"Irreversibility" and the Modern Understanding of Death

By John Fortunato
Discussions
2013, Vol. 9 No. 2 | pg. 1/3 |

INTRODUCTION

Recent advancements in medicine have resulted in technology that allows us to have a better understanding of the essence of life. In turn, this has allowed us to more precisely identify the moment of death through certain criteria, whether through the cardiopulmonary criteria of death or through the newer, brain-oriented criteria of death. According to modern medicine (up-to-date medical technology and health care practices), human life is best measured by evaluation of brain function; however, the specific brain function that most directly relates to the essence of life has not been determined and is often debated (Wijdicks, 2012). At present, the criteria for brain death in the United States are broad, requiring whole brain death to be determined in order for death to be declared. Until further medical advancements again redefine the understanding of the “essence of life,” the criteria of whole brain death is appropriate for practical use, as it captures the essence of life.

As a result of new brain death criteria, questionable and previously uncharted medical situations, including “do not resuscitate” orders, organ procurement and donation, and research on brain-dead patients, have arisen. These issues have increased the need for practical and definitive criteria for the determination of death. One proposal states that not only must an individual appear to be brain dead in a given moment, but they also must irreversibly meet brain-death criteria. While irreversibility has been identified by some as an ambiguous term that does not belong in the definition of death (Cole, 1993; Cole & Lamb, 1992), others argue that the criteria to determine irreversibility are ethically dependent (Lizza, 2005; Tomlinson, 1993), or that “permanence” can be used instead of “irreversibility” to measure death under the cardiopulmonary criteria (Bernat, 2010). In this paper, I will argue that due to modern medicine and our increasingly precise criteria, irreversibility should remain in the definition of death. In addition, I will argue that the criteria that measure death and its irreversibility cannot be influenced by ethics or medical availability. Instead, irreversibility must first be measured only by the capabilities of medical technology first. Only then may ethics and other factors be considered.

A NEW CONCEPT OF DEATH

In 1968, the Ad Hoc Committee of the Harvard Medical School proposed criteria for the diagnosis of brain death with the intention of setting irreversible coma as the benchmark for death. The criteria included (1) unreceptivity and unresponsivity, (2) no movements or breathing, (3) no reflexes and (4) a flat electroencephalogram (a common test used to measure certain types of neurological activity). These standards must be met again 24 hours after they were initially satisfied, and must exclude cases of hypothermia and central nervous system depressants (School, 1968).

In the ensuing years, several other institutions also developed protocols to diagnose brain death. The University of Pittsburgh, Johns Hopkins University, and the National Institute of Neurological Disorders and Stroke all developed guidelines similar to Harvard’s (Watson, 1980). State legislatures also began producing laws that used brain death criteria to define death. In 1981, The President’s Commission recognized both the cessation of circulatory/ respiratory function and the death of the entire brain, including the brain stem, as death (Research, 1981). Today, all fifty states in the United States have laws that include total brain death criteria as acceptable criteria for the declaration of death.

These new criteria for death were developed in accordance with advancements in medical technology. Traditional standards of death were challenged by new equipment such as the ventilator, which can replace lost respiratory function, allowing physicians to indefinitely prolong “life” as it was defined at the time. Stuart Youngner argues that the concept of brain death was developed by the Harvard Committee for two reasons: it allowed physicians to turn off respirators without fear of legal consequences, and it allowed organ procurement without violation of the dead donor rule (Youngner & Arnold, 2001), which simply states that donors must be declared dead by a physician with no conflict of interest before organ procurement begins (Gardiner & Sparrow, 2010). Clearly, related bioethical decision-making is only relevant because technology created ethically-questionable situations. Technological advancements in modern medicine are the foundation of related medical and ethical decision making.

A SLIPPERY SLOPE

Some scholars worried that the acceptance of brain death would create a slippery slope effect in which “surgical assaults” would consequently be sanctioned (Watson, 1980). Philosopher Hans Jonas warned, as Youngner did, that the primary motivation behind the effort of the Harvard Criteria was to expedite the removal of organs for transplantation (Jonas, 1974; Watson, 1980). He also wrote, “the permission [new brain-death criteria] implied in theory will be irresistible in practice, once the definition is installed in official authority.” In other words, once physicians and scientists accept brain death as death, they cannot help but slide down the slippery slope of “unethical” research. This slope includes medical practices such as keeping brain-dead patients on respirators until just before organ procurement begins, conducting surgical and grafting research on the brain-dead, and even using the brain-dead for immunological research and the testing of new drugs (Jonas, 1974; Watson, 1980).

Jonas’ concerns stemmed from an unnecessary, adherence to the cardiopulmonary criteria. Many of these once-perceived “surgical assaults” have become common practice. Organ donation from patients who have been declared dead by brain death criteria but whose bodies have been artificially kept alive has become common – in fact, over 90% of all donated organs come from such patients (Bresnahan & Mahler, 2010). Further research and testing of drugs on brain-dead patients has also emerged.

