Confusion in the Determination of Death: Distinguishing Philosophy from Physiology

CONFUSION IN THE DETERMINATION OF DEATH: DISTINGUISHING PHILOSOPHY FROM PHYSIOLOGY JEFFREY R. BOTKIN and STEPHEN G. POST* Two decades have now passed since the Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Death [I]. The adoption of whole brain criteria as a new standard of death proceeded quickly, supported by the American Medical Association , the American Bar Association, and the President's Commission [2], and has been adopted into legislation in 49 states. One of the final tasks toward the uniform adoption of the whole brain standard is the establishment of criteria for death in young infants [3-5]. But despite this definitional consensus and its rapid adoption, beliefs about what it means to be dead may vary considerably in our highly pluralistic society. Within the medical community alone there remains a startling amount of confusion about the determination of death. The redefinition of death has given rise to a distinct tension between the new definition of death based on brain criteria and common perceptions of the nature of death. Physicians, nurses, and others at the bedside may "know" that a person is dead by established criteria, yet life still may be perceived as long as the heart continues to beat and the skin remains warm to touch. Many clinicians can rattle off criteria for obscure conditions or long differentials for anomalous lab results, yet they cannot offer specific criteria for death. More importantly, it is obvious that many health care professionals, including physicians, simply do not believe patients are dead when their brains alone have ceased to function. Such confusion in the medical professions was clearly documented by Youngner, et al. [6]. This study documented that only 35 percent of physicians or nurses who dealt routinely with critically ill patients could correctly identify the legal and medical criteria for determining death. The authors thank Stuart Younger for his critiques. *Center for Biomedical Ethics, School of Medicine, Case Western Reserve University, 2119 Abington Road, Cleveland, Ohio 44106.© 1992 by The University of Chicago. AU rights reserved. 0031-5982/93/3601-0801$01.00 Perspectives in Biology andMedicine, 36, 1 ¦ Autumn 1992 | 129 Further, 58 percent of the respondents did not apply a consistent concept of death when asked to justify their determination of death in hypothetical cases. The wider public is confused as well—a confusion no doubt fostered by news reports of "brain dead" patients who are kept "alive" by "life-support" technology. We commonly perceive the presence of death when the body is cold and pale, when breathing and heart cease. Little confusion about the presence of death arises in such circumstances. But contemporary technology has fostered confusion by forcing us to recognize the ambiguous nature of the moment of death. We can now restart functions such as breathing or heartbeat when once they would have been irreversibly lost. Certainly someone is not really dead with the cessation of heartbeat if the person can be revived. Yet despite common language about being "brought back to life," we like to think of death as a final and irreversible state, so we must now speak in terms of an "irreversible cessation" of functions. However, what constitutes "irreversible" will no doubt change with technology. This influence of technology on the moment of death indicates that the determination of this moment cannot be made independently of the cultural environment in which death occurs. Additionally , the contemporary ability to entirely replace cardio-respiratory functions with machines further blurs the boundaries between life and death. It was, of course, this latter technological development that was the primary force behind the adoption of the whole brain standard of death. The basic argument we wish to make here is that the moment of death is not a specific physiologic event amenable to scientific determination. Rather, it is a moment defined by philosophic concepts—concepts that speak to what it means to be alive. Since such philosophic contentions defy objective proof, the moment of death must be seen as an event fixed by social consensus. Two implications of this realization will be discussed: first, that education for physicians and other medical professionals must address philosophic concepts if confusion about...