In debates about criteria for human death, several camps have emerged, the main two focusing on either loss of the "organism as a whole" (the mainstream view) or loss of consciousness or "personhood." Controversies also rage over the proper definition of "irreversible" in criteria for death. The situation is reminiscent of the proverbial blind men palpating an elephant; each describes the creature according to the part he can touch. Similarly, each camp grasps some aspect of the complex reality (...) of death. The personhood camp, in contrast to the mainstream "organism" camp, recognizes that a human organism can still be a biological living whole even without brain function. The mainstream camp, in contrast to the personhood camp, recognizes that a person can be permanently, even irreversibly unconscious, and still be a living person so long as his/her body is alive. The author proposes that hylomorphic dualism incorporates both these key insights. But to complete the picture of the entire "death elephant," a fundamental paradigm shift is needed to make sense of other seemingly conflicting insights. The author proposes a "semantic bisection" of the concept of death, analogous to the traditional distinction at the beginning of life between "conception" and "birth." To avoid the semantic baggage associated with the term "death," the two new death-related concepts are referred to as "passing away" (or "deceased") and "deanimation," corresponding, respectively, to sociolegal ceasing-to-be (mirror image of birth) and ontological/theological ceasing-to-be of the bodily organism (mirror image of conception). Regarding criteria, the distinguishing feature is whether the cessation of function is permanent (passing away) or irreversible (deanimation). If the "dead donor rule" were renamed the "deceased donor rule" (both acronyms felicitously being "DDR"), the ethics of organ transplantation from non–heart-beating donors could, in principle, be validly governed by the DDR, even though the donors are not yet ontologically "deanimated." Thus, the paradigm shift satisfies both those who insist on maintaining the DDR and those who claim that it has all along been receiving only lip service and should be explicitly loosened to include those who are "as good as dead." Even so, a number of practical caveats remain to be worked out for non–heart-beating protocols. (shrink)

Canada has recently published a new Clinical Practice Guideline on the diagnosis and management of brain death. It states that consent is not necessary to carry out the interventions required to make the diagnosis. A supporting article not only sets out the arguments for this but also contends that ‘UK laws similarly carve out an exception, excusing clinicians from a prima facie duty to get consent’. This is supplemented by the claim that recent court decisions in the UK similarly (...) confirm that consent is not required, referencing two judgements in _Battersbee_. We disagree with the authors’ interpretation of the law on consent in the UK and argue that there is nothing in _Battersbee_ to support the conclusion that consent to testing is not necessary. Where there is a disagreement about testing for brain death in the UK, court authorisation is required. (shrink)

Abstract:Disturbing cases continue to be published of patients declared brain dead who later were found to have a few intact brain functions. We address the reasons for the mismatch between the whole-brain criterion and brain death tests, and suggest solutions. Many of the cases result from diagnostic errors in brain death determination. Others probably result from a tiny amount of residual blood flow to the brain despite intracranial circulatory arrest. Strategies to lessen the mismatch include improving brain (...) death determination training for physicians, mandating a test showing complete intracranial circulatory arrest, or revising the whole-brain criterion. (shrink)

Recently, there have been a number of lawsuits in the United States in which families objected to performance of apnoea testing for determination of brain death. The courts reached conflicting determinations in these cases. We discuss the medicolegal complications associated with apnoea testing that are highlighted by these cases and our position that the decision to perform apnoea testing should be made by clinicians, not families, judges, or juries.

In popular culture, death is typically presented as clear and binary- someone is either walking and talking and alive, or very obviously still and dead. Reality is more complicated than the movies,...

Navigating tragic circumstances in pediatrics requires consideration of parental grief responses. We meet parents where they are, not where we might want them to be. Different parents grieve differ...

The past decade has witnessed escalating legal and ethical challenges to the diagnosis of death by neurologic criteria. The legal tactic of demanding consent for the apnea test, if successful, can halt the DNC. However, US law is currently unsettled and inconsistent in this matter. Consent has been required in several trial cases in Montana and Kansas but not in Virginia and Nevada. In this paper, we analyze and evaluate the legal and ethical bases for requiring consent before apnea (...) testing and defend such a requirement by appealing to ethical and legal principles of informed consent and battery and the right to refuse medical treatment. We conclude by considering and rebutting two major objections to a consent requirement for apnea testing: a justice-based objection to allocate scarce resources fairly and a social utility objection that halting the diagnosis of brain death will reduce the number of organ donors. (shrink)

The overwhelming weight of legal authority in the USA and Canada holds that consent is not required for brain death testing. The situation in England and Wales is similar but different. While clinicians in England and Wales may have a prima facie duty to obtain consent, lack of consent has not barred testing. In three recent cases where consent for brain death testing was formally presented to the court, lack of consent was not determinative, and in one case (...) the court questioned whether the clinicians were even required to seek consent from the parents of a child at all. (shrink)

Volume 20, Issue 6, June 2020, Page 1-3.

