Episode post here. Transcription by Prexie Magallanes.
Matt Teichman:
Hello and welcome to Elucidations, an
unexpected philosophy podcast. I’m Matt Teichman, and with me today
are Lainie Ross, Carolyn and Matthew Bucksbaum Professor of Clinical
Ethics at University of Chicago Medicine, and Christos Lazaridis,
Associate Professor of Neurology at University of Chicago
Medicine. They are here to talk about defining death. Lainie and
Christos, welcome.
Lainie Ross:
Thank you.
Christos Lazaridis:
Thank you, Matt, for having us.
Matt Teichman:
And welcome back to Christos.
Christos Lazaridis:
Thank you.
Matt Teichman:
So in part one of this episode with just
Christos, we talked about brain death. I wonder if we could get back
into the headspace by doing a quick little 101 on: what is brain
death? What are we talking about?
Christos Lazaridis:
Yes—I was thinking we could just do a
quick recap and talk about how we determine death in the hospital. We
follow the UDDA, which is the Uniform Determination of Death
Act. That’s
the law about how to determine death; and this can be done in two
ways. There are two sets of criteria that diagnose or determine the
same event, which is death: either by the irreversible cessation of
circulatory and respiratory functions, or the irreversible cessation
of all functions of the brain and the brainstem—the so-called whole
brain concept.
Matt Teichman:
Does one of those determine the other? If you
lose circulation and respiration, doesn’t that also cut off your
consciousness? Or are they not causally connected?
Christos Lazaridis:
It does, and they are causally
connected. However, this is not necessarily the rationale. (We can
talk about this later.) If anyone meets either set of criteria, then
they are determined to be dead.
Matt Teichman:
The topic of this episode is defining death,
and you might think we just did it. You might think: well, that’s the
definition; we can all go home. But one of the things that you both
have worked on is the fact that in many cases, there seems to be a bit
of wiggle room in exactly what criterion you’re going to use to
determine whether someone has undergone this process of death. What’s
the range of options there?
Lainie Ross:
Under current law—under the current
UDDA—there are the two options. There is the option of being
declared dead by permanent loss of circulatory and respiratory
function, and the permanent loss of the whole brain. There are other
options that one can envision, but under the law, those are the only
two.
Christos Lazaridis:
Just to follow up on what Lainie said,
there is a third approach, called higher brain death. By the way,
it’s not in law in any jurisdiction; it’s more of a scholarly
proposal: it’s the idea that not the entire brain is necessary for
someone to be determined dead. I think that relates more to the death
of a person, or the cessation of personhood. People have talked
about the higher brain, in the sense that that’s where consciousness
is housed; so the higher brain translates to the permanent or
irreversible (by the way, there is debate about permanence and
irreversibility), but let’s say the permanent loss of the capacity
of consciousness, that equates to death. That’s the higher brain
position.
Matt Teichman:
And is that different from what we just talked
about, with the UDDA? Or is that just another way to think of
irreversible cessation of consciousness?
Lainie Ross:
This goes back to your question about: does
death by circulatory lead to death by neurologic, or vice versa, and
this third one. The fact is that there are two ways to determine
death, under the law. This third method would be not currently
accepted under any law, neither in the United States or anywhere in
the world, but because there are two different ways to determine it,
we also have to acknowledge that we haven’t actually given a pure
definition of death. And so, the fact is that these two different ways
to determine it are social constructs. They are criteria that have
been determined by health care providers—there have been many other
stakeholders involved—but in the end, they’re social constructs.
What Christos has proposed is this third method, which would be death of higher brain, or a loss of the capacity for consciousness. So that’s a third construct. You can envision that the reason that death can be determined by circulatory criteria is that it eventually will lead to death of the entire brain. If you have death of the whole brain, I would argue it’s in that direction of association. If you lost the entire brain, you can continue to maintain cardiocirculatory. But eventually, once you’ve lost cardiocirculatory, you will lose entire brain function. Unless, of course, we do certain interventions to restore your cardiocirculatory.
Matt Teichman:
Right. So the idea here is that, left to your
own devices, without the aid of life support technology, the one kind
of death would lead to the other kind of death.
