A structured analysis of the concept of brain death

Abstract

The tests and procedures used to determine death must be consistent with a coherent concept of death. This concept includes the subject of death, the definition of death, the sign/criterion of death, and the methods used to diagnose death. All four levels must logically build on one another. Additionally, any concept of death must align with the generally accepted meaning of the term “death” in everyday language. Judged by these standards, the current guidelines for determining death based on neurological criteria are not convincing: brain death does not indicate the disintegration of the human organism, and intensive care keeps patients alive and does not ‘mask’ death. Furthermore, ‘permanent’ loss of organ function can never reliably indicate death. Thus, the criterion and the definition of death do not match.

Introduction

Since brain death (BD) was proposed as a new criterion for death by a committee at Harvard University in 1968 [1], there has been much controversy surrounding it. In the practice of transplant medicine, however, it quickly gained acceptance. Whereas physicians and their professional organizations concentrate almost exclusively on the diagnostic accuracy of BD, philosophers and ethicists address different questions. For example: Is death determined by the condition of the biological organism or by the loss of mental capacities? Is death an event or a process? How should the integration of an organism be assessed? Do intensive care measures preserve life or conceal that death has already occurred?

For a concept of death to be coherent, it must offer convincing answers to these questions. It must take into account both its structural aspects and the ordinary use of the term “death”. Applying these principles to the concept of BD reveals serious shortcomings.

The structure of a concept of death

The determination of death rests on conceptual prerequisites that are not apparent in a physician’s actions when confirming death in an individual case. This section will briefly outline these prerequisites, as they provide the foundation for subsequent considerations.

The different levels of the problem

To determine death, one must first understand what the term ‘death’ means. What is death? The answer to this question provides its definition–its conceptual meaning. Death entails a fundamental change in reality. The sign by which death can be recognized is the criterion of death. When this sign is not entirely obvious–like in cases of complete destruction of the body by massive trauma or explosion–special tests and procedures are required to establish that the criterion of death is met.

These three aspects of the topic “death” were distinguished by Bernat, Culver, and Gert in their seminal essay of 1981: the definition of death, the criterion of death, and the tests used to demonstrate that the criterion has been fulfilled [2]. Yet, controversies surrounding the definition of death reflect often deeper disagreements about what it means to be human. Early in the debate on BD, Leon Kass emphasized that any discussion of death presupposes clarity about the subject involved: “these questions about when and how cannot be adequately discussed without some substantive understanding of what it is that dies” [3, p. 699]. Thus, the subject of death must also be considered [4].

In summary, four distinct levels must be differentiated. Each corresponds to one of the four fundamental questions that arise in any determination of death: Whose death is under consideration? What is death? Which criterion indicates that death has occurred? Which tests can demonstrate that the criterion of death is fulfilled (See Table 1)?

Table 1.

The 4 levels of death determination

	Question	Level
1	Whose death?	Subject of death
2	What is death?	Definition/Meaning of death
3	What sign(s) show that death has occurred?	Criterion/Sign(s) of death
4	What tests can be used to show that the criterion/sign(s) of death is (are) present?	Tests for determining death (Diagnosis of death)

These levels are referred to by various terms in the literature.1 For the purposes of this text, only the terminology presented in Table 1 will be used to denote the different levels of the concept of death.

The inherent logic of a concept of death

The four levels must build logically upon one another to form a coherent concept of death:

• The term ‘death’ always refers to a specific subject (level 1). Consequently, the definition of death (level 2) depends on the nature of that subject [8]. Because inanimate objects cannot die, the subject must be a living being. Whether particular characteristics of the subject–such as mental capacities or functions–should be integrated into the definition of death is controversial.

• The definition of death (level 2) provides the basis for identifying one or more signs of death (level 3). Where several criteria or signs are recognized (e.g. cardiac and neurological criteria), it must be examined whether they indicate death with the same degree of certainty.

• Depending on which criterion or sign of death is applied, specific procedures or tests (level 4) may be required to demonstrate that the criterion or sign is indeed present (see Fig. 1).

Fig. 1.

The hierarchical structure of a concept of death

Viewed in reverse–from level 4 back to level 1–the coherence of the concept depends on each higher level being logically and empirically linked to the level below. Tests at level 4 are valid only if they accurately establish the criterion at level 3; that criterion, in turn, is valid only if it reliably confirms that the definition at level 2 has been fulfilled. Ultimately, the definition itself must correspond to the nature of the subject of death at level 1.

Although the determination of death is a complex matter including medical aspects, there is no exclusive expertise for medicine in this field. Physicians possess only the specialized knowledge required to identify certain functional failures that are regarded as signs of death. It is up to medical science to specify which bedside examinations and/or ancillary tests (level 4) can be employed to establish the presence of such signs. With respect to levels 1–3, physicians hold no greater authority than other scholars concerned with the nature of human existence, death, and its possible indicators–particularly philosophers, anthropologists, and bioethicists.

It is therefore problematic that medical associations have issued guidelines for diagnosing BD using the term “death by neurological criteria” (DNC) without further justification  [9–12]. This terminology suggests that death can be determined in an individual case (level 4) on the basis of “neurological criteria” alone (level 3). Verification of this assumption would be possible only if the definition of death (level 2) underlying the concept of DNC were explicitly disclosed. However, the current guidelines do not specify such a definition.

The common understanding of the term ‘death’

To engage in a meaningful discussion on the determination of death, it is essential to address not only the structural dimensions of the issue but also the prevailing connotations associated with the term ‘death.’ As Ludwig Wittgenstein noted in his Philosophical Investigations, the meaning of a word is best understood by examining its ordinary usage: “The meaning of a word is its use in language” [13, par. 43]. The term ‘death’ is used and understood by all members of society. It does not pertain exclusively to the professional vocabularies of clinicians, philosophers, or lawyers. Consequently, any study of ‘death’ must be guided by the common understanding shared by the linguistic community [2; 14, p. 284; 15, 16]. Accordingly, one is not “free to choose” [17] what one calls ‘death’ when a collective understanding of its meaning already exists. Those who wish to convey a concept distinct from the commonly accepted notion of ‘death’ should employ a different term to capture the intended innovation.

The ordinary use of the term “death” is characterized by several generally accepted features:

• Death is the end of life.

• Death pertains to the human being as a biological organism.

• Each individual experiences death only once.

• Death marks the end of the process of dying.