A crucial test for the dominant Rawlsian ‘consensus’ brand of public reason is whether it is complete – sufficient in content, that is, to yield determinate answers to the political questions put before it. Yet while doubts about the incompleteness of Rawlsian public reason have been often voiced, critics have thus far carried out relatively little of the philosophical spadework needed to substantiate them. This paper contributes to remedying this omission, via a detailed analysis of the implications of Rawlsian public (...) reason for an important bioethical problem arising at the end of human life. This is the problem of how to define and diagnose the death of a person, or determine at what point the clinical and legal practices conventionally associated with death, such as the removal of vital organs, may take place. My thesis is that this is a matter on which Rawlsian public reason does indeed have a grave incompleteness problem: the model produces indeterminacy, I argue, between a broad range of legal definitions of death. I also aim to go beyond existing articulations of the incompleteness objection, moreover, by examining what Rawlsian consensus liberalism implies about how decision-makers ought to respond to indeterminacies in public reason. Insofar as the route to a reasoned choice between competing criteria of death is foreclosed, I contend, the Rawlsian view requires that selection among policy options proceed in an intolerably arbitrary fashion. The latter finding alters the cast of the familiar incompleteness objection, by closing the gap between it and what I have elsewhere called the ethical objection – the objection, that is, that public reason can in some cases generate determinate but morally unacceptable decisions. (shrink)

The Ethical and Religious Directives (ERDs) do not currently address brain death (BD) or medical, professional, and conscience objections. Accordingly, Catholic practitioners, patients, and their families are continually caught in the controversies and confusion surrounding BD and the organ procurement process. Therefore, this essay petitions the US bishops to include a new directive in the next edition of the ERDs that (1) recognizes the moral uncertainty and dubious medical practice surrounding BD and (2) allows families and surrogates and practitioners (...) to object—based on conscience, on medical or professional grounds, and via informed refusal— to the BD tests or (at least) the BD organ procurement process. This essay provides justification for such a directive, proposes potential language, and explores how it could look in practice. (shrink)

Prostate cancer has become a major health concern of male Americans. It is now the most common nondermatologic cancer and the second leading cause of cancer death among men. The incidence of detected prostate cancer rose rapidly in recent years, partly because of prostate-specific antigen testing; it is only now tapering off. Screening for prostate cancer with PSA is widespread in the United States, yet controversial: the American Urological Association recommends PSA screening and the American Cancer Society recommends offering (...) screening; however, the United States Preventive Services Task Force and the American College of Physicians recommend against routine screening; and the American Academy of Family Physicians believes that the decision to screen should be left to the patient. (shrink)

Death concept, death definition, death criterion and death test pluralism has been described by some as a problematic approach. Others have claimed it to be a promising way forward within modern pluralistic societies. This article describes the New Jersey Death Definition Law and the Japanese Transplantation Law. Both of these laws allow for more than one death concept within a single legal system. The article discusses a philosophical basis for these laws starting from John (...) Rawls' understanding of comprehensive doctrines, reasonable pluralism and overlapping consensus. It argues for the view that a certain legal pluralism in areas of disputed metaphysical, philosophical and/or religious questions should be allowed, as long as the disputed questions concern the individual and the resulting policy, law or acts based on the policy/law, do not harm the lives of other individuals to an intolerable extent. However, while this death concept, death definition, death criterion and death test pluralism solves some problems, it creates others. (shrink)

Volume 20, Issue 6, June 2020, Page 28-30.

Volume 20, Issue 6, June 2020, Page 17-19.

For more than thirty years, in most of the world, the irreversible cessation of all brain function, more commonly known as brain death, has been accepted as a criterion of death. Yet the philosophical basis on which this understanding of death was originally grounded has been undermined by the long-term maintenance of bodily functions in brain dead patients. More recently, the American case of Jahi McMath has cast doubt on whether the standard tests for diagnosing brain (...) death exclude a condition in which the patient is not dead, but in a minimally conscious state. I argue that the evidence now clearly shows that brain death is not equivalent to the death of the human organism. We therefore face a choice: either we stop removing vital organs from brain dead patients, or we accept that it is not wrong to kill an innocent human who has irreversibly lost consciousness. (shrink)

The neurological criteria for the determination of death remain controversial within secular and Catholic circles, even though they are widely accepted within the medical community. In Determining Death by Neurological Criteria, Matthew Hanley offers both a practical and a philosophical defense. Hanley shows that the criteria are often misapplied in clinical settings, leading to cases where persons declared dead apparently spontaneously revive. These instances are often connected to a rushed decision to retrieve donated organs, thus undermining the trust (...) of the public in organ donation. Hanley calls on health care institutions to take seriously their obligation to establish strict protocols for the determination of death, including who may conduct the examinations. From a broader perspective, Hanley considers how the criteria rely on a philosophical conception of the person as a living organism whose unity disintegrates at death. This view, he notes, corresponds to the Catholic conviction that the soul is the life-principle of the body, which departs at death, bringing about the destruction of the body-soul composite. The Vatican, recognizing that death is a medical judgment, has generally given its approval to the criteria. Hanley also reviews the many and various objections offered by detractors, including against the use of the apnea test, which is faulted as a practice that sometimes hastens death. The problem of the continued presence of certain vital functions within the deceased body of the brain dead is explored in detail, with reference to particular cases and to solutions proposed by leading physicians and bioethicists. Hanley likewise addresses the dilemma of having two separate standards for death, one neurological and the other cardiopulmonary. Given the possibility of resuscitation following loss of the cardio-circulatory system, he concludes that the neurological criteria must be the true standard. Stoppage of the heart leads swiftly to the final necrosis of the brain. -- Provided by publisher. (shrink)

At its inception, “brain death” was proposed not as a coherent concept but as a useful one. The 1968 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death gave no reason that “irreversible coma” should be death itself, but simply asserted that the time had come for it to be declared so. Subsequent writings by chairman Henry Beecher made clear that, to him at least, death was essentially a social construct, (...) and society could define it however it pleased. The first widely endorsed attempt at a philosophical justification appeared thirteen years later, with a report from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research and a seminal paper by James Bernat, Charles Culver, and Bernard Gert, which introduced the insightful tripartite scheme of concept, criterion, and tests for death. Their paper proposed that the correct concept of death is the “permanent cessation of functioning of the organism as a whole,” which tenuously remains the mainstream concept to this day. In this essay, I focus on this mainstream concept, arguing that equating brain death with death involves several levels of incoherence: between concept and criterion, between criterion and tests, between tests and concept, and between all of these and actual brain death praxis. (shrink)

