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D. Alan Shewmon replies:
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Alan Rubenstein highlights the crux of the debate over "brain death" or "total brain failure." It boils down to whether the original term "coma dépassé" represented an insight or an exaggeration; also to whether the "uniqueness" of total brain failure is anything more than that of any extreme of a spectrum.

Total brain failure's supposed uniqueness is actually contradicted by its heterogeneity. Some cases have diabetes insipidus; others do not. Many exhibit cardiovascular instability, but some do not. Some have widespread multiorgan damage, while others have pure brain pathology. Some of the former are what I call "dead brain-dead," whereas many of the latter have every logical right to the same vital status as irreversibly comatose and apneic patients who have some residual brainstem reflex and are by legal and medical standards alive. Total brain failure is also pathologically heterogeneous. Some even debate what "total" means (or should mean) in "total brain failure."

But even when brain failure is truly "total," why is this not simply the extreme in the spectrum of coma, rather than something beyond it? The example of the embryo should not be so quickly dismissed. As Rubenstein indicates, we must look for other signs to judge its life/death status: namely, the antientropic dynamics underlying self-maintenance and self-development. In this respect, total brain failure patients with holistic properties resemble embryos, in that their survival depends on connection via "tube" with a "maternal ICU." If a postnatal organism cannot do something it is supposed to do by nature, this is called a disability. Why should the internal criteria that categorize embryos as alive not apply also to total brain failure patients, with unconsciousness and apnea constituting disabilities? Position two is a laudable attempt to rescue brain death, but time will tell how convinced the rest of the world will be.

Potential donors have a right to know that there is serious debate over whether they will be dead at the time of organ extraction. So do families of total brain failure patients approached by procurement representatives. Informed consent means nothing if it does not include such information. The quotation from Osler about uncertainty applies to most of medicine, but not to the diagnosis of death, where there is no ethical room for false positive diagnoses.

John Lizza's analogy with decapitation has been raised by many, including me. Space does not permit elaborating, except to refer to my book chapter, "Mental Disconnect: 'Physiological Decapitation' as a Heuristic for Understanding 'Brain Death'" (in M. Sanchez Sorondo, ed., The Signs of Death, Vatican City: Pontificia Academia Scientiarum, Scripta Varia 110, 2007, 292 333). In essence, the thought experiment does not shed physiological light on brain death, but requires actual brain death to shed light on it. Nor does it illuminate the ontological aspect; rather, one brings to both the thought experiment and clinical brain death predecided views on the nature of personhood.

In reply to Menzel, one need not be a Kantian to agree that persons should not be used as mere means to an end. Whether "to treat the person as an end in herself " implies that a competent person can legitimately ask to be mutilated or killed for someone else's good is hardly self-evident, and disagreeing with such an implication is not "temerity." I do not consider the dead donor rule sacrosanct or equivalent to the universal injunction against intentional killing of the innocent. As written elsewhere, I believe that, in principle, certain nonheart beating approaches to organ retrieval can fulfill the prohibition against killing, even though they violate the dead donor rule. Menzel, Truog, and others are right to call a spade a spade regarding the charade of death declarations in current transplantation practice.

Project MUSE® - View Citation
Alan Rubenstein. and John P. Lizza. and Paul T. Menzel. "And She's Not Only Merely Dead, She's Really Most Sincerely Dead." Hastings Center Report 39.5 (2009): 4-6. Project MUSE. Web. 8 Jul. 2014. <http://muse.jhu.edu/>.
Rubenstein, A. & Lizza, J. P. & Menzel, P. T.(2009). And She's Not Only Merely Dead, She's Really Most Sincerely Dead.Hastings Center Report 39(5...

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