The Evolution of Death and Dying Controversies

When the Institute of Society, Ethics and the Life Sciences (now The Hastings Center) began its death and dying work in 1970, the first task was to disentangle the definition of death from decisions to forgo life support. We were still in an era when it was often assumed that if one was alive, then health professionals should launch a full-court press to preserve life. The members of the Institute’s Task Force on Death and Dying went to work teasing these two questions apart.

The first major public product contributed to making this basic distinction. A symposium at the American Association for the Advancement of Science (AAAS) in December 1970 included papers directed at clarifying the definition of death. Authors included task force members Robert Morison and Henry Beecher, who was also chairman of the Ad Hoc Committee of the Harvard Medical School that established the definition of brain death. In a debate between them and their commentators (Leon Kass and me), the issues were whether death was a process or a momentary event and whether any support remained for a cardiac definition of death. The process/event debate was published in Science.¹ The clear result was the recognition that while dying is a process (one that is extremely hard to differentiate from chronic illness), death itself is a momentary event, a bright line marking the boundary between being a member of the human community of the living and those formerly living.

Early on, we recognized the crucial public, social, psychological, and legal significance of a categorical distinction between life and death. This distinction must be clear to decide whether spouses count as widows or assaults as homicides, for example, or whether life-insurance policies should pay off and assassinated presidents be succeeded by their vice presidents. If one accepts what is called the “dead donor rule,” being dead is a necessary condition for legitimately procuring life-prolonging organs. We also recognized that the cluster of issues traditionally associated with death might be disaggregated so that some of the conditions could be separated from the pronouncement of death. Under special circumstances, for example, life insurance might pay off while one was still alive, such as in programs in which the terminally ill are allowed to collect their insurance (at a discounted rate) in order to pay medical and other bills. One of the conditions that The Hastings Center research disaggregated early on was forgoing life support.

With forty years of hindsight, it is remarkable how simple the definition-of-death debate seemed back then. We recognized only two options at that time: one died either when circulatory function ceased irreversibly or when all brain functions stopped irreversibly, and most of us thought the brain function option was the more rational, modern view. Moreover, no one questioned the dead donor rule, although many realized that a lot more was at stake in the debate over definition of death than just the procurement of organs. The early work of the task force (eventually called the “research group”) led to a consensus in favor of a whole-brain-based definition of death. The position was endorsed by the entire group (although some of the more thoughtful, provocative members pressed hard about the potential dangers of abandoning the cardiac definition).² This effort led two group members to propose a carefully crafted whole-brain definition that eventually shaped the work of the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.³

Toward Greater Complexity

In retrospect, this simple two-option choice was already in jeopardy by the time of the AAAS meeting. Henry Beecher’s unpublished presentation contained a hidden challenge.⁴ In defending the critical role of the brain, he argued that “the individual’s personality, his conscious life, his uniqueness, his capacity for remembering, judging, reasoning, acting, enjoying, worrying, and so on, reside in the brain, and . . . when the brain no longer functions the individual is dead.”⁵

Beecher was obviously correct that these functions reside in the brain. The challenge however, comes when we realize that...