Requiring family authorization for apnea testing subtracts health professionals control over death determination, a procedure that has traditionally been considered a matter of clinical expertise alone. In this commentary, we first provide evidence showing that health professionals’ (HPs) disposition to act on death determination without family’s prior consent could be much lower than that referred to by Berkowitz and Garrett (2020). We hypothesize that HPs may have reservations about their own expertise as regards death, and (...) may thus hesitate to impose their views on patients’ families. We then address the theoretical question of clinical expertise in death determination by distinguishing judgments about facts (e.g., the presence or absence of spontaneous breathing) from interpretations given of these facts (i.e., their meaning for the vital status of an individual). We argue that, while clinicians may claim some expert authority on the former, they hold no particular authority on the latter. (shrink)

Death by neurological criteria (DNC) continues to stir global controversy. Philosophers and theologians contest its moral significance, clinicians and bioscientists debate its probative accuracy, a...

The neurological criteria for the determination of death remain controversial within secular and Catholic circles, even though they are widely accepted within the medical community. In Determining Death by Neurological Criteria, Matthew Hanley offers both a practical and a philosophical defense. Hanley shows that the criteria are often misapplied in clinical settings, leading to cases where persons declared dead apparently spontaneously revive. These instances are often connected to a rushed decision to retrieve donated organs, thus undermining the (...) trust of the public in organ donation. Hanley calls on health care institutions to take seriously their obligation to establish strict protocols for the determination of death, including who may conduct the examinations. From a broader perspective, Hanley considers how the criteria rely on a philosophical conception of the person as a living organism whose unity disintegrates at death. This view, he notes, corresponds to the Catholic conviction that the soul is the life-principle of the body, which departs at death, bringing about the destruction of the body-soul composite. The Vatican, recognizing that death is a medical judgment, has generally given its approval to the criteria. Hanley also reviews the many and various objections offered by detractors, including against the use of the apnea test, which is faulted as a practice that sometimes hastens death. The problem of the continued presence of certain vital functions within the deceased body of the brain dead is explored in detail, with reference to particular cases and to solutions proposed by leading physicians and bioethicists. Hanley likewise addresses the dilemma of having two separate standards for death, one neurological and the other cardiopulmonary. Given the possibility of resuscitation following loss of the cardio-circulatory system, he concludes that the neurological criteria must be the true standard. Stoppage of the heart leads swiftly to the final necrosis of the brain. -- Provided by publisher. (shrink)

The most controversial issue in organ donation after the circulatory determination of death is whether the donor was truly dead at the moment death is declared. My colleagues and I further analyzed this issue by showing the relevance of the distinction between the “permanent” and the “irreversible” loss of circulatory functions. Permanent cessation means that circulatory function will not return because it will not be restored spontaneously and medical attempts to restore it will not be conducted. By (...) contrast, irreversible cessation means that circulatory function cannot be restored using currently available technology. In this issue of the Report, Kevin Munjal and colleagues criticize the unjustified application of the permanent‐irreversible distinction, which my colleagues and I developed for cDCDD, to their well‐designed and carefully conducted experimental protocol of uncontrolled DCDD (uDCDD) in New York City, for which our analysis was not targeted. They claimed that to determine a donor's death in uDCDD, it is unnecessary to show that permanence is a valid surrogate indicator of irreversibility because the unsuccessful attempt to resuscitate the patient comprises prima facie evidence of circulatory irreversibility. Ironically, that potent justification defending death determination in uDCDD yields limitations that are similar to those created when our permanent‐irreversible distinction is applied to death determination in cDCDD. (shrink)

Volume 20, Issue 6, June 2020, Page 47-49.

The dead donor rule states that organ donors must be declared dead before any vital organs are removed. Recently, scholars and physicians have argued for the abandonment of the dead donor rule, based on the rule’s supposed connection with the concept of brain death, which they view as a conceptually unreliable definition of death. In this essay, I distinguish between methods of death determination and the question of whether or not the dead donor rule should be (...) a guiding principle of organ transplant ethics. In principle, the dead donor rule does not rely on any one definition of death, but only prohibits the taking of vital organs before a patient is declared dead. In light of this distinction, I argue that even if the dead donor rule is tied to brain death in practice, conceptual disagreement about brain death does not provide grounds for rejection of this rule. I then present evidence in support of the consistency and reliability of the diagnosis of brain death. I show that, when performed carefully and under specific clinical circumstances, the diagnosis of brain death is considered by most neurologists to be reliable. Finally, I argue that, without the dead donor rule, organ transplantation programs would become susceptible to violations of the ethical principle of respect for persons. (shrink)

