III. PHILOSOPHICAL AND THEOLOGICAL PERSPECTIVES

The bioethics debate concerning the definition and criteria of human death emerged during the rise of organ transplantation in the 1960s, prompted by the advent of functional mechanical replacements for the heart, lungs, and brain stem, and by the ability to diagnose the pervasive brain destruction that is termed brain death. Previously, there had been no need to explore the conceptual or definitional basis of the established practice of declaring death or to consider additional criteria for determining death, since the irreversible cessation of either heart or lung function quickly led to the permanent loss of any other functioning considered a sign of life. New technologies and advances in resuscitation changed all this by permitting the dissociated functioning of the heart, lungs, and brain. In particular, society experienced the phenomenon of a mechanically sustained patient whose whole brain was said to be in a state of irreversible coma. And there were an increasing number of vegetative patients sustained by feeding tubes, whose bodies had been resuscitated to the status of spontaneously functioning organisms, but whose higher brains had permanently lost the capacity for consciousness. Such phenomena as these pressed a decision as to whether the irreversible loss of whole or higher-brain functioning should be considered the death of the individual, despite the continuation of respiration and heartbeat. With mounting pressure to increase the number of viable organs for transplant within the unquestioned constraint of the Dead Donor Rule which requires that the organ donor be dead before organ removal, the debate concerning whole-brain death arose.

The Beginnings of the Debate

The debate opened in 1968, when the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death (Harvard Committee) recommended an updating of the criteria for determining that a patient has died. The Harvard Committee put forth a set of clinical tests it claimed was sufficient to determine the death of the entire brain. It then recommended that whole-brain death be considered direct and sufficient evidence of the death of the patient. Thus arose the suggestion, which has become entrenched practice in the United States, that a binary standard be used for determining death: that in addition to the traditional heart and lung criteria still applicable in the vast majority of cases, a whole-brain death criterion be used to determine death for respirator-dependent, permanently unconscious patients.

This was the modest beginning of the so-called definitionof-death debate. Rather than having resolved over the last thirty-five years, this debate has evolved and intensified due to fascinating and complex constellations of philosophical, clinical, and policy disagreements. To best appreciate these disagreements, one must understand the definitional debate as one that has three logically distinct, yet interdependent levels: (1) the conceptual or definitional level; (2) the criteriological level; and (3) the medical diagnostic level. Let us look at each of the three levels in turn.

THE THREE LEVELS OF THE DEBATE. Level One: The conceptual or definitional level. At level one, the question is, What is human death? While some people think basic definitions such as this one are somehow written on the face of reality for our discernment, defining death is in fact a normative activity that draws on deeply held philosophical, religious, or cultural beliefs and values. The definition or concept of death reflects a human choice to count a particular loss as death. The level two and level three activities of deciding which physiological functions underlie that loss (i.e., choosing a criterion for determining death), and of specifying the medical tests for determining that the criterion is fulfilled, are medical/scientific activities. The conceptual question can be answered in a general, yet uninformative way by saying that human death is the irreversible loss of that which is essentially significant to the nature of the human being. No one will take issue with this definition, but it does not go far enough. There is still a need to decide what is essentially significant to the nature of the human being.

People differ radically in their views on the distinctive nature of the human being and its essentially significant characteristic (s). Because their fundamentally different perspectives on human nature flow from deeply rooted beliefs and values, the difficult policy question arises concerning the extent to which a principle of toleration should guide medical practice to honor the alternative definitions of human death that exist.

The discussion later in this section will show that the human being can be thought of as a wholly material or physical entity, as a physical/mental amalgam, or as an essentially spiritual (though temporarily embodied) being. The way the human is thought of will influence the view of what is essentially significant to the nature of the human being, and ground one's view about the functional loss that should be counted as human death. A metaphysical decision concerning the kind of being the human is, is the ultimate grounding for the normative choice of criteria for determining that an individual human being has died. There could be no more interesting or important a philosophical problem, then, than the problem of deciding: What is human death? Why? And, there could be no more interesting an ethical/policy problem than that of deciding whether and how to tolerate and enable a diversity of answers to these questions.

Level Two: The criteriological level. Based on the resolution of the ontological and normative questions at the conceptual level, a criterion for determining that an individual has died, reflecting the physiological function (s) considered necessary for life and sufficient for death, is specified. That is, the essentially significant human characteristic (s) delineated at the conceptual level is (are) located in (a) functional system (s) of the human organism. The traditional criteria center on heart and lung function, suggesting that the essentially significant characteristics are respiration and circulation. The whole-brain-death criterion is said by its proponents to focus on the integrated functioning of the organism as a whole. The higher-brain-death criterion centers on the irreversible absence of a capacity for consciousness.

Level Three: The diagnostic level. At this level are the medical diagnostic tests to determine that the functional failure identified as the criterion of death has in fact occurred. These tests are used by medical professionals to determine whether the criterion is met, and thus that death should be declared. As technological development proceeds, diagnostic sophistication increases. The Harvard Committee believed that the death of the entire brain could be clinically diagnosed using the tests it identified in its report, and recommended that the whole-brain-death criterion be used to determine death in cases of respirator dependency. However, it provided no conceptual argument (i.e., no answer to the level one question, What is human death?) to support the criterion and practice it recommended.

These three levels—conceptual, criteriological, and diagnostic—provide a crucial intellectual grid for following the complex definition-of-death debate since 1968. The debate encompasses all three levels. In any reading and reflection associated with this complex debate, it is essential to remember what level of the debate one is on, and what sort of expertise is required on the part of those party to the debate at that level. Further, any analysis and critical assessment of suggested criteria for determining death require that one attend to the important interconnections among tests, criteria, and concepts. Criteria without tests are useless in practice; criteria without concepts lack justification. It is the philosophical task of constructing an adequate concept or definition of human death that becomes central to a justified medical practice of declaring death. As Scot philosopher and historian David Hume (1711–1776) said centuries ago, "Concepts without percepts are blind." At the beginning of the twenty-first century, a criterion for determining death without a philosophical analysis of what constitutes death is equally blind. All in all, there ought to be coherence among concept, criterion, and clinical tests. At least this is the way one would normally wish to operate. Among other things, the definition-of-death debate can be expressed as a debate among alternative formulations of death: the traditional cardio-pulmonary, whole-brain and higher-brain formulations.

The Traditional Cardio-Pulmonary Formulation

Initially, many objected to the whole-brain formulation because they saw it to be a change in our fundamental understanding of the human being, and a dramatic change from the essentially cardiac-centered concept and criterion for determining death (the traditional cardio-pulmonary criteria, which required the final stoppage of the heart). Several have called for a return to the use of the traditional criteria, consistent with an understanding of death as the irreversible loss of the integrative functioning of the organism as a whole. The claim has been that whether mechanically or spontaneously sustained, a beating heart signifies the ongoing integrated functioning of the organism as a whole, whether or not the patient is brain-dead. On this view, death has not occurred until the heart and lungs have irreversibly ceased to function. Some religious traditions adhere stead-fastly to this concept of death, and consider the brain-death criterion an unacceptable basis on which to declare death.

The Whole-Brain-Death Formulation: Concept and Criterion

When the Harvard Committee recommended that a whole-brain-death criterion be used to determine death in respirator-dependent patients, thus creating an exception to the use of the traditional cardio-pulmonary criteria for a specific category of patients, controversy arose over whether the adoption of this criterion constituted a departure from the concept of death implicit in the use of the traditional cardio-pulmonary criteria for the determination of death.

Some saw the use of the brain-death criterion to be a blatantly utilitarian maneuver to increase the availability of transplantable organs. Some opposed it because it was inconsistent with their view of the human self and/or failed to protect and respect dying patients. While others agreed that the neurological focus represented an alternative understanding of the self, they saw the move to be eminently logical: What argument could one have with the notion that someone whose whole brain is dead, is dead? Others continued to affirm that life was essentially a heart-centered reality rather than a brain-centered reality: They saw the shift to a neurological focus on the human to be a discounting of the relevance of the spontaneous beating of the heart and the mechanically sustained functioning of the lungs. So, representatives of some cultures and faith traditions opposed the shift to the brain-death criterion, suggesting that it was a radically unacceptable way of understanding and determining the death of a human being.

The Harvard Committee report was a clinical recommendation, not a philosophical argument. It made recommendations at levels two and three (the criteriological and the diagnostic), and prompted but did not answer a number of level one definitional questions. What is death, such that either the traditional criteria or the whole-brain-death criterion may be used to determine its occurrence? Do the traditional criteria and the brain-death criterion presuppose the same definition of death? If not, should human death be redefined in response to technological change? It gave rise to a philosophical debate that is ongoing on the question, What is so essentially significant to the nature of a human being that its irreversible loss should be considered human death?

The literature has been replete with answers to this question, including the irreversible loss of the flow of vital fluids, the irreversible departure of the soul from the body, the irreversible loss of the capacity for bodily integration, the irreversible cessation of integrative unity (i.e., of the anti-entropic mutual interaction of all of the body's cells and tissues), the irreversible loss of the integrated functioning of the organism as a whole, and the irreversible loss of the capacity for consciousness or social interaction. Without such an account of what is essentially significant, the criterion used as a basis for determining death lacks an explicit foundation. However, the plurality of thoughtful answers to this fundamental conceptual question raises the issues of whether a consensus view can be fashioned, whether to tolerate diverse understandings of human death, and of how to assure societal stability concerning the determination of death.

While the Harvard Committee provided no philosophical defense of its position, adherents of the whole-brain formulation have continued to argue over the years that the traditional criteria and the whole-brain-death criterion share a common concept of death—the irreversible loss of the capacity for integrated functioning of the organism as a whole. Not everyone has agreed with this position, however. Some resist the adoption of the brain-death criterion for this reason, considering the shift to a new understanding of human death to be philosophically unjustifiable. However, others have welcomed the change: Reflecting on the contingency of the definition of death under circumstances of technological change, some have argued in favor of redefining death even further. In their view, the philosophical concept of death said to underlie the whole-brain-death criterion inadequately reflects the essentially significant characteristic of human existence: existence as an embodied consciousness. A more adequate concept of human death, they contend, would center on the permanent cessation of consciousness (requiring a higher-brain-death criterion), not on the permanent cessation of the integrated functioning of the organism. Advocates of the higher-brain formulation of death oppose the whole-brain formulation on the ground that the latter unjustifiably defers to the characteristics biological organisms have in common and ignores the relevance of the distinctively human characteristics associated with life as a person.

If the whole-brain formulation is essentially an organismically-based concept, and the higher-brain formulation is essentially a person-based concept, the controversy between whole- and higher-brain formulations suggests that in order to answer the question, What is human death? another layer of philosophical reflection is required. The central normative question concerning what is essentially significant to the nature of the human being requires a prior account of the nature of the human being. In philosophical terms, such an account of the nature of a being is referred to as an ontological account. One's view of the nature of the human being is informed by philosophical, theological and/or cultural perspectives on the nature of human existence, its essentially significant characteristics, and the nature of its boundary events. In the case of the human, there appear to be two logically distinct choices concerning the nature of the human being: one either sees it as one organism among others, for which meanings-in-common of life and death should be sought; or one sees the human being as distinctive among organisms for the purpose of characterizing its life and death, in ways we signify by the term person. In short we need to make and defend a decision concerning the way we look at the human—as organism or as person—for the purpose of determining what constitutes human death.

The Whole-Brain Formulation: Public Policy

In 1981 the whole-brain-death formulation originally advanced by the Harvard Committee was articulated in a major U.S. policy document. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research published its report, Defining Death: A Report on the Medical, Legal, and Ethical Issues in the Determination of Death. In this document, it provided a model law called the Uniform Determination of Death Act, to encourage the uniform adoption in each of the United States of the traditional criteria and the brain-death criterion as alternative approaches to declaring death. The supporting framework they offered for this recommendation was this: The concept of human death is the irreversible cessation of the integrated functioning of the organism as a whole. This, they claimed, is a function of the activity of the entire brain, not just a portion of the brain, and its occurrence can be measured, depending on the patient's circumstances, either by the traditional criteria or the brain-death criterion.

Questioning the Whole-Brain Formulation

The whole-brain formulation has been attacked at the conceptual level, and on the ground that the answers at each level collectively provide an incoherent account of concept, criterion and clinical tests for determining death. The President's Commission's concept or definition of death has been objected to by those who favor one centered on the essential features of a personal life, as well as by those who favor a circulatory concept and consider that only the irreversible cessation of circulation adequately signals death.

In addition, since 1981, clinical findings have confirmed that what has come to be called whole-brain death is not in fact synonymous with the death of the brain in all of its parts. There are instances of isolated continued functioning in the brain-dead brain. Those wishing to support the established consensus around the use of the brain-death criterion argue that such residual functioning in the brain-dead brain is insignificant to the determination of death. Specifically, then, they refuse to allow that these kinds of residual brain functioning have significance: (i) persistent cortical functioning as evidenced by electroencephalograph (EEG) activity, and in rare cases a sleep/wake pattern; (ii) ongoing brainstem functioning as evidenced by auditory or visual evoked potential recording; and (iii) preserved anti-diuretic neurohormonal functioning. Such instances of residual functioning suggest that brain death, as customarily diagnosed, does not include the hypothalamus and the posterior pituitary. Most importantly, the third instance of residual functioning just cited actually plays an integrative role in the life of the organism as a whole. Hence, one of the residual functions fulfills the concept of life implicit in the definition of death underlying the whole-brain formulation.

So, the clinical tests used to establish the death of the entire brain have been shown to reflect a pervasive but nonetheless partial death of the brain only, opening wide the question, If brain death is to remain a reasonable basis upon which to declare death, which brain functions are so essentially significant that their irreversible loss should be counted as brain death? Why?

Both philosophically and clinically speaking, then, many feel that a rethinking of the U.S. societal adherence to the brain-death criterion is warranted. It rests on a contested understanding of what human death is, raising the issue of whether the brain-death criterion should be used to declare someone dead who holds philosophical/theological/cultural objections to it. It lacks coherence among its levels because (1) the brain-death criterion does not correlate with the irreversible loss of the integrated functioning of the organism as a whole; and (2) because the clinical tests for brain death fail to reflect the death of the entire brain. No important societally established practice can be imagined to be so highly problematic as this one.

The supporters of the whole-brain formulation have nonetheless stood their ground, claiming that the instances of residual cellular and subcellular activities occurring in the brain are irrelevant to the determination of the life/death status of the patient. In their view, the brain-death criterion should continue to be used, despite that it really reflects a pervasive albeit partial brain death.

The basic challenge to the whole-brain formulation has been that its defenders need to provide criteria for distinguishing between brain activity that is relevant and irrelevant for the purpose of determining death. Some have argued that the only bright line that could be drawn in this regard is between the brain functions essential for consciousness and those that are not; others have argued that the brain should be abandoned entirely as a locus for establishing that a human being has died. In point of fact then, advocates of the whole-brain formulation have embraced a partial-brain-death criterion but have failed to provide a non-question-begging, principled basis for it.

Another aspect of the whole-brain formulation that has been challenged concerns its reliance on the non-spontaneous function of the lungs to support the claim that the irreversible cessation of the integrated functioning of the organism as a whole has occurred. They claim that the integrated functioning continues, and that the manner of its support is irrelevant. Their point is that as long as the respirator is functioning, it seems something of a word game to say that the organism is not functioning as an integrated whole.

While in brain death the brain stem is no longer playing its linking role in the triangle of function along with lungs and heart, the respirator is standing in for the brain stem, just as it might if there were partial brain destruction in the area of the brain stem. If the patient were conscious, but just as dependent on the respirator in order to continue functioning as an organism, there would be no inclination to pronounce the patient dead. Hence, it would seem that even the brain-dead patient is exhibiting integrated organismic functioning until the respirator is turned off, the lungs stop, and the heart eventually stops beating. The phenomenon of a mechanically-sustained brain-dead pregnant woman producing a healthy newborn certainly seems to bear out their insight: Whatever the sort of organismic disintegration possessed in such a case, it seems most unfitting to call it death. Integrated organismic functioning is present in brain death, so if brain death should be considered the death of the human being, it is not because brain death signals the irreversible loss of the integrated functioning of the organism as a whole.

As this last point makes clear, the real reason so many people are inclined to agree that the brain-dead patient is dead has much more to do with the fact that the brain-dead patient is permanently unconscious than with the facts of brain stem destruction and respirator dependency. It is this loss of the self, the loss of consciousness and thus of embodiment as a self, that is for many of us a good reason to consider the brain-dead patient dead. This suggests that the concept of human death underlying people's willingness to adopt the brain-death criterion may have more to do with the loss of the capacity for embodied consciousness than with the loss of the capacity for integrated organismic functioning.

The Higher-Brain Formulation

Consistent with this insight, some contributors to the definition-of-death debate propose a higher-brain-death criterion for the determination of death, contending that this criterion presupposes a different and preferable view of what is essentially significant to the nature of the human being. They hold that consciousness, sometimes characterized as a capacity for social interaction, is the sine qua non of human existence, and that the criterion used to determine death should reflect this loss. In their view, requiring that the brain-death criterion be used when the patient is permanently unconscious is biologically reductionistic. That is, the brain-death criterion attaches primary significance to the functional connection of the brainstem, lungs and heart, and not the conscious capacity that that functioning supports. Unless the concept of human death reflects what is essentially significant to the nature of the human being as a person—conscious awareness—it fails to provide a community with an effective moral divide between the living and the dead.

Questioning the Higher-Brain Formulation

Critics of the higher-brain formulation object that the emphasis on consciousness and person-centered functions of the human being places us on a slippery slope that will eventually lead to a broadening of the definition of death to include those who are severely demented or only marginally or intermittently conscious. They argue further that the adoption of a higher-brain basis for determining death would require us to bury spontaneously respiring (and heart beating) cadavers.

These arguments have little to recommend them. First there is a bright and empirically demonstrable line between those who are in a permanent vegetative state (recall the cases of Karen Quinlan, Paul Brophy, Nancy Cruzan, and others) and those who retain the capacity for higher-brain functioning. The slippery slope worry that we would begin to declare conscious patients dead is unfounded. By contrast the slippery slope objection is telling in relation to the whole-brain-death criterion, which does not in fact measure the death of the brain in its entirety. Whole-brain-death adherents have failed to provide criteria for identifying some brain functions as residual and insignificant, so the opportunity for the unprincipled enlargement of the residual functioning category is ever present.

Finally, for aesthetic reasons as well as reasons of respect, society does not permit certain forms of treatment of the dead. There is no reason to think that a consciousnessbased concept of death would lead to the abandonment of long-held understandings of the dignified and appropriate treatment of the body of the deceased person. One would not bury a spontaneously breathing body any more than one would bury a brain-dead body still attached to a respirator. A higher-brain advocate might argue that stopping residual heart and lung function would be as morally appropriate in the case of a permanently unconscious patient as the discontinuation of the ventilator is in the case of a brain-dead patient.

Questioning the Irreversibility of Death

Still laboring under the power of the Dead Donor Rule and a concern to increase the supply of transplantable organs, a 1990s effort to update the clinical tests associated with the cardiac-centered traditional criteria occurred. Several transplant centers began the practice, in the case of a dying patient who had consented in advance to be an organ donor and to forego both life-sustaining treatment and resuscitative efforts, of declaring death two minutes after the patient's last heartbeat, as the measure of the patient's irreversible loss of cardiopulmonary function. This approach to assessing the irreversible loss of cardiopulmonary function challenged people to accept a particular and unprecedented definition of irreversibility in relation to declaring patients dead. Both common understanding and the Uniform Determination of Death Act were understood to require irreversibility of functional loss in the stronger sense that the functional loss could in no way be recovered or restored.

If death is declared two minutes after the loss of cardiopulmonary function, when, conceivably, the heart could resume functioning on its own (auto-resuscitation) or resuscitation could successfully restart the heart, in what sense is the loss of function irreversible? It appears that irreversibility is only a function of a morally valid decision on the part of a patient or perhaps a surrogate to forego resuscitation. Is this change in the association of death with the irreversible loss of function ethically acceptable?

The interest in declaring death as close to the cessation of cardiopulmonary function as possible arises from the need to remove organs before warm ischemia destroys their viability for transplantation. But what sense of the concept of irreversibility should be required to assess a loss of critical function sufficient to ground a declaration of death? In the weak moral sense indicated above, two minutes after the last heartbeat when resuscitation has been refused? In the relatively stronger sense that auto-resuscitation of the heart has become physiologically impossible? Or in the strongest sense, that the heart cannot be restarted by any means?

While many hold the religious belief that the self survives the death of the body, the commonly held view is that the death of the body is a finished, non-reversible condition. The Uniform Determination of Death Act requires that the cessation of brain function be irreversible in the sense that all function throughout the entire brain is permanently absent, or it requires that cardiopulmonary function has ceased in the sense that the patient can never again exhibit respiration or heartbeat. Clearly, then, because it entails a novel understanding of the conceptual connections between death and irreversibility, the variation in the application of the cardiopulmonary criterion adopted by many transplant centers after 1992 requires philosophical justification.

In addition this new strategy for determining death raises interesting issues about the overall consistency of alternative approaches to determining death. It has always been the case that a patient declared brain-dead could not be declared dead using the traditional criteria, since the respirator was maintaining lung and heart functions. Those functions were effectively ruled out as signs of life. Yet after only two minutes of cardiac cessation, the patient is arguably not yet brain-dead, raising a question: Is the non-heart beating donor (NHBD) whose heart has stopped for two minutes but whose brain retains some functional capacity really dead? In order to be declared dead, should a patient be required to fulfill at least one but not necessarily all extant criteria and their associated clinical tests for the determination of death? Which way of being determined dead is more morally appropriate when surgery to procure organs is to be undertaken?

In sum, the definition-of-death debate goes on. The deep and disturbing irony in this debate surrounds the disagreement among ethicists as to whether the public should be informed about the degree of dissension on the conceptual, clinical, and policy issues central to the debate. Despite the rather stable practice in the United States of using the brain-death criterion to determine death, the definition-of-death debate is at loggerheads. The situation is such that, some have argued, parties to the debate should share none of this dissension with the public lest they disturb the acceptance of the brain-death criterion and the improved access to transplantable organs it allows over the traditional criteria for determining death. Others argue that every question in this debate, including the question of the kind of irreversibility that should ground the determination of deaths, is still an open question, and that the public should be informed and polled for its views. Yet others have suggested that one of the prime movers in the definitional debate, the Dead Donor Rule, should be rethought, and the practices of declaring death, discontinuing life-sustaining treatment, and removing organs for transplantation should be decided independently of one another.

Public Policy for a Diverse Society

The public policy issue in the definition-of-death debate arises because there are diverse, deeply held understandings concerning the nature of the human and human death. Because these views derive from fundamental philosophical, religious, or cultural perspectives, should people have any say in the concept and criteria for determining death that might be applied to them? If, for example, a person is aware that being declared dead under the brain-death criterion contradicts his or her religiously-based understanding of death, should that person be allowed to conscientiously object to the use of this criterion? Some argue that toleration in such matters is imperative because of the extraordinary damage done to persons by ignoring and disrespecting their foundational understandings. They claim that individuals should be allowed to use a conscience clause to express their wishes. Others claim that diversity on such a fundamental matter as the determination of when someone has died can only lead to social and legal instability. The next section explores the diverse philosophical perspectives that might be taken on human death. On this basis, the reader must decide on the importance and practicality of a conscience clause for those who disagree with the concept and criteria for determining death that have become established U.S. policy.

Philosophical and Theological Perspectives: Preliminaries

Human groups engage in different behaviors upon the death of one of their members. They do so because they have different understandings of the nature of the individual self and, consequently, of the death of the self. Yet every human society needs a way of determining when one of its members has died, when the quantum change in the self that both requires and justifies death behaviors has occurred, when the preparation of the bodily remainder of the individual for removal from the sphere of communal interaction both may and must begin.

This need for a line of demarcation between life and death suggests that for societal purposes, the death of an individual must be a determinable event. There has been debate, however, about whether death is an event or a process. Those engaged in this debate have appealed to the biological phenomena associated with the shutting down of a living organism. Some of them have argued that death is a discrete biological event; others, that it is a biological process. In fact, neither biological claim settles the philosophical question of whether death is an event or a process. Different communities decide whether to view the biological phenomena associated with death as an event or a process. For societal/cultural reasons, it is essential that some terminus be recognized.

Death is a biological process that poses a decisional dilemma because, arguably, the biological shutdown of the organism is not complete until putrefaction has occurred. Human communities have a need to decide when, in the course of the process of biological shutdown, the individual should be declared dead; they must decide which functions are so essentially significant to human life that their permanent cessation is death. For a variety of reasons, death has come to be associated with the permanent cessation of functions considered to be vital to the organism rather than with the end of all biological functioning in the organism. These vital functions play a pervasive and obvious role in the functioning of the organism as a whole, and so their use as lines of demarcation is reasonable. With their cessation, the most valued features of human life cease forever, and it is reasonable to regard that as the event of a person's death. Advances in medical technology, permitting the mechanical maintenance of cardiac and respiratory functions in the absence of consciousness, force us to evaluate the functions we have always associated with life, and to choose which of them are essentially significant to human life or so valuable to us that their permanent loss constitutes death. The ancient and (until the late-twentieth century) reasonable assumption has been that death is an irreversible condition, so it should not be declared until the essentially significant functions have irreversibly ceased.

In pretechnological cultures, humans undoubtedly drew on the functional commonalities between other animal species and themselves to decide that the flow of blood and breathing were essentially significant functions. When either of these functions stopped, no other important functions continued, and predictable changes to the body ensued. Since it was beyond human power to alter this course of events, the permanent cessation of heart and lung functioning became the criterion used to determine that someone had died.

This choice has clearly stood the test of time. Often referred to as the traditional cardio-pulmonary criteria, there is certainly no reason to impugn this choice for a society lacking the technological life-support interventions characteristic of modern medicine. But it is important to see that even in a pretechnological culture, the choice of the traditional cardiopulmonary criteria was a choice, an imposition of values on biological data. It was a choice based on a decision concerning significant function, that is, a decision concerning what is so essentially significant to the nature of the human being that its irreversible cessation constitutes human death. Such a decision is informed by fundamental beliefs and values that are philosophical/theological/cultural in nature.

If a technologically advanced culture is to update its criteria for declaring death, it must reach to the level that informs such a decision. Deciding the normative issue concerning the essentially significant characteristic of a human being is impossible without an ontological account of the nature of the human being. The assumptions and beliefs we hold on these matters form the combined philosophical/theological/cultural basis upon which we dissect the biological data and eventually bisect them into life and death.

Such assumptions and beliefs constitute the most fundamental understandings and function as the often unseen frame through which people view, assess, and manipulate reality. As a rule, this frame is inculcated through the broad range of processes that a social group uses to shape its members. The frame itself consists of assumptions and beliefs that are used to organize and interpret experience. They are deeply yet pragmatically held beliefs that may be adjusted, adapted, discarded, or transformed when they cause individual or social confusion, cease to be useful, or no longer make sense. Arguably, changes in the capacity to resuscitate and support the human body in the absence of consciousness have brought that society to such a point of non-sense. To respond fully to this crisis, people must consider the various philosophical and theological perspectives in their culture that inform thinking about human nature and death.

Representative Philosophical and Theological Perspectives

Death is the word we use to signify the end of life as we know it. As stated above, individuals and groups hold different understandings of the existence and the death of the self. These understandings are the background for the nuts and bolts medical decision that a person has died, when death should be declared, and what ought/ought not be done to and with the physical remains of the person who has died.

As individuals and as cultural groups, humans differ in their most basic assumptions and beliefs about human death. For some the death of the body marks the absolute end of the self; for others it is a transition to another form of existence for the continuously existing self. This transition may be to continued life in either a material or an immaterial form. Despite these differences, every human community needs a way of determining when one of its members has died, a necessary and sufficient condition for considering the body as the remainder of the individual that can now be treated in ways that would have been inappropriate or immoral before, and for preparing the body for removal from the communal setting. Different philosophical and theological perspectives on the nature of death, the individual self, and the death of the self will yield different choices of criteria for the determination of death, just as these differing perspectives yield very different death practices or death behaviors. To see why this is the case, various philosophical and theological views of death and the self must be reviewed.

In the Hebrew tradition of the Old Testament, death is considered a punishment for the sin of disobedience. It is an absolute punishment. This tradition does not hold a concept of an afterlife following the punishment of death. But it would be misleading to say that this tradition has no conception of immortality, since the communal setting of the individual's experience and life remains the arena of that person's identity and impact, even after the death of the body. Although the conscious life of the person ceases, the person lives on in the collective life, unless he or she lived badly. Thus, immortality is the community's conscious and unconscious memory of the person.

Another view, originating in Platonic philosophy and found in Christian and Orthodox Judaic thought, and in Islam and Hinduism, holds that death is not the cessation of conscious life. The conscious self, often referred to as the soul, survives in a new form, possibly in a new realm. The experience of the self after the death of the body depends on the moral quality of the person's life. The body is the soul's temporary housing, and the soul's journey is toward the good, or God, or existence as pure rational spirit without bodily distractions. Thus, death is the disconnection of the spiritual element of the self (mind, soul, spirit) from the physical or bodily aspect of the self.

Traditions believing in eternal life differ in their view of the soul and its relationship to the body. This has implications for the criteria that might be used to determine death, as well as for the appropriate treatment of the body after death. The soul is viewed by some as separate and capable of migrating or moving into different bodies as it journeys toward eternal life. The Christian tradition, by contrast, posits the self as an eternally existing entity created by God. The death of the body is just that—the person continues, with body transformed, either punished in hell for living badly or rewarded in heaven for having faith and living righteously. These diverse views have a common belief: Everyone survives death in some way. This may influence the understanding of what constitutes the death of the body as well as of what ought/ought not to be done to the body of the person who has died. For some traditions, certain bodily functions are indicative of life, whether or not those functions are mechanically supported, and damage to the body is damage to the self.

In contrast to these theological conceptions of death and the self, three philosophical perspectives, secular in that they hold materialist views of the self, figure in Western thought: the Epicurean, the Stoic, and the existential. A materialist view of the self considers the human to be an entirely physical or material entity, with no soul or immaterial aspect. The Epicurean view of the self holds that humans are fully material beings without souls. The goal of life is to live it well as it is and not to fear death since death is the end of experience, not something one experiences. Therefore, there is no eternal life for souls; the body dies and disintegrates back into the material nature from which it sprang. The death of the body marks the end of consciousness, and thus the death of the self. A materialist holding a view such as this could conclude that the cessation of consciousness itself should be considered death, whether or not the body continues to function in an integrated manner.

The Stoic view acknowledges death as the absolute end of the conscious self but directs persons to have courage about its inevitability and to resign to it creatively. This creative resignation is achieved by focusing on the inevitability of death in such a way that one treats every moment of life as a creative opportunity. The necessity of death becomes the active inspiration for the way one lives. Like the Epicurean view, the Stoic conception ties the self to the body; the end of the self to the death of the body. But it is the consciousness supported by the body that is the creative self.

In contrast existential thought believes that the absoluteness of death renders human life absurd and meaningless. The other materialist views of the self saw death as the occasion for meaning in life, not the denial that life has meaning. Rather than infusing meaning into life and inspiring a commitment to striving, existentialism holds that death demonstrates the absurdity of human striving. While individuals may pursue subjective goals and try to realize subjective values during their lives, there are no objective values in relation to which to orient one's striving, and so all striving is ultimately absurd. Since death is the end of the self, there is nothing to prepare for beyond the terms of physical existence and the consciousness it supports.

Without critiquing these theological and philosophical perspectives on death and the self, an inquiry into their diversity is relevant to a discussion of the debate in bioethics about the criteria for determining that a human being has died. The earlier demonstration that the criteria rest on a decision of functional significance, and that a decision of functional significance is philosophically/theologically informed, coupled with this demonstration of philosophical/theological diversity on the fundamental concepts of self and the death of the self, together show that criteria are acceptable only if they are seen to be consistent with an accepted philosophical/theological frame, and that what is acceptable in one frame may be unacceptable in another.

Further, while it might be the case that virtually every tradition has agreed on the appropriateness of the traditional heart and lung criteria for declaring death, they may do so for vastly different reasons deriving from their specific understanding of death and the self. There may be ways of reconciling virtually every ontological view to the use of the traditional criteria but not to the use of consciousnesscentered criteria like the higher brain-death criterion, or even the brain-death criterion (which appears, to a tradition like Orthodox Judaism, to deny that the still-functioning body is indicative of life, even when the entire brain is dead).

Philosophical and theological commitments relate centrally to society's death practices, including conclusions concerning the acceptability of traditional, and whole-brain, and higher-brain formulations of death. How philosophically and theologically sophisticated has the bioethics debate on the definition of death been, over the years?

The Persistence of the Debate

Why do arguments concerning the definition and criteria of death persist? The debate has been intractable since 1968. One important reason is that the concepts of self and death that inform the various positions in the debate are based on fundamental beliefs and values that suggest that they will remain irreconcilably different. While it is true that persons holding different philosophical/theological/cultural premises may assent to the use of the same criteria for determining death, they may well do so for very different reasons. Because of this, it is reasonable to seek and adopt a broadly acceptable societal standard for the determination of death.

For example, the several materialist views of the self that were examined earlier suggest a consciousness-centered concept of self and death that further recommends a higher-brain formulation of death. But equally, the prevailing Judeo-Christian understandings of the self and death—that of death as the dissociation of consciousness from the body, the end of embodied consciousness—are also compatible with a higher-brain formulation of death.

Some traditions, like Orthodox Judaism, and certain Japanese and Native American perspectives, resist the use of the brain-death criterion because they understand death to be a complete stoppage of the vital functions of the body. The self is not departed until such stoppage has occurred. Such groups will be uncomfortable with the use of the brain-death criterion because it permits the determination of death while vital functions continue. This kind of philosophical/theological difference in perspective on the human self, intimately linked to a person's religious and cultural identity, raises serious questions about how a pluralistic culture should deal with deeply held differences in designing a policy for the determination of death.

Given that there are a finite number of possible perspectives on the human person and on human death, and given the rootedness of these perspectives in conscientiously held philosophical and religious views and cultural identities, public policy on the determination of death in a complex and diverse culture could well manage to service conscience through the addition of a conscience clause in a determinationof-death statute. Similar to and perhaps in conjunction with a living will, a person could execute a conscience-clause exclusion to the statute's implicit concept of death. For instance, an Orthodox Jew could direct that death be determined using the traditional criteria alone, and also indicate personal preferences concerning the use of life-sustaining treatment such as ventilator support in the situation of brain death.

The fact that a conscience clause would permit some to reject the use of the brain-death criterion need not hinder the law from specifying punishable harms against others on the basis of considerations additional to whether death was caused. The exotic life-sustaining technologies now available have already generated arguments concerning whether the person who causes someone to be brain-dead or the person who turns off the ventilator on that brain-dead patient causes the patient's death.

Life-sustaining technologies as well as the alternative concepts of death underscore the need for more precise legal classifications of punishable harms to persons. Such a classification should recognize permanent loss of consciousness as a harm punishable to the same extent as permanent stoppage of the heart and lungs.

The self can be thought of in a variety of ways: as an entirely material entity, as an essentially mental entity, and as a combined physical/mental duality. In contemporary language, the human being may be thought of as a physical organism, as an embodied consciousness (which we often call person), or as an amalgam of the two. As one examines the definition-of-death debate, one sees that fundamentally different ontological perspectives on the human have been taken.

Once such an ontological perspective on the human being has been chosen, a further decision as to what is essentially significant to the nature of the human being can be made. When a conclusion is reached as to which function is essentially significant to the human being, the potential exists for settling on the criterion (or criteria) for determining death. To the extent that these two steps of philosophical analysis support attention to the brain as the locus of the relevant human functions, views may divide on whether a whole-brain or a higher-brain formulation of death is adopted.

A complex entity that manifests its aliveness in a variety of ways has the potential to engender dispute about the ontological perspective that should be taken toward it, as well as about what is essentially significant to it. Hence, there may be no agreement on the definition of death that should be applied. Instead, the greatest achievement may be to articulate a policy on the determination of death that honors a plurality of philosophical/theological perspectives.

karen g. gervais

SEE ALSO: African Religions; Bioethics, African-American Perspectives; Buddhism, Bioethics in; Christianity, Bioethics in; Eastern Orthodox Christianity, Bioethics in; Embryo and Fetus: Religious Perspectives; Hinduism, Bioethics in; Infanticide; Islam, Bioethics in; Life Sustaining Treatment and Euthanasia; Moral Status; Right to Die, Policy and Law;Utilitarianism and Bioethics; and other Death, Definition and Determination of subentries

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