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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        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  | *This paper was first presented and discussed               at the Council's September               2006 meeting. It was prepared by the author solely to aid discussion               and does not represent the official views of the Council or of the               United States Government.*
**Staff Discussion Paper**
The Definition of Death and the Ethics of Organ Procurement from the Deceased**by Alan Rubenstein, Eric Cohen, and Erica Jackson**                             
I. Introduction

(A.) Defining Death: The Human Goods at Stake

(B.) Special Significance of the Newly Dead

(C.) Some Physiological Background

(i.) Heart, Lung, and Brain

(ii.) Details of the Brain

(iii.) Brain Injury

(iv.) Brain Death

(D.) A Note on Terminology and Structure

II. Brain Death

(A.) The Early History of Brain Death

(B.) The Philosophical Debate

(i.) The Original Defense of Brain Death

(ii.) The Standard Paradigm

(iii.) Philosophical Challenges to Brain              Death

1. Brainstem versus Whole-Brain

2. Higher-Brain versus Whole-Brain

3. The Brain and the Integrative Unity of the                Body

(iv.) The New Ontology of Death

1. Death is Real and Unknowable

2. Death is Unimportant

3. Death is Un-real

4. The New Pragmatism as Policy

(a.) Conscience Clauses

(b.) Beyond the "Dead Donor Rule"?

(C.) Conclusion

III. Donation after Cardiac Death

(A.) Background: History and Resurgence

(B.) Who is the DCD donor?

(i.) Controlled DCD

(ii.) Uncontrolled DCD

(C.) The Ethical Issues

(i.) The Decision to Donate and the Decision              to Withdraw Treatment

1. Controlled

2. Uncontrolled

(ii.) Best Care for the Dying Patient and His              Family

1. Controlled

2. Uncontrolled

(iii.) The Declaration of Death in the DCD            Timeframe

IV. A Map of Possible Positions on the Death        Question
**I. Introduction**
        The encounter with death is a perennial human experience. Ancient        accounts of the human corpse, memoirs of grief, fond recollections of        the departed-all still ring true to modern, mortal ears, facing death        themselves or confronting the death of a beloved. This is because, in        the deepest respects, the core realities of death persist unaltered        through time: the finality of the lifeless body, the responsibility of        relinquishing the deceased person's mortal remains, the burden of        mourning the departed and accepting life without them. To be human        means that death is inevitable; to care for our fellow humans means        that caring for the dead is inescapable. Technological and social        progress do not change these human realities.      

        Yet in crucial ways, if not the most fundamental ways, how we die in        the modern age would be unrecognizable to our forbears. Typically,        death arrives on the doctor's watch, and only after an explicit        decision by the dying person's surrogates to forgo additional        life-sustaining treatments. In many cases, knowing when or whether        death has actually arrived is puzzling: the brain dead body hooked up        to a ventilator is not lifeless-the heart still beats, the chest still        moves, the organs still work, if not necessarily as parts of a living        whole. But whether the ventilated, brain dead body still functions as a        *living person*-a whole, integrated organism-is a matter of        ongoing mystery and debate.1 Moreover, once death has occurred, relinquishing the body and        mourning the person are no longer the only concerns. The irreversibly        dead body now has a novel *potential*-to be used for medical        education or scientific research, or as a supply of much-needed tissues        and organs for patients whose tissues and organs are failing.      

        The perennial problems of death thus come with many novel quandaries.        For the most practical reasons-such as knowing when a person is dead        (or "dead enough") so that organs can be removed-we need to address the        most philosophical kinds of questions: What is death, and what do we        owe those who are irretrievably dying or newly dead? The aim of this        working paper is to explore the new problems of death-in particular,        the problem of defining when death has occurred in the age of        ventilators and feeding tubes, and how the definition of death (both        conceptually and in practice) shapes the possibility of procuring        usable organs from the deceased.      

        As we explore these issues, it is important to keep the ontological and        physiological question of defining death as separate as possible from        the question of-and desire for-organ procurement. It is true that much        of the urgency in the 1950s and 1960s for revisiting the question of        when death occurs came from the desire to procure transplantable organs        while they were still useful-that is, before the decay of the body. And        because organ transplantation serves an obvious moral good, there are        compelling reasons to be as precise as possible in defining when the        line from living person to dead body has been crossed, so that the        possibility of taking organs is not unduly restricted by waiting too        long to declare a patient dead. Erring too much on the side of caution        now has a high cost in organs lost. Nevertheless, it would be misguided        to see the death question entirely in light of the transplantation        question, or to adopt a definition of death that is most conducive to        organ procurement but not necessarily the most ontologically,        physiologically, and morally compelling.      
*(A.) Defining        Death: The Human Goods at Stake*
        As we begin this inquiry, it makes sense to ask a very basic question:        Why does having a sound definition of death matter at all? What are the        human goods at stake in getting this question right? What are the moral        hazards in getting it wrong? The first concern centers on caring well        for the dying. In the organ procurement context, this means ensuring        that the care a person receives leading up to his death is never        compromised by the cutting that will be done to him in the hours or        moments after his death is declared. As doctors and loving surrogates,        our first obligation is the wellbeing of the living patient entrusted        to our care, undistracted by all extraneous concerns. This could mean        pursuing aggressive treatment or responsibly coming to terms with the        futility of continuing interventions. In either case, it is the medical        assessment of the natural history of the patient's disease and the        surrogate's best judgment about how to serve the patient as person that        should be decisive.      

        In the current age, however, the prospect of organ donation-an        extraneous concern, at least from the perspective of caring for the        dying patient-is unavoidably a part of this end-of-life care. The        families of potential organ donors need to be asked whether organs can        be procured; and the body of potential organ donors needs to be handled        differently for organs to be retrieved. For those who are brain dead        (i.e., declared dead by neurological criteria), the ventilator is kept        on longer than it otherwise would be, in order to preserve the body's        organs, including the still beating heart. For those whose death will        follow only upon the voluntary removal of life-sustaining treatment,        death occurs in or near the surgical suite, with doctors waiting to act        within moments of death being declared - doctors who need to act alone        without the disrupting presence of the surviving family. Those involved        in organ retrieval have long accepted that the desire to procure organs        should never influence the decision to terminate life-sustaining        treatment; and that the act of procuring organs should never be the        explicit cause of a person's death. If one accepts these obligations as        morally binding-most people still do, some people do not-then defining        death correctly is morally essential, lest we remove organs from the        not-quite dead or perpetuate the corpse of the already-dead. If we are        to care well for both the irretrievably dying and the newly dead, we        need an ontologically sound and clinically practical definition of        death.      

        A second concern in defining death is the wellbeing of those who must        say goodbye to the one who dies. It is the survivors who bear the        burden of living with the absence of the dead, and of caring for the        dead body they still recognize as the person they love. That body is        the *remains*, the *echo*, of a life with a life story. The        "personhood" which is absent from the body is still very much a        presence to the family when the time for procurement comes. This fact        is especially true in light of the suddenness of the circumstances of        death-like a car accident-that are usually required for one to be an        organ donor. Procurement professionals who have the responsibility to        approach the family in this time of trauma have learned to tread very        lightly in the presence of the newly dead. This is viewed by some as a        legal precaution and perhaps an emotional "squeamishness" in the face        of suffering, but it also points to the possibility that these final        moments of life and first moments of death *belong* to the        grieving at least as much as to the departed person.      

        Yet for those whose loved ones are to be organ donors, these moments of        finitude also belong to others: to the surgeons who need to act in a        timely, controlled way to remove their organs, and to the unknown        beneficiary hoping to receive the organs once they are procured. The        good of organ transplantation thus depends on handling the dying and        the newly dead in a way that never impinges unduly on those who must        live with their absence, especially in that brief period of absence        when the dead body is still present. The circumstances in which we let        people die-including the "when" and the "how" of declaring them        dead-are a central part of this drama of grief and mourning, especially        the drama of the last goodbye. One obvious aim is to preserve, as much        as possible, a tranquil death in the arms of family, even amid the        flurry of clinical, technological activity that is required to make        organ donation possible.      

        A final concern, when it comes to defining death, is the good of organ        donation itself. For many people, the prospect of being an organ donor        is a way to give death meaning, to wrest something good out of        something terrible, to engage in one final act of altruism. Mortal        remains, after all, are always the remains of *someone*, and this        someone had values that should be respected as much as possible. Our        current practice of organ retrieval gives everyone the chance to        register their positive desire to be a donor. Professionals who oversee        the process of converting2        a dead *person* into an organ *source* often look at        themselves as advocates for the autonomous right of the person now gone        to decide for himself that he wanted such a conversion to occur. Some        states have included language in their anatomical gift legislation that        specifically "protects" the decedent's wish to be an organ donor, even        against the surviving family's opposition. (Rarely, it seems, does this        happen: most families honor their deceased loved one's wishes, and few        procurement agencies take organs in those rare cases when families        object.)      

        This emphasis on respecting the wishes of the deceased to be a donor        has a source beyond the general desire in medicine to respect personal        autonomy. The present world is one where transplantation-as much as        other medical procedures, like bypass surgery or chemotherapy-is a        familiar part of life. In this reality, people are made familiar with        the great good that transplantation can achieve. Stories of people,        young and old, who are "given their lives back" after years on dialysis        or who are saved from the clutches of death by a heart or lung        transplant are part of our common store of cultural experience. For        many people, this good deed seems worth the cost of accepting a minor        modification to the corpse they are destined to become.        Transplantation, one might even say, alters the experience of death        from what it has always been in ages past. This is not only because it        "frees up" needful items that can save other people's lives, but        because it gives people a novel way to die well, by making their death        a benefit to the living.      

        Thus, while we should not tailor our definition of death to accommodate        the desire to be an organ donor, we have a responsibility to seek the        truth about death in order to understand whether post-mortem donation        is technically and morally possible-or, given where we are, to see        whether our current practice of taking organs from the dead is the best        one. And while there are moral hazards in converting the dead body into        a useful source of body parts, there is also a moral obligation to do        what we can-within morally responsible limits-to help those who suffer        and often die on organ waiting lists.      
*(B.) Special        Significance of the Newly Dead*
        The reason that the definition of death and the ethics of organ        procurement are so closely linked in the public imagination is that the        source of cadaveric organs has always been the *newly* dead.3 A newly dead person fulfils        two fundamental requirements for being a source of organs. First he is        close enough to the living that his organs have not been so long        deprived of oxygen as to become nonfunctional. Second, he is no longer        an inviolable subject in the same way: the dead body can be mistreated        or wronged, but the dead person cannot experience physical harm.      

        The first feature of the newly dead-proximity in time to the        living-addresses a *technical* requirement. The earliest deceased        donors were people who had died in a familiar way: their hearts stopped        beating. (DeVita et al. 1993) With the advent of the mechanical        ventilator, however, a new class of patients were created whose status        as living or dead was ambiguous, despite the fact that their hearts        continued to beat. These individuals-if there were sound reasons to        declare them dead-would become the ideal donor candidates for a simple        technical reason: their organs would be much healthier due to their        perfusion with oxygenated blood all the way through the process of        organ recovery. Only with the "discovery" of this class of dead persons        did the practice of organ transplantation really take off.      

        Yet the technical requirements for successful utilization of cadaveric        organs are always potentially in conflict with the *moral*        requirement that dead donors be truly dead or "dead all the way." Put        simply, the "more alive" the source, the better the results. Medical        technology has created scenarios-brain death is the paramount one but        not the only one-where a person's status as living or dead is truly        difficult to discern. And with the demand for organs now much greater        than the supply, those who are trying to expand the reach of        transplantation are testing the boundaries of whom we judge to be dead        or "dead enough" to make use of as organ sources. For this reason, it        is time for a full reconsideration of the fundamental question: What is        death, when has death occurred, and how can we know? This is what this        paper aims, in a preliminary fashion, to accomplish.      
*(C.) Some        Physiological Background*
        To consider this question, we need some basic understanding of human        physiology, especially the physiology of death. What we mean by "death"        in a physiological sense is indeed puzzling. While looking upon a        corpse is a rare event for most people, we still know a dead body when        we see one. Death appears to us as a real event; being dead as an        indisputable condition. Yet it turns out that even the dead body        retains, for a while, some residual processes of life. Some individual        cells still live; some "nests of cells" still communicate. But no one        would argue that the *human being* is still alive just because        every isolated *process* that might be called life has not yet        ceased.      

        Much more complicated are those cases when a crucial part of the        body-the brain-has died, yet the rest of the body-including the        heart-is maintained by our technological interventions. In the past,        whole-brain death led imminently and irreversibly to the death of the        whole person; the entire body shut down. In the age of modern medicine,        this process of shutting down is potentially suspended, making it        difficult to know when or whether death has occurred.      

        As thinkers began to wrestle with the new problems of death that        confront us in the age of ventilators, a salient distinction was made        between *death of the organism as a whole* and *death of the        whole organism*. The latter term would imply that *all*        processes that could be called "life" have ceased in an individual for        whom they once were operative. It is that absolute lifelessness that        happens sometime after the human person has died. The death of the        "organism as a whole," by comparison, is a much more difficult concept        to grasp. To say that there is an organism as a whole implies that        there is something (someone) that (who) exists over and above the        organism's individual material parts. This entity that exists "over and        above its parts" is mortal in a way that the parts of which it is        composed are not.4 Put        differently, the death of the organism as a whole can leave behind        living components that contributed, perhaps crucially, to the        organism's "alive-ness" while it was still living.      

        Once this notion of a mortal organism as a whole is accepted, the task        is set to determine what life-like activities of its (his) component        parts can persist without being absolute indicators of continuing        organismal life. No one has trouble with positing the co-existence of        life in isolated cells with death of the organism as a whole. Yet the        advent of the ventilator introduces a much more difficult case:        continued function in some of the living parts of an organism after the        organism, itself, may already have died.      

        This leaves us with a series of rather difficult questions: Is the        death of the person equivalent to the death of the integrated organism        functioning as a whole? Is the wholly brain dead person still        functioning as a whole organism? Are there other physiological failures        besides that of the whole brain that might signal that death has        occurred? What functions of the body are necessary for the human person        to continue living? Can we really ever know? And if not, is death        better defined "the old-fashioned way," as the permanent and        irreversible cessation of breathing and heartbeat, when the individual        is indisputably dead as seen through the prism of ordinary human        experience? While these are not physiological questions alone, we        cannot address them philosophically without a more detailed        understanding of modern physiology-that is, of how the parts of the        body relate to the human whole.      
*(i.) Heart, Lung,        and Brain*
        The traditional signs of human life-breathing and heartbeat-are        controlled and maintained by the brain, heart, and lungs. An impulse        generated in the medulla of the brainstem stimulates the diaphragm to        contract, causing the chest to expand and the lungs to fill with air.        Once in the lungs, oxygen spontaneously diffuses into the blood while        the metabolic waste-product carbon dioxide diffuses out to be exhaled.        The oxygen-rich blood is pumped by the heart through the body, where it        delivers oxygen and picks up carbon dioxide. The delivery of oxygen to        bodily tissues therefore depends on three main physiological features:        the mechanical "bellowing" process of ventilation, the blood's ability        to carry oxygen, and the perfusion of oxygen to tissues by the        circulatory system.      

        When any of these vital processes are severely disrupted, death may        result. If an injury destroys the respiratory center in the brainstem,        the diaphragm does not contract and respiratory paralysis (apnea)        occurs. Under prolonged conditions of low oxygen (hypoxia) or no oxygen        (anoxia), cellular functions irreversibly cease and tissues, including        the brain, die. Other injuries, such as lack of circulation following        cardiac arrest (asystole) or occlusion of blood vessels (ischemia) due        to a clot (thrombus) also lead to tissue destroying anoxia. In most        fatal cases, loss of breathing and loss of circulation follow quickly,        the one from the other, and both apnea and asystole of sufficient        duration will lead to death of the organism as a whole. It is important        to note that while the lungs will not naturally ventilate without        stimulation from the brain, the heart can continue to beat        independently. Thus, if a person suffering brain-damage and apnea is        ventilated by a mechanical respirator, the heart can continue to        circulate the blood and perfuse the tissues with oxygen.      
*(ii.) Details of        the Brain*
        The human brain comprises three general anatomic divisions: the        cerebrum, cerebellum, and the brainstem. The cerebrum, with its outer        shell (the cortex) is known as the "higher brain." Its functions give        rise to consciousness, thought, memory, and feeling. By contrast, the        brainstem (comprising the midbrain, pons, and medulla oblongata) is        referred to as the "lower brain." It controls involuntary functions        such as breathing, blood pressure, heart rhythms, blinking, swallowing,        sneezing, and sleep-wake cycles. In addition to directing autonomic,        vegetative activities, the brainstem serves as the main pathway for the        sensory inputs that enable alertness. Therefore, while the content of        consciousness is a function of the higher brain, the capacity for        consciousness resides in the brainstem.

