appropriate than “irreversible” when measuring death using cardiopulmonary criteria. Bernat states that “permanent cessation of circulation constitutes a valid proxy for its irreversible cessation because it quickly and inevitably becomes irreversible and because there is no difference in outcome between a permanent or irreversible standard” (Bernat, 2010). In this example, the patient in the example used earlier would be declared dead because his cardiac arrest is “permanent,” while Tomlinson, using an ethically- tied definition of irreversible, would argue that he is dead because his cardiac arrest is irreversible.
IRREVERSIBILITY: THREE FACTORS
Philosopher John P. Lizza dismisses Cole’s arguments because “Cole invokes a notion of possibility that is irrelevant to the practical matter of defining and determining death” (Lizza, 2005). Instead, Lizza focuses on developing a more plausible and realistic sense of irreversibility. He proposes three factors that influence irreversibility: (1) the physical state of the person, (2) physical factors external to the person, and (3) individual and social decisions. The physical state of the person refers to the condition of the physical body and whether or not it is capable of healing itself or undergoing medical resuscitation and recovery. Physical factors external to the person include both (a) the availability of medical technology and treatment and (b) the ability of current technology to treat or reverse the condition. For example, an individual in cardiac arrest on an uninhabited island does not have access to medical equipment, so medical resuscitation is not possible and the condition is most likely irreversible. As another example, an individual who has lost brain function and has passed all tests for brain death is deemed irreversibly dead, simply because we do not have any technology that allows us to regenerate brain function. Finally, as Tomlinson argues, individual and social decisions refer to the ethical obligations held by health care providers to satisfy the wishes of patients, such as “do not resuscitate” (DNR) orders.
IRREVERSIBILITY: DEFINITION OF DEATH, OR CRITERIA?
In light of the arguments discussed above, it is crucial that a clear distinction is made between the definition of death and the criteria for determination of death and that it is determined whether or not irreversibility as each author discusses it applies to one or both of these concepts. Clearly, Cole questions the validity of irreversibility in the definition of death, while Tomlinson and Lizza logically reject that notion. Irreversibility is inherent to death. In a broad sense, the definition of death, “the irreversible end of life,” never changes. Instead, the criteria from which we measure death and its irreversibility changes throughout time. However, Tomlinson and Lizza never make the distinction between definition and criteria. Their proposals are most coherent when viewed not as attempts to redefine death, but rather, as suggesting specific criteria to measure irreversibility in death, given that irreversibility is a component in the definition of death. This model allows their arguments to have more clarity.
On the other hand, James Bernat does make a distinction between the definition and criteria of death throughout his argument (Bernat, 2010) (Bernat, Culver, & Gert, 1981). As “the irreversible cessation of total brain functions” defines death, medical and technological testing for irreversibility of brain function is used as criteria. The definition, “the irreversible cessation of total brain functions” is used to define death, using medical and technological testing for criteria. However, using the cardiopulmonary criteria, the person must be “permanently dead,” as permanence serves as a surrogate for irreversibility. His explicit distinction between the “definition” of death and “criteria” for death makes his argument much more comprehensible and clear.
All of the factors proposed by Lizza, including Tomlinson’s ethics factor, are important considerations when attempting to identify criteria for the determination of irreversibility. In fact, Lizza may have proposed the most coherent and conclusive criteria yet. However, Lizza makes little comment on the value of each of his three factors in relation to one another: All of the factors depend on modern medicine. Throughout the history of medical and technological improvements, we have continued to increase the precision of the criteria of death. However, as medical technology continues to improve, the criteria that determine the irreversibility of death will change.
IRREVERSIBILITY: THE PHYSICAL STATE OF THE PATIENT
Most obviously, Lizza’s first factor, the physical state of the patient, is dependent on modern medicine. For example, before the use of defibrillators, respirators, or CPR, the status of any individual who sustained cardiac arrest would qualify under factor one as “irreversible.” Their body’s physical state was sufficiently damaged enough to prevent further life because medicine did not know how to reverse or repair the damage. Today, however, cardiac arrest is an insufficient state to determine irreversibility due to our sophisticated medical technology that can re-start a heartbeat and induce pulmonary function. In addition, we now know that cardiac arrest is not the best measurement of death, but rather may be a precursor to brain death. Using Lizza’s own words, the constitutive factors of death may change over time. With it, so too will the degree to which the physical state of an individual may be irreversible. Thus, the physical state of a person must be considered only in light of modern medicine.
ETHICAL INFLUENCE ON IRREVERSIBILITY OF DEATH
As previously discussed, both Tomlinson and Lizza agree that there is an ethical component of brain- death criteria. They use the example of a patient with a DNR order to show how once the patient’s heart stops, there is an ethical obligation to not resuscitate the patient. Thus, barring autorecuscitation, the person is considered dead, while ethical constraints resulted in (physical, actual, whatever) death.
Ethical decisions, just like the other factors previously discussed, are also dependent on modern medicine. Individuals who have DNR orders would not need them in the first place if it weren’t for our technological capability to resuscitate people in cardiac arrest. Today, the capability and accessibility of resuscitation may have varied thresholds as some patients view resuscitation as a “violent and traumatic event.” One patient said resuscitation means “pain then, and pain when - and if - I survive” (Downar et al., 2011). Public perception reflects the fact that resuscitation can cause pain and does not always result in full recovery. If medicine were to advance and improve resuscitation, theoretically resulting in 100% recovery rate and minimal pain, one could assume that the number of DNR orders would decrease dramatically. Clearly, we must be cautious in giving priority to patient wishes over scientific fact in the determination of death when an improvement in medical technology could influence a dramatic change in the wishes of patients.
Let us examine a hypothetical situation given two patients, Patient A and Patient B, who both go into cardiac arrest. Patient A has a DNR, but patient B does not. Using Tomlinson’s model, ethical constraints cause us to pronounce Patient A dead in accordance with the guidelines for declaration of cardiopulmonary death. On the other hand, because Patient B does not have a DNR order, doctors will attempt to resuscitate him long after his heart has stopped. Thus, despite having the exact same condition, one individual is considered “dead” while the other is considered “alive.”
A similar situation arises when the availability of technological equipment is used to determine irreversibility. Instead of having a DNR order, let us say Patient A undergoes cardiac arrest on an uninhibited island, while Patient B undergoes cardiac arrest in front of a hospital. Using availability to determine irreversibility, Patient A would be declared dead once he entered cardiac arrest, while Patient B would not be declared dead and would receive resuscitation. Again, despite having the exact same condition, one individual is considered “dead” while the other is considered “alive.”
James Bernat claimed that “permanence” is an acceptable replacement for irreversible when using cardiopulmonary criteria for death because it has already become “common medical practice” (Bernat, 2010). Instead, we should be much more concerned with proper medical practice. Although cardiac arrest in a patient with a DNR is permanent and leads to inevitable death, that patient is not dead because they have not yet met the other criteria for death that declare them to be irreversibly dead. Therefore, permanence, although it always leads to irreversible death and accurately predicts death, is not an adequate measurement of death.Continued on Next Page »