Is Death Irreversible?

There are currently two legally established criteria for death: the irreversible cessation of circulation and respiration and the irreversible cessation of neurologic function. Recently, there have been technological developments that could undermine the irreversibility requirement. In this paper, I focus both on whether death should be identified as an irreversible state and on the proper scope of irreversibility in the biological definition of death. In this paper, I tackle the distinction between the commonsense definition of death and the biological definition of death to show that even the commonsense concept of death is specified by biological facts. Resting on this argument, I argue that any definition of death is a posteriori. Thus, irreversibility is part of any definition of death because the actual phenomenon of death is irreversible. In addition, I show that the proper domain of irreversibility in a definition of death is circumscribed by physical possibilities and that irreversibility in the definition of death refers to current possibilities for the reversal of relevant biological processes. I conclude that, despite recent technological advancements, death is still irreversible.

Complexity, Not Severity: Reinterpreting the Sliding Scale of Capacity.

In this article, we focus on the definition and application of the sliding scale of capacity. We show that the current interpretations of the sliding scale confound distinct features of the medical decision, such as its urgency, its severity, or its complexity, that do not always covary. We propose that the threshold for assessing capacity should be adjusted based solely on the cognitive complexity of the decision at hand. We further suggest that the complexity of a decision should be identified based on a patient's particular cognitive deficits. We utilize the current research on the types of deficits that characterize amnestic dementias and examine which types of medical decisions might be most complex for patients with that type of dementia. We conclude that applying the sliding scale based on individualized judgments of cognitive complexity will improve accuracy of assessment of capacity and enable capable patients to participate in medical decision making.

White Ignorance in Pain Research: Racial Differences and Racial Disparities.

Racial disparities in pain treatment are well documented. Such disparities are explained with reference to factors related to providers, health care structures, and patient behaviors. Racial differences in pain experiences, although well documented, are less well understood. Explanations for such differences usually involve genetic or psychological factors. Here, we argue that racial differences in pain experiences might also be explained by disparities in pain treatment. Based on what we know about the nature of pain, particularly the cognitive and affective aspects of the phenomenon, it is likely that disparities in the treatment of racialized patients can lead to significant racial differences in pain experience that show up at the population level. We argue that the failure of research programs to consider this causal factor is an example of white ignorance. We also consider several implications of the link between racial disparities in pain treatment and racial differences in pain experience.

A case from the department of neurology.

Uncompleted suicide attempts are a significant cause of morbidity, which in catastrophic cases can be both medically and ethically challenging to manage. We discuss the case of a 63-year-old man who survived a suicide attempt by venlafaxine (Effexor) overdose, causing an intracranial hemorrhage and leaving him in an apparently awake but noncommunicative state. Ethical concerns arose when considering if he should be indefinitely maintained on life support. These include the difficulties of characterizing his level of consciousness and prognosis; establishing his decisional capacity regarding end-of-life decisions in a setting of depression and suicidality; and assessing the suitability of a surrogate decision-maker. In conclusion, we discuss whether the fact that his grave neurological condition was caused by a suicide attempt was relevant to the decision to continue or withdraw life support.

Communicating with subjects: special challenges for resuscitation research.

In May 2005, Academic Emergency Medicine sponsored a one-day consensus conference held in association with the 2005 Society for Academic Emergency Medicine meeting in New York City. The conference, entitled "Ethical Conduct of Resuscitation Research," addressed a variety of issues regarding the successful conduct of research in acute care settings. A number of important breakout sessions were convened based on challenges specific to resuscitation research. "Communicating with Subjects" was one such session, dedicated toward perfecting the conduct of informed consent for research. The breakout session was attended by 15 insightful emergency medicine investigators, administrators, and ethicists. Issues of research information disclosure, subject comprehension, and the voluntariness of research participation were addressed. Consensus statements were developed and are discussed within this report.