        The brainstem and the higher brain play an important role in directing        the integrative functions of an organism. Integrative functions are        those complex processes and spontaneous innate activities that involve        communication, coordination, and regulation of several subsystems        within the body. Examples include respiration, heartbeat,        blood-pressure, temperature regulation, coordinated muscle movement,        neuroendocrine control, and response to light and sound. Yet while some        of these integrated functions directly correspond to a function in the        brain (such as the ability to moderate the depth and pace of        breathing), others (such as blood-pressure and body temperature        regulation) are less clearly dependent on the brain's regulation. The        extent to which brainstem regulation is necessary for somatically        integrative functioning is a central matter of controversy, which will        be looked at below.      
*(iii.) Brain        Injury*
        The brain can lose function or be irreversibly damaged in a variety of        ways. Certain insults will destroy the actual brain tissue anatomy,        while others will lead to loss of function due to anoxic "starvation"        of cells in the brain. Anoxic conditions typically result from lack of        oxygenated blood flow, which is often a direct result of cardiac arrest        (asystole), severe brain swelling, drug intoxication and strokes.      

        Under ischemic or anoxic conditions, the different parts of the brain        succumb at different rates. After only a few minutes (~ 2-4), the        cerebrum and cerebellum may suffer irreparable damage. The brainstem is        much more resilient, however, and may be revived after many minutes (~        15-20) of anoxia. It is this resilience that enables the condition        known as the "persistent vegetative state," in which a person's        brainstem continues to function after the upper brain has been        destroyed. Such a patient entirely lacks cerebral functions of        self-awareness or purposeful communication. "Awake but unaware," he        exhibits brainstem functions of spontaneous breathing, reflexes to        light and pain stimulus, and sleep-wake cycles. This is in contrast to        wholly "brain dead" patients who have no functional brainstem and        exhibit none of these traits.      

        If anoxia persists, the brainstem too will eventually become damaged        beyond the possibility of revival. At this point, the entire brain has        died, and lacking medical intervention the body will undergo rigor        mortis and putrefaction. However, if a mechanical ventilator is        instituted quickly enough to a victim who has suffered death of the        whole brain, the heart may be resuscitated and circulation and other        bodily functions may be restored. This patient, sustained on a        respirator and exhibiting total and irreversible lack of all functions        of the entire brain, is considered "brain dead."      
*(iv.) Brain        Death*
        The tests for brain death proceed in three phases. After ruling out        drug intoxication or hypothermia as causes of a patient's        unresponsiveness, a series of clinical tests examine brainstem        reflexes, including pupillary, oculocephalic, and pain reflexes. The        apnea test, in which a patient is removed from the ventilator to        observe whether spontaneous breathing commences, is perhaps the most        important of the clinical diagnostics. Following on these clinical        tests, laboratory tests will be performed to ascertain total lack of        higher brain function. These lab tests include electroencephalography        (EEG) for electrical activity and tests for cerebral blood flow.      

        A brain dead patient has permanently lost all functions of the entire        brain. These patients are irreversibly unconscious, and exhibit no        reflexes to pain, sound, or light. A mechanical ventilator is necessary        to force air into the lungs. Unable to eat, they are fed intravenously        or through af � feeding tube. Eventually the brain dead individual        comes to exhibit the condition known as "respirator brain," in which        all electrical activity has ceased and autolysis (self-digestion of the        cells) has destroyed the anatomy of the brain. The extent of        destruction is often knowable only by autopsy, which often reveals the        brain tissue of the brain dead to be entirely liquefied or literally        crumbling, even after only a few days of being brain dead.      

        The prognosis for brain dead individuals is usually a deterioration        into asystole within a matter of days. However, depending on several        factors such as patient age and extent of extracranial bodily injury,        patients declared brain dead can occasionally be sustained on a        respirator for extended lengths of time (months or years). "Sustained"        here means that heartbeat, respiration, blood pressure, and body        temperature will be maintained, and the body will not begin the process        of decay. If the ventilator is not turned off and cardiac arrest does        not supervene, certain spinal reflexes and non-brain mediated        integrative functions can, at various intervals of time, sometimes        return. These functions include sympathetic and parasympathetic tone,        thermoregulation, stabilization of blood pressure, and cardiac rhythm.        Yet again, whether the presence of these functions is evidence that the        integrated organism as a whole is still alive is a subject of        continuing controversy and debate-and, as such, the focus of much of        the analysis that follows.      
*(D.) A Note on        Terminology and Structure*
        With a subject as complicated as this one, it is crucial to use terms        as precisely as possible and to justify as much as possible the terms        one uses. For the purposes of this paper, we have chosen to use the        term "brain death" in the way that it is customarily used: to refer to        a person whose whole brain has died and who is thus declared dead        within standard medical practice. This usage has been criticized        widely, most recently by the Institute of Medicine (IOM), since it        seems to present an ambiguity between a "dead organism," i.e., a person        who is declared dead due to brain injury, and a "dead organ," i.e. the        brain itself. When discussing donation from those who have normally        been called "brain dead", the IOM recommends the modified term        "donation after neurological determination of death," or DNDD (IOM        2006, p. 36ff). We hesitate to adopt this language since one of the        questions in dispute is precisely whether those who are brain dead        should in fact be declared dead. The very ambiguity that troubles the        IOM, for understandable reasons, seems necessary to conduct the inquiry        here begun. It may turn out, in the end, that the IOM's proposed        terminology or something like it is ultimately preferable, but we ought        not to presume so in advance.      

        For organ donation that occurs after death is declared due to the        permanent and irreversible cessation of heart and lung function, we        will also use the most widely accepted term "donation after cardiac        death," or DCD. Here, the IOM proposes the following new locution:        "donation after cardiac determination of death," or DCDD. The        usefulness of this innovation seems to be entirely tied up with the        parallel between it and the proposed new term for the declaring death        by neurological criteria, which for this inquiry we have chosen to        avoid.      

        The structure of this paper proceeds as follows: Part II is a critical        discussion of "brain death," which is the central philosophical,        ethical, and practical question when it comes to procuring organs from        the deceased, since the vast majority of organs are taken from        heart-beating, brain dead, ventilated individuals. We begin by        describing the legal, philosophical, and clinical framework that now        governs standard practice, then we consider various challenges to the        standard paradigm of brain death, including those that rely upon        relatively new physiological evidence. Part III is devoted to a        critical discussion of Donation after Cardiac Death. We look at both        "controlled" and "uncontrolled" DCD, describing the clinical realities,        current debates, and ethical dilemmas-in particular, how DCD might        affect care for the dying and the newly dead, both when it comes to the        patient/decedent and his or her family. A final and brief Part IV lays        out, in a necessarily oversimplified way, some of the basic positions        one might adopt when it comes to defining death, as well as the        practical implications of those positions for organ procurement. The        point of this final section is, first and foremost, to help focus        Council discussion.

**II. Brain Death**

*(A.) The Early            History of Brain Death*

        The life or death status of the desperately-injured,        ventilator-dependent individuals described above has been in dispute        since the advent of the technology that created this dilemma in the        first place. Patients whose hearts continued to beat, despite        exhibiting no brainstem function, presented a novel situation: Were        these patients simply machine-dependent individuals with a terrible        prognosis but still a fragile grip on life, or had they covertly        "crossed the line" that separates life and death, this crossing being        simply "masked" by the technological intervention? There were various        practical implications that followed from how this question was        answered: Could the transference of the person's estate be effected?        Could a person who had caused the injury, if there was such a person,        be tried for homicide? Could the providers of care make a unilateral        decision to remove the life-sustaining treatment, thus bringing to an        end the remaining signs of life? Could the patient's body be viewed as        a corpse? Were certain behaviors-such as organ removal-now permissible        that would be a clear violation of the body when it remained a (barely)        still living person?      

        In the 1950s and 1960s, when the possibility of transferring organs        from one person to another-including from the dead to the living-was        first emerging, the status of the brain dead, ventilated individual        took on even greater urgency. If these patients were already dead, they        would be ideal organ donors; and if they were dead, continuing        life-sustaining treatment was a grave misuse of our medical prowess.        These two issues-terminating life-sustaining treatment and procuring        organs from the newly dead-were the explicit impetus for a 1968 report        called "A Definition of Irreversible Coma," produced by the Ad Hoc        Committee of the Harvard Medical School to Examine the Definition of        Brain Death. In this report, the committee spelled out the clinical        criteria for determining that a comatose patient was not *merely*        comatose and respirator dependent, but that he belonged instead to a        smaller, clinically definable class that we would now call "brain        dead." These clinical criteria included: (1) unreceptivity and        unresponsivity to externally applied stimuli and inner need; (2)        absence of spontaneous muscular movements or spontaneous respiration;        and (3) no elicitable brainstem reflexes.5 The report stated that patients who passed        these tests should be considered *already dead*, notwithstanding        the continued function of their circulatory system. Since they were        dead, treatment could be stopped (unilaterally) and organs could be        procured even while the heart was still beating, including the heart        itself.      

        In the next few years, a few states began to enact legislation that        gave legal status to this altered definition of who could be considered        dead. While many argued that medical discretion was sufficient to deal        with the dilemmas of brain dead patients without altering the existing        law, others believed that legal clarity was needed in the form of new        laws. In 1970, Kansas passed a statute that both codified what had been        the standard of death in the common law prior to the advent of the        respirator (absence of spontaneous respiratory and cardiac function)        and added that an absence of "spontaneous brain function" was also a        legally permissible standard for declaring a person dead. Other states        quickly moved to emulate this legislation, while various commentators        (including an influential paper, considered below, by Alexander Capron        and Leon Kass) attempted to provide a deeper philosophical        justification for these legal statutes and to recommend the most        precise language for the laws themselves. Various key groups also made        proposals for declaration of death acts, including the American Bar        Association, the American Medical Association, and the National        Conference of Commissioners on Uniform State Laws (NCCUSL).      

        In July 1980, NCCUSL approved a model statute called the Uniform        Determination of Death Act (UDDA), which read as follows:      
            An individual who has sustained either (1) irreversible cessation of            circulatory and respiratory functions, or (2) irreversible cessation of            all functions of the entire brain, including the brainstem, is dead. A            determination of death must be made in accordance with accepted medical            standards (NCCUSL 1980).        
        This wording was also promulgated by the President's Commission for        the Study of Ethical Problems in Medicine and Biomedical and Behavioral        Research, which issued an influential 1981 report entitled *Defining        Death: Medical, Legal and Ethical Issues in the Determination of        Death* (President's Commission 1981). By the time of the report, 27        states already had statutory definitions of death that included brain        death as a legally permissible standard for declaring death.        (President's Commission 1981, p. 67) Ultimately, the UDDA, or some        slightly modified version of it, was accepted in nearly every state. 6 The equation of brain death        with death became the legal norm everywhere in the U.S.      

        Alongside the legal redefinition of death was an effort to establish        the practice of organ procurement and organ donation within a legal        framework. To this end, the first version of the Uniform Anatomical        Gift Act (UAGA) was promulgated in 1968 and then revised in 1987. The        main purpose of the UAGA is to allow a person to specify that he would        like to be an organ donor *after his death*. Legally, the        determination of death is maintained as a separate statutory matter        from the specification of who may become an organ donor, but the        ultimate effect of the UAGA, in combination with the UDDA, is that        organs may be legally given by and procured from patients who are        medically determined to be brain dead. This altered legal situation        facilitated the transplant "boom" that occurred in the 1980's.7 Treating brain dead individuals        as dead became the standard clinical paradigm, as it remains to this        day. Since ventilator-supported heart-beating patients were able to        provide higher quality organs than patients who had died by the        traditional cardio-pulmonary standards, these patient/donors became the        principal source of organs for all the years of growth in the        transplant field.      
*(B.) The        Philosophical Debate*
        The 1968 Harvard paper prominently announced a medical consensus that        extinction of brain functions was a valid way to determine that death        had occurred. The subsequent statutory changes gave this fact legal        status, removing ambiguity from the perspective of the courts as to        whether to follow the common law notion of death or the views of (a        large part of) the medical community. This legal-clinical redefinition        of death clearly opened up-and necessarily rested upon-a philosophical        reconsideration of death. How can an innovation in the definition of        death be justified? Do we have reason to believe that we have, over        time, gained a more adequate understanding of what death *is*? Is        this the lesson we can learn from our technological ability to        disaggregate some of the system failures that have previously come        bundled when a person dies? How would we adjudicate between various        understandings of the nature of death? How much do we need to know        about the true *nature* of death in order to justify innovations        in whom we *deem* to be dead? For decades, these questions have        remained the subject of ongoing debate-including both novel defense and        ongoing challenges to the idea of brain death, even as the practical        facts of death and transplantation have followed their own relatively        steady course. To understand this debate, it makes sense to go back to        the beginning-to the original defense of "brain death", as articulated        by Capron and Kass in a seminal 1972 article, as well as in the 1981        President's Commission report (for which Capron served as executive        director).      
*(i.) The Original        Defense of Brain Death*
        When it comes to death, Capron and Kass describe four distinct "levels        of 'definition'":      

        ����������� "(1) the basic concept or idea; (2) general physiological        standards; (3) operational      

        criteria; and (4) specific tests and procedures" (Capron and Kass 1972,        p. 102)8

        Capron and Kass crucially distinguish the *basic concept of death*        from the physiological standards that are appropriately chosen to        determine that death has occurred. Innovations in technology, such as        the ventilator, do not change the basic reality of death; our basic        concept of death (level 1) is always an effort to understand and        describe this unchanging reality, even if new medical circumstances        give renewed reason to grapple with death at this most fundamental        level. Ideally, a satisfactory concept of death will point the way        decisively to the correct physiological standards to use for discerning        the reality of death is particular cases (level 2). We can then ask,        for instance, "What *is* death, such that one can say that the        destruction of the whole brain - or this or that critical part of the        brain - disqualifies the (former) patient as a living human being?" The        answer will provide the *rationale* for responding one way or        another to the new medical situation we find ourselves in.      

