And She's Not Only Merely Dead, She's Really Most Sincerely Dead.

To the Editor:

D. Alan Shewmon's work over the last decade has clearly awakened the bioethics community from its dogmatic slumbers. Easy acceptance of the "somatic integration" rationale for equating the condition known as total brain failure with death of the human being is, after Shewmon, a thing of the past. In "Brain Death: Can It Be Resuscitated?" (Mar-Apr 2009), he has made yet another valuable contribution to the debate, providing a close and critical reading of the President's Council's white paper, "Controversies in the Determination of Death." Shewmon asserts that the council's effort is "brave but flawed." Having been involved in the production of the white paper as lead staff researcher and writer, I believe that he is mistaken on a number of points. (All opinions expressed here are mine alone.)

Shewmon's account of the historical foundations of this controversy is far too one-sided. He rightly points out that the initial equation of "irreversible coma" with human death was made without a developed philosophical defense and with an eye to practical consequences that would follow from a new standard. But a more balanced historical account would also note that the condition in question—also revealingly called "coma dépassé," or "beyond coma"—was recognized by neurologists and others as a case apart from all other brain injuries discovered in ventilator-dependent patients. Eelco Wijdick's 2003 historical study of the Harvard Committee's work gives a more nuanced picture, pointing out that "neurologists in the committee knew too well that brain death represented a unique comatose state that could be clearly delineated from other neurologic states." Regardless of the practical context, the task of interpreting this unique state in a way that does justice to the permanent and profound degree of its sufferers' incapacitation had to be taken up.

The "position two" argument in the white paper can be understood as an attempt to provide such an interpretation. It should be noted that this is a more modest way of reflecting on this issue than the "definition-criteria-test" approach that other commentators have followed. The council did not propose a "definition" of death from which a criterion for judging whether someone has died should follow as a logical consequence. Rather, the council keeps its efforts closer to the ground—closer to the reality of the patient and the experience of those who confront the puzzling state of "brain death" in someone they love. Paying close attention to the phenomenon itself—and not to various philosophical devices that have piled up over the years—the white paper encourages us to ask: "What is so unique about this state?" and "Do the phenomena that differentiate this condition have any resonance with the way of being that distinguishes the living from the dead?"

The patient who has suffered total brain failure is closed off from the world, and this closure will never be overcome; not even the very limited recovery that a patient in a persistent vegetative state achieves can be hoped for. The marks of this closure are complete coma—unresponsiveness to pain, to light, and so on—and complete termination of the drive to breathe. Does closure of this sort have any significance to an organism? Here is where the council's discussion of an organism's fundamental, defining work is useful. Openness to the world and the power and drive to interact at the whole organism level is what makes a living thing what it is. "Integration" was certainly never the point. After all, a complex machine is integrated: when assembled and functional, it is more than the sum of its parts. But it is not alive.

Shewmon reasonably asks why breathing and minimal awareness should be singled out as signs of an organism's life and interaction with its environment. He suggests that the council's argument would have difficulty accounting for the embryo, which is alive but does not breathe. According to the council's argument, however, it is not breathing as such that is the fundamental...