Robert Blanks Technology and Death Policy: Redefining Death - Term Paper Example

Brain Death: Definition and Implications. The legal and social definition of death is one of the most significant issues of the time, which has implications on a range of medical and ethical conditions such as Persistent Vegetative State, euthanasia and stem cell research. Robert Blank and Peter Monaghan examine the current definition of death and call for a redefinition, based on public debate. Summary of Robert Blank’s Technology and Death Policy: Redefining Death. Robert Blank’s article revolves round the definition of human death. Any acceptable definition is complicated by continuous technological advances in life-sustaining techniques and diagnostic tests. By the late 1970s, advances in machine-based life-sustaining methods rendered the traditional definition of death as “the moment of permanent cessation of respiration and circulation” (Blank, 192) obsolete, and death came to be increasingly linked to brain function. This ‘brain-death’ definition of human death has engendered several questions on what constitutes human life. Brain-death in this context refers to “the cessation of brain activity and function as measured by specific tests” (Blank, 193). In 1968, the ‘Harvard Criteria’ for brain-death was issued, which was centered on the lack of responses, movements and reflexes. The unavoidable conjecture that this definition of brain-death was linked to the facilitation of organ transplants cast an aspersion on the ethics of this definition. The present standard accepted definition of death, according to the ‘Uniform Definition of Death Act,’ in 1981, encompasses the “irreversible cessation” of either cardio respiratory functions, or all brain functions. This whole brain definition of death remains contentious because, in some cases, circulation and respiration, which are controlled by the brain stem, can continue while consciousness, which is controlled by the cerebral cortex, can be permanently lost. This has raised the issue of a “cerebral death definition” (Blank, 196), which equates human life with consciousness. Region-specific brain imaging techniques are of significance here. This definition directly impacts Persistent Vegetative State and Alzheimer’s patients. Advance directives and prior donor consent assume relevance in this context. Blank concludes by stating that the definition of death is the subject of public policy, with social, cultural and religious ramifications and needs to be debated further. What is the proper definition of brain death? Brain death refers to the irreversible cessation of brain function. In 1968, a Harvard Medical School Committee formulated the ‘Harvard Criteria’ for defining brain death which has become the accepted standard criteria in most of the developed world. The following were identified as the criteria for brain death: unreceptivity or unresponsiveness, lack of spontaneous movement or breathing, and lack of reflexes. A flat EEG, indicating the absence of cerebral activity, is the recommended confirmatory test. In view of the persisting legal and ethical issues surrounding the definition of brain death, the President’s Commission proposed the ‘Uniform Definition of Death Act’ in 1981, which is currently the accepted standard definition. The Act defines as dead “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. This is called the ‘whole brain’ definition of death. What triggered the controversy over brain death? In the past, the accepted definition of death was “the moment of permanent cessation of circulation and respiration” (Blank, 192).This traditional definition of death held its ground as long as the restoration of cardiac and pulmonary functions remained beyond the realm of medical science. However, in the late 1970s, the advent of advanced medical technology which facilitated the restoration of heartbeat and breathing through machine regulation made this definition obsolete and controversial. As cardiopulmonary functions could now be indefinitely prolonged by technological means, the need for a “clear and socially acknowledged basis” (Blank, 192) for defining death was recognized. In this context, in 19891, the U.S. President’s Commission recommended that death be defined as “the direct cessation of brain function” (Blank, 192). This definition is grounded in the fact that while biological processes of the body can be indefinitely maintained by medical technology, higher brain functions, such as consciousness, can never be restored once lost. This has led to a clear differentiation between biological existence, as measured by cardiac and pulmonary functions, and human life, as characterized by consciousness and other higher cerebral activity. There is a growing consensus that brain-death is the most accurate indicator of death, even when biological functions are maintained through medical technology. Some people reject the very concept of brain-death, some do not accept whole-brain death yet others cannot come to grips with labeling as ‘dead’ individuals who continue to breathe although they are brain-dead. In short, the controversy over brain-death continues, triggered to a large extent by advances in medical technology, although social and cultural factors also come into play. What is radically different with proposed cerebral definitions of death? The accepted standard definition of death is the ‘whole-brain’ definition, which requires the “irreversible loss of all functions of the entire brain” (Uniform Definition of Death Act. Blank, 194). However, this definition does not take into consideration several factors, such as the fact that isolated brain cells may continue to show electrical activity in EEGs, even after irreversible destruction of brain function. Spinal cord reflexes may also persist. Moreover, whole-brain death is based on the premise that the functions of the brain cannot be restored or executed by any other means. Advances in medical technology have proved this assumption wrong, as intensive care units are now capable of maintaining the regulatory functions of the brain and can serve as a substitute for the brain stem itself. The loss of cardiopulmonary functions, due to brain stem damage, is no longer