        Although their scheme for defining death suggests the need for a clear        grasp of what death *is* as a foundation for discerning when death        occurs, Capron and Kass acknowledge the perplexing challenge of getting        public or even professional agreement on this fundamental question.        They offer some suggestions of what such a biological-philosophical        definition might look like-" permanent cessation of the integrated        functioning of the organism as a whole," "departure of the animating or        vital principle," "irreversible loss of personhood." (1972, p. 102) But        when it comes to legislating about death, they opt for a kind of        pragmatic agnosticism about the basic concept. As they put it:        "[D]ifferences of opinion would seem hard to resolve, and agreement, if        it were possible, would provide little guidance for practice." (1972,        p. 103)      

        What needs to be defined in practice, therefore, are the general        physiological standards for declaring someone dead. Without        articulating it explicitly, the Harvard group put forward precisely        such a new physiological *standard*: the permanent cessation of        all brain functions. Prior to this innovation, there had only been one        physiological standard for death-the cessation of cardiac and        respiratory function. In accordance with Capron and Kass's argument        that it is at the second level of definition that statutory action        should be taken, the UDDA, as noted above, describes two standards for        determining death: the traditional cardio-pulmonary standard and the        new neurological standard. And just as it does not aim to define the        basic concept of death (level 1), it also does not try to specify the        operational criteria or specific tests (levels 3 and 4) for discerning        whether the physiological standard it codifies (level 2) has been met,        thus allowing for changes in medical practice and granting the        necessary space for the discretion of the clinician entrusted to make        the judgment.9

        In articulating the case for using the brain death standard, Capron and        Kass contend that the question "is he dead?" should always be kept        distinct from the question "should he be allowed to die?" As they put        it:      

 The statute should concern the death of the human being, not the death            of his cells, tissues or organs, and not the "death" or cessation of            his role as a fully functioning member of his family or community. The            problem of determining when a person is dead is difficult enough            without its being tied to the problem of whether physicians, or anyone            else, may hasten the death of a terminally-ill patient, with or without            his consent or that of his relatives. Although the same set of social            and medical conditions may give rise to both problems, they must be            kept separate if they are to be clearly understood. (1972, p. 105) 

        In making this case, they assume that death is a *biological        occurrence*. Our role as a community, with special importance placed        on the physician's expertise, is to ascertain the fact of that        occurrence in a given case as accurately as possible. Death is a        *line drawn by nature* that sometimes may be hard to locate with        precision, as with the brain dead individual hooked up to a respirator,        but it is nonetheless ontologically *real*. Those patients in the        intensive care unit of the hospital who are neurologically damaged,        unconscious, and unable to breathe on their own may or may not have        crossed to the other side of the line. If it were not for the advent of        novel means to support respiration, we would never have to encounter        persons whose status in this regard is ambiguous. Yet because we        possess this means of "masking death," we also need novel methods for        discerning as best we can whether a patient is dead or alive, newly        dead or nearly dead. This is what the operational criteria should be        designed to tell us.      �����������      

        Central to this way of thinking about death is the notion that death is        a *single phenomenon*. This contention is deeply relevant when one        considers the variety of "death behaviors," as they came to be        called,10 that follow on        a determination of death. Organ harvesting is one such behavior, which        in the present environment must wait until the patient is determined        dead. Other death behaviors include the unilateral removal of life        support by hospitals in order to free up ICU beds for other patients,        or the act of burial and the commencement of death rituals by the        family of the deceased. That such behaviors happen at different times        is hardly novel. Yet Capron and Kass argue against having different        definitions of death itself for these different death behaviors:      

        Any new means for judging death should be seen as just that and nothing        more - a change in method dictated by advances in medical practice, but        not an alteration of the meaning of "life" and "death." Once it has        been established that certain consequences - for example, burial,        autopsy, transfer of property to the heirs, and so forth - follow from        a determination of death, definite problems would arise if there were a        number of "definitions" according to which some people could be said to        be "more dead" than others. (1972, p. 106)      

        In sum, Capron and Kass claim that death should be seen as a biological        reality and that medical science, guided by philosophical reflection on        the appropriate grounds for establishing a medical standard, must seek        to identify it as best as it can. Others have argued, as we will see,        that death does not really have the ontological status that this view        wants to grant it. Death, rather, is a transition in social status;        that sequence of changes that occurs at the end of life-organ source,        corpse for burial, the buried person we remember-corresponds to a        sequence of different deaths. At the same time, there are those who        maintain that death is a real, concrete event, but who do not believe        that brain dead persons are really dead or "dead all the way." They        believe that the best standard for declaring a person dead is the        irreversible loss of circulation and respiration, even in the age of        ventilators and feeding tubes. We will explore these various positions        more fully below.      
*(ii.) The Standard        Paradigm*
        While the philosophical debate over the nature of death continues in        full force, a "standard paradigm" has emerged that governs how and when        death is defined in practice-and, by extension, how and when organs are        procured from dead donors. This paradigm can be summarized in the        following four points11:      
-  The "Dead Donor Rule" must always be respected: if someone is to become            an organ donor, they need to meet both the clinical and legal            definition of death.   
-  a. Death is a  biological occurrence or event.  When the presence          of a ventilator obscures us from seeing its usual signs, the reality of          death must be ascertained by neurological tests. b. These tests must establish an irreversible loss of functioning  of                the whole brain including the brainstem . This is the necessary and              sufficient condition for confirming that death has occurred.   
-             Death itself is to be understood as  the irreversible loss of  integrative functioning of the  organism as a whole . This            basic concept provides the philosophical rationale for relying on            neurological tests, since passing those tests means that the body has            lost its  sine qua non  of integrative and anti-entropic            functioning-the brain in its entirety.   
-         The old, cardio-pulmonary standard for declaring death is still a valid        standard and can be used in the vast majority of cases in which death        is declared-that is, in all those cases in which mechanical ventilation        is not part of the clinical picture.

        This picture of death and transplantation is largely the one that was        articulated in the 1981 President's Commission report. Although the        articulation of the basic concept of death presented here-the        irreversible loss of integrative functioning of the organism as a        whole-is mentioned in that report and (with a certain agnosticism) by        Capron and Kass, it is most explicitly endorsed in the work of        Dartmouth neurologist James Bernat.12 Bernat concurs with Capron and Kass that death is a        biological event. The formulation of this concept in his paper with        Culver and Gert is notable:      

            Death should be viewed not as a process but as the event that separates            the process of dying from the process of disintegration. (Bernat et al.            1981, p. 389)        

        Regarding the basic definition of death, Bernat and colleagues        emphasize two points. First, it must be consistent with the meaning of        the word in common usage. Ordinary human beings, not just medical or        legal experts, understand what death is; the clinical definition of        death, as applied in the brain death context, must be in line with this        common understanding.13        Second, what we mean by the death of a human being must in some sense        be the same as what we mean by the death of any living organism. Death        is not the loss of any particular function-including consciousness or        cognition-that we might deem uniquely essential to being a human being.        The death of the person means the death of the biological organism        functioning as a whole.      

        Bernat and colleagues then explain why this definition of death        provides a coherent foundation for accepting and applying the        whole-brain criteria:      

            This criterion is perfectly correlated with the permanent cessation of            functioning of the organism as a whole because the brain is necessary            for the functioning of the organism as a whole. It integrates,            generates, interrelates, and controls complex bodily activities. A            patient on a ventilator with a totally destroyed brain is merely a            group of artificially maintained subsystems since the organism as a            whole has ceased to function. (1981, p. 391)        

        Without the brain, in other words, the functions that remain in the        body are not a sign of integrated activity of the organism. In        addition, Bernat and others have argued, the persistence of those vital        functions is necessarily brief. Without the operation of the brain as        integrator of the body, the life processes will not resist the forces        of entropy.14 After a        short time, the residual functions-masquerading as entropy-resistant        integrative behavior-will fail and these functions will be        extinguished. The mechanism for this final breakdown will be asystole        and the end of spontaneous circulation. In their words:      

            After the organism as a whole has permanently ceased to function,            individual subsystems may function for a time. While this is not true            for spontaneous ventilation, which ceases either immediately after or            just before the permanent cessation of functioning of the organism as a            whole, it is true for spontaneous circulation, which with artificial            ventilation may persist for up to 2 weeks after the organism as a whole            has ceased to function. (1981, p. 390)        

        On this view, the ultimate proof that the brain is the critical        integrating organ for the organism as a whole is seen in the prognosis        of brain dead patients: despite the most aggressive therapy, cardiac        arrest is believed to be imminent and inevitable. As noted briefly        above and explored in detail below, some question whether the brain is        in fact necessary for the continued integrative functioning of the        whole organism. But at present, Bernat's basic framework, both in        theory and in practice, is the standard paradigm.      
*(iii.)        Philosophical Challenges to Brain Death*
        From the beginning, not everyone accepted the idea of brain death, and        in recent years the challenge to the standard paradigm has taken on a        new urgency for various reasons: new physiological evidence about the        state of brain dead individuals, a growing belief that individuals        should decide such ultimate questions about the line dividing life and        death for themselves, and a restless desire to increase the available        pool of organ donors. In this section, we will survey the major        alternatives to the standard paradigm and what they might mean for        organ procurement.      
*1. Brainstem versus Whole-Brain*
        The "standard paradigm" here described is the standard in the United        States. Policies in other countries differ in a number of ways. In the        United Kingdom, for example, the phenomenon in question is actually        known as "brainstem death." The differences between the two countries,        while subtle, are instructive.      

        As already described, the *clinical* tests for brain death        exclusively evaluate the condition of the *brainstem*. In the        United States, however, other confirmatory tests, such as the EEG, are        performed to evaluate activity in other parts of the brain, even if the        results of these tests are not allowed to overrule positive clinical        tests for brain death. In the UK, by contrast, such testing is not        necessary, since the accepted physiological standard for declaring        death in the case of a ventilator-maintained patient is the        irreversible destruction of the brainstem. While it is true that the        majority of the brain-mediation of somatic integrative functions of the        organism are localized in the brainstem, the UK rationale for brainstem        death is not based on a notion of death as the loss of integrative        unity of the organism as a whole. Rather, as explained in the        influential writings of Christopher Pallis, the definition of death is        *loss of the capacity for consciousness combined with loss of the        capacity to breathe* (Pallis 1999, Pallis and Harley 1996, Pallis        1995).      

        Critics of the British approach argue that this formulation is not        adequate as a *definition* of death-i.e., a statement of the basic        concept. What is the rationale, they ask, for choosing the capacity for        consciousness combined with the capacity to breath as the criteria for        continued life? What is *death*, that loss of these particular        capacities should be sufficient to determine that it has occurred?        Pallis argues that in order to find the best conception of the basic        concept of death, we should look to the sociological context out of        which our basic concepts of life and death emerge. In the West, this is        the Judeo-Christian tradition in which *breath* and        *consciousness* are two definitive features of the human soul. As        Pallis argues:      

 The single matrix in which my definition is embedded is a sociological            one, namely Judeo-Christian culture. The "loss of the capacity for            consciousness" is much the same as the "departure of the conscious soul            from the body," just as "the loss of the capacity to breathe" is much            the same as the "loss of the breath of life." (1999, p. 96) 

        Physiologically, these two capacities are dependent on a functioning        brainstem. The brainstem is the pathway for sensory inputs, without        which *alertness*, a property necessary for consciousness is not        possible. The brainstem (in particular the medulla oblongata) also        contains the center that controls the contractions of the diaphragm,        rhythmically expanding and relaxing the chest cavity when we breathe.        Pallis' identification of death with the permanent loss of spontaneous        breathing and consciousness thus corresponds directly with the        physiological center which happens to be the subject of brain death        testing-i.e., the brainstem.      

        Pallis would maintain that irreversible loss of function of the        *whole brain*-the requirement of the brain death portion of the        UDDA-goes beyond the minimal necessary and sufficient condition for        declaring death in neurologically damaged but ventilator maintained        patients. Destruction of the brainstem alone is sufficient. Yet while        Pallis' basic concept of death is very different from the one put        forward by the supporters of a whole-brain standard, the practical        upshot of the UK standard is minimally different than the practice in        the US: the individuals who are defined as dead are nearly the same.      
*2. Higher-Brain        versus Whole-Brain*
        Another neuro-centric view of death that would challenge the        whole-brain criteria is the so-called "higher-brain" or        "consciousness-related" definition of death. This view, in contrast to        the brainstem position, has the potential to classify a significantly        larger class of patients as dead than is done in current practice.        Advocates of this position maintain that the permanent cessation of all        *mental* functions of the human being should be equated with        death.15 The persistence        of bodily functions such as respiration, circulation, and body        temperature regulation do not preclude a pronouncement of the death of        the *person*. In essence, this view holds to the consciousness        half what Pallis considers the critical features of the human soul. If        a person can be judged by the medical experts to have permanently lost        consciousness, they can be (or should be) declared dead,        notwithstanding any continued functioning of the integrated body.      

        Advocates of this view point out that when the Harvard Committee made        the original assertion that patients in "irreversible coma" were        already dead, they had in mind the extinction of the *personhood*        that came along with loss of brain function. As Robert Veatch argues:      

 Writers trying to make the case [in the early "brain death" literature]            for a brain-based definition of death over a heart-based one invariably            pointed out that certain functions were irreversibly lost when the            brain was gone. For instance, Henry Beecher, the chair of the Harvard            Ad Hoc Committee, identified the following functions as critical: "the            individual's personality, his conscious life, his uniqueness, his            capacity for remembering, judging, reasoning, acting, enjoying,            worrying and, so on" (Veatch 1993, p. 19).16

        In other words, the death of the higher brain, not the whole brain or        the whole bodily organism, is what classifies a human being as dead,        because it is the higher brain functions that make human beings        distinctly *human*. We are left to wonder: What is it that remains        in our presence after the person has supposedly died? What is the        living body, supported by the ventilator and/or sustained by artificial        nutrition and hydration? In response, John Lizza offers the following        answer:      

 Advocates of a consciousness-related formulation of death do not            consider such a being to be a living person. In their view, a person            cannot persist through the loss of all brain function or even the loss            of just those brain functions required for consciousness and other            mental functions. what remains alive must be a different sort of being.            a form of life created by medical technology.Whereas a person is            normally transformed into a corpse at his or her death, technology has            intervened in this natural process and has made it possible. for a            person's remains to take the form of an artificially sustained, living            organism devoid of the capacity for consciousness and any other mental            function (Lizza 2004, p. 52). 

        Among those who embrace the higher-brain definition of death, there is        some philosophical disagreement about whether personhood should be        defined as the set of mental qualities-such as memory, character,        intentions- that define a person's identity (the "functionalist" view)        or whether it should be defined as a "primitive substance that        necessarily has psychological and corporeal characteristics" (the        "substantive" view) (Lizza 2004, p. 56). Veatch has maintained that any        functional view of persons cannot provide the grounding for a        definition of death, but that a consciousness-centered notion of death        can "rely on the Judeo-Christian notions that the human is essentially        the integration of the mind and body and that the existence of one        without the other is not sufficient to constitute a living human being"        (Veatch 1993, p. 21).      

        Those who hold to the higher-brain-functions notion of death have done        more work at the level of the *basic concept* (or "definition") of        death than at the level of physiological standards (or "criteria") for        determining when death has occurred in particular cases. It is not        clear what physiological standards they would employ for determining        which neurologically injured patients would be thought to have crossed        the line between life and death. While it is true that those functions        that constitute the "content of consciousness" are to some degree        localized in the cerebrum, studies have shown a significant amount of        variability in the results of neurological tests among permanently        unconscious patients. Steven Laureys, in a 2005 article, provides a        review of this variability, introducing what he calls the "neocortical        death myth":      

            Our current scientific understanding of the necessary and sufficient            neural correlates of consciousness is incomplete at best. In contrast            to brain death, for which the neuroanatomy and neurophysiology are both            well established, anatomophathology, neuroimaging and electrophysiology            cannot, at present, determine human consciousness. Therefore, no            accurate criteria can be defined for a higher brain formulation of            death. (Laureys 2005, p. 904)        

        One could still maintain, as Veatch has pointed out, that the        consciousness-based formulation is the most accurate description of        death, even if it must wait on advances in medical science to find the        correct tests for establishing with a high degree of certainty that it        is present in a given case. One might even hold that the physiological        standards employed in the "whole-brain" paradigm for declaring death        are the safest ones to use until better means become available for        knowing, beyond doubt, that consciousness is gone.17

        The more fundamental question is whether this concept of death really        makes ontological, physiological, and ethical sense. For while the loss        of higher-brain function means the end of certain powers that are        essential to human flourishing, the question we face is precisely how        to care for and regard those who are no longer flourishing. Should        those whose status places them (or their bodies) at the low end of        human function be deemed dead? Lacking the capacity for consciousness,        yet uncontroversially continuing in the capacity for bodily life, can        we write off the person who once was both the body before us and the        mind lost forever? To treat the neurologically damaged but potentially        stable patients as dead would mark an even greater innovation-one might        say revolution-in our understanding of what death is. Not all thinkers        have taken the role of the body to be so inconsequential. As Hans Jonas        reflected decades ago:      

 It is no less an exaggeration of the cerebral aspect as it was of the            conscious soul, to deny the extracerebral body its essential share in            the identity of the person. The body is as uniquely the body of this            brain and no other, as the brain is uniquely the brain of this body and            no other. My identity is the identity of the whole organism, even if            the higher functions of personhood are seated in the brain. How else            could a man love a woman and not merely her brains? How else could we            lose ourselves in the aspect of a face? Be touched by the delicacy of a            frame? It's the person's and no one else's. Therefore, the body of the            comatose, so long as-even with the help of art-it still breathes,            pulses, and functions otherwise, must still be considered a residual            continuance of the subject that loved and was loved, and as such is            still entitled to some of the sacrosanctity accorded to such a subject            by the laws of God and men. That sacrosanctity decrees that it must not            be used as a mere means. (Jonas 1974, p. 139) 
*3. The Brain and        the Integrative Unity of the Body*
        The "brainstem" formulation and the "higher brain" formulation of the        definition of death both challenge the standard paradigm by suggesting        that it has not adequately articulated the basic concept of death. The        practical consequence of a successful challenge from either of these        camps would be an expansion-either small or large-of the class of        patients considered to be dead by neurological criteria, i.e. dead        despite the continuation of ventilator-supported somatic functioning. A        third challenge to the standard paradigm is of a much different sort.        Work in the last decade by UCLA neurologist D. Alan Shewmon has thrown        into serious uncertainty the *link* in the standard paradigm        between the basic definition of death and the physiological criteria        that supposedly follow from it. The upshot of Shewmon's argument is        that *if* we accept the definition of death as the loss of        integrative function of the organism as a whole, then we *cannot*        consider brain dead patients to be dead. And, conversely, *if* we        maintain that brain dead patients are indeed dead, then we must abandon        the loss of integrative functioning as the underlying definition.      

