Pope John Paul II and the neurological standard for the determination of death: A critical analysis of his address to the Transplantation Society

Implications of John Kavanaugh's Philosophy of the Human Person as Embodied Reflexive Consciousness for Conscientious Decision-making in Brain Death

This article reviews the work of Fr. John F. Kavanaugh, SJ (1941-2012), on the human person as embodied reflexive consciousness (RC). It then analyzes the implications of his work for the subject of brain death. Case studies are reviewed which suggest that RC persists unchanged in the setting of substantial brain trauma. RC is posited as an immaterial endowment, rather than a material phenomenon, which is fully present so long as a person is alive and becomes absent when a person is truly dead. As the endowment which makes possible ethical action and is common to all human persons, RC becomes the foundation of human equality. Empirically ascertaining the presence or absence of RC may not be possible-its demonstration may be precluded by physical immaturity or damage. Therefore, until the human person (and not only the brain) has wholly and irreversibly died, RC should be assumed to be present. The current criteria for brain death are incapable of ensuring that the entire brain has permanently and irreversibly ceased to function. Therefore, RC may still be present in those whose organs are harvested after meeting the criteria for brain death. As such, a human person would still be present, albeit a wounded human person. Based on this, a healthcare provider could (and likely should) in good conscience oppose the use of brain death criteria for purposes of harvesting vital organs. On a societal level, utilizing brain death criteria to declare a person dead has the potential in any given case to violate the dead donor rule, and as such conflicts with the widely held moral consensus that organs should only be harvested from those who are dead. Healthcare providers should advocate for medicolegal frameworks consistent with their informed consciences.

Does the Uniform Determination of Death Act Need to Be Revised?

Prompted by concerns raised by the rise in litigations, which challenge the legal status of brain death (BD), Lewis and colleagues recently proposed a revision of the Uniform Determination of Death Act (UDDA). The revision consists of (i) narrowing down the definition of BD to the loss of specific brain functions, namely those functions that can be assessed on bedside neurological examination; (ii) requiring that the determination of BD must be in accordance with the specific guidelines designated in the revision; and (iii) eliminating the necessity for obtaining consent prior to performing the tests for BD determination. By analyzing Lewis and colleagues' revision, this article shows that this revision is fraught with difficulties. Therefore, this article also proposes two approaches for an ethical revision of the UDDA; the first is in accordance with scientific realism and Christian anthropology, while the second is grounded in trust and respect for persons. If the UDDA is to be revised, then it should be based on sound ethical principles in order to resolve the ongoing BD controversies and rebuild public trust.

Summary

This article critically examines the recent revision of the Uniform Determination of Death Act (UDDA) advanced by Lewis and colleagues. The revision only further reinforces the status quo of brain death without taking into account the root cause of the litigations and controversies about the declaration of death by neurological criteria. In view of this deficiency, this article offers two approaches to revising the UDDA, both of which are founded on sound moral principles.

Evolution of the Criteria of "Brain Death": A Critical Analysis Based on Scientific Realism and Christian Anthropology

"Brain death" (understood in the sense of "whole brain death" and not in the sense of "brainstem death") was introduced into clinical practice in 1968 when the Harvard Ad Hoc Committee defined irreversible coma as a new criterion for death (understood in the full sense of the word). According to the Uniform Determination of Death Act (UDDA), promulgated in 1981 by the President's Commission (which also formally advanced the first conceptual rationale for brain death), the legal declaration of death using the brain death standard requires the irreversible cessation of all functions of the entire brain, including the brain stem. The brain death standard has since evolved, however, to include significant modifications even though, on a literal reading, its clinical test criteria have remained unchanged. This article gives an account of why and how the brain death standard has been updated, leading to the currently practiced guidelines for the determination of brain death put forth by the American Academy of Neurology. According to the updated standard, the presence of certain brain or spinal cord functions does not invalidate the diagnosis of brain death. By analyzing these guidelines critically on the basis of scientific realism and Thomistic hylomorphism, this article demonstrates that the updated brain death standard contradicts both the UDDA and the tenets of sound anthropology held by the Catholic Church.