Several authors in bioethics literature have expressed the view that a whole brain conception of death is philosophically indefensible. If they are right, what are the alternatives? Some authors have suggested that we should go back to the old cardiopulmonary criterion of death and abandon the so-called Dead Donor Rule. Others argue for a pluralist solution. For example, Robert Veatch has defended a view that competent persons should be free to decide which criterion of death should be (...) used to determine their death. However, there is very little data on people’s preferences about death determination criteria. We conducted online vignette-based survey with Latvian participants (N = 1416). The data suggest that the pluralist solution fits best with the way our study participants think about death determination—widely differing preferences concerning death determination criteria were observed. Namely, most participants choose one of the three criteria discussed in the literature: whole brain, higher brain, and cardiopulmonary. Interestingly, our data also indicate that study participants tend to prefer less restrictive criteria for determination of their own deaths than for determination of deaths of their closest relatives. Finally, the preferences observed in our sample are largely in accord with the Dead Donor Rule for organ procurement for transplantation. (shrink)

in Western cultures in regard to post-mortem organ donation and the termination of care for patients meeting these strict criteria. But they are of minimal use in Asian cultures and in the ethics of caring for the persistent vegetative patient. This paper introduces a formula for a global Uniform Determination of Death statute, based on the ‘entire brain including brain stem’ criteria as a default position, but allowing competent adults by means of advance directives to choose other criteria (...) for determining death during the process of dying. Keywords: euthanasia, brain death criteria, higher brain death criteria, individual choice, multicultural society, self-determination CiteULike Connotea Del.icio.us What's this? (shrink)

Brain death or determination of death based on the neurological criterion has been an enduring source of controversy in academic and clinical circles. The controversy chiefly concerns how death is defined, and it also bears on the justification of the proposed criteria for death determination and their interpretation. Part of the controversy on brain death and death determination stems from disputed crucial medical facts, but in this paper I formulate another hypothesis (...) about the nature of ongoing controversies. At stake is a misunderstood relationship between, on the one hand, the nature of our lay views about death and, on the other hand, the nature of scientific insights into death and its determination. The misunderstanding of this relationship has partly anchored the controversy and continues to fuel it. Based on a perspective inspired by pragmatism, which stresses the positive contribution of science to ethical and policy debates but also challenges different forms of scientism in science and philosophy found in foundationalist interpretations, I scrutinize three different stances regarding the relationship between lay and scientific perspectives about the definition of death: foundational lay views, foundational expert views, and co-evolving views. I argue that only the latter is sustainable given recent challenges to foundationalist interpretations. (shrink)

One of the most important and difficult tasks in medicine is to determine when patients have the capacity to make decisions for themselves. This determination may determine a patient’s life or death. This article presents criteria and approaches now used to make this assessment and discusses how these approaches are presently applied in five common disorders that can serve as paradigms for approaches in other disorders. I propose that since there are new diagnoses and treatments, reconsidering our current (...) practices is warranted. The possibilities that clinicians can nudge patients to make better choices for themselves and, above all, that clinicians can maintain and maximize positive patient/careprovider relationships during and after these assessments, are emphasized. (shrink)

The distinction between the "permanent" (will not reverse) and "irreversible" (cannot reverse) cessation of functions is critical to understand the meaning of a determination of death using circulatory–respiratory tests. Physicians determining death test only for the permanent cessation of circulation and respiration because they know that irreversible cessation follows rapidly and inevitably once circulation no longer will restore itself spontaneously and will not be restored medically. Although most statutes of death stipulate irreversible cessation of circulatory and (...) respiratory functions, the accepted medical standard is their permanent cessation because permanence is a perfect surrogate indicator for irreversibility, and using it permits a more timely declaration. Therefore, patients properly declared dead in donation after circulatory death (DCD) protocols satisfy the requirements of death statutes and do not violate the dead donor rule. The acronym DCD should represent organ "donation after circulatory death" to clarify that the death standard is the permanent cessation of circulation, not heartbeat. Heart donation in DCD does not retroactively negate the donor's death determination because circulation has ceased permanently. (shrink)

Despite the popularity, success, and growth of programs of organ donation after the circulatory determination of death (DCDD), a long‐standing controversy persists over whether the organ donor is truly dead at the moment physicians declare death, usually following five minutes of circulatory and respiratory arrest. Advocates of the prevailing death determination standard claim that the donor is dead when declared because of permanent cessation of respiration and circulation. Critics of this standard argue that while the (...) cessation of respiration and circulation may be permanent, it may not be irreversible at the moment death is declared because, if cardiopulmonary resuscitation were performed, it might succeed. And because irreversibility of cessation of respiration and circulation is required by both the statute and the biological concept of death, the donor must be alive. Who is correct?Making two related distinctions clarifies the cause of the disagreement over whether the DCDD donor is dead and points to a possible resolution. First, in a determination of death, there is an important distinction between the permanent and the irreversible cessation of circulation and respiration—two associated phenomena that are often confounded. Second, there is an important distinction between the medical practice standard for death determination, in which physicians certify the permanent cessation of vital functions as sufficient for death declaration, and the underlying biological concept of death that requires the irreversible cessation of vital functions because death, by definition, is an irreversible event. (shrink)