These elements are widely acknowledged and shape linguistic and conceptual usage of the word ‘death.’ However, as will be demonstrated in the fourth section, they are not always given adequate consideration and, therefore, warrant further discussion.

Death is the end of life

The fundamental distinction between living organisms and inanimate matter lies in the presence of life. A dead human body lacks the essential property that constitutes being human–life itself. Human beings exist only insofar as they live. Life is not a state of being but rather the mode of existence of human beings. If death were conceived as a complementary state to life, human existence would, in principle, be rendered without temporal limitation–first in the form of life, then in that of death. However, according to the commonly accepted understanding, human existence terminates with death, even though the physical remains persist and undergo progressive decomposition.

The term ‘life’ can be applied to a wide range of entities, including humans, animals, organs, tissues, and cells, as well as, in a metaphorical sense, to social systems and ideas. The latter, figurative uses of the term, however, are beyond the scope of this paper. It is also essential to clearly differentiate between the death of cells or organs and the death of the human being as a whole.

Humans die because they are biological organisms

Humans are living beings belonging to the species Homo sapiens. From an evolutionary perspective, this species is classified among the primates within the class of mammals. In their physical constitution, humans share fundamental biological characteristics with other animals. The concept of ‘death’ applies to all living organisms; it thus refers to the common principle uniting all forms of life–biological existence [2, 6, 16, 18, p. 29].

At the same time, humans claim a distinctive position among living beings. In philosophy and, notably, in jurisprudence, they are not treated in the same way as other organisms. Their prominent status derives from their cognitive faculties and from a spiritual or possibly immaterial dimension. Without specifying the nature of this dimension, it can be stated in general terms: “A human is not a mere body; it is a body combined with something else” [19, p. 365]. This additional dimension of human existence is also reflected in the notion that human beings are more than the sum of their parts [5, 18, 20]. But whatever transcends the biological nature of human beings is not the sole factor that defines them. Humans are, at the very least, mammalian organisms and can die only as such. As expressed succinctly: “All living organisms must die and only living organisms can die” [16, p. 37]. The term ‘death’ therefore articulates what connects humans to animals. As with other living organisms to which the term ‘death’ is applied, humans also die [2, 7, 20]. Death affects the human being as a biological organism and must consequently have “an objective biological meaning” [21].

Theories that define death exclusively by the absence of the capacity for mental activities [8, 22, 23] fail to account for the biological dimension of human existence. If mental capacities alone are regarded as decisive for determining life or death, then it is no longer the human being as such who dies, but only a part thereof. This component–defined as a comprehensive set of consciousness-associated capabilities residing in the brain–is often referred to as the ‘person.’2 Since the subject of death at level 1 is the human being, the ‘death of the person’ signifies only the loss of function in one part of the organism, namely the brain, rather than the death of the human being as a whole. As has been observed, “personhood is a psychosocial construct that can be lost but cannot die” [16, p. 37].

There is only one death

The general understanding of ‘death’ as the cessation of life entails that it occurs only once. Following death, life cannot be resumed or continued; the process is irreversible and encompasses the entirety of the human being. Consequently, the notion of multiple or partial deaths is conceptually untenable.

Death is irreversible

The fundamental understanding of ‘death’ inherently includes its irreversibility. This follows from the very definition of death as the end of life, since ‘to end’ implies that life can no longer continue. Once death has occurred, the individual human being cannot return to life. Every person lives only once and dies only once. Thus, death as the cessation of life is final and irreversible. The attribute of “absolute irreversibility is an intrinsic and necessary condition for any plausible concept of death” [24, p. 27]. Religious or philosophical ideas that postulate ‘life after death,’ ‘resurrection,’ or ‘rebirth’ do not contradict the irreversibility of death when understood in secular or biological terms. All religions acknowledge that there is something called ‘death’ that ends the life of a human being on earth.

It is important to note that the term irreversibility is frequently applied not to death itself but to the functional state of organs. This interpretation of functional irreversibility may easily be confused with the absolute finality of death, particularly when referring to vital organs. However, the irreversible loss of function even of a vital organ does not equate to the death of the organism as a whole. Without medical intervention, such a loss may rapidly lead to death; yet, with current biomedical and technological capacities, organ functions can often be supported or replaced partially or completely.

In contrast, the notion of ‘death’ as it pertains to human beings implies a state from which return is impossible. Death cannot be replaced by life; otherwise, human beings would not be mortal. The irreversibility of death is therefore fundamentally distinct from the irreversibility of organ failure.

Death and life are mutually exclusive

Death marks the boundary between life and non-life, existence and non-existence. In the conventional understanding of the terms ‘life’ and ‘death,’ a human being cannot be both alive and dead simultaneously. Life and death are mutually exclusive [14, 16, 25–27]. By its very nature, the term ‘death’ is an all-or-nothing concept. So long as some degree of life remains, the individual cannot be considered dead. A high level of biological or cognitive function is not necessary for the state of being alive. Even terminally ill patients who are unconscious and dying are still alive.

The transition from life to death is not gradual but sudden. Regardless of the temporal extension of the dying process, dying is a part of life, a period of declining functionality and performance before death. Death, in contrast, is the event that terminates the process of dying and marks the onset of postmortem decomposition [2, 6, 14, 28, 29].

Death is the end of a human being’s existence. Consequently, life and death are not scalable: one is either alive or dead, with no grey areas in between. Degrees of death do not exist; no individual can be ‘more dead’ than another. As long as changes in a patient’s health is possible, the person remains alive. Once death has occurred, the concept of health no longer applies.

Death is related to the whole, not to parts

Human beings, as subjects of the legal and social order, cannot be regarded merely as aggregates of cells or organs. While cells and organs do not have rights, human beings do. Accordingly, human life and death cannot be defined exclusively by the biological ‘life’ or ‘death’ of organs or cells. If a human being is more than the sum of his or her constituent parts [19, 30, p. 69; 31, 32], it is conceptually inappropriate to identify the human being with a mere collection of organs, bones, tissues, and cells.

Claims that life and death may coexist within a single body–when an organ or tissue is ‘dead,’ for instance–refer solely to the condition of body parts, not to the life or death of the human being. “The death of a human being–not the ‘death’ of cells, tissues or organs–is the matter at issue” [5, p. 58]. Death concerns the human being as a whole, not the dysfunction of individual components. For this reason, the term brain death is conceptually misleading, as it seems to equate the failure of one organ with the death of the entire human being. To prevent such linguistic and conceptual confusion, the term death should not be applied to individual body parts. Organs and tissues may lose their function, but they are not identical with the living organism–the human being–for which they have a function.