        Shewmon has shown that neither bodily disintegration nor asystole        *necessarily* follow imminently after brain death (Shewmon 1998).        Over one hundred documented cases demonstrate chronic survival past a        week's time, with one extreme case surviving over 14 years.        Furthermore, he demonstrates that factors such as age, etiology, and        underlying somatic integrity variably affect the survival probability        of brain dead patients. Thus, not only is asystole not necessarily        imminent upon brain death, but it is the integrity of the rest of the        body (the underlying somatic plasticity) and not the condition of the        brain that most strongly influences survival.      

        Shewmon also argues against the consensus that the somatic        disintegration that *is* observed in brain dead patients has as        its cause the loss of neural regulatory centers; instead, he presents        clinical evidence that dis-integration may be explained by the        condition known as "spinal shock." Spinal shock is a transient        condition that occurs following a sudden acute spinal cord injury,        resulting in the temporary loss of function of the spinal region below        the lesion. Such functions may be regained after 2 to 6 weeks, and        include autonomic reflexes, sympathetic and parasympathetic tone, and        thermoregulation. In several brain dead patients in whom life-support        is sustained long enough, this loss and subsequent recovery of spinal        cord regulation has been observed (Shewmon 1998, 1999).      

        Shewmon builds on these arguments in a 2001 paper that looks directly        at the issue of integration and integrative unity. His philosophical        exploration of these notions leads him to the following conclusion:      

 A unity that must be "imposed," so to speak, on otherwise non-united            parts by some master integrator outside the set of parts is only a            pseudo-unity. Moreover, applied to the issue of [brain death], such a            notion of "unity," implicit in the orthodox rationale, entails an            exaggerated dualism between "brain" and "body" (2001, p. 473). 

        In other words, the body has no *integrator* but rather the        holistic property of *integration*. In support of this idea,        Shewmon discusses the various functions of the organism that qualify as        *integrative*. Some of these seem to warrant the designation        "brain-mediated," but many others do not. Among those that do not are,        for example, wound-healing, immunologic defense of "self" against        "non-self," proportional growth, and even successful gestation of a        fetus. (2001, p. 468-9) These functions, and many others he names, have        been exhibited by at least *some* brain dead bodies. Shewmon is        careful to point out that calling these functions "non-brain-mediated"        does not mean that the brain has nothing to do with them in an intact        organism. As he explains:      

 Whether directly or indirectly, to a greater or lesser extent, the            brain is surely involved in all of them. they are all more effective            when modulated by the brain, but they do not entirely vanish without            the brain (2001, p. 471). 

        This observation, Shewmon maintains, applies also to those integrative        functions that *would* usually be classified as        brain-mediated-such as breathing, circulation, blood pressure control,        temperature control, and nutrition. Properly understood, these        integrative functions persist in many patients diagnosed as brain dead.        We will look here at just a couple of Shewmon's examples.      

        "Breathing" is an integrative function of the organism that has special        importance for all whole-brain or brainstem based conceptions of death.        Yet this function, Shewmon points out, is only absent in the brain dead        patient if it is interpreted "in the 'bellows' sense - moving air in        and out of the lungs. grossly substituted by the mechanical ventilator"        (2001, p. 464). Shewmon offers an alternative conception of        "breathing":      

 [I]f "breathing" is understood in the sense of "respiration," which            strictly speaking refers to exchange of oxygen and carbon dioxide, then            its locus is twofold: (1) across the alveolar lining of the lungs, and            (2) at the biochemical level of the electron transport chain in the            mitochondria of every cell in the body. Such respiration is not            mediated by the brain, yet it participates much more intimately in            somatic integration than does movement of air through the trachea            (2001, p. 464). 

        Brain dead patients, Shewmon points out, continue to breathe in this        sense.      

        Shewmon's observations with regard to blood-pressure control are also        enlightening. He points out that, although this function is claimed as        a brain-mediated integrative function of the organism as a whole, the        clinical examination for brain death *does not test* for its loss.        In fact, as he points out:      

        The American Academy of Neurology in its diagnostic practice parameter        mentioned normal blood pressure without pharmacologic support as        explicitly compatible with the diagnosis of brain death. Moreover,        [brain dead] patients who have been maintained on life support for        extended periods of time typically recover a sufficient degree of        hemodynamic stability to sustain somatic life without any special        cardiovascular intervention (2001, p. 466).      

        This certainly makes it seem as though hemodynamic control is a        function that does not *require* brain-mediation. It also seems to        be a likely candidate for a function whose loss in brain dead patients        is a result of the shock of their injury and not *exclusively* a        result of their loss of neuro-regulation. Shewmon goes on to highlight        that in brain dead patients who are used as organ sources, it is often        baldy stated that hemodynamic stability, with minimal pharmacological        assistance in the form of vasopressors, is either required or a sign of        "optimal candidacy." Paradoxically, the most stable organ sources have        a kind of physiological stability-blood-pressure regulation-that might        call into question whether they are truly dead or "dead enough" to be        organ sources.      

        If one wants to maintain the standard whole-brain death rationale on        biological grounds, it would seem that the inventory of *integrative        functions of the organism as a whole* must be limited to those        functions for which a strong case can be mounted that they truly        *require* the brain's mediation. Bernat has offered a response to        Shewmon along these lines, saying that the integrating functions that        can be recovered in a brain dead patient "are not the sole evidence of        functions of the organism as a whole." "The vital functions of        respiration and circulation as well as consciousness are critical        functions," he argues. (Bernat 2002, p.257) Yet leaving aside        circulation, which is not absent in the brain dead (or chronic brain        dead) patient, Bernat seems to have retreated to Pallis' standard of        respiration and consciousness, without (so it seems) adequately        confronting Shewmon's arguments about the reality of continued        respiration in brain dead individuals. In any case, "respiration and        consciousness" is *not* the physiological standard that seems to        fit with the basic notion of death as the loss of function of the        organism as a whole. It seems that the standard paradigm has been        backed into a corner where, in order to hold on to the brain death        determination as it is institutionalized in law and practice, it must        abandon the rationale that has long upheld it.      
*(iv.) The New        Ontology of Death*
        The early philosophical defenders of the neurological standards for        declaring someone dead believed that our clinical definition of death        must begin from our common understanding of what death is. No concept        of death, and no practice that is justified by this formulation, should        fly in the face of what we all intuitively feel we know about the        nature of death. Yet the new conception that equated brain death with        death of the organism as a whole made common sense a less reliable        guide to reality than ever before. It classified a group of hospital        patients as *already dead* who, in light of their warmth, color,        and beating heart, would never before have been seen by the na�ve        observer as warranting this designation. In some cases, the        non-specialist *witness* to death was asked to look beyond what he        was seeing to a reality that was hidden "behind the curtain." He was        asked to do this based on plausible arguments about what the patient's        injuries *signified*, as described by the results of *expert*        medical examination. Alexander Capron has described death as a single        phenomenon that can be viewed through two windows (e.g. Capron 1999, p.        133). Our accustomed view is sometimes obscured but what we have        trouble seeing is still there: death is still death and death is still        a real event that *happens*; at any given time, we can use the        best technological means available to judge that it has occurred.      

        Yet many critics contend that matters are not so clear, at least not        any longer. They argue, in different ways and to radically different        conclusions, that the line between life and death is not really so        finite or that knowing when that line has been crossed is sometimes        impossible. The various challenges to the idea of brain death presented        above all proceeded on the assumption that, one way or another, we        could *know* if a person was alive or dead. The interpretations        explored below suggest that the clinical condition of "brain death"        reveals a stubborn limitation of what is knowable in an area where we        intuitively feel we should be able to know. If this view is right, the        question then becomes: "How can we find our way ethically in caring for        those who seem to exist in a liminal state between life and death,        given the inherent limitations of our knowledge?"      
*1. Death is Real        and Unknowable*
        The philosopher Hans Jonas, in response to the re-definition of death        put forward by the Harvard group in 1968, wrote an essay that        powerfully articulates one response to what he saw as our necessarily        agnostic condition. In "Against the Stream" **(Jonas 1974), Jonas        addresses the two utilitarian aims that the Harvard group explicitly        mentions as the impetus for their work: disconnecting the brain dead        patient from life-support and using the brain dead person as an organ        source.18 He argues that        removing life-support is licit but must not be seen as following,        uncontrovertibly, from the fact that the patient is "already dead":      

 The question can not be answered by decreeing that death has already            occurred and the body is therefore in the domain of things; rather it            is by holding, e.g., that it is humanly not justified-let alone            demanded-to artificially prolong the life of a brainless body. the            physician can, indeed should, turn off the respirator and let the        "definition of death" take care of itself by what then inevitably            happens. (1974, p.136) 

        Jonas does not deny the ontological reality of death. Death is indeed        an *event* that separates dying from decaying. But he doubts that,        in the liminal state that our medical technology has brought into        being, we can ever *know* that the event has occurred. The curtain        that we have drawn by introducing the ventilator obscures our customary        view on the phenomenon of death and *there is no reliable second        window**to look through.* In the face of this uncertainty,        Jonas counsels a conservative course of action:      

 We do not know with certainty the borderline between life and death,            and a definition can not substitute for knowledge. Moreover, we have            sufficient grounds for suspecting that the artificially supported            condition of the comatose patient may still be one of life, however            reduced - i.e., for doubting that, even with the brain function gone,            he is completely dead. In this state of marginal ignorance and doubt            the only course to take is to lean over backward toward the side of            possible life. (1974, p.138) 

        Shewmon's work, benefiting from years of observation of the        physiological course that brain dead individuals follow, provides even        more "sufficient grounds" for suspecting that it is, indeed, a        diminished *life* that remains even after brain death.      

        Many who seem to agree with Jonas about the inscrutability of the        moment of death draw very different ontological, practical, and moral        conclusions. Two versions of this position seem most noteworthy, which        can be described by the shorthand titles: "death is un-important" and        "death is un-real." Note that by "death" in both of these formulations        we mean a physiological standard for determining death that is        justified by a true belief about the nature of the phenomenon. It is        this which is deemed, by some, as either unimportant or incoherent.      
*2. Death is        Unimportant*
        In an *Indiana Law Review* article in 1973, Ronald Dworkin argued        that those who were engaged in the project of redefining the criteria        for discerning when death occurs had gotten off on the wrong foot. He        states his position in these terms:      

            The effort devoted to defining death is wasted at best,            counter-productive at worst. The modern writers on death have failed to            ask the most basic question about the death definition problem: What            difference does it make whether someone is dead? (Dworkin 1973, p. 629)          

        Dworkin points out that there are many different practical consequences        that follow from a person being deemed dead. The consequence that they        become available as an organ source is one, but there are other "death        behaviors" as well: settling the decedent's estate, re-marriage,        prosecution for homicide, burial. For many of these, Dworkin points        out, the law already engages in the practice of tailoring the time when        a person is deemed dead to the particular consequence that is being        considered. For instance, if a person is absent for a prolonged period        of time, the law eventually treats them as dead. The length of time        depends on what "treatment" is at issue. In many states the length of        time is 7 years for purposes of property distribution and 5 years for        purposes of marriage status. This "inconsistency" is, in fact a        desirable feature of the law because different ends are being served by        the determination of death in each case.19 Finding ourselves now in a situation where        the mechanical ventilator has made the determination of death ambiguous        in a new way, we should follow the same principle: choose the standard        by which to deem a person *legally* dead based on the particular        action that the change in legal status will prompt.      

        Dworkin agrees with Jonas that decisions should not be made based on        definitional *fiat* about matters where our knowledge is limited.        He disagrees, however, with the premise that in judging what is right        in the domain of action, life and death should be treated as        dichotomous states. Consider how he speaks of what the law should do        about euthanasia:20

            [One] can define those people who are to be transferred to a status of            indisputable death as dead already, thereby paying lip service to the            sanctity of life while leaving open the question of which people are to            fall into the already dead category. Conversely, he can define them as            alive, thereby either ending discussion since it would be intolerable            to kill a living person or taking the position that killing the living            is sometimes acceptable. Alternatively, the problem could be examined            in its entirety. Analysis does not ignore ethics, but considers it            along with economics, sociology, psychology, judicial administration            and all other factors which bear on the problem. The lack of a            definition of death does not lead to decision for euthanasia; it leads            to an opportunity to consider the question freed of automatic answers.            (1973, p. 637)        

        For Jonas, the inadequacy of a definition of death that would label the        brain dead individual as dead leads to the necessary conclusion that he        is alive - or that there is enough of a chance that he is alive to        forbid us from treating him as an organ source. For Dworkin, the        inadequacy of a definition of death would prompt us to leave aside the        question of whether he is alive or dead. Instead, we should consider        the *consequences* of treating him as an organ source or, better,        we should consider the consequences of setting a policy that treats all        those in his condition as organ sources.      

        Jonas and Dworkin were both writing in the early 1970's, when the        clinical facts that provided the impetus for re-evaluating death were        very different than they are now. At the time, the removal of        life-sustaining machinery was not a commonplace event, discussed openly        by ordinary people and worked out in various ways in the courts. Now,        the law permits individuals to have life-support removed in cases of        far less severe injury than brain death. In addition, organ        transplantation was not yet a widespread practice, so the medical value        of procuring organs from brain dead individuals was not as        demonstrable.      

        Dworkin's ideas have been taken up recently in light of these changes        in circumstance, by thinkers such as Brody (1999)21 and Fost (1999). Brody describes three        death behaviors in particular: unilateral withdrawal of life-support,        organ removal, and burial. The first, he argues, can occur when "the        organism no longer composes a person because the cortex no longer        functions" (Brody 1999, p. 79). The second should wait for "that stage        in the process after the loss of cortical functioning when the organism        can no longer breathe on its own" (1999, p. 80). The third should wait        for extinction of all signs of life. In noting that this proposed        scheme leaves the paradigm for retrieving organs from brain dead        individuals unchanged in practice, Brody explained that the ground for        doing so would be significantly different:      

 We defended it. not by adopting some criterion of death justified by            some definition of death. Instead, we argued for it on the grounds that            it preserves the proper balance between trying to maximize the supply            of organs to save lives and trying to preserve public support for organ            transplantation by not harvesting organs in cases that would be            socially unacceptable. (1999, p. 79). 