For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. However, a series of recent cases in which individuals were declared brain dead yet physiologically maintained for prolonged periods of time has challenged the status quo. This signals a need for deeper reflection and reexamination of the underlying philosophical, scientific, and clinical issues at stake in defining death. In this paper, I consider four levels of philosophical inquiry regarding death: the ontological basis, (...) actual states of affairs, epistemological standards, and clinical criteria for brain death. I outline several candidates for the states of affairs that may constitute death, arguing that we should strive for a single, unified ontological definition of death as a loss of integrated functioning as a unified organism, while acknowledging that two states of affairs may satisfy this concept. I argue that the clinical criteria for determining whole-brain death should be bolstered to meet the epistemic demand of sufficient certainty in defining death by adding indicators of cerebro-somatic dis-integration to the traditional triad of loss of consciousness, loss of brainstem function, and absence of confounding explanations. (shrink)

The informed consent process for genetic testing does not commonly address preferences regarding disclosure of results in the event of the patient's death. Adults being tested for familial colorectal cancer were asked whether they want their exome sequencing results disclosed to another person in the event of their death prior to receiving the results. Of 78 participants, 92% designated an individual and 8% declined to. Further research will help refine practices for informed consent.

With so much attention being paid to the development and refinement of appropriate criteria and tests for death, little attention has been given to the broader conceptual issues having to do with its definition or with the relation of a definition to its criterion. The task of selecting the correct criterion is, however, virtually impossible without proper attention to the broader conceptual setting in which the definition operates as the key feature. All of the issues I will discuss (...) arise because of this lack of concern with conceptual matters. Such problems as incorrectly diagnosing a patient as dead prior to the harvesting of his or her organs, defending the idea that death is reversible, and advocating a brainstem criterion of death, are all, I believe, errors that derive from this misplaced emphasis. (shrink)

The definition of death should be framed in biological rather than psychological or moral terms. Loss of personal identity, for example, does not equal death, even if it is a worse fate.

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the (...) brain, whether standard criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Searching for Peace in DeathLaura WachsmuthDisclaimers. No funding was utilized for this manuscript. The author, Laura Wachsmuth, has worked at several hospitals. The opinions contained herein are her own. All names have been changed to protect the privacy of the patient and the patient's family.I first met Ellen when she was admitted to the Women and Infant unit on a late spring day in May. She was 27 weeks (...) pregnant and was experiencing intense abdominal pain.As a hospital chaplain, I support patients and their families emotionally and spiritually. Sometimes, this looks like praying with patients; other times, it looks like sitting in quiet because there are no adequate words. Over time, I have developed ways to help me cope with the intensity I witness daily. Still, cases come up that I must grieve. The case of Ellen is one such example.The first time I met Ellen, she was waiting to hear back about her scans and tests. A quick look at her chart and a conversation with the medical team revealed that she was in her mid-thirties. While she spoke English fluently, she had immigrated to the US, and English was her second language. She, along with her husband, Mark, and their young son, had come to the United States on a work visa.After knocking on the door and entering her dim hospital room, I noticed right away what a beautiful person Ellen was, inside and out. Lying in bed, her long dark hair piled up on her head, her slim figure was visibly pregnant underneath her hospital gown. She smiled and gently greeted me. Mark was at her side. Clearly, Ellen was in physical pain, and while she and Mark still hoped the doctors were wrong in thinking she may have cancer, the emotional strain of waiting lay heavy upon them.Ellen and Mark kindly welcomed me and were attentive as best they could as I introduced myself and explained my role as a chaplain. They told me [End Page 75] that they were spiritual, not religious, but welcomed chaplain visits. Both exuded a certain peace and kindness, which was striking considering all they were enduring.As Ellen and her family waited for the results to come back, I waited as well and frequently checked her medical chart, looking for updates. About a week after she was first admitted, the medical team broke the dreaded news: Ellen had stage IV gastric cancer; it was estimated she only had 11 months to live. At this point, the Palliative Care team became involved in Ellen's care, and the chaplain on this team supported Ellen through the shock of her diagnosis and the difficult treatment choices she faced.Originally, the plan was for Ellen to deliver her daughter at 29–30 weeks and then to receive 2–3 rounds of chemotherapy. After further deliberation, however, it was decided that it was riskier to deliver a baby at 29–30 weeks than it was to undergo chemotherapy while pregnant, so Ellen began chemotherapy while still carrying her baby. Her chemotherapy was not a curative treatment, but there was hope it might give her more time.While my role became more peripheral at this point, I continued visiting Ellen. She was often tired or in pain, so I was mindful to keep my visits short. Mark, who stayed with his wife day in and day out, was usually in the room when I came by, and I often inquired after his well-being. Since Ellen and Mark's families still lived abroad, Mark was Ellen's primary support, and needed care and support himself.After two rounds of chemotherapy, Ellen made the decision to stop treatments. She made this decision because she was concerned about the risks of chemotherapy on her baby. It was an agonizing decision, and even after she made it, Ellen turned it over in her mind. During one of our visits, she asked me if I thought she had made the right decision. I told her that I fully supported her, but as I left her room, I wondered if I had done the right thing in affirming her choice. Looking... (shrink)

A curious and comparatively neglected element of death penalty jurisprudence in America is my target in this paper. That element concerns the circumstances under which severely mentally disabled persons, incarcerated on death row, may have their sentences carried out. Those circumstances are expressed in a part of the law which turns out to be indefensible. This legal doctrine—competence-for-execution —holds that a condemned, death-row inmate may not be killed if, at the time of his scheduled execution, he lacks (...) an awareness of his impending death or the reasons for it. I argue that the law of CFE should be abandoned, along with the notion that it is permissible to kill the deeply disturbed just so long as they meet some narrow test of readiness to die. By adopting CFE, the courts have been forced to give independent conceptual and moral significance to a standard for competence that simply cannot bear the weight placed upon it. To be executable, CFE requires that a condemned prisoner meet a standard demonstrating an awareness of certain facts about his death. Yet this standard both leads to confusing and counter-intuitive results and is unsupported either by the reasons advanced by the courts on its behalf or by any of the standard theoretical justifications of criminal punishment. If executing the profoundly psychotic or delusional is wrong the law needs a better account of the wrong done when prisoners like Ford are killed. I suggest wherein that wrong might be located. (shrink)