Loss of function in a particular organ or limb is, in principle, compatible with continued human life [2, 3]. Conversely, the determination of death does not require that every cell or tissue of the organism has ceased to function. Death is generally considered to occur long before the human body has completely decomposed, and its last cell has dissolved.

As early as 1971, Leon Kass defined death as the loss of the organism’s integrative unity: “What dies is the organism as a whole. It is this death, the death of the individual human being, that is important for physicians and for the community, not the ‘death’ of organs or cells, which are mere parts” [3, p. 699]. Bernat has rightly emphasized that this position has always implicitly been underlying the traditional meaning of ‘death’ [20].

Death is the end of the process of dying

From a phenomenological perspective, biological changes occurring in the human body before and after death do not differ in principle. Prior to death, severe functional impairments may arise, including multi-organ failure and cellular necrosis. After death, all organs and tissues that remain structurally intact rapidly lose their capacity for function and regeneration. Because these progressive biological and physiological transformations are continuous, some authors interpret the phenomena of decompensation and degeneration observed before and after death as manifestations of a single underlying mechanism. Accordingly, they describe not only dying but also death itself as a process [11, 33, 34].

However, the term death refers to the human being as an integrated whole, that is, to the organism in its entirety. Any residual function of organs, tissues, or cells after death no longer pertains to the life of the human being, but merely to the short-term reusability of individual parts of the corpse, provided that structural disintegration within them has not yet progressed too far. Those who still speak of ‘life’ in this context have replaced the subject of death at level 1: they speak of the ‘life’ (in the sense of functionality) of organs or cells, but no longer of the life of the human being as an organism.

The precise moment of death cannot be identified “because it takes time both for the event to occur and for physicians to determine it” [20, p. 46]. Although the fundamental change in status from ‘human being’ to ‘corpse’ may not be immediately evident in many cases,3 this does not alter the categorical distinction between life and death. The notion that death itself represents a gradual process [35, 36] is incompatible with the conventional understanding of death: human beings are either alive or dead (see above).

Additionally, death cannot be a process because the term ‘process’ requires change. Death means non-existence of the subject who has died and thereby excludes any further change. As non-living individuals no longer exist, death is not a state of being but the event that terminates existence.4 It marks the boundary separating the process of dying from the subsequent process of bodily decay affecting organs, tissues, and cells [2, 6, 27].

The main conceptual assumptions concerning the four levels of the topic ‘death’ discussed in this section are summarized in Table 2.

Table 2.

The four levels of a concept of death with their general meaning

Level	General meaning
Subject	Human being
Definition	End of life of the human being as a biological organism
Criterion/Sign	Irreversible breakdown of the human organism as a whole
Tests for determining death	Tests and procedures to determine that the criterion on level 3 is met

Issues with the concept of brain death

The objective of the Harvard Committee was “to define irreversible coma as a new criterion for death” [1, p. 337]. BD is therefore located at level 3 within the structure of the concept of death: it is supposed to be a sign that a human being has died (Concept of Brain Death, CoBD). In light of the conceptual logic and general meaning of ‘death’ as outlined above, the CoBD proves implausible on several grounds.

Death and isolated loss of organ function

The syndrome of BD results from severe and irreversible damage to the brain, including the brainstem. The brainstem contains the centre regulating spontaneous breathing. Without mechanical ventilation, respiratory arrest would rapidly lead to circulatory collapse and, consequently, to the collapse of the entire organism. Artificial ventilation, however, leads to continued functioning of all organs, tissues and cells outside the brain. Thus, BD is essentially an isolated loss of function, while all other organs and tissues remain intact.

Despite this, BD is frequently regarded as a “definition of death” [10, 31, 37–39]. Such wording misrepresents BD as part of a logical concept of death. Within the concept of death, the loss of brain function may serve as a criterion of death (level 3), but not as a definition of death (level 2). Referring to BD as a “definition of death” conflates these conceptual levels and obscures the principle that every criterion of death must derive from a prior definition of death (see the second section above). As a result, the crucial question of what kind of death the BD criterion is supposed to indicate becomes blurred.

Proponents of the CoBD often argue, explicitly or implicitly, that every death is BD [39–42]. This claim overlooks the fact that the functional loss in BD is confined to a single organ–the brain. In reality, very few people die of this type of ‘single-organ death.’ BD accounts for less than 1 percent of all deaths.5 If, indeed, every death were a case of BD, the current shortage of transplantable organs would not exist.

BD is a distinct clinical syndrome that occurs exclusively in ventilated patients within intensive care settings. It is absent in all other cases of death. In ‘traditional’ death, brain function, respiration, and circulation cease almost simultaneously within minutes, leading to global oxygen deprivation and the cessation of function in all organs and tissues. In the overwhelming majority of deaths, brain failure is part of a generalized loss of somatic integrity. BD, however, is limited to the brain.

Traditional corpses are therefore not merely ‘brain-dead,’ but ‘completely dead.’ The assertion made by the President’s Commission in 1981 that the classical cardiopulmonary criterion and the brain-oriented criterion offer two perspectives on “the same phenomenon” [5, p. 33] was incorrect from the outset. As one critic aptly asks: “How can a body with all non-neurological systems functioning be said to be in the same physiological state as a circulation-less corpse with no systems functioning?” [¹⁸, p. 34]. In conventional death determination, based on unmistakable and irreversible signs (circulatory arrest, livor mortis, rigor mortis, or decomposition), all vital functions have ceased. By contrast, BD constitutes a localized organ failure whose relation to the organism as an integrated whole (see section three above) remains conceptually problematic. The physiological and ontological states of a traditional corpse and a ventilated patient with BD differ fundamentally. Consequently, the statement that ‘every death is brain death’ is logically not consistent.

Death and disintegration

Proponents of the CoBD argue that comprehensive loss of brain function results in the disintegration of the organism as a whole. In their concept of death, loss of integration of the organism as a whole is the definition of death at level 2 [2, 5, p. 33, 58; 6]. This is a plausible idea and the standard rationale for BD [45]. It acknowledges that death pertains to the human organism in its entirety rather than to isolated components. However, it remains contentious whether isolated loss of brain function reliably signifies organismal disintegration and, consequently, the loss of wholeness.