        In other words, Brody looks to the pragmatic reality of the present        situation to find a recommendation for the correct action to take.        Organ procurement from those patients that still exhibit brainstem        function is not ruled out as unethical in any *absolute* way but        rather as a policy that will not achieve the "proper balance" in        today's society. As circumstances change, so might the pragmatic        definition of when an individual is dead enough for certain behaviors        to commence. What matters is not defining death as an event in nature,        but sorting out how we should behave toward those who no longer possess        the moral claims of the living, and whose claims on us change as their        body deteriorates.      
*3. Death is        Un-real*
        A different, if related, challenge to our prevailing assumptions about        death focuses not on the unimportance of death as a meaningful event        but on the unreality of death as an ontological event. It is one thing        to argue that, in the face of our ignorance of when death has occurred,        we should *deem* a person dead according to a standard that does        the least harm or the most good. This approach can be argued for as a        concession to the realistic limits of our knowledge-whether governed by        the obligation never to exploit the dying, the desire to maximize        personal autonomy, or the drive to expand the pool of potential donors.        It is quite different to argue that, in reality, death is not simply        unknowable but un-real. Various authors have made just this case, all        suggesting in various ways that our na�ve notion of death as a unitary        phenomenon is a fundamental confusion about the nature of things. Alan        Shewmon, in his latest turn on the death question, has adopted this        position and puts his version of it this way:      

 "Is the patient dead?" is not only the wrong question to ask on the            practical, physical level; it is not even a meaningful one when asked            on a microscopic time-scale in the transition between life and death.            This would be like zooming in on the prismatic spectrum midway between            green and blue, and demanding that someone not only identify that point            unequivocally as either "green" or "blue" but also have a convincing,            logical rationale for doing so." (Shewmon 2004, p. 292) 

        In other words, by interrupting the cascading failures that lead to        "full death"-upon which the process of decay begins-we have discovered        something about the line between life and death: it was never really        there. Yes, there is a "day" that is life and a "night" that is death,        but in the current age we experience our finitude in the twilight,        where there is no clear demarcation between the polar opposites of        being and non-being. Our undeveloped intuitions about death leads us to        believe that death is an occurrence, one that we can understand by        *describing* more accurately what physiological processes are        connected with what aspects of human functioning. But in reality, our        inspection has "fallen between the cracks" of what is *real*; it        is our intuitions that must be re-trained not to expect to find        evidence for an event that does not actually exist.      

        In this vein, Linda Emmanuel revives the argument that there is no        event of death but only a process of *dying*.22*Life cessation* replaces        *death*, since death, as it is intuitively understood, is not        real: "There is only life and its cessation. The challenge shifts from        understanding death to understanding life and its loss." (Emanuel 1995,        p. 27) She proposes an "asymptotic model of life cessation" where dying        is the gradual loss of "life's aspects":      

            Life seems to slip away almost as the end of a curve approaches its            baseline axis. Indeed, an asymptotic curve may come close to describing            a key aspect of reality. (1995, p. 29)        

        In her view, every aspect of a person's life can be modeled as a        distinct dimension in a multi-dimensional axis, with the gradual        approach toward the baseline axis tracing a different path in each        dimension. The "aspects of life" would include finely articulated        biological systems ("various organic, cellular, and molecular systems")        as well as different aspects of personhood ("continuing self-awareness,        ability to love, etc."). Emmanuel draws a particular concept of life        out of this model:      

 The living person is the product of all the interacting systems of the            body. Life is understood as the totality of biological and cognitive            and spiritual life. The mind and "essence" (or in religious terms,            soul) of the person are supraeffluences of the whole interacting            system, almost as orchestral music is from the sounds of each            instrument. (1995, p. 30) 

        At some point, of course, the whole orchestra is silent, never to        return; the person is simply a corpse, hollowed of all life. But at        what point is the person "dead"-when the lead instrument stops, or when        only a few instruments remain, or when a single drum, like a heart,        beats alone with no semblance of the old melody? For the person, like        the orchestra, there is no single death event, only the dying.      

        The challenge to death as a definable event has been made in similar        ways by Winston Chiong. Chiong articulates his objection as a rebuttal        of the "definition-criteria-tests" model that has been so central to        the standard paradigm of brain death. He claims that implicit in this        model is the idea that there is "some special characteristic common to        all living or to all dead things, in virtue of which they are alive or        dead" (Chiong 2005, p. 23). But this is a misguided premise, according        to Chiong. Basing his arguments on an interpretation of the        Wittgenstein's philosophy of language (and later work by Kripke and        Putnam), Chiong argues that there is "no single characteristic, or even        any conjunction of characteristics, that is both necessary and        sufficient for an organism to be alive or dead" (2005, p. 25). There        is, rather, a "cluster of characteristics" that "contribute to an        organism's being alive and tend to reinforce one another in paradigm        cases." When an organism exhibits a subset of the characteristics in        the cluster, they can be in a *borderline state* between life and        death. In such a state, it is incorrect to claim that the individual is        determinately alive or determinately dead. In response to such a        situation, Chiong suggests, we should create artificially defined        cutoffs "to sort the borderline cases into different categories." He        calls the creation of these cutoffs the "sharpening" of indeterminate        distinctions, believing that some sharpenings are admissible while        others are not: "For a cutoff to be admissible it must agree with the        original distinction in the determinate cases." (2005, p. 27).        Following this line of thought, Chiong advocates the whole-brain        criterion as "an admissible sharpening of death, rather than as a        necessary and sufficient condition for death" (2005, p. 28). He thus        defends the current paradigm for entirely pragmatic reasons, yet he        grounds his pragmatism in the philosophical view that death is not a        real event.      

        There are subtleties to these philosophical views that space does not        permit us to delve into here. They are presented in this survey as        examples of the way contemporary thinkers are responding to the        "present unease" with the standard paradigm. Many feel that the        original efforts to mount a philosophical defense of the handling of        brain dead patients - particularly of the use of such patients as organ        sources - were based on a too coarse metaphysics. The reality of death,        in this view, will not support the *definition-criteria* type of        justification that has been adduced. For those who are uncomfortable        with the rush to pragmatism in deciding what should be allowed in the        treatment of brain dead individuals, these authors offer a view of        reality that relieves one of the burden of expecting any coherent        alternative. Whether this view of nature-seeing death as un-real-is a        truer account of reality is of course an open question, with        significant practical consequences that follow from how we answer it.      
*4. The New        Pragmatism as Policy*
        The view of death as either unimportant or un-real makes pragmatism a        necessity when it comes to defining death in practice. As we have        already seen, this pragmatism can take us in myriad different        directions. Yet two policy proposals, both of them radical departures        from current practice, seem especially worthy of consideration.      
*(a.) Conscience        Clauses*
        One policy idea that fits well with the pragmatic stance regarding the        determination of death is the so-called "conscience clause" approach.        The determination of death statute in New Jersey, for example, tracks        the UDDA very closely but includes language that would prevent a        declaration of death based on neurological criteria if the physician        believes that such an act violates the individual's religious        convictions.23 Robert        Veatch and others (Veatch 1993 1999; Emanuel 1995, Chiong 2005) have        argued for a dramatic expansion of this principle, which would allow        individuals to decide for themselves-not necessarily on the basis of        religious belief-what criteria should be used to declare them dead.        Their autonomous choices would be limited to a reasonable range-from        the higher-brain definition on one side to the cardio-respiratory        definition on the other. In cases where there was no reason to expect        that the person had a preference, the default position would be the        whole-brain criteria.      

        A person who advocates for a conscience clause approach is not        compelled by their position to support the "unbundling" of death        behaviors. While every individual could define death for themselves,        death might remain, at least subjectively, a single, real event. As        Veatch puts it:      

            We should not underestimate the importance of having something            resembling a moment of death. Socially and psychologically, we need a            moment, no matter how arbitrary, that loved ones can identify a            symbolic transition point, at least for a large cluster of these death            behaviors.24 (Veatch 1999            p. 150)        

        Viewed differently, however, leaving individuals to decide the meaning        of death for themselves might lead to the unbundling of death in the        public imagination, in which different conditions of the body        legitimate different death behaviors. Under such a policy, the notion        of any "declaration of death" that would precipitate the taking of        actions toward the deceased begins to fade away. Each act following        upon death, insofar as the law or other institutional policy has any        hand in it, would have its own physiological trigger, yet always        subject to being overridden by the individual's preferences. This        stance reflects in practice the theoretical view that death is un-real;        it comes close to a complete doing away with the very idea of death        itself.      
*(b.) Beyond the "Dead Donor Rule"?*
        A different pragmatic challenge to current practice is the belief that        we should set aside the Dead Donor Rule (DDR), which Stuart Youngner        and Robert Arnold define as follows (Arnold and Youngner 1993):      
-  Patients must not be killed by organ retrieval 
-  Organs must not be taken from patients until they die 

        Under the standard paradigm, this has been the guidepost for        justifiable action. Since the brain dead are seen as *dead*,        extinguishing their last remaining life-like functions by removing        their organs (beating heart included) was not killing them. But if the        arguments against brain death are taken as decisive, then the dead        donor rule is being, and has long been, flouted. The brain dead        patient's beating heart *is* a sign of residual life; removal of        the beating heart is the immediate cause of the patient's death.      

        For Youngner and Arnold, the lesson here is not to require that death        be declared by more stringent cardiac criteria alone, but to see the        DDR as an outdated approach to the ethics of organ procurement. The        person who becomes a donor on (or around) his death has given        consent-even, in some cases, expressed an enthusiastic desire-to being        used in this way. The liminal state between life and death that the        ventilator has created is, to some degree, a fact that ordinary people        understand; even in this ambiguous state, even as dying persons rather        than newly dead bodies, they see organ donation as a morally proper and        indeed morally praiseworthy option.      

        Moreover, when asked their views on brain death, many people give        answers clearly suggesting that they do not see the person as "really        dead."25 Even health care        providers give answers indicating that they do not really see the brain        dead patient as fully dead.26 In the real, lived context of organ procurement situations, the        "dead donor rule" rings somewhat hollow as the guiding principle for        people's action. If we are confident that, over the years of organ        transplantation, we have not been committing the grievous moral sin        that seems to be implied by a violation of the DDR, then we would be        wise to make the ethical guidelines that *do* govern our behavior        more explicit. We need an ethic of procurement from the *dying*        (rather than *dead*) patient that partakes of many of the features        of the ethics of procurement from the *living* patient. We will        return to this view of the matter more fully below.      
*(C.) Conclusion*
        What should be clear from this wide-ranging survey of the brain death        issue is that the definition of death is not a settled question in        theory, even if the standard paradigm still governs almost universally        in practice. And just as it was a conceptual innovation in the past        that created our current understanding of brain death, so might a        theoretical investigation in the present alter our prevailing practice        in the future. This inquiry turns on some crucial and difficult        questions: Is the case for defining brain dead individuals as dead        still convincing in light of the most recent physiological evidence?        Are brain dead patients really dead in some fundamental sense, or must        we defend the brain death standard on more pragmatic, less        ontologically certain grounds? And if the concept of brain death is no        longer convincing, what are the theoretical and practical alternatives        for defining death in particular cases?      

        As we have explored, discontent with the standard paradigm of brain        death comes from many different directions. At the risk of        oversimplifying the complex currents surveyed above, there seem to be        four major critiques: (1) the belief that whole brain death does not        mark the death of the organism as a whole, and that even for brain dead        patients, we should wait until heart and lung function stop        irreversibly before declaring a person dead; (2) the belief that loss        of the higher-brain functions marks the death of the person, since it        marks the end of all distinctly human qualities of consciousness and        self-awareness; (3) the belief that individuals should be allowed to        decide, for themselves, which among the reasonable definitions of death        should apply to them; and (4) the belief that we should abandon the        dead donor rule and permit the removal of organs not only from the        newly dead but also from the nearly dead.      

        How we settle this matter is not simply a theoretical question of the        physiology of death but a moral and social question regarding our        attitudes toward the dying and the dead: What human goods do we value        most, what moral hazards do we need to avoid, and how do we live well        with ambiguity on a question that is, literally, a matter of life and        death? Death may, ultimately, be final; the brain death question is        likely to continue interminably.      

**III. Donation after          Cardiac Death**

*(A.) Background:            History and Resurgence*

        As organ procurement practice now stands, the vast majority of organs        are taken from heart-beating donors who are determined to be brain dead        by the legally established whole-brain criteria. For these donors,        organ procurement happens with the ventilator still functioning; the        event of death is seen as having already happened. Recently, however,        there has been a return to the practice of using individuals for        procurement whose hearts have stopped beating. This includes mostly        individuals whose lives are being sustained by a ventilator, for whom        the decision has been made (independently) to terminate life-sustaining        treatment, and who thus die after prolonged asystole. In such        cases-known as "controlled donation after cardiac death"-the surgeons        wait typically 2 to 5 minutes (or more) after cessation of cardiac        activity sufficient for blood flow, then begin the process of organ        removal and preservation.      

        This source of organs, the non-heart-beating individual, was the        original *cadaveric donor* until the use of brain dead individuals        became common practice in the wake of the 1968 Harvard Ad Hoc Committee        report. As the use of brain dead, heart-beating donors grew in        acceptance, the use of non-heart-beating ones was gradually abandoned        in almost all hospitals.27 The abandonment of the non-heart-beating donor source was        largely a result of the technical advantage that procurement from brain        dead individuals offers, since, in such cases, the heart continues to        provide the organs with oxygenated blood during the recovery. If        procurement must wait for the patient to become asystolic, the        well-controlled timing of removing organs from a ventilated individual        is forgone and the quality of the organs potentially deteriorate. The        extent of organ deterioration is proportionate to the vulnerability to        anoxia of the organ in question.      

        As Michael DeVita explains, the resurgence of interest in donation        after cardiac death has three main causes (DeVita et al. 2000, p.        1709). First, the large gap between organ demand and organ supply has        driven people to look for other acceptable organ sources. Second        patients and the families of patients for whom life-support is going to        be withdrawn sometimes request to become organ donors. Third, the        technical difficulties in procuring healthy organs from non-heart        beating donors have been somewhat ameliorated by the advances in        medical technology.      

        In 1993, the University of Pittsburgh instituted a policy for carrying        out controlled DCD donations and publicly opened up the policy for        scrutiny as a model of what other centers could do. The Pittsburgh        Protocol, as it was called, was developed over a number of years with        involvement from the lay community as well as medical professionals        (DeVita and Snyder 1993). It included a number of procedural        guidelines, dealing with a wide variety of clinical care issues. The        following is just a sample:      
-  Who could be a candidate for DCD procurement. 
-  How the topic of organ procurement could be discussed with the family            and how informed consent for the procedure was to be obtained. 
-  What the responsibility of various hospital staff was in carrying out            the removal of life support and the procurement surgery. 
-  How death was to be determined to have occurred prior to commencement            of procurement. 
-  How hospital costs for procurement were to be handled. 

        Throughout the 1990s, other hospitals and organ procurement        organizations also made the necessary institutional adjustments and        enacted the necessary protocols to accommodate DCD donors. In 1997, the        Institute of Medicine issued a report on DCD practices, finding        significant variation among the 25 OPOs that provided approved        protocols for study. The IOM also found "considerable variation in the        level of interest and involvement in non-heart-beating organ        transplantation." In response, the IOM report suggested that DCD        protocols should be developed more widely and laid out the "underlying        scientific and ethical standards for patient care" that all protocols        should reflect (IOM 1997). The IOM issued a follow up report in 1999        elaborating on some of these ethical standards and reflecting on        lessons learned from DCD practices as they evolved (IOM 2000). In 2001,        the Society for Critical Care Medicine issued a similar set of        recommendations that emphasized their support for DCD in general (SCCM        2001), and in April 2005, a National Conference on Donation After        Cardiac Death was held, which endorsed the practice and laid out        certain ethical guidelines (Bernat et al. 2006). Promoting DCD is also        one of the major aims of the IOM's 2006 report seeking "opportunities        for action" to boost the organ supply, reduce the organ waiting list,        and expand the possibility of being a donor at death. As the IOM put        it:      

            Because the vast majority of Americans die as a result of the loss of            circulatory function, many individuals who during their lifetimes            expressed a desire to be an organ donor are not currently able to have            that wish carried out upon their deaths *for merely technical reasons            and not medical reasons of exclusion.* (IOM 2006 p.183, emphasis            added)        

        Whether these "technical" problems can be overcome-and thus how large a        potential source of new organs DCD might provide-remains an open        question. In cases other than suicide, we do not choose the particulars        of our dying. Even deaths that are "scheduled" in a medical setting        come as a result of some injury or disease that was unbidden and        unwanted. For those who die suddenly of cardiac arrest, procuring        organs in time raises grave practical problems, and getting consent to        procure such organs raises grave moral questions. For those who die in        the hospital, the degenerative path toward death, especially for the        elderly, makes being an organ donor impossible.      

