The Definition of Death: Contemporary Controversies (review)

The Definition of Death: Contemporary Controversies. Edited by Stuart Youngner, Robert Arnold, and Renie Schapiro. Baltimore: Johns Hopkins Univ. Press, 1999. Pp. 368. $56.

Phillipe Aries, in Western Attitudes Towards Death from the Middle Ages, describes modern death as occurring with a whimper, not a bang. Today we die little by little. Aries attributes this to interventions of technology which temporarily sustain failing organ systems, thereby prolonging the onset of death. Helping the public, scholars, and professionals to understand the controversies swirling around the determination of death is one of the purposes of this book; another is to show how definitions of brain death and its criteria influence and are shaped by public policy; and a third may be that public awareness and possibly public consensus on determination of death could help to improve conditions and timing when organs are harvested for transplant. Death, understandably, is more than a biological event, and the moment of death is both elusive and socially constructed.

The Definition of Death is divided into seven sections, each of which examines a different aspect of the problem of defining death. This new volume is a treasure trove of information on legal, clinical, scientific, sociocultural, and ethical views that differ as to when death occurs and what kinds of criteria may be necessary to establish it. The editors are well-known in their studies of organ transplantation and brain death, and they provide a provocative examination of how society keeps changing the boundary between life and death. The contributors are experts of long-standing on these issues.

Few of us would consider a feather or mirror as an adequate test for respiratory function, yet this was one of the methods for determining death centuries ago. But modern definitions of death are as capable of provoking controversy as more ancient methods. There are three definitions of brain death (whole-brain death, brain-stem death, and higher-brain death), and the chapter by Pernick clarifies the distinctions between them. The current standards of the Uniform Determination of Death Act recognize both cardiopulmonary and whole-brain criteria in defining death, yet a lively discussion permeates the volume on the merits or weaknesses of one definition over the others. As might be expected, there are authors who prefer a situational approach (Brody, Charo), in which circumstances would dictate choosing to define death at a time that would be most beneficial.

Lynn and Cranford provide a chronological description of the process that typically takes place from the time a patient loses a critical function. In phase 1, the patient loses critical function, even though the loss may not be documented by a physician and it is not known, at this time, whether the loss is irreversible (e.g., coma, drowning). In phase 2, this loss of critical function is first discovered by examination (recovering the drowned victim, finding the comatose person). In phase 3, the discovery is made that the loss of critical function is irreversible; and in phase 4, the irreversibility is established and death can be known to have occurred in all cases. Phases 2 and 3 can be reversed, if the irreversibility of the loss occurs before the loss itself can be measured. All four phases can occur in very short order or can take days while confirmatory evidence of irreversibility is sought. Establishing parameters for the process of dying is of great value in situations when organs are being harvested, since transplant teams hope to transplant at the earliest time after death.

The chapter "Clinical Standards and Technological Confirmatory Tests in Diagnosing Brain Death" is distinguished not only by its author, but also by its clarity of thought and comprehensiveness. Plum has distilled a lifetime of research and experience into a state-of-the-art discussion of brain death and brain-death standards that should be required reading for the medical profession.

There are two discussions of religious views, these chosen perhaps for their ability to...