Documented cases of extended survival after determination of BD–dubbed as “chronic brain death” [46]–demonstrate persistent systemic functionality, as acknowledged by the President’s Council on Bioethics [47, p. 55 ff.]. The Council accepted that brain-dead patients preserve sufficient somatic integrity to refute the notion that their bodies immediately become disorganized collections of organs. Therefore, it proposed an alternative rationale for BD as a valid criterion of death (see the section ‘necessity of self-control and integration’ below).

Apart from that, recent approaches in the literature that interpret the loss of brain function as indicative of the disintegration of the human organism warrant critical discussion.

Loss of function of the ‘central organizer’

The original justification for the CoBD rested on the assumption that the brain constitutes the central integrative organ of the organism: it was described as the structure that “integrates, generates, interrelates, and controls complex bodily activities” [2, p. 391]. “Only the brain can direct the entire organism” [5, p. 34]. However, this proposition is questionable. Were all somatic functions essential for life truly dependent upon brain function, the organism of a patient with brain failure could not be sustained for extended periods.

Nevertheless, several authors maintain that neurological control is indispensable to the persistence of life. Huang and Bernat, for instance, argue that the organism’s existence depends not merely on the presence of biological functions per se, but on these functions being regulated by the brain [6]. Yet this premise is not self-evident. If certain vital functions can persist without brain-mediated regulation, the necessity of a central neurological control center becomes debatable. In this regard, Green and Wikler offered a more comprehensive interpretation, proposing that the key issue is not the source or origin of a function’s regulation but its effectiveness: “what matters is whether the job is done” [48, p. 113].

Huang and Bernat further emphasize the brain’s unique significance as the locus not only of basic neurophysiological functions–shared with other biologically complex organisms–but also of so-called “neuro-emergent functions,” including self-awareness, abstraction, sapience, and volition [6]. This position raises the question of how such higher-order capacities relate to the organism’s biological life as a whole. While ‘neuro-emergent’ functions enable self-directed agency and qualitative enrichment of life, their loss does not equate to the cessation of biological existence. Attempts to merge person-oriented approaches to determining death with the concept of ‘whole-brain death’ are therefore problematic. Modern intensive care can preserve somatic integration despite loss of consciousness. Under such conditions, only consciousness is irreversibly lost, whereas the somatic-integrative dimension remains unaffected. Numerous regulatory processes within the human body continue to maintain vital activity independently of brain control. This autonomy is particularly evident in metabolic processes such as oxygen utilization and nutrient assimilation–both indispensable prerequisites for the maintenance of biological life.

The human organism–an orchestra?

Melissa Moschella’s notion that patients who have lost brain function are comparable to a conductor-less orchestra also rests on the principle of a “central organ” or “master part” [49]. According to this view, the brain fulfils a unifying role in the human organism analogous to that of a conductor who transforms a group of individual musicians into on single orchestral entity.

However, this analogy is conceptually problematic. Moschella herself refers to a conductor-less orchestra that existed in the Soviet Union during the 1920s, demonstrating that coordinated interaction among multiple musicians can, in principle, occur without a central ‘integrator.’ A similar phenomenon is well documented in the biological realm: organisms such as jellyfish, sea anemones, corals, and sea cucumbers lack a central brain yet are unequivocally alive.6

Living organisms differ fundamentally from other composites in that they are not assembled from pre-existing parts. Rather, they develop intrinsically, with the organismal whole preceding and governing the differentiation of its parts. The whole exists prior to the parts. The totality of the living being is present from the outset, driving the formation of specific cell types, tissues, and organs. Consequently, a structure that emerges later–such as the brain–cannot be the cause of the organism’s unity [25, 50].

In contrast, an orchestra does not arise by intrinsic development but through the intentional assembly of individual musicians who interact to achieve a unified auditory outcome. Its apparent ‘wholeness’ is a product of external coordination rather than internal self-organization. While the orchestra strives to form a cohesive ‘body of sound,’ it remains a collection of independent agents rather than a self-developing entity, and it does not inherently produce a ‘mastermind’ conductor.

To draw a legitimate comparison between a brain-dead patient and an orchestra, one must acknowledge that mechanical ventilation is enough to compensate for the loss of a critical brain function. This condition could be compared to an orchestra whose conductor has disappeared but where another, less qualified individual–perhaps a “high school marching band director” [7]–steps in to maintain tempo and basic coordination. The performance may be crude and imperfect, yet the orchestra persists and continues to perform. Moschella herself concedes that a body deprived of brain function “can go on ‘playing’ relatively simple pieces, albeit poorly” [49, p. 448]. But is that not all it takes to be alive? Nobody doubts that patients with BD are severely incapacitated. However, even low levels of functional performance are sufficient to consider a human being alive as long as it continues to be an organism as a whole.

Coordination vs. integration

Proponents of the CoBD acknowledge that various components of the human organism–organs, tissues, and cells–continue to exhibit interaction in patients who have lost all brain function. However, they seek to distinguish between coordinated interaction and integration. Moschella states that “a brain-dead body is not a single entity, but a multitude of organs and tissues functioning in a coordinated manner with the help of artificial life support” [49, p. 438]. Such a claim requires substantial justification. It remains unclear why a ‘brain-dead body’ should cease to be a single entity, particularly given its phenomenological unity. Patients with loss of brain function lie in hospital beds as unified individuals and are treated clinically as such.7

The literature appears to indicate that the distinction between the terms ‘coordination’ and ‘integration’ is largely gradual rather than categorical. When proponents of the CoBD refer to “partial or limited integration” [51] or to the “mere passive persistence of integration” [52], the boundary between coordination and integration becomes conceptually blurred. Sulmasy et al. acknowledge that patients with total loss of brain function have not lost “all integration, persistence, unity, and autonomy” [21, p. 963]. In doing so, their application of integration as a defining characteristic of life loses explanatory power. It is essential to recognize that life and death are mutually exclusive states (see the above section ‘Death and life are mutually exclusive‘). Thus, describing a condition as involving ‘some integration, but not enough,’ does not pertain to a categorical distinction between life and death.

Moschella distinguishes between “higher-level” or “substantial” biological integration, which purportedly constitutes an ontological whole, and “lower level,” “non-substantial” biological integration arising from the cooperation of various parts [53]. She also references “integrative functions” and “some sort of unity” [49] yet does not provide a clear definition of these terms or demonstrate how they delineate the difference between life and death.