The concept of brain death as equivalent to cardiopulmonary death was initially conceived following developments in neuroscience, critical care, and transplant technology. It is now a routine part of medicine in Western countries, including the United States. In contrast, Eastern countries have been reluctant to incorporate brain death into legislation and medical practice. Several countries, most notably China, still lack laws recognizing brain death and national medical standards for making the diagnosis. The perception is that Asians (...) are less likely to approve of brain death or organ transplant from brain dead donors. Cultural and religious traditions have been referenced to explain this apparent difference. In the West, the status of the brain as home to the soul in Enlightenment philosophy, combined with pragmatism and utilitarianism, supports the concept of brain death. In the East, the integration of body with spirit and nature in Buddhist and folk beliefs, along with the Confucian social structure that builds upon interpersonal relationships, argues against brain death. However, it is unclear whether these reasoning strategies are explicitly used when families and medical providers are faced with acknowledging brain death. Their decisions are more likely to involve a prioritization of values and a rationalization of intuitive responses. Why and whether there might be differences between East and West in the acceptance of the brain death concept requires further empirical testing, which would help inform policy-making and facilitate communication between providers and patients from different cultural and ethnic backgrounds. (shrink)

Background Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians’ attitudes toward assisted death vary across the globe, but little is known about physicians’ actual reactions when facing a request for assisted death. There is a clear gap in evidence on how physicians act and respond to patients’ requests for assisted death in countries where these actions are not legal. Methods A survey including (...) statements concerning euthanasia and PAS and an open question about their actions when facing a request for assisted death was sent to all Finnish physicians. Quantitative data are presented as numbers and percentages. Statistical significance was tested by using the Pearson chi-square test, when appropriate. The qualitative analysis was performed by using an inductive content analysis approach, where categories emerge from the data. Results Altogether, 6889 physicians or medical students answered the survey, yielding a response rate of 26%. One-third of participants agreed or partly agreed that they could assist a patient in a suicide. The majority (69%) of the participants fully or partly agreed that euthanasia should only be accepted due to difficult physical symptoms, while 12% fully or partly agreed that life turning into a burden should be an acceptable reason for euthanasia. Of the participants, 16% had faced a request for euthanasia or PAS, and 3033 answers from 2565 respondents were achieved to the open questions concerning their actions regarding the request and ethical aspects of assisted death. In the qualitative analysis, six main categories, including 22 subcategories, were formed regarding the phenomenon of how physicians act when facing this request. The six main categories were as follows: providing an alternative to the request, enabling care and support, ignoring the request, giving a reasoned refusal, complying with the request, and seeing the request as a possibility. Conclusions Finnish physicians’ actions regarding the requests for assisted death, and attitudes toward euthanasia and PAS vary substantially. Open discussion, education, and recommendations concerning a request for assisted death and ethics around it are also highly needed in countries where euthanasia and PAS are not legal. (shrink)

Requiring family authorization for apnea testing subtracts health professionals control over death determination, a procedure that has traditionally been considered a matter of clinical expertise alone. In this commentary, we first provide evidence showing that health professionals’ (HPs) disposition to act on death determination without family’s prior consent could be much lower than that referred to by Berkowitz and Garrett (2020). We hypothesize that HPs may have reservations about their own expertise as regards death, and may thus (...) hesitate to impose their views on patients’ families. We then address the theoretical question of clinical expertise in death determination by distinguishing judgments about facts (e.g., the presence or absence of spontaneous breathing) from interpretations given of these facts (i.e., their meaning for the vital status of an individual). We argue that, while clinicians may claim some expert authority on the former, they hold no particular authority on the latter. (shrink)

In this paper I address three problems posed by modern medical technology regarding comatose dying patients. The first is that physicians sometimes hide behind the tests for whole-brain death rather than make the necessary human decision. The second is that the tests themselves betray a metaphysical judgment about death that may be ontologically faulty. The third is that discretion used by physicians and patients and/or family in deciding to cease treatment when the whole-brain death criteria (...) may not be met are sometimes open to challenge. In each of these problems I find that the operative concept of death relates to life itself. This point is expanded by examining the uses of the word death in our language and culture. From these I formulate an initial ontology of death. In it, death is described through a relationship with life, rather than as an absence of life, of consciousness, awareness, or sensation. This ontology then leads to a proposal for an ethics of discretion about the discontinuation of treatment for comatose patients. (shrink)

This paper traces two contradicting beliefs about death and immortality in the writings of Rabbi Hayyim Hirschensohn, and examines these opposing beliefs in his Halakhic ruling, in the case of Autopsies. The paper opens by conceptualizing two possible attitudes regarding the relation between this-world and the ʽother-world’, and by analyzing two main beliefs regarding death and immortality in their relation to the body-spirit distinction (the naturalistic and the spiritualistic approach). It demonstrates how Hirschensohn was holding these two different (...) views. The paper then moves to examine whether his halakhic ruling may help us in understanding which approach was Hirschensohn’s favorable belief, by investigating his halakhic ruling regarding autopsies. Hirschensohn permits to perform such surgeries, however subject to some halakhic limitations. The paper concludes that the naturalistic belief regarding death appears to be the more dominant one in his thought. Finally, I point out a few consequences of this paper, for addressing some contemporary ethical dilemmas regarding human corpses. (shrink)

As Nair-Collins and Joffe note, the concern that our tests for brain death do not successfully show that all brain functions have stopped is not new (Nair-Collins and Joffe 2023). As our abilities...