Lainie Ross:
Correct. It’s an interesting issue about how
long it might take. And that would have important implications, for
example, for organ transplantation.
Matt Teichman:
I’m still kind of wondering, what is the
difference between deciding somebody is dead based on neurological
criteria and deciding that somebody is dead based on the loss of
higher brain function? What would be the distinction there, between
the patients in each state?
Christos Lazaridis:
Let me describe how we determine death by
neurologic criteria currently, which is, based on the whole brain
concept. The idea here is that we test clinical functions of the
different levels of the brain. We have someone, a patient, who is in
a coma, that suggests loss of higher cortical functions, and then we
test clinical functions of the brainstem. This is done in a
standardized way. We check the different cranial nerves, and
eventually, we test the different sections of the brainstem: the
midbrain, the pons, and the medulla.
To complete the test, one needs to perform an apnea test, which tests the respiratory centers in the medulla. It involves disconnecting a patient from the ventilator, providing oxygen, but not ventilating them. There’s standardized way that this is done. And at the end of the test, if someone does not take a breath spontaneously, then we determine that the apnea test shows that there is no medullary function.
Matt Teichman:
These are all functions of the brain that
don’t have to do with, thinking, but rather have to do with
automatically regulating the body systems and keeping them going?
Lainie Ross:
Yes. For homeostasis and bodily integration,
absolutely.
Christos Lazaridis:
Where if you would talk about higher
brain or consciousness-based, then testing, for example, apnea, or
testing cranial nerve reflexes in the brainstem may not be necessary
because you may have—
Matt Teichman:
—because we still couldn’t tell if the
person can hear you, or they know you’re there, or anything that we
associate with conscious thought.
Christos Lazaridis:
Right. You can be unconscious without
losing brainstem functions.
Matt Teichman:
Absolutely. Every night I breathe while I
sleep.
Christos Lazaridis:
Well, and that’s why this becomes very
quickly complicated. Part of the problem here is that, with current
means of technology, it’s almost impossible to determine that the
capacity for consciousness has irreversibly been lost. We thought we
could detect that, but it turns out it’s very easy to be mistaken. So
that’s a—
Matt Teichman:
—how did we think we could detect it? And
what was wrong about that? That’s fascinating.
Christos Lazaridis:
A typical case, we used to have this
syndrome—in fact, it still exists—the so-called vegetative state,
right? The idea that you can have somebody who has sleep-wake cycles,
they have intact brain stem function, but they do not have any
consciousness. One of the main problems is that detecting the state
was through behavioral means. It turns out that when you use other
means—for example, electrophysiology, or advanced brain
imaging—you see activations of brain parts that, although there is
no behavioral output, they would still count as potentially signs of
consciousness.
Matt Teichman:
So it seems like there’s somebody still in
there, even though they can’t really move or do anything.
Christos Lazaridis:
Correct.
Lainie Ross:
One thing about that is that, particularly after
a traumatic injury, the person may have no signs of consciousness for
weeks, months, or even years, and then they start to develop certain
signs. This gets into the whole question of: is it truly permanent?
At what point can you say that somebody is permanently unconscious?
Matt Teichman:
Is there a world record of that? Has anybody
been in a coma for 75 years, or some really alarming amount of time?
(I picked a high number.)
Christos Lazaridis:
There are cases of people who may have
been comatose for over a decade.
Lainie Ross:
Yeah.
Matt Teichman:
Wow. And they came back against all odds,
against everybody’s prediction?
Christos Lazaridis:
They start developing signs of minimal
consciousness. Often you will hear families that may detect signs of
some purposeful movements—for example, eye movements. But these
require spending a lot of time with the individual, and usually
clinicians—we only have limited time and exposure to them. So it’s
difficult by behavior alone to objectively detect signs of purposeful
activity, or consciousness.
Lainie Ross:
There have been certain individuals given
certain drugs who have been able to, in a sense, have a short period
of awareness and wakefulness. All very recent, and creating a real
challenge for those who want to determine death by upper brain, to be
able to really say that it’s permanent. Death needs to be a concept
that’s permanent.
Matt Teichman:
You can imagine someone thinking, maybe if
it’s about a family member they love: no, no, let’s keep them, and
wait for the drugs that would be necessary to bring them back to be
invented, etc. You can imagine people going through these emotional
machinations.
