Despite its familiarity and widespread acceptance, the concept of "brain death" remains incoherent in theory and confused in practice. Moreover, the only purpose served by the concept is to facilitate the procurement of transplantable organs. By abandoning the concept of brain death and adopting different criteria for organ procurement, we may be able to increase both the supply of transplantable organs and clarity in our understanding of death.
Over the past several decades, the concept of brain death has become well entrenched within the practice of medicine. At a practical level, this concept has been successful in delineating widely accepted ethical and legal boundaries for the procurement of vital organs for transplantation. Despite this success, however, there have been persistent concerns over whether the concept is theoretically coherent and internally consistent. Indeed, some have concluded that the concept is fundamentally flawed, and that it represents only a "superficial and fragile consensus." In this analysis I will identify the sources of these inconsistencies, and suggest that the best resolution to these issues may be to abandon the concept of brain death altogether.
Definitions, Concepts, and Tests
In its seminal work "Defining Death," the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research articulated a formulation of brain death that has come to be known as the "whole-brain standard." In the Uniform Determination of Death Act, the President's Commission specified two criteria for determining death: (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brainstem."
Neurologist James Bernat has been influential in defending and refining this standard. Along with others, he has recognized that analysis of the concept of brain death must begin by differentiating between three distinct levels. At the most general level, the concept must involve a definition. Next, criteria must be specified to determine when the definition has been fulfilled. Finally, tests must be available for evaluating whether the criteria have been satisfied.4 As clarified by Bernat and colleagues, therefore, the concept of death under the whole-brain formulation can be outlined as follows:
Definition of Death: The "permanent
cessation of functioning of
the organism as a whole."
Criterion for Death: The "permanent
cessation of functioning of
the entire brain."
Tests for death: Two distinct sets of
tests are available and acceptable
for determining that the
criterion is fulfilled:
(1) The cardiorespiratory standard
is the traditional approach
for determining death and relies
upon documenting the pro-longed
absence of circulation or
respiration. These tests fulfill the
criterion, according to Bernat,
since the prolonged absence of
these vital signs is diagnostic for
the permanent loss of all brain
(2) The neurological standard
consists of a battery of tests and
procedures, including establishment
of an etiology sufficient
to account for the loss of all brain
functions, diagnosing the presence
of coma, documenting apnea
and the absence of brainstem
reflexes, excluding reversible
conditions, and showing the
persistence of these findings over
a sufficient period of time.
Critique of the Current Formulation of Brain Death
Is this a coherent account of the concept of brain death? To answer this question, one must determine whether each level of analysis is consistent with the others. …