Summary

This article examines the evolution of the "brain death" standard from the time of its introduction by the Harvard Committee until the current guidelines established by the American Academy of Neurology. This evolution consists mainly of a selective discarding of certain brain and spinal cord functions that are deemed insignificant. Based on the principles of scientific realism and a Thomistic substance view of human nature, this article shows that the evolved standard contradicts both the Uniform Determination of Death Act definition of brain death and the fundamental tenets of Christian anthropology as taught by the Catholic Church.

Unpacking Robert Spaemann's Philosophical Contribution to the Brain Death Debate

Questions of life and death are primarily philosophical questions, as philosopher Robert Spaemann argues. Spaemann argues that "brain death" is philosophically unsatisfactory as a definition of death, and as the exclusive criterion for determining death, for two main reasons: first, because it attempts to annul the basic perceptions of the ordinary person in regard to death. Second, because the cause of life and unity in a living being cannot be reduced to the brain. This essay is an explication of Spaemann's contribution to the "brain death" question, which consists in illuminating the philosophical issues at stake.

Summary

This article presents Robert Spaemann's philosophical case that "brain death" suffices neither as a definition of death nor as the sole criterion of death.

Brain Death and the Formation of Moral Conscience

In this article, we provide an update to Catholic ethicists and clinicians about the current status of Catholic teaching and practice regarding brain death. We aim to challenge the notion that the question has been definitively settled, despite the widespread application of this concept in medical practice including at Catholic facilities. We first summarize some of the notable arguments for and against brain death in Catholic thought as well as the available magisterial teachings on this topic. Although Catholic bishops, theologians, and ethicists have generally signaled at least tentative approval of the neurological criteria for the determination of death, we contend that no definitive magisterial teaching on brain death currently exists; therefore, Catholics are not currently bound to uphold any position on these criteria. In the second part of the article, we describe how Catholics, particularly Catholic medical practitioners, must presently inform their consciences on this issue while awaiting a more definitive magisterial resolution.

SUMMARY

Some prominent Catholic theologians and physicians have argued against the validity of brain death; however, most Catholic ethicists and physicians accept the validity of brain death as true human death. In this paper, we argue that there is no definitive magisterial teaching on brain death, meaning that Catholics are not bound to uphold any position on brain death. Catholics in general, but especially Catholic medical practitioners, should inform their consciences on this intra-Catholic debate on brain death while awaiting more definitive magisterial teaching.

Opinions on the Legitimacy of Death Declaration by Neurological Criteria from the Perspective of 3 Abrahamic Faiths

Traditional criteria to identify death may not fit all circumstances. This manuscript explores religious jurisprudence to ascertain whether death declaration by neurological criteria (DDNC) is accepted as a valid method by 3 Abrahamic religious traditions ie. Islam, Judaism, and Catholicism. Among Islamic sources (order of primacy), neither the Qur'an, Sunnah as reported in Hadith, Ijma' (scholarly consensus), nor Qiyas (precedent-based analogy) clearly describe death determination criteria. Through Ijtihad (lowest level of Shari 'ah), 5 of 6 identified non-binding fatwa support DDNC. Faith-based medical organizations are divided. Eleven of 13 surveyed Muslim-majority countries have laws supporting DDNC. Concern exists that premature death declaration could violate the Shari'ah concept of Hifz-An-nafs (saving life). As such, DDNC remains debated in Islamic circles. Among the 3 main sources of Jewish law (Halacha), the Torah (oral and written) does not clearly define death declaration criteria. Although Talmudic interpretations of Misnah Oholot 1:6 and Gamara Hullin 21a suggest a possible justification for death determination using neurologic criteria in some conditions, the bulk of mitzvot d'rabbanan (Rabbinic Law) rejects DDNC and adheres to cardiorespiratory criteria. Lastly, Catholic Church Cannon Law and the Holy Scripture recorded in Bible does not define death determination criteria. Following the Council of Vienne, Saint Thomas's loss of integration view has predominated. In 2000, Pope John Paul II expressed tentative and qualifid support for DDNC, however the topic remains controversial. Despite dissenting opinions in each faith, DDNC is currently accepted as valid by many Muslims and Catholics, while rejected by Judaism.