RESEARCH ON THE RECENTLY DEAD

There are a few records of research on brain-dead patients dating back to the early 1980s (Carson R.A., 1981; DeFrias C., 1980) and one additional report from the late 1980s (Coller B.S., 1988). Subsequently, though, interest in brain-dead research seemed to wane (Wicclair, 2008). However, in the early 2000s, a revitalization of interest was seen from renowned institutions in the United States. One institution that began approving research on the brain- dead was the University of Pittsburgh Medical Center. UPMC created a new panel, the Committee for Oversight of Research Involving the Dead (CORID) to regulate the then-completely-unregulated field of research on dead -- including brain dead -- patients. This committee was formed in response to the UPMC Institutional Review Board’s decision that such research was out of the Board’s jurisdiction because they only regulate research conducted on live patients. In its first year of existence, CORID reviewed 29 different studies from 17 different departments in the hospital and university (Yasko, Wicclair, & DeVita, 2004). Therefore, based on the University of Pittsburgh’s findings, Jonas’ hypothesis held true: once brain-death criteria were acceptable, or rather medicine “proved” that death occurred with the loss of whole brain function and the notion was seen to be ethically acceptable, subsequent research was irresistible in practice.

Although Jonas was correct in predicting that acceptance of brain death criteria would eventually lead to research on the brain-dead, his opinion that the slippery slope would take medicine down the wrong path is controversial. Many would argue that instead, it took medicine down the correct path. Medical advancements have allowed medical practice to advance and develop more precise criteria for death. Thus, brain death criteria and approval processes like CORID have helped limit potentially controversial practices and encouraged respectful, ethical and extremely beneficial research.

IRREVERSIBILITY: FUNDAMENTAL, YET AMBIGUOUS

Research on brain dead-patients increases the need for precise brain death criteria because post-mortem action is often quickly taken. Protocols call for the determination of brain death by a physician independent of the research team (DeVita, Wicclair, Swanson, Valenta, & Schold, 2003; Pentz, Flamm, Pasqualini, Logethis, & Arap, 2003). It is especially important that close attention is paid to the irreversibility of death of patients who seem to be brain dead. Inherently, death needs to be irreversible by definition, or else it would not really be death. In addition, there are several medical conditions, such as hypothermia or the presence of depressant drugs in the blood, which can result in apparent brain death for an extended period of time (Harley, 1983; School, 1968). When these apparently brain-dead states are, in fact, reversible and the patients can recover, the patients are obviously not dead. However, if these patients were tested for brain death without acknowledgement of their special cases, their death could be incorrectly declared. First, it is important that irreversibility is included in the definition of death due to both the common understanding of death and irreversibility’s intrinsic nature as a counterpart of death. It is also important that, due to these special cases, doctors pay close attention to the criteria of brain death that are set forth to satisfy the irreversibility of each case before any research is conducted.

How should we understand “irreversibility”? It is a fundamental and natural component of death criteria, yet there has been some disagreement on the use of irreversibility amongst the academic community. In 1992, David J. Cole of the University of Minnesota Duluth argued that the term “irreversible” is an ambiguous term with multiple definitions and should not be used in the definition of death at all. Irreversible, according to Cole, could have three different meanings: (1) There is no logical possibility of restoring function now or in the future, (2) function cannot be restored with present technology and clinical skills, or (3) a morally defensible decision has been made not to restore function even though it may be technically possible (Cole, 1993; Cole & Lamb, 1992; Youngner & Arnold, 2001).
Cole acknowledges that medical technology has allowed us to keep patients alive or even resuscitate them. However, if not for these medical advancements, these people would have been declared dead. Similarly, he states that future technology may make it possible to restore a body that is dead by today’s criteria. Cole argues that irreversibility should mean that at no time present or future will anyone be able to reverse the condition (Cole & Lamb, 1992). In other words, irreversible should mean eternally permanent. Using this logic, since we cannot predict potential medical advancements in the future, the irreversible component of the definition of death can be neither measured nor satisfied. Thus, no one can ever clearly be dead, and a physician’s responsibility to a patient would then extend far past the present definition of death, such that there would be a responsibility to maintain cadavers in the best possible condition in anticipation of medical breakthroughs.

By presenting extreme examples where an individual could be dead at one moment but alive in the next, Cole makes his case as to why the term “irreversible” is inadequate and should not be included in the definition of death. To Cole, all conditions are potentially reversible, so there are no criteria that can measure irreversibility. Instead, he argues that the definition of death should correspond to the ordinary concept of death, where life processes cease and the organism loses the capability of resuming them (Cole & Lamb, 1992).

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