Christos Lazaridis:
This is definitely part of it. You know,
there’s a real epistemologic problem in terms of how could we know
that someone has permanently lost the capacity to be conscious. As I
said earlier, with current technologic means, this is really close to
impossible. The other issue is that we don’t really know very well how
consciousness arises. And so, we’re talking about higher brain, but
at the same time, there are theories that put the brain stem right at
the center of consciousness generation. So talking about just the
higher brain may actually be misleading.
Matt Teichman:
Do you think it’s likely that future
developments in neuroscience, brain imaging, etc. will force us to
change our definitions of what counts as dead according to these
criteria? How likely do you think that is?
Lainie Ross:
It’s an interesting question. Right now, when we
determine death, we consider it a clinical test, both for circulatory
death, as well as death by neurological criteria. One could imagine a
change that would say that it’s required for the determination of
death to include some ancillary testing, whether an EEG, or looking at
blood flow, or something of that sort. If that were to become the law
of the land, that would really change how we determine death.
Matt Teichman:
So we’ve established two things. One: it’s
morally important to try to be clear about whether a person is dead or
not. On the other hand, it’s really hard to do it, and we don’t
necessarily always have the medical technology to be able to do it. So
what do we do, faced with those two things? Are we just in a dilemma,
or is there a way through?
Lainie Ross:
If I understand the question, what you’re asking
is: given that there are different criteria that are being used, how
then do we know that somebody is dead? Because that leads to changes
in the way we treat the body. We treat people who are living one way;
once you’re declared dead, it changes how you are treated. It also
changes your relationship with your family member. You go from being a
spouse to a widow, and things of that sort.
So it’s really important to know at what moment you are alive, and at the next moment when you’re declared dead. To the extent that we have these two determinations, it already tells us, in that I’ve suggested that the permanent loss of circulatory and respiratory function will eventually lead to death of the entire brain, including the brain stem. Suggesting it’s not purely a biological test that we’re talking about, in this determination: that some degree of it is value laden. Once you start realizing, then, that our determinations of death involve values, we can say that there’s a social construct of death.
And if we accept that, then one question comes: why just these two options? These are the two that are enshrined in the UDDA, but it doesn’t mean that these are the only two. There are a group of people—and I include myself in that group—who would love to be declared dead by higher neurological function. Unfortunately, right now we don’t have a great set of tests that would ensure permanent death by higher brain function, so I understand that won’t happen. At least not right now. It’s also the case I might not be ready to die right now. But—
Matt Teichman:
—so maybe the wish is: well, if there’s a
good test by the time I pass away, I would prefer that criterion to be
used.
Lainie Ross:
Or if there were a good test at the time
where I were to have lost permanent upper consciousness—
Matt Teichman:
—right. Exactly.
Lainie Ross:
Then I would like to be determined to be dead by
those criteria, yes. Now, it’s really important that that’s the type
of choice that I as a first person decide. I think we can get into a
lot of trouble if we allow family members to just say: oh, this is the
way we’re going to determine death for this person. Because sometimes
there might not be the purest of motives.
Matt Teichman:
Right.
Lainie Ross:
It would be really important if we were going to
make that one of the options for how death is determined. That we
really were to educate the public at large, so that people who wanted
that determination could make that while living, and make their wishes
clearly known.
Matt Teichman:
And it seems like if you pick the irreversible
loss of higher brain function criterion, you’re making it easier to
count yourself as dead, than if you pick the circulatory
criterion. That could be something that you and your family members
disagree about: you might disagree about how easy it should be for you
to count as dead.
Lainie Ross:
Yes.
Christos Lazaridis:
Can I add something?
Matt Teichman:
Please.
Christos Lazaridis:
I just want to go back: I don’t want us
to create the misperception that current criteria are loose, or that
they are not well defined. There are standardized ways to determine
death by circulatory criteria, and there is a standardized way to
determine death by neurologic criteria. There are guidelines for
both, and determinations, for obvious reasons, have to follow those
guidelines.
