Symposium on the Definition of Death: Summary Statement

Abstract

This statement summarizes the conclusions of the Symposium on the Definition of Death, held at The Catholic University of America in June 2014. After providing the background and context for contemporary debates about brain death and describing the aims of the symposium, the statement notes points of unanimous and broad agreement among the participants, and highlights areas for further study.

I. INTRODUCTION

Prior to the development of the mechanical ventilator, the determination of human death was based on cardiopulmonary criteria: the irreversible cessation of heart and lung function. Yet, with the aid of mechanical ventilation, loss of brain function was no longer necessarily accompanied by nearly immediate and irreversible loss of heart and lung function. This great technological advance made it possible to save the lives of those who, due to illness or injury, had temporarily lost the brain-mediated capacity for control of circulation and respiration, or for whom the connection between the brain and the rest of the body had been functionally severed (as in those who suffer high cervical spinal cord transection injuries). Yet in other cases—cases in which the patient had suffered total and irreversible loss of brain function—doctors began to wonder whether a patient being maintained on a ventilator could be considered already dead.

In 1968, an ad hoc committee of the Harvard Medical School studied the question and came to the conclusion that patients whose hearts were still beating with the aid of mechanical ventilation could be declared dead on the basis of neurological criteria which indicated the total and irreversible loss of brain function (Ad Hoc Committee of the Harvard Medical School, 1968). Some were skeptical of the report’s conclusions, suspecting that the committee was unduly influenced by a desire to redefine death in a way that would facilitate the procurement of vital organs for transplantation (a recent medical advance at the time, made possible by the development of immune-suppressive drugs). Nonetheless, the Harvard Committee’s recommendations came to be widely accepted within the medical community, and eventually legislation was adopted in all 50 states that allowed for the determination of death based on neurological criteria, modeled on the Uniform Determination of Death Act proposed in a 1981 President’s Commission report (President’s Commission, 1981).

Despite this broad legal and medical consensus, public confusion remains regarding the meaning of “brain death,” along with suspicion that many whose vital organs are harvested for transplantation after a declaration of death based on neurological criteria are not in fact truly dead prior to the removal of their organs. Further, a new wave of doubts regarding the validity of neurological criteria for death has arisen among experts as a result of evidence that seems to indicate that a higher degree of integration can persist in the human body after total brain failure than had previously been thought possible. This new evidence, presented largely by neurologist Alan Shewmon (1998) led the President’s Council on Bioethics in 2008 to reconsider the validity of neurological criteria for death. While impressed by the evidence, the Council did not decide that neurological criteria for death were invalid, but rather proposed a new rationale for the validity of those criteria that did not rely on the claim that organismal integration could not persist in the absence of all brain function (see below for further discussion; President’s Council on Bioethics, 2008).

Shewmon’s arguments have also led to increased skepticism among Roman Catholic thinkers regarding the validity of neurological criteria for the determination of death. The dominant Roman Catholic position ¹ remains in favor of allowing the use of neurological criteria to determine death, in line with John Paul II’s affirmation that determining death on the basis of “complete and irreversible cessation of all brain activity…does not seem to conflict with the essential elements of a sound anthropology” (John Paul II, 2000, no. 5). ² Yet John Paul II’s statement—and the dominant Catholic view—presuppose that total brain failure inevitably marks the loss of human organismal integration, a presupposition that Shewmon’s evidence seems to undermine.

The current neurological criteria for determination of death have also been criticized by doctors and bioethicists who question whether total loss of brain function is in fact required for death. There is surprisingly little consensus among professional neurologists regarding the justification for considering an individual dead after permanent cessation of brain function (Joffe et al., 2012), with some seeking to redefine death as permanent loss of consciousness (i.e. “higher brain death;” Machado and Leisman, 2009). By contrast, in an attempt to bypass the controversy over neurological criteria for death, some physicians and ethicists argue for relaxing laws on criminal homicide and abandoning the current “dead donor rule” ³ to allow consensual organ procurement from neurologically intact, living individuals on life support prior to a declaration of death and prior to the withdrawal of life support (Miller and Truog, 2008; Truog, Miller, and Halpern, 2013).