        In 2004, only 21 of 59 OPOs reported having 5 or more DCD cases. That        year did show the highest total yield of donors of this type (391, or        5.5% of all deceased donors), continuing the trend of increasing total        DCD cases that began around the year 2000 (IOM 2006, p. 165). The        numbers suggest that, in areas where DCD has been made a part of        hospital and OPO policy, its practice is expanding to more patients.        Yet many health care institutions are resistant to developing such        programs, and even those places that are strongly committed to DCD        have, as yet, only a comparatively small number of donors. The question        we need to address is: Who among the pool of individuals that suffer        cardiac deaths can be made into an organ donor, and what        constraints-technical, ethical, financial and otherwise-do limit or        should limit the set of permissible candidates?      
*(B.) Who is the DCD        donor?*
        As we begin a more detailed analysis of DCD, we need a more precise, if        still basic, clinical understanding of who the potential donors are. A        DCD donation, it bears repeating, must follow a determination of death        after cardiac arrest. This event begins a severely limited window of        time during which organ procurement must be carried out. This creates        the basic technical constraint that defines DCD-namely, the death must        be managed in such a way that the surgical team is on site and ready in        a short time after death is declared. DCD cases are typically divided        into two types following from this basic constraint. The first type,        named above, is the "controlled DCD," where cardiac arrest is awaited        by the surgical team after a decision is made to remove        ventilator-support from a patient. Procurement follows within minutes        of asystole. The second type is known as "uncontrolled DCD," where        cardiac arrest happens, to one degree or another, unexpectedly, whether        in the hospital or in the myriad settings of everyday life. In this        case, the length of time between asystole and procurement is by        necessity longer and, because of this, invasive procedures to preserve        the decedent's organs must be initiated to "buy time" before the        surgery can commence.28        At present, uncontrolled DCD in the United States is very uncommon.        This is true for logistical, clinical, and ethical reasons, hinted at        above and explained more fully below. Yet it is also the area where        some, like the IOM, see the greatest potential for expanding the        opportunity to be a donor at death.      
*(i.) Controlled        DCD*
        The controlled DCD cases that are now possible in the United States        draw on a very specific subset of those patients who die in the        hospital after removal of a ventilator. This subset ordinarily consists        of individuals who are irretrievably dying yet not suffering from a        degenerative condition that would make their organs inadequate for        donation. The majority of such patients appear to have suffered from a        brain injury or acute neurological event that leaves them mortally        impaired but not quite brain dead. For such patients, removal of the        ventilator leads predictably and quickly to cardiac arrest. The        prediction that this will occur is made:      

            by assessing respiratory drive, respiratory muscle strength, dependence            on oxygen and positive end-expiratory pressure for maintaining            hemoglobin oxygen saturation, and degree of pharmacologic and            mechanical support of the circulation. (DeVita et al. 2000 p. 1710)29

        The importance of making an accurate prediction regarding the patient        becoming asystolic after removal of life-support highlights the        time-sensitive nature of even controlled DCD. As the patient lies in        the operating room or ICU, ventilator removed, waiting for his final        breath and the cessation of his cardiac contractions, the health of his        organs is deteriorating. This time is counted as "warm ischemic        time"-the length of which is usually understood to be inversely        proportional to the health of the organs procured.30 After a certain amount of time-hospital        protocols vary, but seem to range from 30 minutes to 4 hours, with 1        hour the most common-the individual is no longer a suitable donor.        Thus, the DCD donor must be a patient for whom ventilator support        removal is planned and whose overall condition is poor enough that such        removal will quickly bring on his death, yet not so deteriorated that        his organs are beyond being useful.      

        The following case study from the literature is an example of a DCD        case that meets the above technical requirements:31

            A 19-year-old patient was brought to a level 2 trauma center after a            motor-vehicle crash. The patient was initially asystolic, but was            resuscitated with 30 minutes of chest compressions. Neurological            examination revealed loss of all brainstem reflexes, with the exception            of a slight cough and a sluggish pupilary response. The patient was            connected to a ventilator and received other supportive care measures.            The prognosis in the judgment of the physicians was that the injuries            were non-survivable. In light of this, the family made the decision to            withdraw life-support.        

        Here we see a case where the patient is "just barely on the safe side"        of brain death, as exhibited by the minimal brainstem reflexes. The        medical team judges that, upon removal of the ventilator, asystole will        follow very quickly. The family is given the option of "waiting an        additional 24 hours for brain death to occur" or allowing DCD upon        termination of life-support. In the discussion of this case, the author        notes, "It is not uncommon for an OPO to evaluate an otherwise healthy        young person with a severe neurologic and spinal cord injury who is not        brain dead" (Nelson and Lewis 2003). If an active hospital protocol for        DCD is in place, then patients like this, who have severe neurological        damage short of brain death, can become organ donors.32

        This sort of case is often mentioned as the prototypical, though by no        means the only, controlled DCD case. When DeVita and colleagues        reviewed the sixteen DCD cases that occurred at the University of        Pittsburgh Medical Center from 1993 until June 1998, they discovered        the following:      

            All patients had suffered severe brain injury but were not diagnosed            brain dead because they either had some residual brainstem function or            had not undergone studies to determine whether brain death was present.            (DeVita et al. 2000, p. 1710)        

        Along similar lines, the 1999 IOM report specifies that "in most cases,        the patient who becomes a non-heart-beating donor has suffered        devastating neurological damage, most often from trauma or stroke. In        rare cases, a conscious, paralyzed, ventilator-dependent person has        requested non-heart-beating donation." (IOM 2000, p. 42)      

        Yet the most recent major publications on DCD practice do not highlight        the frequency of DCD being carried out on neurologically compromised        patients. In the report from the 2005 DCD conference, the authors say:      

            Potential candidates for DCD include patients whose life-sustaining            treatment is under consideration for withdrawal/refusal of this            treatment. Conditions that may lead to consideration of DCD eligibility            include irreversible brain injury, end-stage musculoskeletal disease            and high spinal cord injury (Bernat et al. 2006, p. 282).        

        Likewise, the 2006 IOM report on organ transplantation makes no        particular mention of neurologically-injured patients as the pool from        which DCD cases are drawn. The reason that such publications do not        emphasize the etiology of patients who are eventually considered for        controlled DCD donation seems two-fold: first, the IOM and others want        to expand the practice of controlled DCD as widely as ethically        possible; and second, the moral foundation of controlled DCD does not        depend on neurological impairment specifically but on an ethical        judgment that continuing life-sustaining treatment is not in the best        interests of the patient, as well as the desire of individuals or        surrogates to make themselves or their loved ones available as donors        at death.33 We will        consider these ethical issues more fully below.      
*(ii.) Uncontrolled        DCD*
        With the exception of the 2006 IOM report, we found only limited        discussion of uncontrolled DCD cases in our survey of the literature.34 What was found indicates        that there is substantial variety in the clinical picture of what would        be classified as an "uncontrolled" case. One type of uncontrolled case        is that of a patient who is already brain dead but goes into cardiac        arrest before the normal procurement procedure is set in motion.        Another type of uncontrolled DCD case is when cardiac arrest ensues        unexpectedly before the planned removal of a ventilator or other        life-sustaining treatment. A third, quite different type of        uncontrolled DCD case is that of a patient who has gone into cardiac        arrest outside of the hospital setting. Zawistowski and DeVita mention        a case where an individual "suffers a myocardial infarction at home and        consequently suffers a cardiac arrest; resuscitation is attempted by        the ambulance crew, taken over by the team in the emergency department,        and discontinued secondary to lack of response to treatment by the        patient" (Zawistowski and DeVita 2003, p. 191).      

        In the first two cases, there are some crucial similarities with both        donation after brain death and donation after controlled cardiac death.        This is at least true with regard to giving the patient's family time        to consider the DCD alternative and understand what would be involved.        Another case from the literature describes just such an "uncontrolled        DCD" situation (adapted from Nelson and Lewis 2003):      

 A 19-year-old patient was brought to a level 1 trauma center after a            motor-vehicle crash. He arrived at the center paralyzed and intubated            and, upon examination by the trauma surgeon his injuries were            determined to be non-survivable. Approximately 10 hours later, tests            for brain death were initiated but broken off when the patient            responded to the apnea test with extreme hypotension and bradychardia.            The patient subsequently went into pulseless electrical activity. At            the family's insistence, CPR was initiated. The operating room was            alerted and the trauma intensivist managing the patient accompanied the            team for an uncontrolled DCD. 

        In other words, some cases of uncontrolled DCD look similar to        controlled DCD and to brain death. The major difference is less the        *pre-death condition* of the patient, more the *post-death        circumstances* that require *reacting* to cardiac arrest when        it happens rather than readily *waiting* for it to happen. And        because procurement requires having a surgical team in place and an        operating room available, procurement in such circumstances is        logistically difficult and thus rare. Of the 391 reported DCD donors in        2004, only 22 were "uncontrolled" cases, and indications in the        literature suggest that most (perhaps all) of these cases resemble the        one described here.      

        The recent push by the IOM to promote uncontrolled DCD as a way to        expand the donor pool is not focused on cases like this, however. Here        is their description of the phenomenon and their call to expand its        scope:      

            Uncontrolled DCDD typically involves individuals who have collapsed            suddenly out of hospital, and arrive in the emergency department            without spontaneous vital signs after having received CPR from            emergency medical services (EMS) personnel. The American Heart            Association estimates that each year in the United States about 335,000            deaths are due to sudden cardiac arrest. Although reports of the rates            of survival vary among EMS systems, about 95 percent of sudden cardiac            arrest victims die before they reach the hospital. At present,            virtually all of these individuals and their families are denied the            opportunity to be organ donors. (IOM 2006, citations omitted)        

        Of course, it should be noted that the majority of such individuals are        probably not candidates for organ donation due to pre-existing health        conditions; most people who die suddenly of cardiac arrest are not        otherwise healthy and neither are their organs. The question, however,        is whether that small subset of individuals who are potential organ        donors can become actual organ donors.      

        This type of uncontrolled DCD has been tried extensively only at one        center in the United States. For roughly four years in the 1990s, the        Washington Hospital Center (WHC) in the District of Columbia had, as        part of their DCD protocol, instructions for carrying out "Rapid Organ        Recovery."34 Over the        four year period when this program was active, only 7 donors were        obtained. The way that the protocol was carried out, the cooling of the        organs was viewed as an invasive procedure that needed to wait for the        approval from the family. Other interventions to keep the person's        kidneys adequately healthy could be initiated without prior consent,        but these were only effective for roughly 45 minutes. In many cases, it        was not possible to find the family with sufficient speed to even ask        for consent; this difficulty was compounded by the necessity of making        the request for donation at the same time as informing the family of        the lethal injury. With their energies and attentions and emotions        focused elsewhere, many families simply refused. Another impediment was        the difficulty of getting a release from the D.C. Medical Examiner,        whose approval is required for the initiation of any procedures on such        individuals after death. And even when the inter-human dimension of the        situation proceeded as efficiently as possible, the logistical        challenge of moving and preparing the body and getting it into surgery        was both difficult and expensive, since it required keeping a        procurement team on call at the hospital all the time. For all these        reasons, the program was ultimately terminated.      
*(C.) The Ethical        Issues*
        As mentioned already, both controlled and uncontrolled DCD raise myriad        ethical issues. These moral concerns relate first to the best care of        those who are irretrievably dying or in a crisis mode between life and        death, and second to the first moments of grief after death has        occurred. In what follows, we explore three sets of ethical issues in        the context of DCD: (1) the decision to withdraw life-sustaining        treatment, (2) best care for the dying, the newly dead, and the family        of the departed, and (3) the specific criteria for declaring death in        the DCD context. Many of these issues-though not all-have been        addressed explicitly in some form by hospitals and OPOs in their DCD        protocols or by those bodies that have made recommendations for        reforming or expanding our DCD practice.      

*(i.) The Decision          to Donate and the Decision to Withdraw Treatment*

*1. Controlled*

        One characteristic of controlled DCD donations that distinguishes it        from donation after brain death is the decision to terminate        life-sustaining treatment for a living patient. Some authors worry that        the desire to make organs available could interfere in various ways        with responsible end-of-life decision-making. To address this concern,        the IOM has offered two procedural recommendations:      
-  The decisions, actions, and personnel involved in the withdrawal of            life-sustaining treatment and the declaration of death should be kept            separate from the decisions, actions, and personnel involved in the            recovery of organs. (2000, p. 17) 
-  The decision to withdraw treatment should be made prior to any            staff-initiated discussion of organ and tissue donation. (2000, p. 16) 

        Yet the IOM also notes the following:      

            In an environment of support for donation, the potential for actual or            perceived conflict of interest between patient care and organ recovery            is more complex. In non-heart-beating donation, medical treatment is            modified in order to allow donation to proceed. These modifications            include medications and procedures, and the process of withdrawing            life-sustaining treatment and declaring death. (2000, p. 17)        

        In reality, it is impossible to keep the two activities        *completely* distinct: for organ donation to be possible, the        dying body needs to be managed in a particular way during the        transition from dying to dead; preparations need to be made well in        advance of the ventilator being removed. But this is not necessarily        morally objectionable at all. Indeed, many argue that such management        of a person's final moments is a justifiable, even redemptive, pursuit        of the good of organ donation. Moreover, based on our survey of the        literature, there is no indication that life-sustaining treatment is        being terminated *in order* to facilitate organ donation; rather,        organ donation is being facilitated once it is determined that removing        life-sustaining treatment serves the best interests of the patient.        With the right procedural safeguards, this moral concern does not seem,        at present, like a genuine moral hazard.      
*2. Uncontrolled*
        In cases of uncontrolled DCD, there is not a "decision to withdraw        treatment" in the same sense as in the controlled case. In considering        the decisions that *are* made, we should draw a distinction, as we        did above, between the "hospital" uncontrolled DCD cases (where cardiac        arrest happens before a planned termination of treatment) and the        "ambulance" DCD cases (where cardiac arrest happens unexpectedly in an        ordinary life-setting, not in a hospital). In the hospital cases, CPR        may be administered precisely for the purpose of keeping the patient's        circulation going long enough to make organ procurement in the        operating room possible. There is no concern about the right time to        stop this CPR, since it is being done only with facilitating organ        donation in mind. Presumably, this is a process that the patient or his        surrogates have given informed consent for prior to the event.      

        In the "ambulance" case, there is a moment when treatment is withdrawn        because it is deemed to be *futile*. Here the possibility of a        conflict of interest becomes a real question. It would certainly seem        clear that, all things being equal, any sensible person would prefer to        have the paramedics who are trying to resuscitate them focused        exclusively on that effort rather than concerned, even to a small        extent, about taking the necessary steps to insure the viability of        one's organs if resuscitation fails. The IOM, drawing upon the        procedures that are in place in those European countries where this        practice is carried out, recommends the following safeguards (2006 p.        179):      
-  Keeping distinct the personnel who make the decision to discontinue CPR            from those concerned with procurement. 
-  Training the personnel who administer CPR in the exact conditions for            determining when the further intervention is futile. These guidelines            would be based on the most current knowledge in resuscitative medicine            and should be enumerated in publicly created protocols. 

        Yet even if these safeguards work well in individual cases, there is        also the danger of a perception problem: that is, a belief that        designating oneself as an organ donor might compromise the quality of        one's care in a moment of crisis. And given, so it seems, the "low        yield" of this type of uncontrolled DCD, one might question the wisdom        of engaging in this practice at all if there is even minimal risk of        undermining public confidence in the organ procurement system as a        whole.      

*(ii.) Best Care for          the Dying Patient and His Family*

*1. Controlled*

        Mildred Solomon, in a paper that is ultimately supportive of DCD        practices when carried out in a carefully controlled and monitored        manner, describes what she calls an "underlying irony" in DCD:      

        Non-heart-beating donors are, by definition, individuals who have        chosen, or whose families have chosen, to forgo life-sustaining        treatments, often because they want a lower-"tech" death and more        opportunities for what the public and lay media have called "a good        death." Yet, in non-heart-beating donating, the family's altruism may        result in a more technologically invasive death than the family        understands. (Solomon 2000, p. 76)      

        This raises a very specific question: How is it that DCD might involve        a more "technologically invasive death" than we would ordinarily expect        for a critically ill patient who is to be taken off life-support and        allowed to die?      

        Renee Fox, in a 1993 article responding to the newly publicized        Pittsburgh Protocol (Fox 1993), points to a number of concerns, some of        which seem to have had a direct effect on the evolution of DCD        protocols. For one thing, she worried about the comfort care of the        patient: first, that not all appropriate palliative narcotics would be        administered out of a fear that this would seem to be hastening the        patient's death; and second, that the precise steps that are taken        while weaning the patient off life-support would not be followed in a        sequence that insured the most comfort for the patient. The IOM's 1999        report responds to these issues directly:      

            The withdrawal of support and the provision of palliative care should            be the same for both donors and non-donors. In particular, comfort            measures should not be withheld because a person is going to be a            donor. (IOM 2000, p. 50).        

