'Near PVS': a new medico-legal syndrome?

Brain death, states of impaired consciousness, and physician-assisted death for end-of-life organ donation and transplantation

In 1968, the Harvard criteria equated irreversible coma and apnea (i.e., brain death) with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism (locked-in syndrome), minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. (1) Brain death does not disrupt somatic integrative unity and coordinated biological functioning of a living organism. (2) Neurological criteria of human death fail to determine the precise moment of an organism's death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. (3) Brain-based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. (4) Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. (5) The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs.

Hidden places, uncommon persons

Specialized hospital units recently created to house and maintain ventilator or other technology-dependent persons in the United States are new cultural forms that enable beings who are neither fully alive, biologically dead, nor "naturally" self-regulating, yet who are sustained by modern medical practices, to exist. These institutions both fabricate and complicate the persons who are patients there through surveillance and maintenance of their conditions. This article concerns the relationship of person to place when the consciousness of an individual, considered to be the essence of personhood in the modern Western philosophical tradition, is problematic because the person resides in a technologically produced border zone between life and death. The article explores the ways in which place and person become implicated one another: first, how consciousness and thus personhood is assessed and negotiated through the inter-subjective knowledge of hospital staff; second, how that knowledge is tied to the particular situate-dness of patients; and third, how embodiment itself-the reflexive knowledge of the-self-in-the-body-is perceived as emplaced in social and spatial relations.