Now, there are challenges. For example, in terms of the neurologic criteria, one challenge that’s out there, and has led to the United Law Commission looking at revising the UDDA, is the current tests we use: do they really test the whole brain? That is a debate that’s an open question. And several people argue convincingly that we actually do not test all of the functions of the entire brain. So that’s somewhere where the language of the UDDA could potentially be modified.
On the other hand, even for circulatory criteria—and I’m just going to give you an example where there is an open challenge that has to do with circulatory criteria—there is something that we call donation after the circulatory determination of death. There, death is declared after five minutes of no circulatory function: for example, five minutes of cardiac standstill. And if there is no activity in the heart within these five minutes, then death is declared at that point. So one challenge that has come up is: is five minutes enough? Why five minutes? But these are side challenges to these sets of criteria. The criteria are there, they’re standardized, and they are implemented hundreds of times, or thousands of times, every day.
Matt Teichman:
In your minds, is the question about whether
to count someone as dead the same question or a different question
than the practical question: am I going to withdraw life support or
not?
Lainie Ross:
Well, they’re very distinct issues. You can
decide to withdraw life support because, for example, I have an
advance directive that says that I don’t want you to intubate, or that
I didn’t want to be intubated if I’m already intubated. You might want
to refuse life-sustaining treatment, for example, if you were dying of
other causes and this would just prolong the dying process. So there
are reasons why withdrawal is actually very separate.
Now, once a person is declared dead by neurological criteria, then the question is: what do you do with an individual who’s now declared dead but is still on a ventilator? Still having circulation, despite the fact that the individual is dead. There might be a decision about withdrawal of the ventilator after death has already been declared. Clearly, to be dead by circulatory and respiratory function, you would already have had to have the ventilator withdrawn, because otherwise you would still be oxygenating and ventilating, even though it was being helped by mechanical means.
So they’re really very separate. It becomes important in the area—just about respecting the individual’s choice about withdrawal of life-sustaining treatment—but it also becomes important in the issue of: when is someone declared dead, so that their organs could be procured for transplantation.
Matt Teichman:
Right. So I guess is what we should say about
that is that in certain respects, it can be a similar type of question
about when to do it, but there are many cases in which the question
comes up where the person is clearly not dead. I guess that’s what we
should say about that.
Lainie Ross:
Even if you’re not dead, in fact, particularly
when you’re not dead, if you have an advance directive that says you
would not want to be resuscitated, or that you would not want to be
maintained on life support, you would have the right to have those
therapies withdrawn. More problematic is: what if you’re declared
dead by neurological criteria, but your family wants to keep your body
perfused—the oxygen perfused—so that you look warm and you look
like you’re just sleeping, even though you’ve now been declared dead.
Matt Teichman:
Yeah, let’s get back into that. I’m intrigued
by what you said earlier: namely, that it should be your decision,
rather than your family’s decision, as the patient. Maybe we could
talk about why that is. I can certainly think of a lot of friends of
mine who would think: no, it should be the family’s decision, because
they’re the ones who are going to have to live with the loss of the
person.
Lainie Ross:
Let me clarify. I agree that families are the
ones who have to live with the outcomes. My feeling is that we have
these two ways to determine death, and those are the standard
ways. Once you start talking about determining death by higher brain
function, that’s an outlier, and it’s at that point where it really
should be the individual choosing and not the family.
You could say that’s the more liberal end. On the more conservative end is: the only reason I want to be declared dead is by circulatory. My family might not be willing, for religious reasons, to accept death by neurological criteria. Even if I were to do the full clinical tests, and be able to say that this body now meets the determination of death by neurological criteria, they might want to maintain the ventilator, in order to keep the body perfusing. They may have a belief that as long as there’s breath, there’s life. And so in that case, we probably should not have actually done the whole testing to determine whether the individual is dead by neurological criteria.
Now, there may be good reasons and bad reasons. It may be that the family knows that this individual values somatic existence, but again, because that’s the outlier, since almost all of us in the United States have accepted these two different ways to determine death, I think the outliers should be a first-person consent issue: that I get to say, if I want to go off the standard routine, I should make my wishes well known.
Matt Teichman:
Are there people with the opposite preference
to you, who strongly prefer for the circulatory criterion to be used
on them?