Suicidal Thoughts is a compilation of some of the most moving and insightful writing accomplished on the topic of suicide. It presents the thoughts and experiences of fifteen writers who have contemplated suicide-some on a professional level, others on a personal level, and a few, both personally and professionally. Through this collection, the reader is able to bear witness to the struggle between life and death and to the devastating aftermath of suicide. Suicidal Thoughts provides readers with a better (...) understanding of the reasons why some individuals give serious consideration to killing themselves. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Patient Self-Determination ActElizabeth Leibold McCloskey (bio)What are the ethics of extending the length of life? We know that we cannot artificially end life (Thou Shalt not Kill), but how about artificially extending life? Is that always good, sometimes good?... In ethics, is keeping people alive the highest good? Should our priority be to keep people breathing?... What does basic religious ethics say about this?(John C. Danforth, letter (...) to the author, 19 August 1989)The Patient Self-Determination Act, signed into law as part of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) last November, marks the first time that Congress has passed legislation concerning the ethics of life-sustaining medical treatment. The bill was spearheaded by Senator John C. Danforth (RMO), who has a special interest in this area. An Episcopal priest, Danforth was formerly an assistant chaplain at New York's Memorial Sloan-Kettering Cancer Center and now sits as a senior member of the Senate Finance Committee, which oversees Medicare and Medicaid. Although Senator Danforth's legislative initiative was not a result of the Cruzan case, it was in his state of Missouri that the U.S. Supreme Court case involving removal of Nancy Cruzan's feeding tube arose (Cruzan v. Director of Missouri Department of Health, U.S. Supreme Court, 58 LW 4916, 26 June 1990). From his unique vantage point, he felt it was time to craft a legislative response to some of the difficult issues surrounding prolongation of life.The short answer to Senator Danforth's questions about when to artificially extend life is simple enough: people must be free to determine that for themselves. Common law and common sense dictate such a conclusion; living will and health care proxy statutes, enacted in almost every state, codify that right. The Catholic moral tradition teaches that one is not morally obligated to use extraordinary means to prolong life, a tradition shared both by the mainline Protestant and the reform and conservative Jewish community. Yet most people are unaware of their fundamental legal right to make such decisions, and as court cases from Quinlan (In re Quinlin, 137 N.J. Super. 227, 1975) to Cruzan demonstrate, few know [End Page 163] how to make arrangements for this right to be exercised if they become incapacitated.Meanwhile, health care practices are often driven by a denial of death. When Senator Danforth and Senator Daniel Patrick Moynihan (D-NY) introduced the bill on October 17, 1989, Senator Danforth said:More and more it is arguable that we play God by subjecting people to unwanted and sometimes unnecessary treatment, treatment that unnaturally prolongs the dying process. Our health care system has become obsessed with extending life, at times neglecting the caring component of medicine and trampling on the rights of patients.(Congressional Record 1989, 135:5.13566)The American Hospital Association estimates that 70 percent of deaths now occur after a determination to withhold or withdraw medical treatment. Many of those decisions are made without the benefit of an incapacitated patient's views, yet a Harvard study revealed that 95 percent of the population would like to prepare in advance for such decisions. Only 4 percent of hospitals have a systematic method of asking patients if they have an advance directive. Family members confront painful choices in the face of uncertainty about their loved one's wishes and it can be even more painful when a family knows the patient's desires but providers and the courts act otherwise because clear evidence is lacking.The Patient Self-Determination Act is rooted in the belief that people should be given information that enables them to specify the extent of medical treatment they wish to receive should they become incapacitated. The public should be educated about applicable state laws that protect the individual's right to make such choices through the use of an advance directive.The Act moves toward that goal by promoting knowledge of state laws. It requires every hospital, nursing home, home health agency, hospice, and health maintenance organization that participates in Medicaid or Medicare to routinely give all adult patients information about advance directives. Patients will also be given information on the... (shrink)

The past decade has witnessed escalating legal and ethical challenges to the diagnosis of death by neurologic criteria. The legal tactic of demanding consent for the apnea test, if successful, can halt the DNC. However, US law is currently unsettled and inconsistent in this matter. Consent has been required in several trial cases in Montana and Kansas but not in Virginia and Nevada. In this paper, we analyze and evaluate the legal and ethical bases for requiring consent before apnea (...) testing and defend such a requirement by appealing to ethical and legal principles of informed consent and battery and the right to refuse medical treatment. We conclude by considering and rebutting two major objections to a consent requirement for apnea testing: a justice-based objection to allocate scarce resources fairly and a social utility objection that halting the diagnosis of brain death will reduce the number of organ donors. (shrink)

Sex selection in India and China is fostered by a limiting social structure that disallows women from performing the roles that men perform, and relegates women to a lower status level. Individual parents and individual families benefit concretely from having a son born into the family, while society, and girls and women as a group, are harmed by the widespread practice of sex selection. Sex selection reinforces oppression of women and girls. Sex selection is best addressed by ameliorating the situations (...) of women and girls, increasing their autonomy, and elevating their status in society. One might argue that restricting or prohibiting abortion, prohibiting sex selection, and prohibiting sex determination would eliminate sex selective abortion. But this decreases women's autonomy rather than increases it. Such practices will turn underground. Sex selective infanticide, and slower death by long term neglect, could increase. If abortion is restricted, the burden is placed on women seeking abortions to show that they have a legally acceptable or legitimate reason for a desired abortion, and this seriously limits women's autonomy. Instead of restricting abortion, banning sex selection, and sex determination, it is better to address the practice of sex selection by elevating the status of women and empowering women so that giving birth to a girl is a real and positive option, instead of a detriment to the parents and family as it is currently. But, if a ban on sex selective abortion or a ban on sex determination is indeed instituted, then wider social change promoting women's status in society should be instituted simultaneously. (shrink)