        It is an ethical requirement, says the IOM, that "hospital protocols        for withdrawing support and providing palliative care are prerequisites        for non-heart-beating donation" (IOM 2000, p. 50).      

        A different kind of concern raised by Fox is perhaps far more difficult        to solve by developing well informed policies. She writes:      

 If asked to identify what is most dreadful about it, I would single out            the desolate, profanely "high tech" death that the patient/donor dies,            beneath operating room lights, amidst masked, gowned, and gloved            strangers, who have prepared his (her) body for the eviscerating            surgery that will follow. 

 This contrasts sharply with the procedures that the nursing and medical            staff responsible for the care of hospitalized, non-donor patients try            to follow when they sense that an imminent death is approaching.            Usually it is not until the relatives have "witnessed death in their            loved one," if they wish to do so, "and said goodbye," that the nurses            cover the patient's hands and face with a plastic shroud, and            relinquish the body to escort personnel for transport to the morgue.            (1993, p. 236, internal quotations and citations omitted) 

        There is no complete "solution" to such a difficulty. To procure        organs, the surgical team needs to operate immediately after the heart        has permanently stopped; it needs to cut into the just dead. The        crafters of ethical guidelines have all attempted to develop procedures        that give the family of donors the best options possible for being with        their loved ones as they die. One option is allowing patients to be in        the operating room when the ventilator is removed and until asystole        occurs-that is, to be present to their loved one in his final living        moments. But then they need to be ushered out quickly so that        procurement can commence. Another option is for the withdrawal to        happen in the ICU with the family present, and then for the patient to        be quickly transported to the operating room immediately upon the        declaration of death.      

        A final concern voiced by Fox also stems from an unavoidable fact about        controlled DCD donation: the patient for whom life support is removed        might not die in a timely enough manner for donation to proceed. As        mentioned above, the personnel who make the determination that the        patient is a candidate for controlled DCD must use the best medical        criteria available to choose only those patients who are likely to die        quickly when life support is removed. Those criteria are being improved        all the time to make them as evidence-based and uniform as possible,        but the body is unpredictable. There will always be cases where the        prediction is in error. This unexpected, extended demise can sometimes        impose additional trauma on the surviving family members, who have        perhaps said their last good-byes and steeled themselves for their        loved one's final moments. Some might have done so in the expectation        that the good of being an organ donor will help ameliorate the tragic        reality of death. If this does not happen, a further anguish is        potentially delivered upon them.      

        After pointing out the "underlying irony" of controlled DCD, Solomon        describes the obligations that follow:      

 First, there are obligations to disclose how the patient's care will            change as a result of the decision to donate. Many families will still            make the choice to donate, but there is an ethical imperative to            disclose the trade-off. Secondly, hospitals and OPOs should recognize            this irony and strive to create the most family-supportive environment            possible during the final hours and moments of their loved one's life.            (Solomon 2000, p. 276) 

        Those involved in organ procurement ought to acknowledge that there is        a significant sacrifice made by the family in allowing death to be        managed to allow DCD donation to occur. Solomon's prescription for a        clear disclosure of all the details of the process seems to be wise and        worth emphasizing. To put oneself in the position of the family who        makes the decision to pursue donation in the midst of their trauma is        to feel the pull of two competing goods: that of making a meaningful,        altruistic act out of the senseless loss of a loved one and that of        entering the long tunnel of one's grief with as little undue        interference as possible.      

2. *Uncontrolled*

        In the cases of uncontrolled DCD precipitated by an unanticipated        out-of-hospital cardiac event, there arise very pointed ethical        problems connected to patient care, consent, and respect for the        grief-stricken. In order for procurement to be possible in such a case,        as mentioned above, it is typically necessary to initiate certain        procedures aimed at preserving the viability of organs very soon after        CPR is discontinued. This would be done in order to "preserve the        option for donation while the families are contacted," as the IOM        describes it. (IOM 2006, p.180) Such procedures involve the insertion        of a cannulae through which cold perfusion of the organs *in situ*        is carried out. When the family is contacted, they must be informed, in        rapid succession, of both the unexpected sudden death of their beloved        and of the initiation of these procedures toward the end of converting        the newly deceased loved one into a source of useful organs. The cold        perfusion procedure itself is an invasive one that would certainly,        under normal circumstances, be deemed to require consent from the        family. For this reason, four jurisdictions (District of Columbia,        Virginia, Florida, and Illinois) where uncontrolled DCD of this form        has either been attempted or anticipated have passed specific        legislation permitting perfusion and cooling without consent. The 2006        IOM report argues that such legislation is not really necessary:      

            [C]ourts might very well regard postmortem cannulation to be            permissible as a potentially life-saving medical practice, in the            absence of legislation explicitly prohibiting it. (IOM 2006, p. 181)        

        Leaving aside the legal uncertainty, one might certainly wonder if such        a practice is ethically or practically sound. In normal donation        situations, a great deal of care is exercised to insure that the family        of the newly deceased or dying person are approached in a sensitive way        that does not *presume* that they will give permission but rather        makes a genuine request. There is time for conversation and reflection,        for the preliminary acceptance of death that leads to a willing act of        altruism. Yet the kind of presumption implied in the uncontrolled DCD        case seems like a notable departure from this guiding principle of        respect for the newly bereaved family. It risks undermining the empathy        that OPOs have worked hard to cultivate in both the manner and timing        of their requests. Imagine, by contrast, a phone call that would        convey, quickly, that the person you had breakfast with this morning        and planned to have dinner with this evening is now gone forever-then        asks, can we use his organs to save someone else? Perhaps, with the        calm of hindsight, some families would prefer being asked for        permission to recover their loved one's organs. But in the moment of        crisis, one might justifiably see it as inhumane to burden the        grief-stricken family in the very moment of their loss, or to expect        something from them in the moment when they need the support of others        most of all.      

        The IOM also discusses those cases where the concern about consent for        cannulation is not, in their view, a problem: namely, when the newly        dead individual is a registered donor. As the report states:      

            In the view of the present IOM committee, when an individual has signed            a donor card or joined a donor registry, OPOs have adequate permission            to proceed with the recovery of organs from patients after death is            declared. (IOM 2006 p. 180)        

        The implication here is that the cooling procedures and even the later        procurement surgery could be done without ever reaching the family, if        doing so for some reason proves impossible. Although many States have        enacted "first-person consent" laws that allow a person's status as a        registered donor to trump the wishes of a reluctant family, it appears        that most OPOs will not proceed if the family resists, even if such        restraint means, in some cases, overruling the deceased person's wish        to donate. There is a notable concession to reality implied here: the        emotional needs of a family in the midst of a devastating tragedy are        not easily ignored, even by those whose support for donation, and for        the right of an autonomous individual to make this choice, is very        strong. This concession expresses the need, as best as possible, to        preserve the delicate balance between the good of donation and the        wellbeing of those who still see the potential donor as the person they        love, a person who is still here (in body) but now gone forever. Yet as        the IOM envisions it, those who die unexpectedly could be "converted        into donors" with the family *not even given the chance to be        present*, or with the family first learning about a loved one's        death after his or her organs have already been removed.      
*(iii.) The        Declaration of Death in the DCD Timeframe*
        The concerns discussed above have focused largely on care for the        dying, the newly dead, and the family of the just departed. Yet DCD        also raises complicated questions-like brain death-about the nature of        death itself and the clinical criteria for declaring someone dead. When        a patient is declared dead by neurological criteria, the physician who        determines that death has occurred has time to verify that the loss of        brain function is, indeed, irreversible (at least within the limits of        current medical knowledge). Doing so involves repeating the various        tests for absence of brainstem function several hours after they are        initially administered. In DCD cases, by contrast, there is no luxury        of time. For this reason, the declaration that "irreversible" or        "permanent" cessation of circulatory and respiratory function has        occurred must happen as quickly as possible. The controversy over        whether the patient is really dead in DCD procurement stems from the        rapidity with which a judgment of irreversibility must be made. This        raises the crucial question: What is the standard of irreversibility?        How long must the procuring surgeons wait after the heart has stopped        before beginning the process of organ removal?      

        According to accepted medical standards, a patient who has, for a        determinate length of time, satisfied the criteria of apnea, absent        circulation and unresponsiveness, will not experience restoration of        spontaneous circulation. What constitutes an adequate "determinate        length of time" has been a matter of some controversy, though no cases        have been demonstrated that contradict the figure of two minutes. This        was the length of time set by the Pittsburgh Protocol. The IOM, in its        1997 report, set the appropriate length at five minutes and specified        that the cessation of function must be verified by electrocardiogram        and arterial pressure monitoring. The Society of Critical Care        Medicine, in a 2001 position paper supporting the practice of        controlled DCD, concluded that, "No less than 2 minutes is acceptable,        and no more than 5 minutes is necessary given the IOM recommendation        and the current practice of critical care medicine." (SCCM 2001, p.        1828)      

        Yet some critics would challenge the current standards for determining        death in these situations. They would not deny that the chances of        autoresuscitation are vanishingly small after 2 (or 5) minutes. Rather,        they question whether this is an adequate reading of the word        "irreversible," both legally as it appears in the Uniform Declaration        of Death Act ("irreversible cessation of circulatory and respiratory        functions") and morally as it relates to our obligations to the dying.        The term "irreversible" might be interpreted in a number of ways. In        one construal, it means that the chances of the loss of function        reversing *on its own* are vanishingly small. On a second        construal, it means that the chance of reversal given *any kind of        available intervention* is vanishingly small. By the strictest        construal, it means that restoration of lost function is biologically        impossible, no matter what we do. Alexander Capron, in a 1999 article,        favored something like the middle construal, saying that        "irreversibility must mean more than simply 'we choose not to reverse,        although we might have succeeded'" (Capron 1999, p. 132).      

        To make this more vivid, one could imagine a patient who is declared        dead after 2 minutes of absent circulation and then, for whatever        reason, revived through aggressive intervention. Has this person        returned from the dead? And is the standard of "irreversibility"        different in those cases in which there is no intention of attempting        resuscitation, precisely because an explicit decision has been made to        terminate life-sustaining measures so that nature can takes its course?      

        Others add to this critique by arguing that the *brain* is still        functional in such patients (i.e., after 2 to 5 minutes of cardiac        arrest) until it is "starved" by lack of circulating blood (Lynn 1993,        Menikoff 2002). This starving of the brain does not occur within the        five minute window that the IOM and SCCM suggest. According to this        argument, a person who dies in the ICU after life-sustaining treatment        is removed must also meet the neurological standard for death; at the        least, they say, the amount of time allowed before procurement begins        must be calibrated to our best estimates of when the lack of oxygen in        the brain causes irreparable damage (perhaps 10 minutes). Only those        patients whose death happens apart from life-sustaining technologies        can reliably be declared dead by cardio-pulmonary criteria alone,        since, for these patients, brain death will be a necessary consequence        of the cessation of heart and lung functions. Consider, again, the        person who is revived after two minutes of asystole. It is possible        that he will exhibit as much brain function as he did "before he died."      

        Those who defend the declaration of death in the 2-5 minutes window        accept, either tacitly or explicitly, the weaker construal of        "irreversible" that Capron and Menikoff reject. Under this construal,        "a function is irreversibly lost if a morally defensible decision has        been made not to try to reverse the loss" (Youngner, Arnold and DeVita        1999, p. 16). This represents an abandonment of a strict physiological        notion of death similar to the abandonment that we have seen advocated        in the brain death context above. It represents yet another effort to        deal with the moral perplexities created by our new technological        powers: in this case, the possibility of temporarily "bringing back"        those patients whom we believe are best cared for by being allowed to        die. One sign of this change in thinking is a change in terminology        that has been suggested and, to some degree, adopted by those who        support DCD (e.g. IOM 2006, p. 177. See also Bernat 2006): namely,        declaring death by saying that the patient's heart and lungs (and        brain) have ceased to function *permanently* rather than        **irreversibly. The stoppage is permanent because it *won't*        be reversed, not because it *can't* be.      

        As with brain death, some question whether defining death in such cases        is really the crucial issue. Rather than pretend that certain        nearly-dead patients are truly dead, or search for philosophical        justifications for declaring death in situations of unavoidable        uncertainty, they argue for setting aside the dead donor rule in the        name of a more honest utilitarianism. As Arnold and Youngner write:      

 What if, instead of continually gerrymandering the line between life            and death, we simply ask "Are there some patients whose quality of life            is so unacceptable and whose death is so imminent (by fate or their own            decision) that we may take their organs before they die?" Instead of            pretending that we can continue to develop more accurate definitions of            death (that coincidentally expand the donor pool), we would allow organ            procurement from patients with severe head injuries who were            irreparably damaged and near death but who have not lost all brain            function. (Arnold and Youngner 1993, p. 270) 

        The central tenet of organ procurement, they argue, could shift from        "is dead" to "violates no interest." A patient or their surrogate        should be able, they say, to consent to organ donation under the same        circumstances that he or she is permitted to request removal of        life-sustaining treatment. In the place of a "dead donor rule," this        approach would allow the principles of non-malfeasance and consent to        guide the practice of organ procurement, by treating the nearly-dead or        perhaps-dead person as someone who cannot be harmed by organ removal,        especially if being a donor is what the person wanted (Truog 1997). Of        course, we might also ask whether we, as a society, would be harmed by        treating those who are still living, even in such a diminished state,        as available organ sources.      

        Many defenders of controlled DCD believe that such a drastic change in        the moral framework that governs current practice is not necessary or        desirable (see, e.g. Bernat 2006). With proper protocols and        safeguards, they argue, controlled DCD can proceed without removing        organs from the still-living, and without organ removal ever becoming        the proximate cause of death. Nevertheless, this defense of DCD within        the dead donor rule framework must confront the novelty of our        situation: the desire to declare death as quickly as possible, lest the        *potential* of the dead body be lost. Inevitably, there will be a        tension between declaring someone dead only with caution and declaring        someone dead as early as possible. It also means that death, to some        degree, is now defined not simply by the biological facts alone, but by        the context of death-such as whether "letting die" or "trying to save"        is what we owe the patient entrusted to our care. The ontology of death        now seems to depend, at the margins, on our intentions toward the        dying.      
**IV. A Map of        Possible Positions on the Death Question**
        Defining death, as we have seen, is no easy matter. While we can still        rely on our native sense of the ontological difference between the        living person and the dead body, our sensibilities are confounded by        those who seem to exist in a liminal state between life and death, in a        condition unique to the age of modern, high-tech medicine. Confronted        with individuals in this seemingly in-between state, we seem to need a        "concept" of death to guide experience; and we seem to need an        expertise about the body-standards, tests, protocols, criteria-to        discern whether death has occurred in particular cases. This        philosophical and physiological complexity is only more difficult-and        more urgent-in the real world context in which we face it, with so much        riding on how we define death, both in theory and in practice. The        question needs to be considered in itself, yet there are so many        reasons to settle impenetrable ambiguities by appealing to other        goods-including the desire to procure organs from the dead to save the        living.      

        The above discussion has tried to make sense of the death        question-first and foremost in itself, and only then in the context of        organ procurement. It would be impossible to summarize this        many-faceted debate in any simple way, but it is also necessary to        tease out the possible conclusions one might draw and the possible        positions one might take in light of the above discussion. Any typology        of positions is by nature inadequate; it exists to simplify, and thus        flatten much of the complexity in the positions that real people        actually take. But we need to simplify in order to discuss; the        following positions, at the very least, map the terrain for the purpose        of stimulating a more precise Council discussion and seeing where the        Council, as individuals and as a body, might come down on these        questions.      

***On the Question of Brain Death****:*

        One might defend the standard paradigm of brain death, in the belief        that: (a) death is a real event in nature; (b) that death means the        irreversible loss of integrative functioning of the organism as a        whole; (c) that we can develop reliable criteria for discerning when        this "irreversible loss" has occurred; (d) that wholly brain dead        individuals meet this standard; and (e) that removing organs from        wholly brain dead individuals, even while the heart is still beating,        is morally licit.      