In response to these ongoing debates regarding the validity of total brain death as a criterion for the determination of human death, The Catholic University of America and the Bioethics Defense Fund organized an interdisciplinary symposium in order to study the question, clarify points of disagreement, and move toward a consensus with a more philosophically rigorous basis than the rationale proposed by the President’s Council. Our aim, in particular, was to take steps toward the development of a consistent Roman Catholic position on the topic. Held in June of 2014 at the Catholic University of America, the Symposium brought together philosophers, theologians, biologists, physicians and attorneys who share a view of the human person and of the nature of death that is in accordance with the Catholic philosophical and theological tradition, but who disagree regarding the validity of neurological criteria for death. Despite this diversity of perspective, the participants arrived at substantial areas of unanimous or near unanimous agreement on the appropriate criteria for determination of death. We believe that the Symposium’s conclusions are of broad relevance, given that the Catholic Church is the largest non-governmental provider of medical care in the world, and that thinkers within the Roman Catholic tradition have played an influential role in the brain death debate from the beginning. ⁴

II. POINTS OF UNANIMOUS AGREEMENT

The following are points on which there was unanimous agreement among the participants:

• 1.The dead donor rule should be reaffirmed in the face of recent proposals that it be abandoned.
• 2.Total brain death (or total brain failure) means irreversible loss of brain function, including the brain stem. It should be clearly distinguished from higher brain death, which all participants agree does not mark the death of a human being.
• 3.Death of a human is a single event, resulting from the departure of the human organizing principle (often referred to as the soul) from the physical body. This event cannot be directly observed, ⁵ and therefore determination of death must rely on signs that clearly indicate death has already occurred. ⁶
• 4.When reasonable doubt remains as to whether a human being is dead, the individual should be presumed to be alive until such doubt is removed (Brugger, 2016).
• 5.The question of whether or not brain death marks the death of a human being turns not on the persistence of immediately exercisable “higher” brain functions such as memory, reason or consciousness (see point 2 above), but rather on the question of whether or not the capacity for human organismal self-integration can persist after death of the brain. Thus there is no contradiction between accepting that brain death marks the death of a human being and claiming that human life begins at sperm-egg fusion. For, even prior to formation of the brain, a human embryo clearly possesses the capacity for human organismal self-integration (including the capacity to develop a human brain and other support structures necessary for the exercise of rationality), and is therefore clearly a living human being.
• 6.While there is some uncertainty about the exact metaphysical status of cells and tissues ex vivo, all are convinced that with external support, individual cells as well as groups of cells and tissues ex vivo can be maintained and can communicate locally with one another in ways that give rise to complex coordination, but that this is insufficient to make them an integrated, whole organism (see Condic, 2016). And all agree that distinguishing between such locally coordinated events and true organismal self-integration is important for establishing robust criteria for death.
• 7.Public education about the differences between total brain death and conditions like coma or “persistent vegetative state” (PVS) is essential. Patients in a coma or PVS are not brain dead and have a right to basic care (nutrition, hydration, nursing care), appropriate rehabilitative treatment in accord with their condition, and monitoring for signs of possible recovery.
• 8.Greater clarity and uniformity are needed regarding the protocols for the determination of death on both cardiopulmonary and neurological grounds.
• 9.Greater clarity and uniformity are needed regarding the protocols for organ donation, in order to avoid potential abuses or conflicts of interest, and to alleviate the public suspicion about organ donation that has arisen due to actual and/or perceived abuses and lack of clarity. Specifically, protocols for donation after cardiac death should uniformly require sufficient time to elapse prior to the declaration of death to ensure that neurological recovery is no longer possible even if extraordinary interventions were provided. ⁷ Informed consent policies are also needed to educate potential organ donors about the debate over the adequacy of the protocols for determining death on both neurological and cardiopulmonary grounds.