Much of the debate over the definition and criteria for determining our death has focused on disagreement over the correct biological account of death, i.e., what it means for any organism to die. In this paper, we argue that this exclusive focus on the biology of death is misguided, because it ignores ethical and social factors that bear on the acceptability of criteria for determining our death. We propose that attention shift from strictly biological considerations to (...) ethical and social considerations that bear on the determination of what we call “civil death.” We argue for acceptance of a neurological criterion for determining death on grounds that it is the most reasonable way to synthesize biological, ethical, and social considerations about our death.. (shrink)

From the data of the 1989 Bangladesh Fertility Survey, aggregate deaths reported at ages 0-12 and 13-60 months are used to estimate infant and child mortality. Multivariate analysis shows that preceding birth interval length, followed by survival status of the immediately preceding child, are the most important factors associated with differential infant and child mortality risks; sex of the index child and mother's and father's education are also significant. Demographic factors are influential during infancy as well as childhood, but social (...) factors, particularly mother's and father's education, now emerge as significant predictors of infant mortality risks. This indicates a change in the role of socioeconomic factors, since the earlier Bangladesh Fertility Survey in 1975. (shrink)

The present chapter explores conceptual links in folk cognition between death, existence and personal identity. There is some evidence that people’s judgments about death determination differ relatively widely (Dranseika and Neiders 2018, Neiders and Dranseika 2020). If folk judgements about death differ between people, however, can those differences at least in some degree be driven by people’s beliefs about what we are, when we cease to exist and whether ceasing to exist is identical to death (...) (so-called Termination Thesis)? In order to answer these questions, we conducted two studies. The first study looks into how people think about when they begin and cease to exist as well as when they are born and die. The second study replicates the findings of the first study in a different language and country and also extends these results by also looking at what people think about ‘what we are’, and whether their position on the latter issue is associated to their thinking about when they begin and cease to exist as well as when they are born and die. The studies presented in this chapter show that, first, people seem to hold a considerable variety of different views about death, coming into existence, ceasing to exist and what we are. The studies also recovered a number of conceptual links between these concepts. These results potentially bear on a number of issues in bioethics, i.e., not only discussions on death determination, but also on abortion or embryonic research. As for death determination, the results can be taken to provide further support for the so-called pluralist proposal. Second, study results provide little evidence for the claim that people’s beliefs about death are driven by their assumptions about personal identity, i.e., their understanding of ‘what we are’. In particular, there is little evidence that differences among people on death result from differences among people on personal identity. Finally, the studies show that people don’t reason in accordance with the Termination Thesis. The link between folk ascriptions of death and cessation of existence, while present, is weak. (shrink)

Abstract:Disturbing cases continue to be published of patients declared brain dead who later were found to have a few intact brain functions. We address the reasons for the mismatch between the whole-brain criterion and brain death tests, and suggest solutions. Many of the cases result from diagnostic errors in brain death determination. Others probably result from a tiny amount of residual blood flow to the brain despite intracranial circulatory arrest. Strategies to lessen the mismatch include improving brain (...) death determination training for physicians, mandating a test showing complete intracranial circulatory arrest, or revising the whole-brain criterion. (shrink)

In the United States, patients have a clear right to determine what is done to them by doctors. Starting in the early 20th century, multiple court cases paved the way for our current understanding...

Examining Levinas’s critique of the Heideggerian conception of temporality, this book shows how the notion of the feminine both enables and prohibits the most fertile territory of Levinas’s thought. According to Heidegger, the traditional notion of time, which stretches from Aristotle to Bergson, is incoherent because it rests on an inability to think together two assumptions: that the present is the most real aspect of time, and that the scientific model of time is infinite, continuous, and constituted by a series (...) of more or less identical now-points. For Heidegger, this contradiction, which privileges the present and thinks of time as ongoing, derives from a confusion about Being. He suggests that it is not the present but the future that is the primordial ecstasis of temporality. For Heidegger, death provides an orientation for our authentic temporal understanding. Levinas agrees with Heidegger that mortality is much more significant than previous philosophers of time have acknowledged, but for Levinas, it is not my death, but the death of the other that determines our understanding of time. He is critical of Heidegger’s tendency to collapse the ecstases of temporality into one another, and seeks to move away from what he sees as a totalizing view of time. Levinas wants to rehabilitate the unique character of the instant, or present, without sacrificing its internal dynamic to the onward progression of the future, and without neglecting the burdens of the past that history visits upon us. The author suggests that though Levinas’s conception of subjectivity corrects some of the problems Heidegger’s philosophy introduces, such as his failure to deal adequately with ethics, Levinas creates new stumbling blocks, notably the confining role he accords to the feminine. For Levinas, the feminine functions as that which facilitates but is excluded from the ethical relation that he sees as the pinnacle of philosophy. Showing that the feminine is a strategic part of Levinas’s philosophy, but one that was not thought through by him, the author suggests that his failure to solidly place the feminine in his thinking is structurally consonant with his conceptual separation of politics from ethics. (shrink)

