Editor’s Note

Bioethicists have, of course, always been concerned with death: we have asked when should we allow it to happen without trying to stave it off any longer; whether is it ever acceptable for doctors to hasten or cause it; how can we make death a dignified and relatively humane experience for the dying and for their loved ones; and how we can and cannot treat human remains. We discussed all of these classic ethical issues even when death itself seemed to be a fairly straightforward, all-or-nothing concept: life and death were natural, biological states, and people were either alive, with a beating heart and a working brain, or they were dead, and everything in them had stopped. But over the last several decades, technological advances have made the nature of death itself more and more complicated and philosophically puzzling, and less and less binary. We can now replace natural hearts with artificial hearts, sustain “life” artificially even in the absence of any sort of agency or consciousness, and distinguish between the “death” of different parts of the brain. For these reasons, it is no longer obvious what counts as death or being dead. And concomitantly, we face new ethical issues around interventions into life and death that cannot be reduced easily to ending or continuing life.

This issue of the Kennedy Institute of Ethics Journal contains a series of papers that explore some of these new ethical issues that arise as death becomes technically managed and broken into parts in new ways. Each paper explores its topic with concrete nuance, rather than as an abstract conceptual puzzle, and they thereby jointly display just how complicated the place of death in medicine has become.

In “The Total Artificial Heart and the Dilemma of Deactivation,” Ben Bronner asks when it is ethical to deactivate a patient’s artificial heart. On the one hand, since having an artificial heart is not a natural state but a kind of therapeutic intervention, it seems like it should be up to a competent patient to ask doctors to discontinue this intervention. On the other hand, many people think it is not permissible for a physician to intentionally kill a patient. Bronner explores this tension, which is produced by the blurring of the line between self-sustaining and artificially supported life. In “Sedation Until Death: Are the Requirements Laid Down in the Guidelines Too Restrictive?” Govert den Hartogh examines the ethics of sedation until death, focusing on guidelines that require the preservation of the patient’s consciousness to whatever extent possible. He argues that these guidelines are unjustified, and explores the ethical complexities involved in forcing consciousness upon a patient. Finally, in “Sustaining a Pregnant Cadaver for the Purpose of Gestating a Fetus: A Limited Defense,” Bertha Manninen looks at the painful topic of brain-dead pregnant women, whose fetuses develop into viable children if they are artificially kept “alive.” Brain-dead patients on life support are not neatly classifiable as either alive or dead, but their fetuses may be alive, albeit only in a special dependent and underdeveloped state. Balancing the needs and interests of two beings, neither of which can be quickly categorized either as a living person with interests or as a non-person, is a deep and tricky problem. Together these articles explore boundaries between life and death and the ethical complexities raised by our technological ability to manage these boundaries.

In addition, this issue features two essays that concern the codification of medical and bioethical norms. Harold Schmidt and Jason Schwartz, in “The Missions of National Commissions: Mapping the Forms and Functions of Bioethics Advisory Bodies,” provide a framework for thinking about what the ethical and practical role of national ethics commissions should be. We invest a great deal of energy into such commissions but so far they have operated without any settled or explicit view concerning what sort of voice they should adopt. Schmidt and Schwartz explore various roles for such committees, and defend a model in which they should be pluralist bodies that include a variety of ethical perspectives and interests. Finally, Thomas Huddle’s article, “Putting Patient Autonomy in...