III. POINTS OF BROAD AGREEMENT

The following are points on which a majority of participants agreed:

• 1.At the conclusion of our discussion, the great majority of participants agreed that total and irreversible brain failure is a valid criterion for the determination of human death, on the grounds that total brain failure marks the loss of the capacity for organismal self-integration.
• 2.At the conclusion of our discussion, a substantial majority of participants agreed that total brain failure is the only true criterion for human death—the only sign that the capacity for organismal self-integration has been irreversibly lost—although everyone endorsing the neurological criteria agreed that in practice cardiopulmonary criteria can still be acceptably used in many cases (see II.9), because total brain failure imminently follows upon cardiac failure in the absence of extraordinary interventions.
• 3.The above points of broad consensus are particularly important given that in 2008 The President’s Council rejected the “loss of somatic integration” rationale for the validity of neurological criteria of death. They rejected this rationale based on evidence presented by Alan Shewmon, which convinced them that somatic integration may be able to persist after total brain failure, contrary to what had previously been thought. By contrast, while a few of the Symposium’s participants think that Shewmon’s evidence give grounds for reasonable doubt, (see IV.1, IV.2), most participants believe either that Shewmon has not adequately demonstrated that genuine somatic integration persists after brain death (see Condic, 2016), and/or that Shewmon’s argument is not logically and philosophically compelling (see Moschella, 2016). Further, almost all participants agree that self-integration is the mark of a living organism as a whole, such that if genuine self-integration does persist after total brain failure, then the human person persists after total brain failure as well (but see IV.4 below for Lee’s distinction between organismic integration and properly human integration). Thus, almost all participants agree that the position of the President’s Council—accepting that organismal self-integration can persist after brain death, but continuing to accept the validity of neurological criteria for death—is untenable. Unlike the loss of somatic integration rationale, the President’s Council’s new rationale for the validity of neurological criteria for death, based on the idea of an “organism’s ‘fundamental work,’” lacks adequate philosophical grounding.

IV. POINTS FOR FURTHER STUDY

The following emerged as the key points on which further study is needed in order to deepen our understanding of the issues and, if possible, move toward greater consensus one way or the other.

• 1.The difference between genuine organismal integration and mere local coordination between cells and tissues (see Condic, 2016) needs to be further clarified both philosophically and biologically. Most of the participants who think that neurological criteria for death are valid are convinced that the functions that can sometimes persist in a body supported by a ventilator after death of the brain are all functions that can be explained by local coordination between cells and tissues. Those participants who remain skeptical of neurological criteria think that the integration/coordination distinction needs to be further elaborated in conjunction with both a metaphysical analysis (see Moschella, 2016) and with clear empirical criteria so as to be able to explain why, for instance, a terminally ill patient on a ventilator with multi-organ failure still counts as integrated while an individual after total brain failure does not, even if heart and lung function are stable (with the help of a ventilator) and non-brain-mediated systems are working normally.
• 2.Several of the participants maintain that sufficient integration remains following death of the brain to raise reasonable doubt regarding whether an individual remains alive, albeit in a severely impaired state (see Austriaco, 2016; Brugger, 2016). They argue that the burden of proof lies with those who argue the opposite. Resolving this issue will require further discussion of the distinction between integration and coordination, as well as additional detail regarding the precise nature of the biologic processes that persist after death of the brain. In light of the unanimous agreement on the importance of self-integration (see II.3, above), resolution of this issue is possible in principle based on more detailed scientific and medical information, as well as a clearer philosophical definition of “self-integration.”
• 3.The question of whether or not a “primary organ” is needed as the material basis for organismal integration in organisms beyond a certain size/degree of complexity—and of whether or not that primary organ is the brain (including the brain stem but not including the spinal cord) in postnatal humans—also bears further study both philosophically and biologically. Furthermore, the question of whether death may have occurred after the irreversible loss of specific brain functions that are essential for sentience and bodily integration (rather than failure of the whole brain) warrants additional study and elaboration.
• 4.Several participants (see Lee, 2016) argue that it is unnecessary to resolve the question of whether or not body-wide integrated processes can persist after total brain failure. Rather, they claim that, since human beings are rational animals, and animals are sentient, the integration proper to a human being requires possession of at least the radical capacity ⁸ for sentience (sensory cognition). Therefore, these participants concluded that determining whether or not a human being has died only requires determining whether or not the radical capacity for sentience has been lost. Since, in mammals, a brain (or an active disposition toward the development of a brain) is a condition for the radical capacity for sentience, that capacity is clearly lacking in a human body after the death of the whole brain. While many found this approach convincing, others expressed concern that it could be used to justify definitions of death based on total and irreversible failure of higher brain function alone (see Austriaco, 2016). Another concern raised was whether this understanding of a “root capacity” was adequate; it was argued that even if an organism cannot develop certain structures, it might still have the capacity to use them if they were added on by an external cause (for example, artificial limbs that are controlled by neural impulses). Further work is needed in order to respond more fully to these concerns and to clarify the relation between this new rationale for the validity of neurological criteria for death and the traditional loss of organismal integration rationale; specifically, the concept of “integration proper to a human being” requires further elaboration.
• 5.The question of whether and to what extent hypothalamic function can be preserved in some cases that otherwise meet the current clinical criteria for brain death requires further investigation. If it is established that significant hypothalamic function can be retained, despite a rigorous adherence to the current clinical criteria for brain death, this is a matter of grave concern, since this function could potentially mediate some forms of integration.