In this issue of the Report, James L. Bernat proposes an innovative and sophisticated distinction to justify the introduction of permanent cessation as a valid substitute standard for irreversible cessation in death determination. He differentiates two approaches to conceptualizing and determining death: the biological concept and the prevailing medical practice standard. While irreversibility is required by the biological concept, the weaker criterion of permanence, he claims, has always sufficed in the accepted standard medical practice to declare (...) class='Hi'>death. Bernat argues that the medical practice standard may be acceptable on the ground that proving circulatory or brain permanence is sufficient to assure complete accuracy for death diagnosis. -/- The topic requires public deliberation: processes to survey people's opinions and mechanisms to channel their opinions into policy-making. What is at stake is the nature of our society. Do we want an expertocracy, in which an enlightened few design policies for the greater good of the majority and exploit the lack of public knowledge to achieve compliance? (shrink)

In this essay, we consider questions arising from cases in which people request medical assistance in dying (MAiD) in unjust social circumstances. We develop our argument by asking two questions. First, can decisions made in the context of unjust social circumstance be meaningfully autonomous? We understand ‘unjust social circumstances’ to be circumstances in which people do not have meaningful access to the range of options to which they are entitled and ‘autonomy’ as self-governance in the service of personally meaningful goals, (...) values and commitments. People in these circumstances would choose otherwise, were conditions more just. We consider and reject arguments that the autonomy of people choosing death in the context of injustice is necessarily reduced, either by restricting their options for self-determination, through their internalisation of oppressive attitudes or by undermining their hope to the point that they despair.Second, should MAiD be available to people in such circumstances, even when a sound argument can be made that the agents in question are autonomous? In response, we use a harm reduction approach, arguing that even though such decisions are tragic, MAiD should be available. Our argument engages with relational theories of autonomy as well as recent criticism raised against them and is intended to be general in application, although it emerges in response to the Canadian legal regimen around MAiD, with a focus on recent changes in Canada’s eligibility criteria to qualify for MAiD. (shrink)

Deprivationism cannot accommodate the common sense assumption that we should lament our death iff, and to the extent that, it is bad for us. Call this the Nothing Bad, Nothing to Lament Assumption. As such, either this assumption needs to be rejected or deprivationism does. I first argue that the Nothing Bad, Nothing to Lament Assumption is false. I then attempt to figure out which facts our attitudes concerning death should track. I suggest that each person should have (...) two distinct attitudes toward death: one determined by agent’s reasonable expectations about when she will die and one determined by the amount of metaphysically possible good one reasonably believes death precludes. (shrink)

Since the 1980s, Islamic scholars and medical experts have used the tools of Islamic law to formulate ethico-legal opinions on brain death. These assessments have varied in their determinations and remain controversial. Some juridical councils such as the Organization of Islamic Conferences' Islamic Fiqh Academy (OIC-IFA) equate brain death with cardiopulmonary death, while others such as the Islamic Organization of Medical Sciences (IOMS) analogize brain death to an intermediate state between life and death. Still other (...) councils have repudiated the notion entirely. Similarly, the ethico-legal assessments are not uniform in their acceptance of brain-stem or whole-brain criteria for death, and consequently their conceptualizations of, brain death. Within the medical literature, and in the statements of Muslim medical professional societies, brain death has been viewed as sanctioned by Islamic law with experts citing the aforementioned rulings. Furthermore, health policies around organ transplantation and end-of-life care within the Muslim world have been crafted with consideration of these representative religious determinations made by transnational, legally-inclusive, and multidisciplinary councils. The determinations of these councils also have bearing upon Muslim clinicians and patients who encounter the challenges of brain death at the bedside. For those searching for ‘Islamically-sanctioned’ responses that can inform their practice, both the OIC-IFA and IOMS verdicts have palpable gaps in their assessments and remain clinically ambiguous. In this paper we analyze these verdicts from the perspective of applied Islamic bioethics and raise several questions that, if answered by future juridical councils, will better meet the needs of clinicians and bioethicists. (shrink)

Protocols for retrieving vital organs in consenting patients in cardiovascular arrest rest on the assumptions that irreversible asystole a) identifies the instant of biological death, and b) is clinically assessable at the time when retrieval of vital organs is possible. Unfortunately both assumptions are flawed. We argue that traditional life/death definitions could be actually inadequate to represent the reality of dying under intensive support, and we suggest redefining NHBD protocols on moral, social, and antrhopological criteria, admitting that irreversible (...) asystole can only equate a clinically determinable point of no return in the process of dying, where organ retrieval can be morally and socially accepted in previously consenting patients. (shrink)