mandatorily linked to the loss of consciousness and higher mental activity. To retain its relevance, the definition of brain death must differentiate between the two dimensions of brain function: (1) regulatory biological functions, such as respiration (2) the capacity for consciousness and mental activity. These two brain functions are localized in different regions of the brain: regulatory functions in the brain stem, and higher mental activities in the cerebral cortex. The brain stem can continue to function, even after the loss of consciousness. Even when the brain stem itself is damaged, its functions can be indefinitely sustained by life-support systems. This dilemma has lead to the proposed cerebral definition of death. While the traditional definition requires the loss of both brain capacities for a person to be declared dead, the cerebral death definition radically differs in its stand that human existence is equated with consciousness. As the death of the neo-cortex signals the irreversible loss of consciousness, it is the functioning of the cerebral cortex which should be the criteria for defining death. By this definition, persons with functioning brain stems, who can breathe independently, and those who are on life-support systems, due to brain stem damage, are to be declared dead if they have no cerebral function. This is a radical departure from the current accepted definition of whole-brain death, as it labels as ‘dead’ a person who may continue to breathe spontaneously. Why is it difficult to institute a policy defining PVS (Persistent Vegetative State) patients as brain dead? Persistent Vegetative State is a condition subject to debate on various counts. It is the result of lack of blood or oxygen to the brain for more than 4 – 6 minutes. This leaves the brain stem intact but completely destroys the cerebral cortex. There is a total loss of consciousness, but the eyes remain open and all brain stem functions, such as breathing, sleeping and reflexes, continue. Persistent Vegetative States can last for years. In such a situation, formulating a policy which defines PVS patients as being brain-dead is very difficult. Although medical know-how and advanced diagnostic techniques can effectively confirm the irreversible cessation of higher brain activity, such tests are still subject to debate. Moreover, anecdotal cases stating the recovery of patients wrongly diagnosed as being in a PVS, further cloud the issue. PVS patients cannot easily be accepted as brain dead because the person remains biologically alive, and human life cannot unequivocally be equated with consciousness alone in the prevailing ethical and social environment. Burying or cremating a breathing person is beyond the acceptance of the vast majority of society. Defining PVS patients as brain dead, based on the cerebral-death definition, also raises the disturbing possibility of this definition being further extended to include people with advanced dementia or Alzheimer’s, or extremely low IQs. This raises additional ethical and social issues such as euthanasia. Summary of Peter Monaghan’s The Unsettled Question of Brain Death. Peter Monaghan examines the concept of brain-death, mainly from the perspective of Margaret Lock and Dr. Stuart J. Youngner, and explores the various cultural, social, legal and medical issues involved. According to the report submitted by the Harvard Medical School Committee in 1968, the irreversible cessation of brain functioning, even when cardiopulmonary functions continue, may be defined as death. This ‘brain-dead’ concept is accepted in most developed countries and serves as the justification for the removal of organs from brain-dead donors for transplant. Ms. Lock suggests that this conventional definition of death is largely based on cultural convention and needs to be reexamined in the light of advances in critical care technology. She contrasts the North American acceptance of brain death as a given, with the more ambivalent attitude prevalent in Europe and Japan, where the legal determinant of death largely continues to be the irreversible cessation of cardiopulmonary functions. Ms. Lock argues that brain death cannot incontrovertibly be measured and is linked to the facilitation of organ transplant. While brain death is a widely debated bioethical issue in Japan, other developed countries appear to have accepted the medical criteria for brain death and organ transplant without considering the religious and legal implications. She attributes this to Western society’s emphasis on the brain as the crux of life and the equating of human existence with consciousness. In contrast, the Japanese also ponder on the metaphysical questions on life and death and do not accept rigid demarcations between mind and body. Death in Japan has familial and social connotations, which supersede purely medical criteria. In the West, death is more a biological event and there is a prevalent thinking that the retrieval of organs for transplant is of priority. Advanced life-support technology has extended the biological functioning of brain-dead persons. Such ‘human-machine hybrids’ are accepted in Japan, while the West is very ambivalent about such ‘living cadavers.’ Dr. Youngner also calls for a fresh debate on the concept of brain death and the elucidation of the legal determinants of death in order to build up a clear consensus. Until then, he advocates putting on hold issues such as organ transplants and the use of lethal injections in cases of PVS patients. Both Ms. Lock and Dr. Youngner call for a fresh debate on the moral and ethical connotations of brain death and contest the standing of brain death as an accepted fact. How do countries outside the U.S.A. tackle the ethical problem of death definition? Most of the developed world follows the Harvard Criteria of defining death, by which death can be either the irreversible cessation of cardiac and respiratory functions, or the irreversible cessation of brain functions. In the U.S.A. the stoppage of brain functions, even when the heart beat and breathing continue independently or on a life-support system, is defined as brain death and such an individual is considered to be dead. The organs of such brain dead persons may be removed