Phenomena can, of course, be interpreted in diverse ways. The President’s Council on Bioethics did not dispute that the extensive functionality observable in bodies of patients with absent brain function may be interpreted as indicative of life: “… globally coordinated work continues to be performed by multiple systems, all directed toward the sustained functioning of the body as a whole. If being alive as a biological organism requires being a whole that is more than the mere sum of its parts, then it would be difficult to deny that the body of a patient with total brain failure can still be alive, at least in some cases” [47, p. 57].

Reconstruction of a conglomerate of organs?

Moschella describes patients who have lost brain function as “a multitude of living entities that cooperate with one another for continued survival” [49, p. 448]. This description does not seem appropriate. Despite referring to parts of a living being, these parts are nonetheless classified as ‘living entities.’ As parts of an integrated whole, organs and tissues do not possess a ‘life’ of their own. Rather, they function within and for an organism as a whole [51, 54]. Accordingly, assigning to them an intrinsic ‘goal’ of self-preservation reflects an unfounded assumption of purposeful behaviour. Organs do not intend to cooperate. They simply do what they are supposed to do to keep the organism alive: the lungs facilitate gas exchange, the heart circulates oxygenated blood, the kidneys eliminate metabolic waste, etc. So long as these coordinated processes persist to maintain an organism, it is implausible to assert that this organism has ceased to exist as a whole solely because brain function is lost.

Nevertheless, it is worthwhile to consider which and how many functions have been preserved and to what extent [7, 21]. Condic has compiled a list of coordinating activities that can persist in isolated cells and tissues maintained in culture or depend on biochemical signals “that could easily be reproduced in the laboratory” [51, 258]. This view seems to rest on the assumption that organs and tissues could be combined into an ‘organ network’ or ‘organ cluster’ that can be sustained by artificial means such as mechanical ventilation and other supportive technologies. Such a conglomerate would be comparable to a patient after brain death: not a human being but rather a collection of functioning organs, an “artefact” [49], in which “the locus of integration and persistence of the organism is no longer the organism itself but the humans tending to it” [21, p. 963].

However, this is a purely hypothetical scenario. It is highly questionable that such an organ cluster could ever be created. It would be necessary to ‘reconstruct’ an organism from human organs and tissues that possesses the same capabilities and characteristics observed in intensive care patients after BD. Describing brain-dead patients as a “collection of human cells that continue to exhibit some of the natural properties they had during life” [51, p. 259] falls far short of reality. A ‘brainless’ organ cluster would need to perform an array of integrated systemic functions: pulmonary oxygen uptake and diffusion, circulatory distribution, metabolic processing, nutrient absorption, excretion, immune defence, tissue repair, and, in females, pregnancy over the course of several weeks and months. Such complex and interdependent functionality cannot arise from a mere aggregation of organs. Even with optimistic projections for biomedical innovation, the construction of a comparably integrated biological system remains “pure science fiction” [54]. Until credible evidence demonstrates that such synthetic human artifacts could attain the systemic characteristics of BD patients, equating them with a collection of organs enclosed in a bag of skin [4, 45] is scientifically unjustified.

In principle, the concept of assembling human beings misconstrues the nature of living systems. Unlike machines, living organisms are not produced by the mechanical assembly of parts but by intrinsic, continuous self-development and differentiation of a whole into its parts. Human life begins from a single totipotent cell whose successive divisions generate diverse cell types that differentiate into specific tissues and organs. This process presupposes integration at every developmental stage and stands in direct opposition to any notion of organismal construction by composition. Human beings do not emerge from their parts. Human beings evolve as integrated organisms that ‘produce’ all their parts themselves.

This developmental continuity reflects a unified organizational principle. In reference to Aristotle’s theory of the soul, this principle may be conceived as the “unifying, vivifying, and organizing principle of a living being” [51, p. 264]. Why should this principle not be still effective in patients with BD, even if they can no longer perform acts requiring functioning brain structures, such as thinking, deciding, and feeling? It would be sufficient for the principle to unify and vivify the organism. This apparently is the case in patients with BD.

Multisegmented integration?

In the literature on BD, the concept of integration is closely associated with the unity of the organism. Integration is regarded as the principle that accounts for the organism’s status as a single living entity despite identifiable parts. Where an organism constitutes a whole, integration is present; and there is only one unity and one integration. Conversely, when unity is absent–or no longer present–the entity can no longer be considered an organism but rather a collection of parts. Accordingly, the issue is not integration in subordinate areas, but rather “organism-level integration” [49].

Sulmasy and DeCock likewise consider death as the “loss of integration at the organismal level” [52, p. 324]. However, they identify four different types of integration, which in certain constellations supposedly result in “human organismal self-integration”: (A) mind–body integration, (B) respiratory integration, (C) circulatory integration, and (D) cerebro-somatic homeostatic integration [52, p. 321, Fig. 1]. They argue that the loss of A+B+C or A+B+D should be equated with the death of a human being. However, no plausible justification for this assumption is provided. Why should the loss of all forms of ‘partial’ integration (A+B+C+D) not be required? Conversely, if not all types of integration need to be included, why would the loss of A+B alone not suffice? In addition, why are other organismic functions not considered–such as immune response, wound healing, or the processing of fluids and food–which are also characteristic of a living human organism?

Upon closer examination, the four types of “integration” identified by Sulmasy and DeCock prove to be physiological functions of the human organism that are often discussed in the debate on the CoBD. Their proposal thus represents only a seemingly new approach to a multi-segmented concept of integration. Analysing each “type of integration” in patients with complete loss of brain function yields the following:

“Circulatory integration” remains fully intact in patients with BD syndrome, as the circulatory system continues to function. The heart possesses an intrinsic pacemaker, the sinoatrial node, which maintains cardiac activity independently of the brain.

“Respiratory integration” is also preserved. The physiological process of oxygen utilization begins with air inhalation, continues with alveolar gas exchange, proceeds with the distribution of oxygenated blood throughout the body, and culminates in cellular oxygen consumption for energy production. In ventilated patients, only the first step–airflow generation–is mechanically supported [45]. Overall, respiration is not “a brain stem function” [55]; rather, only a minor component of oxygen utilization depends on brainstem activity, while the major part is performed through the intimate and coordinated action of various organs and tissues.