Machine generated contents note: Table of Cases xi -- Table of legislation xv -- Introduction: Medicine Men, Outlaws and Voluntary Euthanasia 1 -- 1. To Kill or not to Kill; is that the Euthanasia Question? 9 -- Introduction-Why Euthanasia? 9 -- Dead or alive? 16 -- Euthanasia as Homicide 25 -- Euthanasia as Death with Dignity 29 -- 2. Euthanasia and Clinically assisted Death: from Caring to Killing? 35 -- Introduction 35 -- The Indefinite Continuation of Palliative Treatment (...) 38 -- Withholding or Withdrawing Treatment 44 -- The Principle of Double Effect 54 -- Physician Assisted Suicide 60 -- Mercy Killing 64 -- Conclusions 66 -- 3. Consent to Treatment but Not to Death 69 -- Introduction-Why Consent? 69 -- Without Consent 70 -- Killing and Consent 73 -- Valid Consent, Freely Given? 74 -- Old Enough to Consent 80 -- Deciding for Others 82 -- Conclusions-A Consent Too Far? 93 -- 4. Autonomy, Self-determination and Self-destruction 95 -- Introduction-Autonomous Choices 95 -- Choosing to Die-Suicide and Autonomy 100 -- Suicidal Intentions 107 -- Autonomous Clinical Discretion 110 -- Deciding to Live or Die-Whose Decision? 112 -- 5. Living Wills and the Will to Die 115 -- Introduction 115 -- I Know My Will 118 -- This is My Will 121 -- I Will Decide 128 -- Will My Will be Done? 134 -- Where There's a Will 137 -- Conclusions 143 -- 6. Is Euthanasia a Dignified Death? 145 -- Introduction-Why Dignity? 145 -- Needing Dignity 146 -- Finding Dignity 149 -- Achieving Dignity in Dying 151 -- Dignifying Death 157 -- 7. Conclusions: Dignified Life, Dignified Death and Dignified Law 165 -- Select Bibliography 175 -- Index 183. (shrink)

Based on the fieldwork at two Norwegian Intensive Care Units, we wish to discuss the sometimes inconsistent manner in which death is handled, determined and made real by nurses and other healthcare personnel in high‐tech hospital situations. These discrepancies draw our attention towards different ways of attending to the dying and dead and views about appropriate or inappropriate codes of professional behaviour. As we will argue below, the analytical tools developed by Annemarie Mol are useful for sharpening our understanding (...) of the enactment of multiple ontologies of death as they are enacted within the ICU. Annemarie Mol and John Law’s notion of ‘ontological politics’ increases our awareness about the non‐arbitrary way some but not other practices are considered self‐evident whereas others are denigrated as muddled and illogical. (shrink)

Hegel contends that judgements are contradictory, finite and untrue. Prominent schol- ars argue that Hegel’s issue with judgements is resolved in the later stages of his Logic. Specifically, Ng suggests that this solution is found in Hegel’s discussion of life. In this article, I argue that not only does life fail to resolve Hegel’s problem with judgement— death highlights its insolubility. To support this claim, I examine Hegel’s discussion of judgements in the Logic, showing that judgements are inherently contradictory (...) because they both unite and separate individuals and universals. Instead of being resolved ret- rospectively, I demonstrate that contradiction, finitude and untruth are intrinsic to judgements. Moreover, since judgements play a constitutive and determinative role in Hegel’s metaphysics, they pass their contradictions, finitude and untruth onto the objects they constitute. Specifically, I argue that for living beings, judgement is literally a matter of life and death, because the contradiction of judgements implies the finitude of the objects they constitute—namely, the perishability of things and the mortality of organisms. (shrink)

Shortly after implantation the embryonic lineage transforms from a coherent ball of cells into polarized cup shaped epithelium. Recently we elucidated a previously unknown apoptosis‐independent morphogenic event that reorganizes the pluripotent lineage. Polarization cues from the surrounding basement membrane rearrange the epiblast into a polarized rosette‐like structure, where subsequently a central lumen is established. Thus, we provided a new model revising the current concept of apoptosis‐dependent epiblast morphogenesis. Cell death however has to be tightly regulated during embryogenesis to ensure (...) developmental success. Here, we follow the stages of early mouse development and take a glimpse at the critical signaling and morphogenic events that determine cells destiny and reshape the embryonic lineage. (shrink)

Based on the fieldwork at two Norwegian Intensive Care Units, we wish to discuss the sometimes inconsistent manner in which death is handled, determined and made real by nurses and other healthcare personnel in high‐tech hospital situations. These discrepancies draw our attention towards different ways of attending to the dying and dead and views about appropriate or inappropriate codes of professional behaviour. As we will argue below, the analytical tools developed by Annemarie Mol are useful for sharpening our understanding (...) of the enactment of multiple ontologies of death as they are enacted within the ICU. Annemarie Mol and John Law’s notion of ‘ontological politics’ increases our awareness about the non‐arbitrary way some but not other practices are considered self‐evident whereas others are denigrated as muddled and illogical. (shrink)

Concern with elective-death decisions usually focuses on individuals' competence and understanding of their situations and prospects. If problematic influences on individuals are considered, they almost invariably have to do with matters such as depression and the effects of medication. Too little attention is paid to how individuals, as subjects, are products of both external cultural and social influences on them, and of internal efforts and needs that determine their subjectivity.