Lainie Ross:
Yeah, I mean, in New Jersey, they currently have
an exception clause. It’s based on religion that you can refuse to be
determined to be dead by neurological criteria if, for example, you’re
an Orthodox Jewish family, but other religions as well. If you give a
religious belief that the definition of life and death is based on
respiration, with good technology, we can keep respiration going for
weeks, months, and years, even if there’s really no brain function.
Christos Lazaridis:
So for example, would it be coherent to
say that I object to circulatory criteria? And that connects back to
what you actually mentioned: the idea that when systemic circulation
ceases, brain circulation ceases as well. That’s why most of the
challenges that make it to the courts have to do with neurologic
criteria. People object to the idea of being determined dead as long
as there’s a heart beating.
Lainie Ross:
You could imagine a court challenge, if a family
was told that the physicians would refuse to perform ECMO (that’s
Extracorporeal Mechanical Oxygenation). Let’s say you had bad trauma
and you want to give the heart and lungs some time to rest, to see if
they’ll be able to function again. If, for whatever reason, this
hospital said we refuse to do it, there might be a case where refusing
to accept cardiocirculatory definitions of death could happen.
Christos Lazaridis:
I think that would fall within conflict
between a family requesting measures that the clinical team would
consider inappropriate, on the basis of neurologic prognosis, for
example.
Lainie Ross:
Which is, again, a value judgment about what is
a quality of life worth living, and gets into the whole notion that
death really does have this value component.
Matt Teichman:
So I guess the idea is: if it’s part of my
religious belief that if I’m breathing, I’m alive, then I might
strongly want the circulatory criterion to hold for me. If, on the
other hand, I think that life involves something crucially more than
just breathing—namely, being able to consciously think, and have
relationships with other people, interact with them in some way,
something like that—maybe that will push me to want the higher brain
criteria to apply to me. Is that the way to think about the decision
calculus here?
Christos Lazaridis:
I would say when restricted to the higher
brain, you would want neurologic criteria and then we can discuss
about what these criteria should be: what are the necessary and
sufficient criteria to determine that someone has died based on brain
function.
Matt Teichman:
But I could imagine that I would want it to be
more than just automatic reflexes, but no ability to interact with
other people, have relationships, etc.
Lainie Ross:
Well, all the definitions with neurologic would
include the permanent loss of consciousness.
Matt Teichman:
Okay. Yeah.
Lainie Ross:
But your point is very well taken, because if I
have permanent loss of consciousness and I can be declared dead by
whole brain criteria, if I have a weak gag and that’s the only test
that I fail—
Matt Teichman:
—yeah, exactly.
Lainie Ross:
Or, I have a test where if you put cotton on my
eyeball, I have a blink reflex, that might be enough to say that I
don’t meet the criteria for the determination of death by neurological
criteria. And I can’t see the moral value of a weak gag, and so
that’s why I would want to be declared dead by just upper brain
criteria.
Matt Teichman:
Right. And a lot of people would agree that
that doesn’t count as living, really, just being able to do those
things.
Lainie Ross:
But I do think it’s important that we have very
specific protocols for the determination of death. We don’t want this
to just be: any criteria are adequate. There has to be a clear
determination, because we treat people and bodies very differently
when they’re living versus when they’re dead. And even if it’s a
social man-made construct, there still has to be a line before which
I’m alive and after which I’m dead, and different behaviors come in
response to that. I go from being a spouse to my husband would then
become a widow. I go from having life insurance to my life insurance
kicking in. Things of that sort. So it’s really important to
understand the determination of when an individual is declared dead.
Matt Teichman:
This is all going to be within a certain
range. You can imagine somebody being ridiculous, like, well, if I
don’t make this amount of money, I might as well not be living. You
know, completely outlandish criteria, we’re going to rule those
out. But within this generally accepted by the medical community to be
reasonable range, we can have a preference.
Lainie Ross:
Correct. And Christos mentioned the Uniform
Commission of Legislatures, the UCL, is considering now whether we
need to make any revisions to the two standard determinations of
death. But again, most of the discussion is based on tweaking these
criteria, not looking for an entirely new determination of death.
Christos Lazaridis:
That’s correct. Like for example, this
whole higher brain conversation—
Lainie Ross:
—it’s not on the table—
Christos Lazaridis:
—does not enter at all, you know, the
current discussion.