“Cerebro-somatic homeostatic integration”, according to Sulmasy and DeCock, encompasses stability of temperature and blood pressure, water balance (absence of diabetes insipidus), and cerebral regulation of hormone levels [52]. Yet these integrative functions may remain partially preserved or can return in many patients with total brain failure. A substantial proportion of ‘brain-dead’ patients do not exhibit diabetes insipidus [56]. With ongoing treatment after the diagnosis of BD, hemodynamic stability can often be achieved to a degree that vasopressors become unnecessary [57]. Body temperature decreases only to a slightly lower level [45]. The only integrative element that is consistently8 absent is consciousness.

Taken together, these observations demonstrate that even the additive combination of such ‘partial’ integrations fails to substantiate the claim that their loss defines human death. The only consistently missing component–consciousness (A)–does not pertain to biological integration, whereas the remaining components are largely (B), completely (C), or frequently partially (D) preserved. Deficits in B, C, and D can, moreover, be compensated for through intensive medical care (see the section ‘Death and intensive care‘ below).

Lack of disintegration

The theories reviewed thus far indicate that the interpretation of existing biological phenomena in brain-dead patients depends fundamentally on the author’s conception of the organism as a whole. Is an organism defined by the natural interaction of its constituent parts [60], by an anti-entropic and emergent neurophysiological function [6], by integration through a “master part” [53], by partial integration [51], or by a constellation of “partial integrations” [52]? The broad range of physiological activity observed in patients after BD–encompassing all cells, tissues, and organs except the brain–strongly supports the view that the organism continues to exist as an integrated whole.

Strictly speaking, however, the definition of death pertains not to integration but to disintegration. This calls for a shift in perspective. It is less important to define the precise nature or degree of biological integration than to determine whether integration has ended. Death can be asserted with prudential certainty only when the organism no longer exists as a unified whole but has dissolved into its component parts. Understanding how integration arises is, therefore, secondary to recognizing when it has ceased.

All patients who lose brain function were living human beings prior to brain injury; hence, they were unquestionably living organisms. The critical question is whether the loss of brain function truly entails the loss of previous organismic unity. A clear distinction should exist between ‘brain-dead’ patients and those who are manifestly alive. Yet, at the organismic level, patients diagnosed with BD are practically indistinguishable from other unconscious, mechanically ventilated patients in intensive care. They respond to medical treatment, exhibit reflexes and automatic movements [61–63], consume oxygen, metabolize nutrients, excrete waste products, and mount immune responses [45, 47 (p. 56)]. Their physiological condition may deteriorate due to illness (e.g., pneumonia, fever) and subsequently improve again. Surgical wounds heal, and in some instances, “brain-dead” women have maintained pregnancies for weeks or months and delivered healthy babies [64]. The longest reported case–a 145-day gestation–occurred in Germany in 2018 [65].

How, then, can it be seriously claimed that such organisms are undergoing disintegration? If death is defined as disintegration (level 2), its occurrence must be observable as an actual process of dissolution. The condition considered as a criterion for death at level 3—in this case BD—would have to indicate that the organism, which initially existed as a whole, is disintegrating into its parts. This is clearly not the case.

The postmortem condition of an ordinary corpse provides a benchmark for recognizing true disintegration. Within an hour of circulatory arrest, early signs of death–postmortem lividity–appear as red blood cells settle in dependent regions, forming characteristic reddish discolorations. At this point, systemic circulation and global physiological function are irreversibly lost; resuscitative efforts are futile. Interaction among tissues and organs has ceased, and only degradative processes are taking place. Such disintegration, typical of death, does not occur in patients with BD; their bodies differ profoundly from corpses [66].

Advocates of the CoBD attempt to explain the absence of visible disintegration by suggesting that death is “masked” by intensive medical support [5, p. 33]. The U.S. President’s Council on Bioethics similarly stated that “the neurological standard for death based on total brain failure relies fundamentally on the idea that the phenomenon of death can be hidden” [47, p. 52].

This proposition, however, is incompatible with the foundational framework of the concept of death. Death is a change in reality and must therefore be recognizable by specific signs (level 3) corresponding to its definition (level 2). If death denotes the disintegration of the organism as a whole, an empirical sign of death must then reflect the consequences of such disintegration–the dissolution of the whole into its parts. Although this process may not be visible immediately, its consequences soon become evident: complete loss of coordination and higher-order interactions, followed by structural breakdown and the standard physical markers of death–lividity, rigor mortis, and eventual decomposition. None of these processes occur in patients with isolated loss of brain function. The process of falling apart does not even begin. Patients who meet the clinical criteria for BD remain integrated enough to not disintegrate.

‘Invisible’ disintegration is not disintegration. A merely virtual or theoretical disintegration cannot justify declaring patients dead. After the determination of BD the physiological functions of the human body remain essentially intact. Nonetheless, proponents of the CoBD expect acceptance of ‘invisible disintegration,’ i.e. a process that is empirically undetectable. Such reasoning is epistemically unsound. The alleged disintegration of ventilated, brain-dead patients is as ‘real’ as the splendid robe in Christian Andersen’s tale The Emperor’s New Clothes.

When integration comes to an end, a gradual process of decay should become apparent. Since the condition of patients with brain failure remains stable for some time and can remain stable for extended periods, the event that supposedly led to disintegration–death–cannot have occurred. The claim that the loss of brain function equates to the loss of organismic unity lacks scientific foundation. It rather appears as an intellectually refined denial of observable reality.

Death and intensive care

Proponents of the CoBD maintain that patients who have irreversibly lost all brain function are erroneously regarded as being alive. In their view, artificial medical interventions merely create the appearance of life. They argue that the genuine self-regulatory capacity characteristic of a living organism has been lost, and that residual organ functions are no longer generated by the organism itself but maintained through external technological control and regulation. Consequently, the purpose and significance of intensive care in such circumstances warrant critical examination.

Artificiality of medical interventions

All patients meeting the criteria for the determination of BD are maintained on mechanical ventilation and receive varying degrees of intensive medical support. Ordinarily, such measures are categorized as life-sustaining interventions. Within the framework of the CoBD, however, the artificial nature of these procedures is interpreted as evidence that the patients are already dead. What remains is seen merely as “artificial life” [39].

This interpretation, however, stands in contrast to the well-established outcomes of contemporary intensive care. Artificial life-sustaining measures are an integral component of modern medicine. When a physiological function fails, medical technology can temporarily or permanently compensate for this deficit, thereby preventing the natural progression of disease or injury–even when complete recovery remains unattainable. In situations involving life-threatening loss of function, such interventions prevent death. To deny their life-preserving role on the grounds of ‘artificiality’ misunderstands the nature of medical practice itself. Medicine is, by definition, an artificial enterprise–its purpose is precisely to intervene in, and modify, the natural course of disease and dying.

