[Machines and arguments: from life support technologies to the definition of brain death]

The article analyzes academic production about the debate surrounding the definition of brain death, based on bibliographic and documental research of international medical periodicals in the 1960s. The development and adoption of life support technologies during the twentieth century sparked a heated debate that sought to legitimize new procedures like organ transplants. As its practices changed, medical science set about inventing new knowledge about these practices. Discussions as to the definition of brain death turned it into a 'black box', dismantled by anthropological studies into the topic starting in 1980s. The present article explores the deconstruction of brain death as a black box.

A history of ethics and law in the intensive care unit

Because they provide potential benefit at great personal and public cost, the intensive care unit (ICU) and the interventions rendered therein have become symbols of both the promise and the limitations of medical technology. At the same time, the ICU has served as an arena in which many of the ethical and legal dilemmas created by that technology have been defined and debated. This article outlines major events in the history of ethics and law in the ICU, covering the evolution of ICUs, ethical principles, informed consent and the law, medical decision-making, cardiopulmonary resuscitation, withholding and withdrawing life-sustaining therapy, legal cases involving life support, advance directives, prognostication, and futility and the allocation of medical resources. Advancement of the ethical principle of respect for patient autonomy in ICUs increasingly is in conflict with physicians' concern about their own prerogatives and with the just distribution of medical resources.

[Francis Bacon on the origin and preservation of life: theory and experiments]

The paper analyses Bacon's views of life, as contained in De Sapientia Veterum, Historia vitae et mortis, and in a newly published manuscript, entitled De vijs mortis. Bacon saw the prolongation of life as one of the main goals of science and medicine, According to him, life is the result of the action of spirits on matter. In order to preserve life, it is necessary to investigate various kinds of generation, notably, those which occurr without seeds. The study of putrefaction is also crucial for the prolongation of life.

On the history of modern resuscitation

The development of modern cardiopulmonary-cerebral resuscitation (CPCR) has given every person the ability to challenge death anywhere. Despite sparks of knowledge and occasional applications of possibly effective lifesaving efforts since antiquity, the possibility to reverse acute terminal states or clinical death by modern, physiologically sound, and effective measures did not come about until around 1900 inside hospitals, and around 1960 outside hospitals. Additional potentially effective cerebral resuscitation, research since around 1970, may be taken to clinical trials before the year 2000. The history of resuscitation medicine around 1900, when many opportunities to assemble existing bits of knowledge into an effective system were missed, should be a warning for those individuals who will lead CPCR beyond the year 2000. History has shown the need for continuing communication and collaboration among investigators of different countries, and between laboratory researchers, clinicians of various disciplines, and prehospital rescuers. The lessons learned from history, for research challenges in the near future, include: a) the development of ultra-advanced life support to be initiated outside the hospital, to bridge cardiopulmonary resuscitation (CPR)-resistant cases to definitive cardiac procedures in the hospital; and b) cerebral resuscitation to complete recovery after 10 to 15 mins of normothermic cardiac arrest without blood flow. Both challenges above will require research projects at multiple levels--from the molecular and cellular levels, to the use of small and large animal models (with organs' and organisms' process and outcome evaluations), to studies of patients and communities. Beyond the year 2000, resuscitation research might become more challenging and cost-effective in the area of multiple trauma, which concerns the young and fit. Research challenges concerning brain trauma, uncontrolled hemorrhagic shock, and "suspended animation" for delayed resuscitation have their own histories, and are not covered here. The author apologizes for not having recognized many important contributors to the history of CPCR because of space constraints or lack of knowledge about such contributions. Input on this subject from readers of this paper is hereby invited.

Care of the dying: an ethical and historical perspective

OBJECTIVE

To provide a historical perspective, from ancient Greece to the middle of the 20th century, on ethical issues and principles commonly associated with medical care for the dying in Western civilization.

SOURCES

Writings of noted philosophers, historians, ethicists, and physicians, as well as published legal and ethical guidelines. INFORMATION EXTRACTION: The sources used highlight the origins of various ethical principles associated with care of the dying. They also identify the opinions of prominent individuals throughout the history of medical ethics.

SUMMARY

Devotion to medical beneficence, concern for the quality of life, and respect for the sanctity of life are all expressed in the earliest medical and philosophical writings of ancient Greece. With regard to care of the dying, these considerations led to a wide acceptance of avoiding or terminating treatment in hopeless cases. They also led to active debate regarding medicine's role in hastening the dying process. The rise of Christianity during the Middle Ages markedly suppressed such debate by strongly reinforcing the principle of sanctity of life. Later, the optimism of the enlightenment added the hope of prolonging life. Finally, modern advances in medical science have made that hope a reality of complex ethical dimensions.

CONCLUSIONS

Ethical debates regarding appropriate care for the dying are as old as medicine itself. Although beneficent concerns have characterized the medical community in almost every period of history, tensions have repeatedly arisen as diverse religious and philosophical ideologies have produced varying standards to define such beneficence. In the Christian world, the sanctity of life was often extolled as the paramount standard. For the ancient Greeks and Romans, and again in many post-Renaissance philosophies, quality of life considerations assumed equal or greater importance. Modern life-prolonging technologies heighten the debate by allowing these two standards to dramatically conflict, particularly in the critical care setting.

Brain death--a review of the concept

The early origins of the concept of brain death have been retraced. Using practical examples from clinical experience it has been demonstrated that conventionally, cardiac death is always accompanied by brain death. Cardiac death implies brain death. The two are inseparably linked or coupled. Death on a ventilator uncouples the two, revealing death of the brain as the true determinant of the cessation of a person's life and the heartbeat as a false measure.