Lainie Ross:
And one of the reasons—I’m an observer on that
committee and I haven’t pushed it—is because I acknowledge that we
don’t currently have the ability to determine permanent cessation of
upper brain function. If we could, then I would really hope that we
would be able to modify our Uniform Determination of Death Act.
Matt Teichman:
Fascinating.
Lainie Ross:
But the fact that we want to tweak it, also I
just want to keep emphasizing, goes back to the fact that it’s not
just biological criteria, that death really is a social construct. And
so, while clinicians should have the authority to make determinations
of death, I think it’s a much broader number of stakeholders,
including the public—including the people listening to this
podcast—who need to help define what are, in a sense, the two
different ways that we’re going to determine death.
That may be based on personal holistic values. It may be based on religious and spiritual values. That’s all okay; we should be able to have a system that can accommodate people with widely disparate beliefs. And so, therefore, some who may say: as long as I have breath, I’m alive, we should be able to respect that. Just as we should be able to respect, eventually, the person who says: if I can’t have meaningful relationships and be aware of my surroundings, that I too want to be declared dead.
Christos Lazaridis:
Although I agree with Lainie, I want to
highlight that there’s large disagreement about what kind of question
is, what is death? Should it be treated as a purely biological
question to be answered by facts in biology? Or should it take into
account moral, normative reasons, and issues on how to define death as
policy, as a social construct?
And I would venture to say that at least until now, the view that it’s a question that should take into account moral facts—normative facts—and it’s a construct: it’s a minority view. I think the dominant view has been that this is a biologic question. That’s where the more recent challenges about brain death—I mean, not recent, they’ve been around for some time—have to do with the fact that it doesn’t really match biologic reality. And now, it becomes a deep and interesting question about, for example, you have to define what an organism is. When you turn to biologists and philosophers of biology, they actually give you multiple answers. There’s not one agreed upon definition of what an organism is. And so—
Matt Teichman:
Or what life is, right? The opposite of death.
Christos Lazaridis:
Exactly.
Lainie Ross:
Which is a really important point: the same
debates we’re having about: at what moment do we change from treating
a person as a living person, and now declare them dead, and treat them
as a decedent—we have those same debates about: when does life
begin.
Matt Teichman:
Absolutely.
Lainie Ross:
And while there are processes of being born, and
there are processes of dying, at one moment you have to be born, and
at one moment you have to be dead.
Matt Teichman:
One disanalogy there, I guess, is that
breathing dramatically changes from gestation to birth in a way that
it doesn’t for death. It struck me that that’s maybe a difference
between those two.
Lainie Ross:
You can view the placenta as the ECMO of the
fetus.
Matt Teichman:
Exactly.
Lainie Ross:
But these same debates are happening at the
other extreme as well, right? Again, it gets into the difference on
how we treat human persons, versus how we treat other animals. When
does life begin and when does death occur?
Matt Teichman:
Speaking of pregnancy, doesn’t the question
about how exactly to determine death interact interesting ways with
pregnancy? What happens if somebody is in one of these borderline
states while pregnant?
Lainie Ross:
This gets into the fact that even if someone can
be declared dead by neurological criteria, we can keep their body
oxygenated with technology. And so, it does raise the question of: you
have a living fetus inside a woman who’s declared dead by neurological
criteria; what do you do? If the fetus is 36 weeks and could live and
breathe on its own, qdo you treat it differently? Do you take the
woman to the operating room? Versus if the fetus is only 12 weeks?
Then you get into questions of whether you’re going to maintain
circulation of the woman, so that she continues to gestate the
fetus. Really personal questions: something that most pregnant women
are not thinking about.
And so, when you get into these horrible scenarios, the most likely event is that the docs are going to turn to the family and ask: how do you want to go ahead? But people also need to understand that there’s laws in many states, including the one we’re sitting in right now, which says that my advance directive, which tells you what I would want done with my body, doesn’t have to be respected when I’m pregnant, here in the state of Illinois. So the doctors, or my husband, can make healthcare decisions that violate my expressed wishes, as documented in my advance directive.