Transformation through intensive care?

As previously discussed, there may be a threshold beyond which the application of artificial life-sustaining procedures no longer preserves the patient as an integrated human organism, but rather as an ‘organ preparation’ maintained through technological means. This condition does not necessarily warrant the designation ‘dead,’ since extensive systemic characteristics of life remain present (see the above section ‘Reconstruction of a conglomerate of organs?’). Sulmasy et al. characterize the ventilated ‘brain-dead’ patient as a “non-organismal, medically supported biological entity” that may nonetheless be declared dead [21]. Lizza advances this argument further, framing the condition as a form of transformation: “what remains alive must be a different sort of being. It must either be a human being, as distinct from a person, or a being of another sort, e.g., a ‘humanoid’ or ‘biological artifact’. By ‘humanoid’ or ‘biological artifact,’ I mean a living being that has human characteristics but falls short of being human, a form of life created by medical technology” [67, p. 52].

However, such a conception lacks biological plausibility. Living organisms–particularly mammals–do not undergo transformations that alter their species identity. While individuals of certain species, such as butterflies, exhibit profound morphological changes during development (from larva to pupa to imago), no empirical evidence supports the transformation of an individual of one species into another. Therefore, if a human organism remains biologically alive with medical support despite the loss of all brain functions, it continues to be a human organism. The loss of essential capacities may have severe physiological and existential consequences, potentially culminating in death, but it does not alter the organism’s fundamental nature as a member of the human species.

Necessity of self-control and self-integration

The President’s Council on Bioethics assigns central importance to an organism’s capacity for autonomous activity. According to its view, a living organism must engage in “fundamental vital work,” characterized by interaction with its environment and the active acquisition of necessary resources. This activity is understood as being driven by an intrinsic “felt need” that compels the organism “to act as it must, to obtain what it needs and what its openness reveals to be available” [47, p. 60]. The Council cites spontaneous respiration as an example of such vital activity, asserting that the irreversible loss of the ability to ventilate the lungs signifies the cessation of life. This position, however, disregards the widespread medical practice of substituting or supporting bodily functions through technological means, even though such interventions are universally recognized as life-sustaining. Technological support frequently prevents the physiological disintegration that would otherwise result in death. If death is defined as the irreversible loss of an organism’s integrative unity, then cases in which medical interventions maintain this integration cannot be classified as states of death.

Restricting the definition of life to self-performed or self-controlled functions [47, 51, 52, 55, 68] would render much of intensive care medicine conceptually incoherent. Under such a criterion, all unconscious patients who depend on artificial ventilation, nutrition, or hydration would have to be designated as dead, as their continued existence relies entirely on external technical support. Clinically and ethically, however, these patients are understood to be alive, despite their lack of spontaneous respiratory or ingestive drives. The substitution of somatic functions is effective irrespective of whether the organism exhibits corresponding biological ‘drives’ or whether control is exerted by the brainstem.

By positing that a living organism must possess intrinsic needs or drives, the Council implicitly links the definition of life to a rudimentary form of consciousness. Yet life, in its biological sense, does not require consciousness. The notions of ‘drive’ and ‘need’ are psychological rather than biological constructs, functioning in this context as analogues of a metaphysical life principle akin to Aristotle’s Psyche (soul) [4].9 Thus, despite explicit claims to the contrary [47, p. 52], the Council’s position effectively adopts a consciousness-oriented concept of death. “The true criterion is the loss of a rudimentary level of consciousness” [69, p. 443].10

Like the President’s Council on Bioethics, several authors argue that a defining characteristic of a living organism is its capacity for self-integration. Essential vital functions–particularly respiration–must be regulated internally rather than externally [21, 52, 53]. From this perspective, the acts of inhalation and exhalation constitute an intrinsically integrative activity. A ventilator, by contrast, contributes only a limited mechanical component to the broader, coordinated process of respiration (see the above section ‘Multisegmented integration?). Respiration cannot therefore be reduced to a mere “brainstem function” [60]. When examined as a systemic process, only a minor portion of the capacity to utilize oxygen for sustaining life depends on the brainstem; the predominant share arises from the complex, interdependent activity of multiple organs and tissues throughout the body.

The distinction between internal and external control does not alter the clinical efficacy of medical support. Genuine internal control can be said to exist only when damaged tissues or organs possess the ability to recover–that is, to heal. When restoration is no longer possible, technical support may substitute for lost physiological control, as in the case of pacemakers or implanted drug perfusors. Despite their artificial nature, these devices function as internal regulators by virtue of their anatomical integration. In contrast, technologies situated outside the body–such as dialysis or extracorporeal membrane oxygenation (ECMO)–represent external control. Yet patients who depend on these external systems are not regarded as dead; the same principle should logically apply to mechanical ventilation.

Ultimately, the decisive factor is that a living organism can only be successfully supported medically if it has the inherent ability of self-integration. Living patients react to intensive therapeutic measures, whereas corpses cannot. A dead body may be mechanically inflated but it would not intake oxygen. Intravenously administered substances would have no physiological effect. Fluids may fill vessels but would not be metabolized. Corpses cannot be resuscitated, but patients declared “brain-dead” can [70]. When such interventions elicit responses comparable to those in other patients, self-integration must be regarded as preserved.

Dependency on medical assistance does not negate the presence of life. A biologically dependent life is still life. It would be arbitrary to disregard this solely in the context of organ transplantation.

Loss of function and restoration of function

The commonly accepted notion that death is an irreversible event has direct implications for levels 3 and 4 within the conceptual framework of death. Since death by definition is irreversible, the criterion of death likewise must be an irreversible state. When this criterion involves loss of function or organ damage, such loss must also be irreversible. Finally, the diagnostic assessments used to establish the criterion of death must demonstrate an irreversible cessation of function (see Table 3).

Table 3.

Irreversibility and death

Level	General meaning	Irreversibility
Subject	Human being	Human beings are mortal and cannot come back to life after death
Definition	Death is generally speaking ‚the end of life.‘	Return to life is impossible =  > Death is irreversible
Criterion/Sign(s)	Loss of function or organ failure	Irreversible loss of function or organ failure
Tests for determining death	Tests to determine the relevant function or organ failure from level 3	Proof of loss of function or organ failure according to level 3 and its irreversibility

In the CoBD, the loss of brain function substitutes for the traditional criterion of death (level 3). Accordingly, death can only be declared after an irreversible loss of brain function. However, this condition does not exist in any case of BD.

