Organismal Superposition and Death.

Organismal superposition holds that the same individual both is and is not an organism, as a consequence of organismal pluralism. When coupled with the assumption that death is the cessation of an organism, this entails that there is no unique answer as to whether brain death is biological death. This essay argues that concerns about organismal pluralism and superposition do not undermine a theory of biological death, nor entail any metaphysical indeterminacy about the biological vital status of a brain-dead individual.

Abortion, Brain Death, and Coercion.

A "universalist" policy on brain death holds that brain death is death, and neurologic criteria for death determination are rightly applied to all, without exemptions or opt outs. This essay argues that advocates of a universalist brain death policy defend the same sort of coercive control of end-of-life decision-making as "pro-life" advocates seek to achieve for reproductive decision-making, and both are grounded in an illiberal political philosophy. Those who recognize the serious flaws of this kind of public policy with respect to abortion must apply the same logic to brain death.

Frequent Preservation of Neurologic Function in Brain Death and Brainstem Death Entails False-Positive Misdiagnosis and Cerebral Perfusion.

Some patients who have been diagnosed as "dead by neurologic criteria" continue to exhibit certain brain functions, most commonly, neuroendocrine functions. This preservation of neurologic function after the diagnosis of "brain death" or "brainstem death" is an ongoing source of controversy and concern in the medical, bioethics, and legal literatures. Most obviously, if some brain function persists, then it is not the case that all functions of the entire brain have ceased and hence, declaring such a patient to be "dead" would be a false positive, in any nation with so-called "whole brain death" laws. Furthermore, and perhaps more concerning, the preservation of any brain function necessarily entails the preservation of some amount of brain perfusion, thereby raising the concern as to whether additional areas of neural tissue may remain viable, including areas in the brainstem. These and other considerations cast significant doubt on the reliability of diagnosing either "brain death" or "brainstem death."

Expanding the Social Status of "Corpse" to the Severely Comatose: Henry Beecher and the Harvard Brain Death Committee.

This essay examines the development of the seminal report, "A Definition of Irreversible Coma," by the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death in 1968. Detailed examination of original documents archived in the Henry K. Beecher Papers at Harvard's Countway Library reveals a variety of concerns and values at play in the development of the report, along with disagreement on a few key points among Committee members. One important goal of the Committee was to render treatment removal from patients in severe coma mandatory-not merely permissible-and without need for permission or consultation with the patient's family. Protecting and supporting organ transplantation also played a significant role in the Committee's writings and deliberations. Multiple concepts of death and justifications for brain death can be found, most of them inconsistent with each other and offered without a clear rationale. The essay emphasizes what is perhaps the most important aspect of this period in history: this is the moment when, without clear physiologic justification, the social and legal status of "corpse" became compulsorily applied to living human bodies.

Current Practice Diagnosing Brain Death Is Not Consistent With Legal Statutes Requiring the Absence of All Brain Function.

The legal standard for the determination of death by neurologic criteria in the United States is laid out in the Uniform Determination of Death Act (UDDA), which requires the irreversible cessation of all functions of the entire brain. Most other nations endorse a "whole-brain" standard as well. However, current practice in the determination of death by neurologic criteria is not consistent with this legal standard, because some patients who are diagnosed as brain-dead, in fact retain some brain function, or retain the capacity for the return of some brain function. In response, the American Academy of Neurology published updated guidelines, which assert that hypothalamic function is consistent with the neurological standard enshrined in the UDDA. Others have suggested that it is an open question whether the hypothalamus and pituitary are part of "the entire brain," as delineated in the UDDA. While we agree that determination of death practices are worthy of continued dialogue and refinement in practice that dialogue must adhere to reasonable standards of logic and scientific accuracy.

It Is Time to Abandon the Dogma That Brain Death Is Biological Death.

Drawing on a recent case report of a pregnant, brain-dead woman who gave birth to a healthy child after over seven months of intensive care treatment, this essay rejects the established doctrine in medicine that brain death constitutes the biological death of the human being. The essay describes three policy options with respect to determination of death and vital organ transplantation in the case of patients who are irreversibly comatose but remain biologically alive.

