DEATH--PROOF AND CERTIFICATION---definitions of death

DEFINITIONS OF DEATH

Books selected and reviewed by James Park,
whose evaluative comments and responses appear in red.
The books are organized by quality beginning with the best.

1. Stuart Younger, Robert M. Arnold, & Renie Schapiro, editors

The Definition of Death:
Contemporary Controversies

(Baltimore, MD: Johns Hopkins University Press, 1999)
(ISBN: 0-8018-5985-9; hardcover)
(Library of Congress call number: RA1063.D44 1999)
(Medical call number: W820D285 1999)

    This book was created from a conference in 1995.
Brain-death was well established by that time.
But some details were still being questioned.
And some people advocated higher-brain definitions of death,
which would allow even earlier declarations of death,
which is always better for harvesting organs for transplant.

    This review will deal selectively with the chapters indicated below.

Chapter 3: "How Much of the Brain Must Be Dead?"
by Baruch A. Brody, PhD.

    Many common definitions of brain-death
say that the integrative functions of the brain have ceased.
And they cannot be restarted.
But one common integrative function
that remains in brain-dead cadavers is hormonal regulation.
Even when machines are needed to keep the heart and lungs functioning,
the brain-stem is sometimes still putting out hormones
that regulate various biological functions.

    On a literal level, hormone regulation
is one remaining integrative function of the brain.
But hair and nails keep growing too.
These are cell-activities that need no brain at all.
If all that my brain-stem can do on its own
is to produce hormonal regulators,
then I should be declared dead.

    In fact, I prefer permanent unconsciousness as the definition of death
that should be used at the end of my life.
I have no philosophical problems being declared brain-dead.

    If others agree with Dr. Brody's objection,
we might need to modify the definition of brain-death
to say that most of the integrative functions of the brain have been lost.
I do not think we should add any new tests
to see if the brain-stem is still producing hormones.

    Brody argues that biological death is a process rather than a moment.
Various functions of the brain and body shut down at different times.
If we wait for each and every part of the process of dying to be completed,
it could be 3 days later when death is finally declared,
which would usually mean that the organs would be useless for transplant.

    But we do need a consistent and comprehensive definition of death.
And we need good ways to convince the relatives of the dying patient
that death has really happened,
even tho some tests show continuing functions,
such as the production of the hormones
that regulate some biological balances.

    This question about laypersons with concerns and objections
is more serious than the technical questions of testing and certification.
Some relatives will be quite conservative about the definition of death.
They will look only at the traditional concept of death
—all bodily functions have permanently and irreversibly stopped.
They want to be completely certain that death has occurred
before burial or cremation—or anything else happens to the body.

    This reviewer thinks that the following will probably emerge:
The scientific definitions and tests will apply to most declarations of death.
And organ-transplants will follow some declarations of brain-death.
But there will be a minority of families who will never accept brain-death.
They will insist on using their traditional definition of death.
At the other extreme, some donors will authorize in advance
using consciousness as the dividing line between life and death.

    At the end of his chapter Brody raises the issue of anenchephalic infants.
These are infants born with most of their brains simply missing.
They will never have even a single moment of conscious thought or feeling.
But their brain-stems can sometimes keep their bodies alive for a few days.
The American Medical Association now approves
of using babies born without brains
as organ-donors to save the lives of other babies.
According to the traditional definitions of death,
they would still be 'alive' when their organs are harvested.

    But this situation could be clarified by certifying
that these babies were born permanently unconscious.
And they should be officially declared to be dead
by an independent physician
before any organs are harvested for transplant into other infants.
Should such infants be officially declared brain-dead
before organ-donation is even considered?
This would avoid the very odd situation of declaring the time of death
to be when the first vital organ was removed.