Matt Teichman:
I could see, for political-slash-religious
reasons, different states and different countries coming down
differently on that question. Whether to respect the wishes of the
pregnant mother prior to brain death, or whether to prioritize the
birth of the gestating fetus over everything.
Lainie Ross:
It’s not just in the issue of death. We get in
the issues of pregnancy, you know, a woman who has cancer. Whether
she has the right to say: I’m going to take these drugs that will kill
a fetus in order to try to save my own life. So the maternal-fetal
conflict is real, and not just at these edges.
Christos Lazaridis:
And Matt, let me also mention that the
example of the pregnant woman who is determined to be dead by
neurologic criteria and yet remains on artificial support for weeks or
months and gestates a healthy fetus—it really puts a lot of pressure
and tension to this idea that the brain is the central integrator.
That without the brain, the homeostatic integration of the organism
falls apart. Because it demonstrably doesn’t, right? That’s why
people have challenged this idea that you would call a living pregnant
organism that is gestating a fetus a cadaver. And so I think that
challenges the idea—
Matt Teichman:
—that would be a crazy tale to tell your
friends in school growing up. You know, when I was born, my mother
was a corpse. That would be a weird conversation to have.
Christos Lazaridis:
Exactly. And I think that’s where you
have to move from purely biologically defining death to when death
behaviors are appropriate, which incorporates, as we just said, moral
issues and normative issues.
Lainie Ross:
Slightly tangential, but it’s important to think
about what that might mean for the caregivers at the bedside. I just
want everyone to take a pause and think about if a woman, like myself,
were to have very strong preferences about how my body should be
treated, once declared dead by neurological criteria. Even if I were
to have said while alive that my wish is to bring a healthy baby into
the world, and I have a family willing to support this child, and all
of that, so this is a great thing, I still think from the perspective
of the caregivers at the bedside, the difficulty of caring for a body
that is dead in order to bring this fetus to term would be very
emotionally challenging. When we think of what we do in medicine, we
don’t think we’re drawing blood from a dead body, caring for a dead
body, in the way that we do in the intensive care unit, versus in
preparation for burial or cremation.
Matt Teichman:
I think what we’ve established in this
discussionk, so far, is that it’s far from simple to determine whether
someone is living or dead in at least numerically many cases, if not
proportionally many cases, and that this is a reality that physicians
have to wrestle with on a day-to-day basis. So now that we’ve
acknowledged that there’s this complexity, where we have to bring in
moral considerations, legal considerations, and not just purely
scientific or biological considerations, where do you think we should
go from there?
Lainie Ross:
Well, the good news is it’s not a daily
basis. It’s often pretty straightforward whether someone is alive or
dead. These are the cases at the margins. And one of the things that
I’ve always argued: first, the value of choice, given that these are
tensions, and one can understand why different people coming from
different religious and other social backgrounds might have very
different views. It argues for the value of allowing all the states to
look like New Jersey. In New Jersey, you can choose whether you only
want to be declared dead by circulatory and respiratory criteria or
whether you’re also willing to be declared dead by neurological
criteria.
The idea, though, that it’s only in New Jersey where you have this freedom—it’s technically in about seven states that there’s some degree of accommodation, but New Jersey is the clearest of them. But what about the other 43 states? It seems to me that where we should move is to just acknowledge the right for individuals to make these decisions about how they want to be determined to be dead throughout all 50 states, and so that there should be the case for choice.
Some people worry that this will lead to huge costs of oxygenating bodies that have no neurological function, and things of that sort. I, again, just want to emphasize: it’s the rare individuals who think that that’s a living person there, and so, I think that’ll be a rare exception. If we were to accept death by higher brain, the costs would even out because, those individuals would be declared dead sooner. And even if we don’t accept death by higher brain, the fact is the costs have not been prohibitive. The number of cases in New Jersey are small, and I think that even if we expanded it across the United States, the numbers would remain small, and would be more respectful of all of us who live in this pluralistic liberal society.
Matt Teichman:
As a born and bred New Jerseyan, I could not
possibly be happier with the suggestion that other states should all
become like New Jersey. Lainie Ross and Christos Lazaridis, thank you
so much for coming.
Lainie Ross:
Thank you.
Christos Lazaridis:
Thank you so much, Matt.