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Chapter twelve The Irreversibility of Death Metaphysical, Physiological, Medical or Ethical? Tom Tomlinson Current law in the United States, under the Uniform Anatomical Gift Act, prohibits the removal of vital organs for donation before the donor has been declared dead. This requirement raises a question about so-called “Donation after Cardiac Death” (DCD) organ procurement protocols. In such protocols, ethically warranted decisions are first made to withdraw a life-sustaining ventilator from patients who are severely brain-damaged but not brain dead, followed by agreement to organ donation . The withdrawal of the ventilator quickly leads to death in most cases, after which the organs may be removed. The question concerns the standard condition in ethical and legal criteria of death that the loss of the vital functions, whether brain- or heart-oriented, be “irreversible.” But when does death become irreversible in the DCD context? For example, the University of Pittsburgh Medical Center’s protocol states that removal “cannot begin until the patient meets the cardiopulmonary criteria for death, that is, the irreversible cessation of cardiopulmonary function” (UPMC Policy 1993, A6). The procedures then go on to specify when “irreversible” cessation has occurred. When the patient’s heart is unlikely to resume beating on its own—when “autoresuscitation ” is unlikely to occur—the patient is dead. In the UPMC protocol, this is set at just two minutes after the heart has stopped beating. Thus, under the protocol , a patient whose cardiopulmonary arrest might well be reversible by means of standard CPR or by other medical means could nevertheless be declared dead for the purpose of organ removal. This rapid determination of death serves the ultimate transplantation purposes of the protocol because it minimizes organ damage from warm ischemia. But does it do so by an ad hoc and objectionable redefinition of the proper meaning of “irreversible ” in the standard definitions of death? 238 Tom Tomlinson The answer to this question may seem to turn simply on what we mean by “irreversibility .” But I will argue that there neither is nor should be a single fixed meaning of “irreversible” in determining when someone has died. The criteria for determining irreversibility will vary with the contexts in which determinations of death are made. A person who would properly be declared dead in one context might not be properly declared dead in another. In what follows, I examine four types of criteria for determining the irreversibility of death: metaphysical, physiological, medical, and ethical. How does each fare in the variety of contexts in which death must be declared? Metaphysical Irreversibility David Cole thinks that the irreversibility condition in the standard definitions of death could only refer to a kind of metaphysical irreversibility—irreversible in all possible worlds one might say. Cole points out that since we cannot predict what future scientific and medical advances might be able to do with a “dead” body, we can’t ever say with certainty that a person’s loss of vital functions would never be reversible. If irreversibility were a necessary condition for death, it would then be impossible to ever determine that someone had died. Cole concludes that irreversibility cannot properly be part of the concept of death. The irreversibility condition should be jettisoned in favor of a more “ordinary” concept of death that permits declarations of death such as those permitted in DCD protocols : On my view, the ordinary concept of death involves loss of capacity for autoresuscitation , but the concept is compatible with reversal by extraordinary therapeutic procedures. . . . Thus . . . the operational definition embodied in the criteria set forth in the UPMC protocol is closer, I think, to the ordinary concept of death than the explicit definition of death it purports to satisfy. (Cole 1993, 150–51) Cole’s reasoning is set out in more detail in an earlier article published in the Journal of Medical Ethics. Irreversibility cannot not be part of the ordinary concept of death, Cole argues, because otherwise it would be a plain contradiction to say, “X was dead but later was brought back to life” (Cole 1992, 27). In addition, Cole argues that both strong and weak construals of an irreversibility requirement have unacceptable implications for our treatment of the “dead.” If “irreversible” is taken in a strong sense to mean “can never be reversed,” then “no one, on this strong construal of the irreversibility condition, is clearly dead . . . [because] . . . at some time in the future it may be possible to restore a body in very The Irreversibility of Death 239...


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