Organ donation after a circulatory determination of death is possible in selected patients where consent is given to support donation and the patient has been legally declared dead by two doctors. The National Health Act (61 of 2003) and regulations provide strict controls for the certification of death and the donation of organs and tissues after death. Although the National Health Act expressly recognises that brain death is death, it does not prescribe the medical standards (...) of testing for the determination of brain death (neurological determination of death), circulatory death (circulatory determination of death) or for determination of death based on somatic criteria. However, in all cases of organ donation, including after circulatory death, the National Health Act mandates that two doctors certify the death, with one doctor possessing more than 5 years of experience. Additionally, both doctors must be independent from the transplant team. The standard for such determination, as for brain death, aligns with accepted medical standards. The Critical Care Society of Southern Africa has published South African (SA) Guidelines on Death Determination that outline rigorous standards for death determination in hospital settings by either a neurological or circulatory method. Legislation and the Health Professions Council of SA’s (HPCSA) professional guidance direct clinicians on obtaining informed consent for donation either from the patient or in cases of incapacity from their surrogate decision maker. Collectively, the legislation, regulations and professional guidelines in SA provide a robust ethical framework that supports organ donation after circulatory death. (shrink)

The determination of death by neurological criteria remains controversial scientifically, culturally, and legally, worldwide. In the United Kingdom, although the determination of death by neurological criteria is not legally codified, the Code of Practice of the Academy of Medical Royal Colleges is customarily used for neurological death determination and treatment withdrawal. Unlike some states in the US, however, there are no provisions under the law requiring accommodation of and respect for residents' religious rights and commitments when secular (...) conceptions of death based on medical codes and practices conflict with a traditional concept well-grounded in religious and cultural values and practices. In this article, we analyse the medical, ethical, and legal issues that were generated by the recent judgement of the High Court of England and Wales in Re: A [2015] EWHC 443. Mechanical ventilation was withdrawn in this case despite parental religious objection to a determination of death based on the code of practice. We outline contemporary evidence that has refuted the reliability of tests of brainstem function to ascertain the two conjunctive clinical criteria for the determination of death that are stipulated in the code of practice: irreversible loss of capacity for consciousness and somatic integration of bodily biological functions. We argue that: the tests of brainstem function were not properly undertaken in this case; the two conjunctive clinical criteria set forth in the code of practice cannot be reliably confirmed by these tests in any event; and absent authentication of the clinical criteria of death, the code of practice wrongly invokes a secular definition of death based on the loss of personhood. Consequently, the moral obligation of a pluralistic society to honor and respect diverse religious convictions to the greatest extent possible is being violated. Re A is contrasted with the US case of Jahi McMath in which the court accommodated parental religious objection to the determination of neurological death codified in the Uniform Determination of Death Act. We conclude that the legal system in the United Kingdom should not favour a secular definition of death over a definition of death that is respectful of religious values about the inviolability and sanctity of life. We recommend the legal recognition of religious accommodation in death determination to facilitate cultural sensitivity and compassionate care to patients and families in a pluralistic society. (shrink)

The debate on concept possession in animals has moved at a very abstract level, with scant detailed consideration of case studies in animal behaviour. In this paper, we go against this trend by examining a specific prey defence mechanism, thanatosis or death-feigning, in order to determine what it can tell us about the minds of the predators it targets. We argue that thanatosis gives us evidence of conceptual abilities in predators. In particular, we defend that the best available explanation (...) for the evolution of thanatosis comes from positing that the predators whose cognition acted as selection pressure and shaped thanatosis displays satisfy the concept possession requirements of distance, inferentiality, aspectuality, generality, and a minimal semantic net. Moreover, we argue that the semantic content of the concept targeted by thanatosis likely corresponds to a minimal concept of death. We end on a methodological note, by showing how the consideration of case studies can help move this philosophical debate forward, while also generating concrete empirical predictions that can be put to the test, thus favouring interdisciplinary collaborations. (shrink)

In the United States, patients have a clear right to determine what is done to them by doctors. Starting in the early 20th century, multiple court cases paved the way for our current understanding...

