Why is a patient with a destroyed brain considered dead rather than moribund and irreversibly comatose? The world has been grappling with this question for the past four decades with little success. The recently released white paper of the President's Council on Bioethics is in many respects a refreshing, thoughtful, and comprehensive reexamination of this complex topic.1 It offers a very helpful analysis of the major positions on the determination of death, and it proffers a creative new solution of its own. Unfortunately, the new solution does not put the problem to rest, but the humility with which the council discusses its own position and the honesty with which it confronts the consequences of being wrong alone make this report a very commendable document.
What is refreshing about the white paper emerges best when it is put in historical perspective. In 1968, the Harvard Committee catalyzed a monumental socio-medico-legal revolution: the reformulation of death in terms of brain function.2 The only rationale given by the committee for why the irreversible cessation of all brain functions should be equated with death was legal utility: it would free up beds in intensive care units and facilitate organ transplantation.
The Harvard report ushered in a brief era of wild transplantation.3 In a domino effect beginning in 1970, state after state revised its statutory definition of death, despite the absence not just of official diagnostic criteria for irreversible cessation of all brain functions, but also of any generally accepted philosophical rationale for why irreversible nonfunction of the brain should constitute death. By 1978, over thirty different diagnostic criteria had been published, none of them validated; neither had any consensus on the conceptual basis emerged.4
The next milestone in the history of "brain death" was the 1981 President's Commission.5 Its comprehensive report included a proposed Uniform Determination of Death Act (UDDA), which served as the model for the remaining twenty-three states that had not yet revised their death statutes to include a brain-based criterion. Its medical consultants proposed a set of diagnostic criteria that instantly became the standard for the United States. And most importantly, it articulated a then-plausible rationale for equating irreversible cessation of all brain function with death—namely, the loss of integrative unity of the organism. It argued that the brain is the body's central integrator, without which the body necessarily and imminently literally "dis-integrates" and succumbs to asystole despite all technological interventions. The President's Commission also maintained that "brain death" and ordinary death are physiologically identical states, only in the former case the equivalence is "masked" by artificial ventilation and circulatory support. That same year, James Bernat, Charles Culver, and Bernard Gert published an influential paper promoting even more forcefully the integrative unity rationale, which quickly became the mainstream conceptual justification for brain death in the United States and many other countries.6
Over the next two decades, however, new clinical data made it increasingly clear that patients with total brain [End Page 18] failure were not physiologically identical to non-heart-beating corpses, and they did not necessarily "dis-integrate" despite all technological support. Moreover, the rare longer-surviving ones exhibited holistic properties such as homeostasis, proportional growth (of a child), teleological repair, and general ability to survive outside a hospital setting with relatively little support (ventilator, tube feedings, and nursing care—much less than many sick patients in intensive care units require, who are nevertheless clearly living organisms). Such properties are difficult to reconcile with the mainstream assumption that these bodies were nothing but bags of partially interacting subsystems.
The mainstream rationale also made little headway into the minds of people at large. Even now, reporters refer to "brain-dead" patients as being "kept alive" by machines or as "dying" when the ventilator is turned off. Much of the public and a surprising proportion of the medical profession still consider "brain-dead" patients "as good as dead" or "better off dead," but not yet really dead. Moreover, many who do regard them as dead do so on the grounds of loss of...