V. SIGNATORIES

Affiliations are listed for identification purposes only. The views of the signatories do not necessarily express the views of the institutions with which they are affiliated.

Ryan Anderson, Ph.D.

William E. Simon Fellow

The Heritage Foundation

Rev. Thomas V. Berg, Ph.D.

Professor of Moral Theology

St. Joseph’s Seminary, Yonkers, NY

Father Shenan J. Boquet

President

Human Life International

Dorinda C. Bordlee, J.D.

Vice President, Senior Counsel

Bioethics Defense Fund

E. Christian Brugger, D. Phil.

J. Francis Cardinal Stafford Professor of Moral Theology Saint John Vianney

Theological Seminary

Robert J. Buchanan, M.D.

Chief of Functional and Restorative Neuroscience and Neurosurgery

Seton Brain and Spine Institute, Austin, TX

Joseph A. Capizzi, Ph.D.

Associate Professor of Moral Theology

The Catholic University of America

Maureen Condic, Ph.D.

Associate Professor of Neurobiology and Anatomy

University of Utah School of Medicine

Samuel Condic, Ph.D.

Assistant Professor of Philosophy

University of Mary

Ignacio de Ribera-Martin, Ph.D.

Assistant Professor of Philosophy

The Catholic University of America

Jason T. Eberl, Ph.D. Semler Endowed Chair for Medical Ethics Marian

University College of Osteopathic Medicine

Kevin Flannery, S.J.

Ordinary Professor of Philosophy

Pontifical Gregorian University (Rome)

Edward Furton, Ph.D.

Ethicist and Director of Publications

The National Catholic Bioethics Center

Marjorie A. Garvey, M.B., B.Ch.

Division of Translational Research,

National Institutes of Mental Health

Robert P. George, J.D., D.Phil.

McCormick Professor of Jurisprudence

Princeton University

Sherif Girgis, M.A.

Ph.D. Candidate, Princeton University

J.D. Candidate, Yale Law School

Michael Gorman, Ph.D.

Associate Professor of Philosophy

The Catholic University of America

John S. Grabowski, Ph.D.

Associate Professor and Director of Moral Theology/Ethics

The Catholic University of America

John M. Haas, Ph.D.

President

The National Catholic Bioethics Center

Daniel Kane, M.S.

Associates in Medical Physics, LLC

Patrick Lee, Ph.D.

John N. and Jamie D. McAleer Chair of Bioethics

Franciscan University of Steubenville

Melissa Moschella, Ph.D.

Assistant Professor of Philosophy

The Catholic University of America

Nikolas T. Nikas, J.D.

President, CEO and General Counsel

Bioethics Defense Fund

Peter Ryan, S.J., Ph.D.

Executive Director, Secretariat of Doctrine United States Conference of Catholic Bishops

John Sullivan, M.D.

Associate, Pediatric Critical Care Medicine

Janet Weis Children’s Hospital/Geisinger Health System

Christopher Tollefsen, Ph.D.

Professor of Philosophy

University of South Carolina

John M. Travaline, M.D.

Professor of Medicine

Temple University School of Medicine

Amina White, M.A., M.D.

National Institutes of Health

Clinical Center, Department of Bioethics