In the December 2015 Issue of the Police Journal Sam Poyser and Rebecca Milne addressed the subject of miscarriages of justice. Cold case investigations can address some of these wrongs. The salient points for attention are those just before his sudden death: Milligan was appointed Private Secretary to Jonathan Aitken, the then Minister of Arms in the Conservative government in 1994. The known facts are as follows: 1. Stephen David Wyatt Milligan was found deceased on Tuesday 8th February 1994 (...) at his Chiswick, West London house where he lived alone. His body was found by his secretary Vera Taggart who was told by Julie Kirkbride where a spare key to his London house was kept and who decided to go to his house that day because he was not answering his telephone. Police said he had made one last telephone call on Saturday evening at 9.00pm. 2. Stephen David Wyatt Milligan had been the elected Member of Parliament (‘MP’) for Eastleigh in Hampshire since 1992. 3. The important topics this MP was addressing in 1994 at the time of his death included: (i) rail privatization plans and the impact through job losses on communities, especially his own constituency of Eastleigh; (ii) arms dealings with Saudi Arabia, especially with his previous intelligence gathered as an economics journalist for esteemed publications; (iii) the UK military industry; (iv) homosexuality among senior government Ministers, as revealed by British footballer Fasanu; (v) personal relationship and planned marriage to his fiancée (Julie Kirkbride) who at the time was a political journalist. 4. Stephen Milligan was also appointed as Parliamentary Private Secretary to Jonathan Aitken, Arms Minister and this position must have required that he came ‘up to speed’ on international arms trade and indeed its relation to bribery and corruption across jurisdictions. Milligan’s experience and knowledge as a former high-level political and economics journalist must have been of huge benefit to government minister Jonathan Aitken who was later imprisoned for perjury. 5. Regarding Stephen Milligan’s death in 1994, the Guardian newspaper in their immediate obituary said that ‘The death of one of the government's most outspoken and loyal supporters will pose a stiff electoral test for the Tories to surmount. He was on the left of the Tory party - he had even had a brief flirtation with the SDP when it was formed - and was a noted Euro-enthusiast… the death of one of the government's most outspoken and loyal supporters will pose a stiff electoral test for the Tories to surmount. Regarding Stephen Milligan’s sudden and unexpected death in 1994, MP David Willetts (Conservative, Havant) said in March 2015, in his address in the House of Commons. ‘…The inevitable ups and downs and triumphs and disasters of politics are among the great features of this place. There are colleagues in all parts of the House who are tolerant and understanding. There are friendships that keep the downs as well as the ups of politics in perspective. Having entered the House in 1992, I think particularly of two good friends, Judith Chaplin and Stephen Milligan, who both died within two years of being elected; that loss stayed with me for a long time...’ 6. On 28 February 2000, in the House of Commons, at Column 106, Mr Mike Hancock (Portsmouth) said, on the deaths of Michael Colvin and of Stephen Milligan MP: ‘I knew Michael Colvin for nearly 30 years, from when he was first elected to Hampshire county council. During my time as leader of that council, he and the late former Member of Parliament for Eastleigh, Stephen Milligan, were usually the only Members of Parliament who readily supported the council when necessary. Michael Colvin supported many ventures in the county of Hampshire. He will be missed here, in his constituency, and in Europe, and I stress that Hampshire has lost a staunch supporter. I am sure that the county will at some stage want to record its regret at his death and its deepest appreciation of the part that he played in its life....’ -/- Mike Hancock had, like Stephen Milligan, served on the Select Committee on Defence. It is interesting that he mentioned Stephen Milligan’s support as MP for Eastleigh when Milligan had only been so appointed a couple of years before his sudden death, as compared to 30 years of support from Mike Colvin. 7. Mr Andrew Robathan (for Blaby) said in the House of Commons Hansard Debates on 27 January1997, (Column 62) (on the registering of sex offenders): ‘I remember the death of my honourable friend Stephen Milligan, who represented Eastleigh. The press reports of the time stated that each Metropolitan police station had a police officer in the pay of newspapers. I do not know whether that is true, but I am aware that the police are not renowned for being entirely secure with their information…’ This statement is mischievous and it has been demonstrated time and time again, as being untrue, especially during the recent press inquiry leading to the four-volume Leveson Report, published in November 2012, into phone hacking and the ethics and culture of the UK media, pursuant to section 26 of the Inquiries Act 2005, and ordered by the House of Commons to be printed on 29 November 2012, ISBN: 9780102981063, by the Stationery Office Limited on behalf of the Controller of Her Majesty’s Stationery Office. In Volume 4 of the 2012 Leveson Report, chapter 4 concluded on the Press Complaints Commission (‘PCC’) and its effectiveness and revealed that the PCC does not initiate its own investigations other than those ‘needed to head off criticism of the press or self-regulation- or to accept complaints from third parties across the board and on a transparent basis… and the report states that ‘the resources of the police are limited’ in terms of being able to fully inspect the Press and media reports. (shrink)

“Brain death,” the determination of human death by showing the irreversible loss of all clinical functions of the brain, has become a worldwide practice. A biophilosophical account of brain death requires four sequential tasks: agreeing on the paradigm of death, a set of preconditions that frame the discussion; determining the definition of death by making explicit the consensual concept of death; determining the criterion of death that proves the definition has been fulfilled by (...) being both necessary and sufficient for death; and determining the tests of death for physicians to employ at the patient's bedside to demonstrate that the criterion of death has been fulfilled. The best definition of death is “the cessation of functioning of the organism as a whole.” The whole-brain criterion is the only criterion that is both necessary and sufficient for death. Brain death tests are used only in the unusual case in which a patient's ventilation is being supported. Brain death critics have identified weaknesses in its formulation. But despite its shortcomings, the whole-brain death formulation comprises a concept and public policy that make intuitive and practical sense and that has been well accepted by many societies. (shrink)

Exploring the Philosophy of Death and Dying: Classical and Contemporary Perspectives is the first book to offer students the full breadth of philosophical issues that are raised by the end of life. Included are many of the essential voices that have contributed to the philosophy of death and dying throughout history and in contemporary research. The 38 chapters in its nine sections contain classic texts and new short argumentative essays, specially commission for this volume by world-leading contemporary experts. (...) Exploring the Philosophy of Death and Dying introduces students to both theoretical issues as well as urgent practical issues raised by human mortality, enabling instructors to adapt it to a wide array of institutions and student audiences. As a pedagogical benefit, PowerPoints, discussion questions, and test questions for each chapter are included as online ancillary materials. (shrink)

In her interesting paper on cross-jurisdictional legal approaches to brain death, Ariane Lewis considers whether informed consent is required for DNC testing in the UK, and proposes that it is not...

In the context of deceased organ donation, donors are routinely tested for HIV, to check for suitability for organ donation. This article examines whether a donor’s HIV status should be disclosed to the donor’s next of kin.On the one hand, confidentiality requires that sensitive information not be disclosed, and a duty to respect confidentiality may persist after death. On the other hand, breaching confidentiality may benefit third parties at risk of having been infected by the organ donor, as it (...) may permit them to be tested for HIV and seek treatment in case of positive results.We conclude that the duty to warn third parties surpasses the duty to respect confidentiality. However, in order to minimize risks linked to the breach of confidentiality, information should be restrained to only concerned third parties, that is, those susceptible to having been infected by the donor. (shrink)

Berkowitz and Garrett (2020) raise important arguments in favor of consent for apnea testing used in determining death by neurological criteria (DNC); and yet, a fundamental consideration is left u...