The term irreversible generally denotes a condition that cannot be reversed or undone. Although it is true that many brain functions cannot be restored, others can, notably the control of pulmonary ventilation. The brainstem regulates respiratory activity by stimulating the diaphragm and intercostal muscles to generate negative intrathoracic pressure, thereby enabling air inflow. When brainstem function is lost, a mechanical ventilator can assume this role. The device compensates for failure of the brain’s respiratory centre by providing an artificial yet adequate substitute for this vital function.

The principle of functional replacement is generally accepted in medicine. The President’s Commission stated in 1981 that “an artificial substitute can forge the link that restores the organism as a whole to unified functioning. Heart or kidney transplants, kidney dialysis, or an iron lung used to replace physically impaired breathing ability in a polio victim, for example, restore the integrated functioning of the organism as they replace the failed function of a part” [5, p. 36]. This is precisely the role performed by a ventilator. The fact that it supports respiration via positive-pressure ventilation, rather than the negative-pressure mechanism of an iron lung, is of no conceptual relevance.

Clinicians describe replacement of cardiac function in analogous terms. The use of extracorporeal membrane oxygenation (ECMO) “effectively prevents arrest of cardiopulmonary function” [31, p. 8]. Similarly, mechanical ventilation prevents the arrest of the brain-controlled function of spontaneous breathing. Although respiration is no longer spontaneous–being externally initiated and maintained by the device–the ventilator prevents the cessation of respiratory function just as ECMO prevents the arrest of cardiopulmonary function.

The CoBD thus reveals a fundamental internal contradiction: BD can only be diagnosed in patients who are mechanically ventilated, yet in these same patients the most important brain function essential for survival–breathing–has already been replaced. Consequently, an irreversible loss of brain function cannot be demonstrated.

Advocates of the CoBD argue counterfactually that life-sustaining interventions merely conceal a pre-existing, ‘masked’ death. However, if death is defined as the disintegration of the organism, BD does not satisfy that definition. The criterion of death (level 3) fails to correspond with the definition of death (level 2). Patients diagnosed with BD exhibit no evidence of physical disintegration. Becker’s observation remains valid: “[…] organisms may lose functions necessary to their survival. If these functions are provided mechanically, and thus the organism survives as an organism, it is not dead, it is simply an organism kept alive mechanically” [71, p. 353].

The interrelation of biological integration, disintegration, functional loss, and mechanical life support is illustrated in Fig. 2.

Fig. 2.

Integration (life) and disintegration (death)

Death and permanent loss of organ function

One of the most notable changes in recent years in the guidelines for determining BD is the redefinition of the required functional loss of the brain: this loss no longer needs to be irreversible but only permanent. In this context, permanent refers to a loss of function that will not resume spontaneously and for which no medical interventions will be undertaken to attempt restoration [9–12]. This modification represents a profound paradigm shift, as death is perceived as an irreversible state rather than merely a permanent one (see the above section ‘Death is irreversible’). Consequently, the loss of organ function that indicates death must also be irreversible (level 3), and individual test results at level 4 must not simply represent “momentary observations”, but findings that indicate irreversible cessation of function (see Table 3).

A condition that does not change on its own, or that remains unchanged solely because no restorative measures are undertaken, cannot reasonably be described as irreversible. The ‘permanent standard’ now used in the US, Canadian, and UK guidelines thus fails to capture the essential meaning of “death.”11

Irreversibility and permanence are distinct concepts: the decision not to resuscitate a patient does not make a cardiac arrest irreversible. The same principle applies to the brain. If brain function can still be restored, all available options for restoration must be exhausted before irreversibility can be established. The strong arguments against equating irreversible with permanent [72–75] have never been refuted. A merely permanent condition cannot serve as valid evidence of irreversible death.

In the context of organ transplantation, however, the interpretation of irreversible as permanent has been widespread for many years. This assumption now appears to be so deeply embedded in medical practice that professional societies not even provide justification for why, contrary to the conventional understanding of death, a permanent loss of brain function should suffice for the determination of death [9–11].

Proponents of the ‘permanent’ standard invoke the traditional determination of death following cardiac death. Under cardiorespiratory criteria, death is declared at the occurrence of the last heartbeat, without awaiting confirmation of irreversibility [24, 40, 41, 76]. This may be pragmatically acceptable only if the individual is not treated as a corpse immediately. After approximately 30–60 min, a truly irreversible state is reached. Immediately after the final heartbeat, however, this is not the case, as cardiac arrest remains reversible for a limited period. Accordingly, resuscitation is typically indicated for at least 20–30 min [77] or even up to 40 min [78]. Declaring a person dead immediately after cardiac arrest constitutes not a diagnosis but a prognosis [75]. Although death will occur soon without intervention, it has not yet occurred irreversibly.

The presence or absence of death cannot depend on whether a decision has been made to refrain from resuscitation efforts. Such decisions may often be ethically justified. However, a decision alone does not cause death. The determination of death requires the disintegration of the human organism. The decision not to attempt resuscitation does not change the physiological status of the human organism. Therefore, the adoption of permanence as a standard for death determination is fundamentally inappropriate for reliably determining death.

Conclusion

Determining death is a complex issue. To evaluate the various concepts, definitions, and signs of death, it is essential to understand the different levels of analysis, as well as the basic, generally accepted assumptions underlying the notion of death. A convincing concept of death must be consistent across all levels.

The core issue with the CoBD lies in the fact that isolated loss of brain function does not indicate the ‘disintegration of the organism as a whole.’ Levels 3 and 2 of the CoBD do not match. Additionally, proponents of the CoBD misjudge the significance of intensive care support. The diagnostic tests used to determine BD (level 4) further contribute to conceptual incoherence. A major problem at this level is that irreversible death cannot be reliably established solely based on a ‘permanent’ loss of function.12

It appears doubtful that medical institutions applying the CoBD are genuinely concerned with the conceptual foundations of their practice. Existing guidelines for determining BD fail to address the underlying conceptual aspects of death determination [9–11]. Even a position statement of the American Academy of Neurology, which is intended to provide “guidance on objections to BD/DNC” and support for “public trust” [80], does not discuss any of the issues raised in the present analysis.

Clinicians not only declare patients dead but also proceed to perform organ retrieval procedures. Such actions must rest on a sound and irrefutable concept of death. The CoBD does not meet these requirements.