Hypothalamic function in patients diagnosed as brain dead and its practical consequences.

Some patients who have been diagnosed as "dead by neurologic criteria" continue to exhibit certain brain functions, most commonly, neuroendocrine functions. In this chapter, we review the pathophysiology of brain death that can lead either to neuroendocrine failure or to preserved neuroendocrine functioning. We review the evidence on continued hypothalamic functioning in patients who have been declared "brain dead," examine potential mechanisms that would explain these findings, and discuss how these findings create additional confounds for brain death testing. We conclude by reviewing the evidence for the management of hypothalamic-pituitary failure in the setting of brain death and organ transplantation.

Evaluating the translational value of postmortem brain reperfusion technology.

A novel pulsatile-perfusion technology, dubbed BrainEx, has been shown to restore microcirculation and cellular functions in the pig brain, 4 h postmortem. This technology has generated enthusiasm for its translational value for human neuroresuscitation. I offer a critical analysis of the study and its methodology, providing several reasons for skepticism. This includes: all phenomena were observed at different degrees of hypothermia; the physiological and biochemical milieu of the experimental preparation is radically different than the clinical setting of hypoxic-ischemic brain injury; and the study is confounded by uncontrolled traumatic brain injury and lifelong stress in all the animals.

From the Slaughterhouse to the Laboratory Bench: On the Ethics of Using Slaughtered Animals for Biomedical Research.

Is it ethically permissible to acquire biological materials from a slaughterhouse for biomedical research? This essay examines this question, using a recent, high-profile research program as a case study. Using roughly 300 decapitated pig heads acquired from a slaughterhouse, researchers reperfused the animals' brains and observed a variety of cellular and molecular activities. The study was exempted from review and oversight by the Institutional Animal Care and Use Committee (IACUC), on the grounds that the animals were already dead. This essay argues that the IACUC was mistaken in exempting the study from their oversight, and furthermore, that acquiring animals or their parts from a slaughterhouse for research purposes is unethical and should not occur again. Examination of the study within a broader societal context helps to illuminate why each of us has an ethical obligation to do what we can to abolish the vicious and cruel treatment endured by billions of animals every year on factory farms and in slaughterhouses.

The Public's Right to Accurate and Transparent Information about Brain Death and Organ Transplantation.

The organ transplantation enterprise is morally flawed. "Brain-dead" donors are the primary source of solid vital organs, and the transplantation enterprise emphasizes that such donors are dead before organs are removed-or in other words that the dead donor rule is followed. However, individuals meeting standard diagnostic criteria for brain death-unresponsiveness, brainstem areflexia, and apnea-are still living, from a physiological perspective. Therefore, removing vital organs from a heart-beating, mechanically ventilated donor is lethal. But neither donors nor surrogates nor the public in general are typically informed of this obviously relevant information. Therefore, donors or surrogates do not provide valid consent for a lethal medical procedure. This is a serious moral failing on the part of the transplant community. To address this concern, I advocate for accurate and fully transparent communication of information to the public to allow for an informed civic dialogue about the ethics and legality of lethal organ procurement. Furthermore, I advocate that systems be put in place by the transplant community to allow for valid consent for lethal organ procurement.

Medical Futility and Involuntary Passive Euthanasia.

Conflicts between providers and patients or their families surrounding end-of-life care are both regrettable and extremely challenging, interpersonally and ethically, for all involved. These conflicts often implicate the concept of medical futility. The concept of futility is too often conflated with distinct concepts that are more ethically salient, including the fiduciary responsibility to assess surrogate decision-making, and distributive justice. By distinguishing these concepts from futility, it becomes clear that there are some situations in which forgoing life-sustaining treatment over objection is permissible, and perhaps even obligatory. But the justification lies in the constellation of rights and responsibilities surrounding surrogate decision-making, or in distributive justice, but not futility. Once futility is disambiguated from these other concepts, the practice of withholding or withdrawing life-sustaining treatment over the objection of a valid surrogate or a competent patient, based on the alleged futility of such treatment, is more clearly described as involuntary passive euthanasia.