This guest editorial opens with a brief overview of the transformations of medicine and mental health that can be observed since the second half of the twentieth century. New genetics and biotechnologies hold out the promise of overcoming presumed limitations in the field of mental health care, that is, the fact that diagnostic procedures in psychiatry and clinical psychology still largely rely on the narratives of patients and questionnaires, supposedly subjective assessments by physicians and psychologists. It is envisioned that innovative (...) genetic and proteomic tools, imaging technologies, and objective laboratory tests for blood biomarkers will enable better diagnosis and treatment of mental diseases. We argue that emerging biotechnologies do not revolutionize mental health, despite their promise to do so. Instead, we observe a pluralization of research and treatment approaches in the domain of mental health. The second part of this editorial discusses the contributions to this special issue on emerging biotechnologies and mental health and outlines how they address some of the gaps in social studies of psychiatry and mental health in the twenty-first century. (shrink)

Since the introduction of the concept of brain death by the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death in 1968, the validity of this concept has been challenged by medical scientists, as well as by legal, philosophical, and religious scholars. In light of increased criticism of the concept of brain death, Stephen Napier, a staff ethicist at the National Catholic Bioethics Center, set out to prove that the whole-brain (...) class='Hi'>death criterion serves as good evidence for death in the Catholic bioethical framework, on the grounds that when whole-brain death has occurred the soul has already departed from the body. Opponents have argued that (1) brain death does not disrupt the somatic integrative unity and coordinated biological functioning of a living organism and (2) clinical tests outlined in the practice guidelines for determining brain death lack sufficient power to exclude persisting function and fail to detect elements of the brain that, although currently functionless, may retain potential for recovery under conditions of optimal medical care. It is therefore possible that heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of active euthanasia and physician-assisted death, both of which, either concealed or overt, the Catholic Church opposes. (shrink)

Introduction : Rorschach tests -- A question of style -- Live or tell -- Kierkegaard's seductions -- Hegel's seductions -- Talking cures -- A penchant for disguise : the death (and rebirth) of the author in Kierkegaard and Nietzsche -- Passing over : the death of the author in Hegel -- Conclusion : the melancholy of having finished -- Aftersong : from low down.

We investigate the epistemological consequences of a positive polymerase chain reaction SARS-CoV test for two relevant hypotheses: V is the hypothesis that an individual has been infected with SARS-CoV-2; C is the hypothesis that SARS-CoV-2 is the cause of flu-like symptoms in a given patient. We ask two fundamental epistemological questions regarding each hypothesis: First, how much confirmation does a positive test lend to each hypothesis? Second, how much evidence does a positive test provide for each hypothesis against its negation? (...) We respond to each question within a formal Bayesian framework. We construe degree of confirmation as the difference between the posterior probability of the hypothesis and its prior, and the strength of evidence for a hypothesis against its alternative in terms of their likelihood ratio. We find that test specificity—and coinfection probabilities when making inferences about C—were key determinants of confirmation and evidence. Tests with 8) for V against ¬V regardless of sensitivity. Accordingly, low specificity tests could not provide strong evidence in favor of C in all plausible scenarios modeled. We also show how a positive influenza A test disconfirms C and provides weak evidence against C in dependence on the probability that the patient is influenza A infected given that his/her symptoms are not caused by SARS-CoV-2. Our analysis points out some caveats that should be considered when attributing symptoms or death of a positively tested patient to SARS-CoV-2. (shrink)

Organ donation after brain death has been practiced in China since 2003 in the absence of brain death legislation. Similar to international standards, China’s brain death diagnostic criteria include coma, absence of brainstem reflexes, and the lack of spontaneous respiration. The Chinese criteria require that the lack of spontaneous respiration must be verified with an apnea test by disconnecting the ventilator for 8 min to provoke spontaneous respiration. However, we have found publications in Chinese medical journals, in (...) which the donors were declared to be brain dead, yet without an apnea test. The organ procurement procedures started with initiating “intratracheal intubation for mechanical ventilation after brain death,” indicating that a brain death diagnosis was not performed. The purpose of the intubation was not to resuscitate the patient but rather was directly related to facilitating the explantation of organs. Moreover, it was unmistakably stated in two of these publications that the cardiac arrest was induced in these patients without brain death determination by cold St. Thomas cardioplegic solution or other cold myocardial protection solutions. This means that the condition of these donors neither met the criteria of brain death nor that of cardiac death. In other words, the “donor organs” may well have been procured in these cases from living human beings. Thus, brain death definition is abused in China by some individuals for organ harvesting, and a systematic investigation is needed to clarify the situation of organ donation after brain death in China. (shrink)