for organ transplant. In contrast to these generally accepted criteria of brain death in the U.S.A., the concept gained legal standing in Japan only in 1997 and it continues to be debated and limited in application. The prior consent of brain-dead individuals is required for organ donorship. Even Western nations, such as Germany, Sweden and Denmark, recognize the concept of brain-death, but continue to use the traditional standard of heart and lung cessation as the criteria of legal death. In Japan, brain-death is a bioethical issue which excites public opinion and debate. No rigidly defined concept of death has been accepted and public consensus is yet to be reached. In Japanese thinking, the irreversible loss of consciousness is not unequivocally linked to death. The separation of mind and body, or life and death is far from clearly defined. The metaphysical dimensions of death are acknowledged and death and existence are not debated in merely medical and legal terms. Death is dealt with on a social and familial plane and the dignity of the body is given solemn significance. Death is defined in ethical terms and these ethics supersede medical authority. How does the discussion about brain death and the cerebral definition of death impact other sensitive medical and social-ethical areas? The irreversible cessation of brain function is defined as brain death. Due to advances in life-support mechanisms, circulatory and respiratory functions can be maintained indefinitely even after brain function has ceased. The whole brain and cerebral cortex definition of death directly impacts sensitive issues such as organ transplants and stem cell research. In fact, there is a school of thought which holds that the brain-dead definition of death was itself formulated with the motive of facilitating organ transplants. The procurement of organs from the body of a breathing donor has social and ethical dimensions which are being ignored in the medical obsession with keeping patients alive. The unequivocal equating of consciousness with existence has not been proved beyond doubt. However, the acceptance of brain death as the definition of death and the procurement of organs for transplant from such ‘living cadavers’ is largely prevalent in North America. An increasingly loud demand for the reexamination of this issue in moral and ethical terms is being heard. In the light of medical advances, such as cloning cells to produce human tissues and organs, it can be hoped that the pressure for the supply of organs from brain-dead people will ease off and lead to a more ethical definition of death. The acceptance of brain-death will impact on embryonic stem cell research as the definition of life as consciousness is used as the common justification in both cases. Immature embryos can be said to be unconsciousness and therefore dead and can be used for research. How does the recent PVS case in Florida (the Terry Schiavo case) illustrate the problems addressed in the text? Terri Schiavo suffered irreversible brain damage in 1990 due to a bulimia related potassium deficiency, which triggered heart failure. Her cerebral cortex was extensively damaged and she slipped into a Persistent Vegetative State (PVS). However, her cardiopulmonary functions continued and she was maintained on a feeding tube for nutrition. The current legal definition of brain death – the irreversible cessation of brain function – was accepted by her husband, who asked for the feeding tube to me removed so that her regulatory functions would gradually stop. However, her parents contended that as the brain stem regulated functions continued, she was not brain dead and had the right to live. This legal battle stretched on until 2005, when her feeding tube was finally removed on court orders. This case illustrated the wide divide in public opinion about the morality and ethics of declaring a breathing body dead. Are family members, who cannot give up, justified in prolonging PVS in a loved one? Can medical tests unequivocally affirm that brain damage is irreversible? Are the economic costs of keeping brain dead persons alive justified? All these questions need to be addressed and debated before arriving at an accepted standard definition of death. Both Blank and Monaghan treat the definition of death as a policy issue which has significant social and cultural implications. They agree that continuing advances in medical technology, particularly life-support systems, confuse the issue. They call for a redefinition of death and acknowledge that the current definition of brain death is linked to the facilitation of organ transplants. However, they differ markedly in their recommendation of the criteria to be employed in any proposed redefinition. Blank adopts a more scientific approach and calls for a cerebral definition of death, while Monaghan employs a moral/ethical perspective which questions the concept of brain death itself. Blank, equating human existence with consciousness, advocates moving from the ‘whole brain’ to the ‘cerebral’ definition of death, while Monaghan proposes a return to the traditional ‘heart and lung stoppage’ definition of death. When the arguments marshaled by Blank and Monaghan are considered, Blank’s contentions are measured, based on medical technology and incorporate both the scientific and ethical dimensions of death. In contrast, Monaghan gives emphasis only to the moral implications and uses a rather simplistic approach. His stand against the concept of brain death appears to be biased and based more on emotional connotations and does not give fair treatment to all differing points of view. It is also rather ‘Japan centric’ and does not resonate with North American culture and society. However, considering that the definition of life and death is one of the most crucial aspects of human existence, the arguments of both authors is largely relevant and thought-provoking and contributes to the ongoing debate on this issue. Works Cited. Blank, Robert H. Technology and Death: Redefining Death. Mortality, Volume 6, No. 2, 2001 Carfax Publishing. Monaghan, Peter. The Unsettled Question of Brain Death. The Chronicle of Higher Education, Washington, February 22, 2002. Volume 48, Issue 24, Page A14 Read More