OBJECTIVES: To determine the epidemiology and the underlying pathological conditions of natural deaths among motor vehicle drivers. Sudden death while driving may cause damage to properties, other vehicles or road users. Although the Medical Commission on Accident Prevention recommended restrictions to drivers at risk of sudden death due to their medical conditions, these restrictions are useless if they do not result in greater safety to the public. DESIGN: A retrospective study of natural deaths of motor vehicle drivers. SETTING: (...) Natural deaths of motor vehicle drivers reported to the coroner for Birmingham and Solihull. SUBJECTS: 86 consecutive natural deaths of motor vehicle drivers in a five-year period between 1984 and 1988. RESULTS: Of the 86 fatalities reviewed, 80 (93%) sudden deaths were caused by ischaemic heart disease. Fifty vehicles were involved in collision with 32 properties, 20 other vehicles and six pedestrians. Fifty-one out of 80 cardiac deaths had past cardiac history and three had reported chest pain prior to the sudden death. CONCLUSION: An applied normative ethical assessment based on the basic moral principles of autonomy, justice, beneficence and non-maleficence are discussed. We conclude that medical screening of drivers has little benefit for the drivers or other persons. (shrink)

“What if the death penalty were a drug?” This question opens the essay and is pursued through two very different kinds of texts. On the one hand, Derrida's 1999–2000 Death Penalty Seminar is brought to bear for its analysis of what is called there the “anesthesial logic” of capital punishment. This logic, Derrida argues, has determined both pro– and anti–death penalty discourses since at least the mid-eighteenth century. On the other hand, the essay gathers evidence of events (...) that led, in 2010, to the unavailability in the United States of sodium thiopental—the anesthetic component of the three-drug protocol of the lethal injection—which forced many death penalty states to halt executions. Current events thus confirm the philosopher's analysis that anesthesia is indeed the lynchpin of the apparatus of state-sanctioned executions. But the analysis of this anesthesial logic also leads one to pose the further question of who is being anesthetized by this protocol and its discursive devices: the sentenced or the sentencers? (shrink)

Every artwork is the first and last of its kind. Nothing happens the same way twice. But if this is the case, then what limits can we impose on our understanding of the historical development of art? The poles in our conceptual schema of the development of art are analogous to human life, which is placed between two poles of non-existence. This schema is used in our understanding of art, interpretation, and metaphor. Being a complex part in the intersection between (...) life and death, this becomes transposed from experiences to things, reified objects that can make the analysis of these entities cognitively respectable. To transfer them back to experience is to see them as part of our cultural understanding: the movement from death to life and back again is grounded in the dynamic tension between the creative/deviant and conventional/established sense-making determinations. By these experiences our views of the world are both transgressed and confirmed. (shrink)

"Whole brain death" (neurological death) is well-established as a legal standard of death across the country. Recently, New Jersey became the first state to enact a statute recognizing a personal religious exemption (a conscience clause) protecting the rights of those who object to neurological death. The Act also mandates adoption through the regulatory process of uniform and up-to-date clinical criteria for determining neurological death.

Laura Specker Sullivan (2022) makes a fairly compelling case for the value of the perspectives of Buddhist practitioners in neuroethics. In this study, Tibetan Buddhist monks have been asked, among other things, whether consciousness, in brain-injured patients in a minimally conscious state, entails a duty to preserve life. In our view, some of the participants’ responses could be used to inform the bioethical debate on death determination.

A crucial test for the dominant Rawlsian ‘consensus’ brand of public reason is whether it is complete – sufficient in content, that is, to yield determinate answers to the political questions put before it. Yet while doubts about the incompleteness of Rawlsian public reason have been often voiced, critics have thus far carried out relatively little of the philosophical spadework needed to substantiate them. This paper contributes to remedying this omission, via a detailed analysis of the implications of Rawlsian public (...) reason for an important bioethical problem arising at the end of human life. This is the problem of how to define and diagnose the death of a person, or determine at what point the clinical and legal practices conventionally associated with death, such as the removal of vital organs, may take place. My thesis is that this is a matter on which Rawlsian public reason does indeed have a grave incompleteness problem: the model produces indeterminacy, I argue, between a broad range of legal definitions of death. I also aim to go beyond existing articulations of the incompleteness objection, moreover, by examining what Rawlsian consensus liberalism implies about how decision-makers ought to respond to indeterminacies in public reason. Insofar as the route to a reasoned choice between competing criteria of death is foreclosed, I contend, the Rawlsian view requires that selection among policy options proceed in an intolerably arbitrary fashion. The latter finding alters the cast of the familiar incompleteness objection, by closing the gap between it and what I have elsewhere called the ethical objection – the objection, that is, that public reason can in some cases generate determinate but morally unacceptable decisions. (shrink)

Organ donation after brain death has been practiced in China since 2003 in the absence of brain death legislation. Similar to international standards, China’s brain death diagnostic criteria include coma, absence of brainstem reflexes, and the lack of spontaneous respiration. The Chinese criteria require that the lack of spontaneous respiration must be verified with an apnea test by disconnecting the ventilator for 8 min to provoke spontaneous respiration. However, we have found publications in Chinese medical journals, in (...) which the donors were declared to be brain dead, yet without an apnea test. The organ procurement procedures started with initiating “intratracheal intubation for mechanical ventilation after brain death,” indicating that a brain death diagnosis was not performed. The purpose of the intubation was not to resuscitate the patient but rather was directly related to facilitating the explantation of organs. Moreover, it was unmistakably stated in two of these publications that the cardiac arrest was induced in these patients without brain death determination by cold St. Thomas cardioplegic solution or other cold myocardial protection solutions. This means that the condition of these donors neither met the criteria of brain death nor that of cardiac death. In other words, the “donor organs” may well have been procured in these cases from living human beings. Thus, brain death definition is abused in China by some individuals for organ harvesting, and a systematic investigation is needed to clarify the situation of organ donation after brain death in China. (shrink)

