Brain Death and Spontaneous Breathing

When is a person dead? Or more precisely: what criterion should be used to determine when someone is declared dead? The answer may have great practical importance, for perhaps it should determine when medical efforts whose aim is to sustain a patient's life may be discontinued or when a patient's organs may be removed for transplant to others. If the wrong criterion is used—if someone is not already dead when these things are done—then in doing some of them we may kill him, and this, many will say, is wrong.

The contemporary debate about this issue focuses on at least four different positions. One is the traditional cardiopulmonary criterion (CPC): a person is dead when his heart permanently stops beating and he permanently does not inhale and exhale air. The possibility of attaching people to respirators that artificially induce respiration has, in the minds of some, created problems for the CPC, because, they argue, someone can be dead even though a machine is mechanically producing respiration. Among those who raise this problem for the CPC are the proponents of a second criterion for death, the death of the whole brain (WBC). More accurately, they claim that a person is dead when no part of the brain survives that supports integrated functioning of the organism. It is the latter, they say, that characterizes life and in the case of humans, it cannot be present when significant parts of the brain die. Cardiopulmonary activity is a sign of life only if it is a sign of such brain activity, and it is not such a sign when produced by machines.

The WBC has come under attack from two different directions. Some have claimed that integrated functioning of the organism can be present when tests for whole brain death are satisfied. For example, growth, healing, neurohormonal regulation, and other organism-wide functioning have been said to occur in those who satisfy these tests.¹ The problem here seems to be that the tests are not adequate to accurately determine death of the whole brain which is the WBC. However, at least hypothetically it could be true that the WBC was satisfied and yet integrated functioning of the organism continued. (Indeed, it has been argued that cases presented by Dr. Alan Shewmon do involve integrated functioning in the definite presence of whole brain death.)² If integrated functioning of the organism is what characterizes life, then whenever it is still present, death is not. Hence, absence of integrated functioning per se could be peeled apart from the WBC and be used as a third criterion (which I shall call the integrated functioning criterion, IFC).

It is my understanding that in cases in which there is said to be integrated functioning when the whole brain is dead and/or the tests for WBC are met there is held to be some spontaneous integrated functioning of the organism although there is also partial artificial life-support (e.g., a ventilator). What if the integrated functioning of the organism as a whole itself was artificially produced? Would it still be a characteristic of life? The WBC was introduced at a time when such artificial production of integrated functioning of the organism as a whole was not possible. Robert Truog claims that is now possible.³ Arguably a system whose integration is maintained artificially would be alive just in virtue of integrated functions of the whole even if they are mechanically generated. If artificial integration were not sufficient for life, the theory that life is integrated functioning of the organism would face a problem. That higher consciousness is sufficient for life but is not integrated functioning of the organism as a whole is another problem. Higher consciousness could be present if there were arti fi cial integration of the organism. If the latter was not sufficient for life but the former was sufficient, then life would not have to be constituted by integration of the organism as a whole. This would be a criticism of the IFC. (It would be a criticism of the WBC only if higher consciousness...