This article aims to analyze the views of two pioneering Ḥanafī scholars, Abū Manṣūr al- Māturīdī and Abū Zayd al-Dabūsī, on the meaning of death and life in terms of their general doctrine of religion. In the first part, the general framework of Māturīdī and Dabūsī’s evidentialist conception of religion are drawn. In the second part, Māturīdī's views on the meaning of death and life and are explored. In the third part, the views of Abū Zayd al-Dabūsī on (...) the meaning of death and life, who establishes a striking connection between the divine order and existence, divine prohibition and non-existence, are examined, and a general evaluation is offered in the last section. Al-Māturīdī proposed a very original and systematic example of doing philosophy of religion, which still promising for the modern problems of the field, by opening the phenomenon of religion itself to discussion, and analyzing the nature and elements of religion. Māturīdī aims to place the problems on a universal and theoretical basis and to present a holistic, metaphysical understanding while discussing specific and particular issues in religion. Just as there are main notes in classical Western music that repeat throughout the symphony in baroque style, there are universal principles in al-Māturīdī’s metaphysics that cut all particular debates vertically. The basic principle of the al-Māturīdī’s metaphysics is based on this idea: God is a wise being, he does not do anything wise. Accordingly, it is absurd to create something to destroy; God did not create man to perish. The love of life and the fear of death are the deepest existential problems facing man as a finite being that goes towards death. Religion can be regarded as a powerful alternative to other worldviews to the extent that it provides a reasonable explanation for man’s deep concern about finitude. For al-Māturīdī, neither pessimistic understandings that emphasize only the fear of death nor hedonistic understandings that ignore death offer a reasonable solution. God created death as something that people fear the most and avoid, and life as something they love and desire. The testing of man is about being between the fear of death and the desire to live in the world. According to al-Māturīdī, this dilemma that man is facing also shows him the way out. If people do good and useful deeds because of their love for life, and avoid nonsense and ugly deeds because of their afraid of death, they can make their life eternal with their own efforts and escape from eternal/permanent death. The other Hanafī thinker, a philosopher of law Abū Zayd al-Dabūsī’s views on the meaning of death and life are parallel to Māturīdī's. According to al-Dabūsī, to test man, what God has placed in human nature is not only the soul and reason but also the spirit (al-nafs) and whim (al-hawa). While the spirit and whim invites man to the temporary by ignorance, it calls the soul and reason to the permanent by knowledge. The test for human beings is to choose between the temporary and the eternal life. For al-Dabūsī, man’s saving himself from falling into nothingness and gaining the eternal life depends on his use of reason. In other words, the reason binds human beings to life, and the whim leads them to nothingness. Drawing a parallel between reasoning and existence, ignorance and absence, Dabūsī defines the terms divine command and divine prohibition in a very original way. For him, the divine command is the things that must exist, and the divine prohibition is the things that must not exist. If the man helps exist the things that God wills to exist, he can make his own existence eternal. If the man helps exist the things that God does not will to exist, he puts himself into nothingness. Lastly, both for al-Māturīdī and al-Dabūsī, life is a divine grace bestowed on human being to gain eternal life through the good deeds he does at any moment. In short, reason is necessary in religion because its use is a preference of existence to non-existence. This metaphysical system, which sees goodness as a bridge from this finite world to heaven and eternity and makes a connection between faith and deeds on the ontological and ethical level is the essence of the worldview of the Hanafī-Māturīdī tradition. (shrink)

In an earlier paper I argued that we do not have an objective conception of best interests and that this is a particular problem because the courts describe that they use an ‘…objective approach or test. That test is the best interests of the patient’ when choosing for children. I further argued that there was no obvious way in which we could hope to develop an objective notion of best interests. As well as this, I argued that a best-interest-based approach (...) was a particular problem around the time of death of some children. A response from a legal perspective argued that, while there is not a clear conception of objective best interests, the courts have a well-described approach to finding a child's objective best interests. In this paper, I argue that without clear agreement on an objective conception of best interests, the courts are unable to locate an objective sense of best interests and that the solutions do not solve the problems that were identified in the initial paper ‘Death and best interests’. (shrink)

BackgroundThe global COVID-19 pandemic confronts people with their fragility, vulnerability, and mortality. To date, scales to measure death awareness mainly focus on the anxiety-provoking aspect of mortality cues. This study aims to cross-culturally adapt and validate the Death Reflection Scale, a scale for measuring positive, growth-oriented cognitions of life reflection and prosocial behavior following confrontation with the finiteness of life.Materials and MethodsThe Death Reflection Scale was translated and adapted in a multi-step process to the German language. In (...) this anonymous, cross-sectional, online survey at a large university in Germany, students, healthcare professionals and other staff completed the DRS alongside comparison measures. Multi-group confirmatory factor analysis was used to assess configural, metric, and scalar measurement equivalence across four age and occupational groups. Convergent/divergent validity testing was done via Spearman correlations.Results1,703 participants provided data for a response rate of ∼5%. 24% of respondents were HCP, 22% students. Confirmatory factor analysis showed a higher-order structure of the DRS with a strong general factor and the originally proposed five subscales. Multi-group CFA showed partial metric equivalence across age groups and partial scalar invariance across occupational groups. Non-invariant scales were the Motivation to live, Putting life into perspective, and Legacy subscales. In the convergent validity testing, two hypotheses were fully confirmed, two partially and four were not confirmed. Experiencing a propensity for increased contemplation and life reflection during the pandemic together with spirituality showed correlations of moderate to large size to the DRS and its subscales.ConclusionFurther conceptual work for death awareness to explore the construct’s stability in different population groups needs to be undertaken. However, the DRS can be mostly used to assess positive and growth-oriented aspects of death awareness and death reflection which may be an important avenue when developing counseling and support interventions for groups experiencing a high burden during the pandemic. (shrink)

Brain death certification can be a clinically and ethically challenging affair. Healthcare workers are expected to refer patients for brain death certification to identify potential organ donors, but family members may be ill-prepared for this turn of events. Already distraught families may not appreciate delays in brain death certification, but such delays are common because of the need to manage the patient’s altered physiological state to allow testing. Opportunities for donation are sometimes lost because of the unnecessary (...) delay. With focus on an opt-out organ donation law, we discuss causes of delays in brain death certification, and the ethical issues faced by clinicians in using tests to certify patients. To resolve the issues, we argue for the use of supplementary confirmatory tests as part of a more protocol-driven approach to brain death certification to avoid delays. Such tests should be regarded as part of the donation process funded by the state. (shrink)