Death Be Not Political

I strongly feel that the definition of death focuses on as biological a feature of life as there can be. Along with birth and taxes, death is one of the Big Three, and I do not think there is any validity to the claim that what we regard as death is determined by political considerations. Technological advances in sustaining life might increase the difficulty in making the diagnosis of death. However, this does not impact the undeniable reality of the clinical situation when a person is declared dead. Historically, when cardiac and brain death coincided with one another temporally, there was no discussion. The ability to sustain heart and pulmonary function independently of the brain was perceived as a serious threat to the definition of death. The introduction of the brain-death definition was designed to rectify this difficulty. The definition of brain death—meaning no detectable brain activity in the cortex or brain stem confirmed by electroencephalogram, brain scan, or clinical examination—is still death. Patients who are brain-dead cannot sustain respiratory effort for more than a few minutes, at which point they die; that is, they have cessation of cardiopulmonary activity within minutes of the halting of ventilatory support.

Patients who are in a persistent vegetative state are not dead. This is biology. Diminished quality of life is not synonymous with death. The world's literature is replete with the imagery that suggests the impoverished person, the barren woman, and the parent who loses a child are figuratively dead. There are those who want to add individuals who have irretrievably lost higher cortical function to this list of the "dead." Our hearts go out to these people, but that does not change their biology—they are alive and deserve all the protections of the living. Before abandoning the dead donor rule, let us leave aside the concerns arising from the pressing shortage of organ donors. Instead, let us simply ask this question: in the absence of a request for organ donation, are we ready as a society to put individuals without higher cortical function yet the ability to breath independently in coffins and bury them? My suspicion is that we are not and that this represents our inherent repugnance for those who would obfuscate about the definition of death. In the same way that Kass (1997) has written that cloning is an assault on our biological sense of self and parenting, calling the definition of death a sociopolitical issue undermines our ability to confront our ultimate demise with honesty, dignity, and grace.

There are clearly legal consequences to any declaration of death. An individual's death triggers the process of inheritance, defines the permissibility of the spouse to remarry. In Jewish law the authorization to violate the Sabbath and perform any form of proscribed work to rescue victims of a natural disaster is operational only when there is reasonable hope that there are survivors (Mishnah, Tractate Yoma, ch. 8, Laws 6 and 7). The identity of the person trapped in the ruble of a collapsed home—whether a Nobel Prize winner or someone in a persistent vegetative state—is irrelevant. As soon as it is clear that everyone has died, the allowance is suspended. However, the nature of the consequences has no bearing on the underlying biological reality or definition of death.

The death of a loved one has lasting consequences not just for the person who has died but also for those who are left alive and who will carry on the memory and legacy of the deceased. Abandoning the dead donor rule is likely to create among survivors profound and lasting unease generated by suspicions that they have abandoned their loved ones, misinterpreted their wishes, or misappropriated their last resource. As a pediatric nephrologist, I share Koppelman's anguish at our inability to provide timely organ transplants to those in need. However, emotional duress and real human suffering do not provide license to alter our definition of death...