Death and transplantation: Let's try to get things methodologically straight

Bioethics

Volumn 21, Issue 1, 2007, Pages 32-40

  Boniolo, Giovanni ^a,b  

^a UNIVERSITY OF PADOVA   (Italy)

^b FIRC INSTITUTE OF MOLECULAR ONCOLOGY   (Italy)

Author keywords

Death; Definition; Explantability window; Methodology; Transplantation

Indexed keywords

ARTICLE; BIOETHICS; BRAIN; DEATH; HEART; HUMAN; METHODOLOGY; ORGAN TRANSPLANTATION; PROBLEM IDENTIFICATION; TRANSPLANTATION;

BRAIN DEATH; DEATH; HUMANS; ORGAN TRANSPLANTATION; TISSUE AND ORGAN PROCUREMENT;

EID: 33845667022     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2007.00521.x     Document Type: Article

References (46)

1. Notice that I differentiate in a classical way 'ontology' from 'metaphysics'. The former concerns what a given theory speaks about. The latter has to do with our commitment on the status of 'what a given theory speaks about' is.
2. R.M. Veatch. 1994. The Beginning of Full Moral Status. In The Beginning of Human Life. F.K. Beller & R.F. Weir, eds. Dordrecht: Kluwer Academic Press: 22-24.
3. Cf. Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine. Recommendations For Nonheart-beating Organ Donation. Crit Care Med 2002; 29: 1826-1831. Here there is a relevant question upon which we cannot dwell: the difference between spontaneous recovering and artificial recovering.
4. S.J. Youngner et al. When is Dead? Hastings Cent Rep 1999; 29: 14-21. It should be noted that the authors point out that their data are no so good as it could appear and therefore that they have to be considered as 'the weakest possible evidence for a recommendation'.
5. Cf. a) P. Mertens et al. Restoration of Spontaneous Circulation After Cessation of Cardiopulmonary Resuscitation. Lancet. 1993; 341: 841.
6. b) G. Quick et al. Prolonged Asystolic Hypercalemic Cardiac Arrest With No Neurologic Sequelae. Ann Emerg Med 1994; 24: 305-311.
7. c) W.H. Maleck et al. Unexpected Return of Spontaneous Circulation After Cessation of Resuscitation (Lazarus Phenomenon). Resuscitation 1998; 39: 125-128.
8. d) J.G. Bray. The Lazarus Phenomenon Revisited. Anesthesiology 1999; 78: 991.
9. e) H. Maeda et al. Death Following Spontaneous Recovery From Cardiopulmonary Arrest in a Hospital Mortuary: 'Lazarus Phenomenon' in a Case of Alleged Medical Negligence. Forensic Sci Int 2002; 127: 82-87. Note that W.H. Maleck et al. quote more than twenty cases reported between 1982 and 1998. They also emphasise how the phenomenon is underestimated due to the possible medical-legal consequences.
10. With reference to the difficulties concerning the notion of 'irreversibility', cf. D. Hershenov. The Problematic Role of 'Irreversibility' in the Definition of Death. Bioethics 2003; 17: 89-100.
11. Cf. Ad hoc Committee of The Harvard Medical School to Examine the Definition of Brain Death. JAMA 1968; 205: 85-88.
12. J.L. Bernat et al. On the Definition and Criterion of Death. Ann Intern Med 1981; 94: 390-391.
13. Actually, they also discussed the heart approach characterised by the criterion of the permanent loss of cardiopulmonary functioning and the tests related to such a loss. Nevertheless, they criticised this approach and supported the brain one.
14. 'The Uniform Determination of Death Act' proposed by the 'President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioural Research' in their: 1981. Defining Death: A Report on the Medical, Legal, and Ethical Issues in the Determination of Death. Washington D.C. U.S. Government Printing Office: 73. Let us recall the following passage: 'On this view, the heart and lungs are not important as basic prerequisites to continue life but rather because the irreversible cessation of their functions shows that the brain had ceased functioning. [. . .]. The "primary organ" view would be satisfied with a statute that contained only a single standard - the irreversible cessation of all functions of the entire brain. Nevertheless, as a practical matter, the view is also compatible with a statute establishing irreversible cessation of respiration and circulation as an alternative standard, since it is inherent in this view that the loss of spontaneous breathing and heartbeat are surrogates for the loss of brain function.'
15. Actually Bernat et al. (op. cit. note 8) proposed a justification: 'What we call tests have sometimes themselves been called "criteria", but it is important to distinguish these second-level criteria from the first-level criteria. While the first-level criteria determining the death of an organism must be understood by the layman, the second-level criteria or test determining permanent loss of functioning of the whole brain need not to be understood by anyone except qualified clinicians' (p. 392). From the methodological point of view, this distinction appears to be extremely weak. Moreover, from a sociological point of view it appears also a little bit unfair. It should be noted that the authors seem to have some difficulties in supporting this distinction; they themselves write that 'test' has to be understood as 'criterion', even if a second-level one.
16. For example, Bernat himself, in a subsequent paper (J.L Bernat. How Much of the Brain Must Die in Brain Death? J Clin Ethics 1992; 3: 21-26), acknowledged that some brain functions can be retained in brain death, and that 'the designation "whole brain" death is an approximation'. Therefore he suggested identifying brain death with the destruction of a theoretically determinable critical neuronal population. Yet, he could not specify how much of the brain must die.