Traditionally, people were recognized as being dead using cardio-respiratory criteria: individuals who had permanently stopped breathing and whose heart had permanently stopped beating were dead. Technological developments in the middle of the twentieth century and the advent of the intensive care unit made it possible to sustain cardio-respiratory and other functions in patients with severe brain injury who previously would have lost such functions permanently shortly after sustaining a brain injury. What could and should physicians caring for such patients do? (...) Significant advances in human organ transplantation also played direct and indirect roles in discussions regarding the care of such patients. Because successful transplantation requires that organs be removed from cadavers shortly after death to avoid organ damage due to loss of oxygen, there has been keen interest in knowing precisely when people are dead so that organs could be removed. Criteria for declaring death using neurological criteria developed, and today a whole brain definition of death is widely used and recognized by all 50 states in the United States as an acceptable way to determine death. We explore the ongoing debate over definitions of death, particularly over brain death or death determined using neurological criteria, and the relationship between definitions of death and organ transplantation. (shrink)

Desire satisfaction theories of well-being and deprivationism about the badness of death face similar problems: desire satisfaction theories have trouble locating the time when the satisfaction of a future or past-directed desire benefits a person; deprivationism has trouble locating a time when death is bad for a person. I argue that desire satisfaction theorists and deprivation theorists can address their respective timing problems by accepting fusionism, the view that some events benefit or harm individuals only at fusions of (...) moments in time. Fusionism improves on existing solutions to the timing problem for deprivationism because it locates death’s badness at the same time as both the victim of death and death itself, and it accounts for all of the ways that death is bad for a person. Fusionism improves on existing solutions to the problem of temporally locating the benefit of future and past-directed desires because it respects several attractive principles, including the view that the intrinsic value of a time for someone is determined solely by states of affairs that obtain at that time and the view that intrinsically beneficial events benefit a person when they occur. (shrink)

Constantin Reliu had been working for twenty years as a cook in Turkey when he returned to his hometown of Barlad, Romania, to discover that, there, he was dead. His former wife had, unbeknownst to him, at some point during his stay in Turkey registered him as deceased in Romania. He has since been living a legal nightmare trying to prove to Romanian authorities that he is, in fact, alive. Reliu is not alone in finding out that the legal system (...) is not as attuned to physiological activity or biological assessment by doctors in determining death as one might think. If one starts with the assumption that death is a purely biological concept, solely the province of doctors, Reliu's story seems entirely unrelated to the concept of death in the medical context. A brain scan would not lead to a reversal of his being assessed as dead. The story is a reminder, however, that how death is used is not just biological, and therefore that the standard of death even in the clinic must answer to cultural considerations. Values, the law, and custom matter a great deal in determining who is alive and who is not, whether in the courtroom, the coroner's office, or the clinic. (shrink)

The overwhelming weight of legal authority in the USA and Canada holds that consent is not required for brain death testing. The situation in England and Wales is similar but different. While clinicians in England and Wales may have a prima facie duty to obtain consent, lack of consent has not barred testing. In three recent cases where consent for brain death testing was formally presented to the court, lack of consent was not determinative, and in one case (...) the court questioned whether the clinicians were even required to seek consent from the parents of a child at all. (shrink)

The so-called Kulturkampf, the conflict between the German Reich and the Catholic Church in the 1870s and 1880s, is one of the most important ideological conflicts of the late nineteenth century and reveals a political theological dynamic characteristic of the modern (German) nation state. This paper analyzes the paradoxes of this conflict along the lines with Eric Santner’s analysis of political representations. During the Kulturkampf, Catholic citizens were publicly suspected of not being loyal Germans, and the Catholic Church is widely (...) figured as an (inner) enemy in the liberal press and in modern caricatures. In these polemics, numerous political theological figures emerge: images of a gendered relation of domination of the (female) church by the (male) state, phantasies of the body politic and its precarious unity as well as of its purification respectively of the extermination of its others that continue to determine other ideological conflicts in the twentieth century. (shrink)

Dilemmas about resuscitation and life-prolonging treatment for severely compromised infants have become increasingly complex as skills in neonatal care have developed. Quality of life and resource issues necessarily influence management. Our Institute of Medical Ethics working party, on whose behalf this paper is written, recognises that the ultimate responsibility for the final decision rests with the doctor in clinical charge of the infant. However, we advocate a team approach to decision-making, emphasising the important role of parents and nurses in the (...) process. Assessing the relative burdens and benefits can be troubling, but doctors and parents need to retain a measure of discretion; legislation which would determine action in all cases is inappropriate. Caution should be exercised in involving committees in decision-making and, where they exist, their remit should remain to advise rather than to decide. Support for families who bear the consequences of their decisions is often inadequate, and facilitating access to such services is part of the wider responsibilities of the intensive care team. The authors believe that allowing death by withholding or withdrawing treatment is legitimate, where those closely involved in the care of the infant together deem the burdens to be unacceptable without compensating benefits for the infant. As part of the process accurate and careful recording is essential. (shrink)