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When is dead?

The definition of death and its implication for organ transplantation

Cristina Gavrilovici, MD, MA, PhD

Empirical and conceptual issues


Statutory definition of death: Uniform determination of death act: an individual who has sustained either (1) irreversible cessation of circulation and respiratory function or (2) irreversible cessation of all functions of the entire brain, including the brain stem is dead

Empirical and conceptual issues


Death = natural event or process the two notions approach: the patient as person the person as body
there are dead bodies but no dead persons how do we decide whether a body has ceased to function ?

Irreversibility
UPMC protocol: legally dead after 2 minutes of pulseless apnea, unresponsivenes to verbal stimulus, EKG
the moral questions:
whether the withdrawal of life support and subsequent removal of organs are morally permissible killing vs letting die

Irreversibility
UPMC protocol: irreversible cesation of cardiopulmonary function (legally dead after 2
minutes of pulseless apnea, unresponsivenes to verbal stimulus, EKG ()

the moral questions:


whether the withdrawal of life support and subsequent removal of organs are morally permissible killing vs letting die

the empirical question:


how much time after cardiopulmonary function is lost one must wait to ensure that spontaneous recovery will not occur?

Irreversibility
David Cole: central to UPMC protocol is irreversible concept, that is dangerously ambiguous:
irreversible by whom? When? Under what circumstances? The UPMC protocol involves a totally implausible and weak construct of what is for a loss of function to be irreversible central to UPMC protocol is the absence of auto-resuscitation

Irreversibility
Tom Tomlison: a critique of Cole:
irreversibility is a requirement that arises only at the level of the criteria for the determination of death rather than at the level of the concept of death.
Why would anyone think that the determination of death should be a determination of the irreversible?

A significant important translation of irreversible in the criteria for determining death is the possibility of reversal is not ethically significant.

Irreversibility
Lynn and Cranford: four possible times of death:
T1: when critical function is lost T2: when the critical function is observed to be lost T3: when the function is irreversible lost T4: when the function is demonstrated to be irrversible lost

Public ambivalence and confusion


Acceptance in great part of the brain death criteria because it was seen by the public as a defense against the invasive indignities of technological medicine.
The number of minutes needed to declare death might be ignored

Public ambivalence and confusion


Trust in physicians and health care system is often a problem in minorities communities
fear of exploitation of innocent victims by medical scientists

Recommendations
1. When stipulating how long one must wait after the cessation of circulatory function to declare death, protocols should explicitly explain the empirical and philosophical grounds for their position 2. If one holds the weakest position of irreversibility, data will be helpful to reassure skeptics that autoresuscitation will not occur.

Recommendations
3. Transplant community should take seriously the need for data based justifications for pushing the time of death closer and closer to when circulatory function is lost.
4. There should be organ procurement organisations functioning as a regional engine for opinion and practice change

Recommendations
5. NHBD policies should be uniform with the regards to the declaration of death 6. Institutional protocols should be developed with community involvement and input.

Recommendations and conclusion

Death is both a biologically based and socially constructed notion about which there is little prospect for social consensus

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