Death as the extinction of the source of value: the constructivist theory of death as an irreversible loss of moral status

In 2017, Michael Nair-Collins formulated his Transitivity Argument which claimed that brain-dead patients are alive according to a concept that defines death in terms of the loss of moral status. This article challenges Nair-Collins' view in three steps. First, I elaborate on the concept of moral status, claiming that to understand this notion appropriately, one must grasp the distinction between direct and indirect duties. Second, I argue that his understanding of moral status implicit in the Transitivity Argument is faulty since it is not based on a distinction between direct and indirect duties. Third, I show how this flaw in Nair-Collins' argument is grounded in the more general problems between preference utilitarianism and desire fulfillment theory. Finally, I present the constructivist theory of moral status and the associated moral concept of death and explain how this concept challenges the Transitivity Argument. According to my view, brain death constitutes a valid criterion of death since brain death is incompatible with the preserved capacity to have affective attitudes and to value anything.

Heart donation and transplantation after circulatory determination of death: expert guidance from a Canadian consensus building process

Controlled donation after circulatory determination of death (DCD), where death is determined after cardiac arrest, has been responsible for the largest quantitative increase in Canadian organ donation and transplants, but not for heart transplants. Innovative international advances in DCD heart transplantation include direct procurement and perfusion (DPP) and normothermic regional perfusion (NRP). After death is determined, DPP involves removal and reanimation of the arrested heart on an ex situ organ perfusion system. Normothermic regional perfusion involves surgically interrupting (ligating the aortic arch vessels) brain blood flow after death determination, followed by restarting the heart and circulation in situ using extracorporeal membrane oxygenation. The objectives of this Canadian consensus building process by a multidisciplinary group of Canadian stakeholders were to review current evidence and international DCD heart experience, comparatively evaluate international protocols with existing Canadian medical, legal, and ethical practices, and to discuss implementation barriers. Review of current evidence and international experience of DCD heart donation (DPP and NRP) determined that DCD heart donation could be used to provide opportunities for more heart transplants in Canada, saving additional lives. Although candid discussion identified a number of potential barriers and challenges for implementing DCD heart donation in Canada, it was determined that DPP implementation is feasible (pending regulatory approval for the use of an ex situ perfusion device in humans) and in alignment with current medical guidelines for DCD. Nevertheless, further work is required to evaluate the consistency of NRP with current Canadian death determination policy and to ensure the absence of brain perfusion during this process.

Refinements in the Organism as a Whole Rationale for Brain Death

Death can be defined as the permanent cessation of the organism as a whole. Although the organism as a whole is a century-old concept, it remains better intuited than analyzed. Recent concepts in theoretical biology including hierarchies of organization, emergent functions, and mereology have informed the idea that the organism as a whole is the organism's critical emergent functions. Because the brain conducts the critical emergent functions including conscious awareness and control of respiration and circulation, the cessation of brain functions is death of the organism. A newer concept, the brain as a whole, may offer a superior criterion of death to the whole-brain criterion, because it more closely matches accepted clinical brain death tests and confirms the cessation of the organism's emergent functions. Although the concepts of organism as a whole and brain as a whole remain vague and in need of rigorous biophilosophical analysis, their future precision will be restricted by the categorical limitations intrinsic to theoretical biological models.

Controversy in the Determination of Death: The Definition and Moment of Death

This essay reviews recent controversy in the determination of death, with particular attention to the definition and moment of death. Definitions of death have evolved from the intuitive to the pathophysiologic and the medicolegal. Many United States jurisdictions have codified the definition of death relying on guidance from the Uniform Determination of Death Act (UDDA). Flaws in the structure of the UDDA have led to misunderstanding of the physiologic nature of death and methods for the determination of death, resulting in a bifurcated concept of death as either circulatory/respiratory or neurologic. The practice of organ donation after circulatory determination of death (DCDD) raises a number of ethical questions, most prominently revolving around the moment of death and manifested as an expedited time to determination of death, a departure from the unitary concept of death, a violation of the dead donor rule, and a challenge to the standard of irreversibility. Attempts to redefine the determination of death from an irreversibility standard to a permanence standard have significant impact on the social contract upon which deceased donor organ transplantation rests, and must entail broad societal examination. The determination of death is best reached by a clear, strict, and uniform irreversibility standard. In deceased donor organ transplantation, the interests of the donor as a person are paramount, and no interest of organ recipients or of the greater society can justify negation of the rights and bodily integrity of the person who is a donor, nor conversion of the altruism of giving into the calculus of taking.

The human organism is not a conductorless orchestra: a defense of brain death as true biological death

In this paper, I argue that brain death is death because, despite the appearance of genuine integration, the brain-dead body does not in fact possess the unity that is proper to a human organism. A brain-dead body is not a single entity, but a multitude of organs and tissues functioning in a coordinated manner with the help of artificial life support. In order to support this claim, I first lay out Hoffmann and Rosenkrantz's ontological account of the requirements for organismal unity and summarize an earlier paper in which I apply this account to the brain death debate. I then further support this ontological argument by developing an analogy between the requirements for the unity of an organism and the requirements for the unity of an orchestra. To do so, I begin by examining the role that a conductor plays in unifying a traditional orchestra, and then go on to show that the human organism (at least in postnatal stages) functions like a traditional orchestra that relies upon a conductor (the brain) for its unity. Next, I consider the conditions required to achieve orchestral unity in conductorless orchestras and show that, in contrast to simpler organisms like plants, the postnatal human organism lacks those conditions. I argue, in other words, that although conductorless orchestras do exist, the human organism is not one of them. Like a traditional orchestra without a conductor, the brain-dead body is not a unified whole.

When is somebody just some body? Ethics as first philosophy and the brain death debate

I, along with others, have been critical of the social construction of brain death and the various social factors that led to redefining death from cardiopulmonary failure to irreversible loss of brain functioning, or brain death. Yet this does not mean that brain death is not the best threshold to permit organ harvesting-or, as people today prefer to call it, organ procurement. Here I defend whole-brain death as a morally legitimate line that, once crossed, is grounds for families to give permission for organ donation. I do so in five moves. First, I make the case that whole-brain death is a social construction that transformed one thing, coma dépassé, into another thing, brain death, as a result of social pressures. Second, I explore the way that the 1981 President's Commission tried to establish the epistemological certainty of brain death, hoping to avoid making arcane metaphysical claims and yet still utilizing metaphysical claims about human beings. Third, I explore the moral meaning of the social construction of a definition that cannot offer metaphysical certainty about the point at which somebody becomes just some body. Fourth, I describe how two moral communities-Jewish and Catholic-actually ground their metaphysical positions with regard to brain death in the normativity of prior social relations. Finally, I conclude with a reflection on the aesthetic-moral enterprise of the metaphysical-epistemological apparatus of brain death, concluding that only such an aesthetic-moral approach is sufficiently strong to stave off the utility-maximizing tendencies of late-modern Western cultures.

When are you dead enough to be a donor? Can any feasible protocol for the determination of death on circulatory criteria respect the dead donor rule?

The basic question concerning the compatibility of donation after circulatory death (DCD) protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term "death" nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death can be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of "irreversibility" need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty.