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October 25, 2022

While the definition of death is being fiercely debated in the medical literature, the public has been kept in the dark.  Or is the public being intentionally misled?  As bioethicist David Rodriguez-Arias writes, “[t]he history of death determination in the context of organ donation can be described as an indoctrinating attempt to settle a moral controversy.”

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The definition of life as a body-soul union helps us when it comes to defining death.  Most religions of the world have some form of this belief.  It is different from the Renaissance view that we are our brains, brains who operate and direct their bodies like machines.  Death occurs when the spirit departs from the body, causing the body to lose the complex integration of all its systems, leading to the disintegration of those systems.  In biological terms, death is the loss of integration of the organism as a whole.  At death, the body stops maintaining itself with heart rate, breathing, blood pressure, temperature control, digestion, and waste management and becomes a corpse.

This definition of death prevailed until 1968, when the ad hoc committee of Harvard Medical School redefined death to include people in an “irreversible coma” as dead.  They did this by decree; there were no new studies, tests, or evidence that comatose people were actually dead.  The committee listed only pragmatic and utilitarian reasons for this new definition.  Its chairman, Dr. Beecher, said not only that it is a waste of resources to keep the hopelessly unconscious patient on the ventilator, but also that society cannot “continue to condone the discard of [their] tissues and organs … when they could be used to restore the hopelessly ill but otherwise salvageable individual.”

In 1981, the ad hoc committee’s findings were signed into law as the Uniform Determination of Death Act.  This act, known as the UDDA, allowed people with beating hearts to be declared legally dead and taken for organ-harvesting while still biologically alive.

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The current UDDA reads as follows:

An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.  A determination of death must be made in accordance with accepted medical standards.

Since the UDDA was passed into law, much debate has taken place as to whether the standards have been used to bypass the Dead Donor Rule, which states that organ donors cannot be killed to obtain their organs.  Doctors Miller, Truog, and Brock wrote in the Journal of Medicine and Philosophy:

Nevertheless, scholars have argued cogently that donors of vital organs, including those diagnosed as ‘brain dead’ and those declared dead according to cardiopulmonary criteria, are not in fact dead at the time that vital organs are being procured[.] … This leaves the current practice of organ donation based on the ‘moral fiction’ that donors are dead when vital organs are procured.

“In response to a number of recent lawsuits related to brain death determination,” the American Academy of Neurology has proposed a revision to the UDDA, the RUDDA.  The revisions to the UDDA are not inconsequential.  The first change would seek to replace the term irreversible in the standards with the term permanent.  At first glance, this may not seem like much of a change, but the definitions make a difference.  “Irreversible” is commonly held to mean “not capable of being reversed.”  The term permanent is being offered as meaning that “no attempt will be made to reverse the situation.”  So, because doctors are not going to attempt to correct the patient’s problem, it now becomes “permanent.”  Dr. Ari Joffe clarifies this for us: “[i]s a drowning man dead because no one will swim out to save him?  Or is he merely going to die?”  The term “permanent” is being inserted to allow patients whose prognosis is death to be called dead.

The second change would narrow down the definition of brain death from “the entire brain” to just selected functions of the brain stem that can easily be tested at the bedside.  This change recognizes that current practice does not test all functions of the entire brain, since most people diagnosed as brain-dead still have a functioning hypothalamus, a part of the brain.  Many also still have electrical activity on electroencephalogram (EEG), which is one of the reasons that EEG testing as a requirement for a brain death diagnosis was dropped in the 1970s.