17. B. Russell. 1910. Philosophical Essays. London: Allen and Unwin. By the way, this is the idea underlying 1931 A. Tarski's theory of truth. This proposal contained a definition of truth but not a criterion of truth. That is, Tarski's theory allows us to know the meaning of the locution 'truth', but not when a statement is true.
18. With reference to the differences between definition of truth and criterion of truth, also in relation to A. Tarski, cf. S. Haack. 1978. Philosophies of Logic. Cambridge: Cambridge University Press.
19. Of course, by 'tests' I mean 'empirical tests', that is, the tests which are relevant for our biomedical context.
20. Note that we are using the terms 'truth', 'falsity' and the derived ones in a very loose way, that is, without philosophical accuracy. Nevertheless, such accuracy is not required here.
21. For example, a) M. Giacomini. A Change of Heart and a Change of Mind? Technology and the Redefinition of Death in 1968. Soc Sci Med 1997; 44: 1465-1482.
22. b) R.M. Arnold et al. The Dead Donor Rule: Should we Stretch tt, Bend it or Abandon it? Kennedy Inst Ethics J 1993; 3: 263-278.
23. Cf. P. a) Singer. Rethinking Life and Death. 1994. New York: St. Martin's Press.
24. b) D.A. Shewmon. Recovery from 'Brain Death': A Neurologist's Apologia. Linacre Q 1997; 64: 30-96.
25. Cf. a) D.A. Shewmon. Chronic 'Brain Death'. Meta-Analysis and Conceptual Consequences. Neurology 1998; 51: 1538-1545.
26. b) D.A. Shewmon. Is it Reasonable to Use as a Basis for Diagnosing Death the UK Protocol for the Clinical Diagnosis of 'Brain Stem Death'?. 1998. In Proceedings of the International Conference to celebrate the Twentieth Anniversary of the foundation of the Linacre Centre. London: The Linacre Centre: 315-333.
27. Cf. D.A. Shewmon. The Brain and Somatic Integration: Insights into the Standard Biological Rationale for Equating 'Brain Death' with Death. J Med Philos 2001; 26: 457-478.
28. Cf. a) R.D. Truog et al. Rethinking Brain Death. Crit Care Med 1992; 20: 1705-1713.
29. b) R.M. Veatch. The Impending Collapse of the Whole-Brain Death Definition of Death. Hastings Cent Rep 1993; 23: 18-24.
30. c) R.D. Truog. Is it Time to Abandon Brain Death? Hastings Cent Rep 1997; 21: 29-37.
31. With reference to the problem of vagueness, cf. D. Graff, T. Williamson (eds.). 2001. Vagueness. Ashgate: Aldershot;
32. R. Keefe, P. Smith. 1996. Vagueness: A Reader. Cambridge, MA: MIT Press;
33. R. Keefe. 2000. Theory of Vagueness. Cambridge: Cambridge University Press;
34. T. Merricks. Varieties of Vagueness. Philos Phenomenol Res 2001; LXII: 145-157;
35. T. Williamson. 1994. Vagueness. London: Routledge;
36. T. Williamson. What Makes it a Heap? Erkenntnis 1996; 44: 327-339;
37. G. Boniolo, S Valentini. Forthcoming. Vagueness, Kant and Topology. A Study of Formal Epistemology. Journal of Philosophical Logic.
38. A definition can be implicit or explicit. The definiens of a term is given 'implicitly' when the statement in which it occurs belongs to a set of statements where there are other terms capable of implicitly specifying its meaning. It is used in some formal axiomatisations, and this is not our case.
39. Differently from a linguistic definition, by means of which we modify the language by enlarging it with a new term, in the metalinguistic definition, we do not modify a given language and we settle on a particular locution. For example, when we say '. . . 'man' is an animal belonging to the species Homo sapiens' we do not enlarge the language containing the terms 'animal' and 'Homo sapiens' and we settle, by resorting to a metalanguage, on the fact that the locution 'animal belonging to the species Homo sapiens' has to be termed 'man'. By choosing this latter view, I am implicitly affirming that the biomedical language has already the right terms to permit us to speak about that particular state of human being that we want to identify with a certain term.
40. It is worth noting that we could introduce a definition per genus et differentiam without committing ourselves in giving an essentialistic value to the definiens.
41. Also the ostensive definition is denotative. Of course we must reject such a possibility. For we could simply indicate a dead body and say: 'Death is the state of this body'. Unfortunately in doing so we should have decided in advance when a body is a dead one.
42. Someone could object that I am using the term 'human being' when before I said it is vague. Actually, by taking into account the pragmatic taste of my pars construens, this is not a serious objection. However, I assume, without any bad consequence for my analysis, that a human being is any individual belonging to the species Homo sapiens. For a more detailed discussion, cf. G. Boniolo. The Ontogenesis of Human Identity. In Biology, Philosophy, and Life. A. O'Hear ed. Supplement to Philosophy 2005; 56: 49-82. Cambridge: Cambridge University Press.
43. Cf. C. Hensshe et al. The Estimation of the Time Since Death in the Early Postmortem Period. London: Arnold, 2002.
44. Cf. M. Weber. Der Sinn der 'Wertfreiheit' der soziologische und ökonomische Wissenschaften. 1917.
45. Now in M. Weber. 1951. Gesammelte Aufsätze zur Wissenschaftslehre. Tübingen: Mohr.
46. n considering the tests which, in that particular technological situation, allow us to fix, and therefore define, the neurological explantability window. The problem, as seen, is to fix the first extreme of the explantability window. From what discussed in § 2, I believe that it should concern a devastating and irreversible cerebral lesion (as in the brain dead donors protocols), or a resuscitation period sufficiently long (in case of uncontrolled non-beating-heart donors), or an acceptable refusal of resuscitation (in case of controlled non-beating-heart donors).