        One might defend the brain death standard on more pragmatic, less        ontologically certain grounds, in the belief that: (a) death is either        un-real as an event or sometimes unknowable, but that brain death is a        reasonable standard for declaring someone dead; and/or (b) that there        is no compelling reason to challenge brain death as the prevailing, and        widely accepted, standard of practice, even if we can never settle with        certainty the theoretical question of whether brain dead individuals        are dead "all the way" or dead as "whole, integrated, functioning        organisms."      

        One might hold the view that death should be declared when the        higher-brain functions are irreversibly lost, in the belief that: (a)        death is a real event; (b) that death means the complete and        irreversible loss of consciousness and self-awareness, which are the        qualities of psyche that distinguish human life as human; (c) that we        should develop accurate tests for declaring with certainty or with        great confidence, that the higher-brain functions are lost; and (d)        that once such tests exist, higher-brain death should become the        standard, even if we permit individuals, in their advance directives,        to articulate a more stringent standard that gives more weight to the        living body.      

        One might hold the view that whole-brain death is an inadequate        criteria for declaring the death of the person, in the belief: (a) that        even the brain dead individual does function or might function as a        whole integrated organism; and/or (b) that integrative functioning of        the organism as a whole is inadequate as a basic concept of death;        and/or (c) that defining death as the irreversible cessation of all        cardiac and respiratory function remains truest to our lived experience        of the difference between life and death; and/or (d) that removing        organs from heart-beating donors is an ethically questionable act, one        that potentially harms not only the donor but our sensibilities in        seeing the living body as a natural resource.      

        One might hold that given the ambiguity and uncertainty surrounding the        life or death status of brain dead patients, individuals should be        permitted to decide for themselves what criteria for declaring death        should apply to them-ranging from death of the higher-brain function to        whole-brain death to death by cardiac criteria alone.

        Position (1) and (2) would essentially maintain the status quo though,        it can be hoped, on more solid theoretical grounds than those        previously proposed. Position (3) and, possibly, position (5) would        expand the pool of deceased persons available as organ sources. It is        worth noting two distinct ways in which this might happen. A patient        who has irreversibly lost awareness but is not brain dead is usually        classified as being in a permanent vegetative state (PVS).35 Persons in this condition who        have been stabilized and removed from ventilator support still require        technological maintenance in the form of a feeding tube and usually        intensive nursing care to prevent infections. If a change in our        thinking led to these patients being considered dead or led to the        conclusion that, though not dead, they were "beyond harm" and eligible        to be donors with their prior, informed consent or that of their        surrogate, practical difficulties would still remain in converting them        into organ donors. The means of allowing such a patient to die would        involve either removing their feeding tube and allowing them to succumb        to starvation and dehydration or refraining from treatment of some        secondary terminal condition. In either case, their organs would be        compromised by the progression toward the asystolic event that        terminated what remained of their lives. Some might contend that, since        they are already dead in this hypothesized framework, they could be        given a lethal dose of drugs to precipitate asystole or, alternatively,        that their organs could be procured while their hearts were still        beating - most likely while under general anesthesia.      

        There is a less drastic form of expanding the donor pool to        neurologically damaged persons who are not brain dead, as well. One        could simply eliminate the stringent tests for brain death in patients        who come to the emergency room with neurological injuries. All that        would be required is that a) the patient be seen as one who, with a        high degree of confidence, will not recover his cortical functions and        b) the family and doctors agree that he should be allowed to die. As        was explored above (see, especially, the case described on page 36),        such patients might now become non-heart-beating donors after the        family agrees to donation under a DCD protocol. A change in our        thinking about death in the direction of higher-brain criteria might        simply make it possible for these patients to become heart-beating        donors instead, by removing their organs in that limited period when        they are ventilator dependent. If the patient did "come through" the        period of most acute vulnerability and progress to a true condition of        PVS - stabilized and breathing on their own - they would, under this        view, have "missed the chance" to become heart-beating donors.      

        Following the logic of position (4), patients who are "brain dead"        under the current paradigm are not really *categorically* distinct        from other devastatingly injured patients. Rather, they are different        from them *in degree*. The same ethically serious and        compassionate set of considerations that would govern the decision to        remove treatment from any patient must be brought to bear on the one        whose whole brain has ceased to function. With regard to procurement,        this would mean doing away with the distinction in practice between        heart-beating donation and non-heart-beating donation. All "brain dead"        patients would simply be assimilated into the DCD protocols. The upshot        of this would be a mandate that hospitals never procure organs while        the ventilator is still on and the heart is still beating. All patients        would need to be allowed to become asystolic and *then*, if they        had expressed an interest in donation, converted into organ sources.        This would likely mean a drop in the number of organs recovered. It        would almost certainly mean a severe drop in available lungs, hearts        and intestines. Perhaps, however, this course would put pressure on the        medical research community to find ways of improving the results of        transplantation after cardiac death. In any case, if position (4) is        considered to be the right ethical choice, truest to the reality of        death itself and to our obligations to the not-yet-dead, the        elimination of heart-beating donation would be the right course,        without regard to its practical effects on the organ supply.      

***On the Question of Donation after Cardiac Death****:*

        One might support the expansion of controlled DCD, so long as certain        safeguards are in place ensuring: (a) that the possibility of organ        procurement does not unduly affect the decision to withdraw        life-sustaining treatment; (b) that the wellbeing of surviving family        members, both in their final moments of goodbye and in their first        moments of grief, is always respected; and (c) that an adequate waiting        time after the cessation of heart beat and breathing is required to        ensure that the donor is truly dead "all the way."      

        One might oppose controlled DCD for prudential reasons, believing: (a)        that the possibility of organ procurement introduces unnecessary and        undesirable moral hazards both in how we care for the dying and in the        difficult decision about whether to terminate life-sustaining        treatment; and (b) that the drive to procure organs as soon as possible        after death will mean, despite the desire for safeguards, that we will        not err on the side of caution in declaring individuals dead, and thus        may remove organs before we can confidently say that cardiac function        has ceased irreversibly.      

        One might support the expansion of uncontrolled DCD, either more or        less aggressively: more aggressive support would authorize emergency        medical technicians to begin organ cooling prior to obtaining consent        from the deceased person's family, and would permit organ procurement        from registered organ donors even if the surviving family cannot be        reached; less aggressive support would only permit invasive        organ-sustaining activities with the explicit consent of the surviving        family or only for those individuals who are registered organ donors.        In general, support for this practice might be driven by both the        desire to expand the supply of available organs and the desire to allow        as many people as possible to fulfill their wish to be organ donors        when they die.      

        One might oppose uncontrolled DCD, believing that: (a) practically, it        is unlikely to work well, yielding only a small number of organs at a        high relative cost; and (b) ethically, that it is disrespectful of the        grieving to request the organs of their deceased loved one in the very        moment of informing them of his or her wholly unexpected death.

_______________________ 
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_______________________ 
ENDNOTES
 1. The term "person" is          used here and in the rest of this paper in a non-technical sense. It          does not presume an answer to the question of how we should regard a          human being who has lost those capacities of mind that we usually          regard as *distinctively* human.          

 2. The term "conversion"          is an important one in organ procurement. Hospitals and Organ          Procurement Organizations are evaluated based on their "conversion          rate." This is the number of actual donors divided by the number of          deceased persons eligible to be donors. 

 3. This term was famously          used by William May in the title of his Hastings Center Article, "Attitudes Toward the Newly Dead" (May 1973). The discussion below          will cast some doubts on whether this is an entirely accurate term. 

 4. This way of speaking          ('something that exists,' 'this entity') is not meant to prejudge the          question of whether the organism as a whole is distinct *in          substance* from the parts of which it is composed.          

5. The Harvard group          described the presence of an isoelectric EEG to be of "confirmatory          value."          

 6. The states that have          not adopted the exact wording of the UDDA have chosen other          formulations that include the equation of brain death with death of          the individual. A list of jurisdictions that have adopted the act can          be found at          http://www.nccusl.org/nccusl/uniformact_factsheets/uniformacts-fs-udda.asp.          

 6. Renee Fox describes          this expansion of organ transplantation in *Spare Parts* (Fox          1992, p. 7-8).          

 7. The "definition of          death" debate after 1981 adopted this basic scheme for distinguishing          the various parts of the problem, yet with a slight modification.          Capron and Kass's "basic concept of death" came to be referred to as          the *definition of death*. Their "general physiological          standards" became the *criteria* for determining that death has          occurred. Their "operational criteria" and "specific tests and          procedures" were collapsed into a single level referred to as *tests* to confirm that the *criteria* are met. Thus, the          modern system for conceptualizing the issue has come to be known as          the *definition-criteria-tests* model (Bernat, Culver and Gert          1981). In the discussion below of Capron and Kass, however, I will          use their own terms.          

 8. A set of medical          criteria, such as the one that the Harvard group laid out for          defining "irreversible coma," would be a "definition" at the third          level in this scheme. Any medical condition that warrants a unique          diagnosis and a specific linguistic designation might be said to have          a set of operational criteria that the medical community works out in          order to determine that such a condition is present. This set of          criteria develops over time, as advances in medical science are made.          Indeed, the Harvard criteria were only the first in a line of          published criteria for use by clinicians to identify the condition of          brain death. To give just a few examples: In 1971, A University of          Minnesota group published a revised set of criteria (Mohandas and          Chou 1971). The medical advisors to the President's Commission in          1981 put forth their own criteria and published this revision in JAMA          (President's Commission 1981). More recently, the American          Academy of Neurology has issued a similar report (American Academy of          Neurology 1995). One might offer a similar analysis of the set of          tests and procedures (the fourth level) for a medical condition like          brain death. A criterion like "unreceptivity and unresponsivity to          externally applied stimuli and inner need" might be tested a number          of different ways. The best practices of medical science along with          adaptations to the resources at hand can guide the physician in          choosing the appropriate tests to insure that the criteria are met. 

 9. See Veatch 1976, p.          26.          

 10. We have borrowed the          term 'standard paradigm' from Michael Potts (Potts 2001). His          description differs from ours presented here. 

 11. The first clear and          unambiguous statement of what we are calling the "standard paradigm"          appeared in Bernat, Culver and Gert 1981. This paper is cited in the          President's Commission report, so one can assume that its          argumentation was influential. The discussion of the standard          paradigm that follows draws heavily on that 1981 paper. ����������          

12. Whether brain death          meets this standard is a complicated question. Most people do not          think about death as the "irreversible loss of integrative          functioning of the organism as a whole"; this is, in a sense, a          definition of death that only scientists and philosophers can          understand. And even if common sense has been reeducated to see brain          dead individuals as dead, there remains a sense in which we accept          death as final only after the heart has stopped beating forever, only          after the body appears to us as lifeless. This issue is explored more          fully below. 

13. The argument for the          whole-brain criteria in terms of the collapse of an entropy-resistant          system is made in Korein 1978 and Korein 2005.          

 14. There are, in fact,          many variations of the higher-brain formulation. The defenders of          some of these might take issue with way the argument is presented          here. In a 2005 paper, Robert Veatch, for instance, is careful to          distinguish his position from the "mentalists." In this vein, he          says, "life.is the characteristic of all humans with '*embodied* capacity for consciousness'" (Veatch 2005, p. 370, author's          emphasis). The loss of the *union* of body with mind, implied by          the permanent loss of the latter, is human death.          

15. The quotation from          Beecher is cited in Veatch 1976, p. 39.          

 16. Veatch also points          out, in this vein, that the whole-brain formulations and even the          cardio-pulmonary formulation can also be criticized for not having          tests that are perfectly accurate.          

17. The essay was          written in 1970 but not published until 1974.          

18. Perhaps an even          better case is the legal notion of 'simultaneous death' which covers          two individuals whose deaths are brought about by an event, such as a          car accident, that injures both of them. If their deaths co-occur          within a certain window of time, the law judges them to have died *simultaneously*. This is a legal fiction, to be sure, but          practically preferable to sorting out their estates based on hard          evidence of who really died first.          

 19. Using this example          is not meant to suggest any connection, by Dworkin or us, between          euthanasia and treatment of the brain dead individual.          

 20. In this paper, Brody          repeats a proposal originally made in Halevy and Brody 1993. Halevy          and Brody articulated their idea in response to physiological          evidence that, similar to that adduced by Shewmon, challenged the          whole-brain standard for death. The most important evidence in this          regard was continuing brain-mediated neurohormonal regulation          (secretion of ADH) exhibited in patients who qualified as brain dead.          The continuance of this neural activity shows that there are parts of          the brain that can survive even when the brainstem is so damaged that          the patient passes the tests for brain death. This evidence has been          much discussed in the literature since it seems to cut away at any          practical difference between a *brainstem* standard and a          *whole-brain* standard. If continued activity of the          non-brainstem portions of the brain is irrelevant, then why not be          explicit, as the UK standard is, about focusing exclusively on the          brainstem dysfunction? Halevy and Brody do not take this course, but          other former defenders of the standard paradigm have.          

 21. This point was          argued in a 1971 *Science* article by Robert Morrison entitled "Death: Process or Event" (Morison 1971). 

 22. "The death of an          individual shall not be declared upon the basis of neurological          criteria. when the licensed physician authorized to declare death,          has reason to believe, on the basis of information provided by a          member of the individual's family or any other person knowledgeable          about the individual's personal religious beliefs that such a          declaration would violate the personal religious beliefs of the          individual. In these cases death shall be declared, and the time of          death fixed, solely upon the basis of cardio-respiratory criteria" (New Jersey Declaration of Death Act (1991). L.1991,c.90; NJSA          26:6A-5). 

 23. In his 2005 paper,          Veatch clarifies this position against those he calls the "disaggregators." He does support separating *some* societal          responses to death from a single defined moment of death but insists          that "There will remain a core cluster of 'death behaviors' that must          remain aggregated. They will remain aggregated because precisely the          same rationale will be seen as justifying each of these behaviors" (Veatch 2005, p. 359). Included in this core cluster, in his view, is          transition of the individual into an organ source. 

 24. See Siminoff,          Burant, Youngner 2004. Over half the respondents either called the          brain dead patient "alive" or "as good as dead" rather than "dead."          

 25. See Youngner et al.          1989 and, for some revealing anecdotal accounts of health care          provider views Youngner 1996.          

 26. An exception to this          was the University of Wisconsin Hospital where procurement from these          donors was practiced continuously since 1974 (Lewis et al. 2003).          

27. Sometimes these 'organ cooling' measures are performed in controlled DCD cases as          well to allow time for the family to be with the newly dead patient          before he is moved to the operating room. 

 28. An evidence-based          formula, along these lines, was designed at the University of          Wisconsin to predict if a patient is a suitable candidate for DCD          (Lewis et al. 2003).          

 29. The 2005 conference          on DCD made a recommendation that warm ischemic time be reported to          reflect the two distinct 'phases' - that "from the withdrawal of          ventilatory support to cardiopulmonary cessation" and that "from          cessation of circulation to the initiation of cold perfusion" (Bernat          et al. 2006 p. 284). 

 30. This case and the          one discussed below were both adapted from a report by Helen Nelson          and Jonathan Lewis (Nelson and Lewis 2003).          

 31. As we will discuss          in section IV below, these patients could actually become          *heart-beating* donors if the standard for determining death          were moved in the direction of neo-cortical death or if the dead          donor rule were abandoned and an adequate alternative rationale for          using them in this way was accepted.          

 32. For a gripping and          instructive description of a case where DCD followed termination of          support in a fully conscious patient with a high spinal cord injury          see Spike 2000.          

 33. Some recent articles          have addressed this: Sanchez-Fructoso et al. 2006 discusses the          practice at a hospital in Madrid, Spain. Gagandeep et al. 2006          discusses the success of kidney transplants after uncontrolled DCD          procurement. Sung and Punch 2006 is a response that encourages wider          use of such a strategy. The Washington Hospital Center program,          discussed below, is reported in Kowalski et al. 1996 and Light et al.          1996.          

 34. See Appendix F in          the 2006 IOM report.          

35.  Discussing the          clinical status of PVS patients is beyond the scope of this paper. It          should be noted, though, that - unlike brain death - PVS is not a          condition with a well established set of operational criteria for          diagnosis. It is also not unheard of for PVS patients to recover          functions that were believed to be irreversibly lost.                                                                         |