    Thus, this reviewer's answer to Dr. Brody's question:
"How much of the brain must be dead?" is:
Let the parents of infants decide for their babies.
And let adults decide for themselves.
My personal answer is that permanent unconsciousness
is a good definition of death.
And I should certainly be declared dead if I am brain-dead.

~~~~~~~~~~~

Chapter 4: "Refinements in the Definition and Criterion of Death"
by James L. Bernat, MD

    Dr. Bernat agrees with Dr. Brody
that death is more like a process than an event.
But common-sense usage requires that we say of an organism
that is it either still alive or that it has died.
We need a defined moment of death for a variety of reasons:
organ-donation, life insurance, burial, etc.
And a declaration of death allows the removal of life-support systems
without asking for informed consent from anyone.
The family need no longer be asked to approve any medical procedures
since a dead body does not warrant any medical treatment.

    Sometimes we can only be certain of the moment of death in retrospect.
One such situation would be the failure to restart vital functions.
When someone dies in a hospital, the 'crash team' is often called
whose job it is to restore any and all failing vital functions.
And they keep trying for a significant number of minutes.
If their efforts are successful, the patient was not really dead—only dying.
If resuscitation does not work,
then we can say that the patient was doomed from the start of the CPR.
And death will be declared after the failure of resuscitation.
In retrospect, we can say that for all practical purposes,
the patient died some minutes earlier.
But the official time of death will be declared
as the moment when the resuscitation efforts were terminated.

    The basic change Dr. Bernat proposes
is adding the word "critical" to the following expression:
"Death occurs when the critical functions of the whole brain have ceased."
Thus we do not need to concern ourselves
with the random firing of groups of neurons in the brain
—if such activity makes no difference
to the critical function of the brain as integrator of bodily functions.
Likewise, the secretion of hormones
and continuing auditory-pathway signals
do not count in the determination of death.

    Such subtle distinctions will be lost on most laypersons.
We simply want to know: Is the patient alive or dead?
And we will normally not object to the declaration of death by a physician
—using acceptable criteria and tests for separating life from death.

~~~~~~~~~~~~~

Chapter 8: "The Conscience Clause:
How Much Individual Choice in Defining Death Can Our Society Tolerate?"
by Robert M. Veatch, PhD.

    Most laypersons have given no thought to the definition of death.
So they just follow what seems most comfortable and familiar to them.
This will often be colored by their religious background or cultural group.
And the more religious they are,
the more traditional their definition of death will probably be.
Some religious groups refuse to acknowledge that someone is dead
if the heart is still beating and the lungs are still breathing.

    But the medical profession and the law has moved ahead.
Some states now permit physicians to declare death
based solely on brain functions.

    Veatch proposes that the default definition of death
be the whole-brain criterion:
If all the functions of the whole brain have ceased,
the patient may be declared dead.
If the patient or the family have not expressed any views,
then this definition of death can be used without any further question.

    But patients and/or families ought to be permitted to deviate
from this default definition of death in either direction:
Conservatives could insist that heart and lungs must have stopped.
Liberals could deviate toward higher-brain definitions of death.
For example, when all consciousness is over forever,
such permanent unconsciousness could be defined as death.

    There must be limits, however:
We will not tolerate relatives declaring the merely-disabled to be dead.
At the other end, we will not tolerate our hospitals maintaining corpses
because the relatives refused to allow death to be declared
until the very last cell in that body is obviously dead.

    In most human deaths, the differences in definitions
will have no practical effect.
Opting for the more conservative definitions
will mean that the doctor will wait a few more minutes
before declaring death based on signs obvious to all present.
If the patient or corpse is not yet dead
according to everyone's understanding,
it will be completely dead within a short period of time.

    The most difficult cases will involve life-support machinery:
When the heart and lungs are being kept going by life-supports,
then the follow-on stages of degeneration
that clearly indicate death to everyone would be missing.
In such cases, the conservative relatives might be convinced
by having the life-supports switched off
to see if the patient lives or dies.

    Philosophically we might all agree
that death is a process rather than an event.
But we nevertheless need a date of death
in order to know when to start other behavior related to death:
When will we have the funeral or memorial service?
When with health-care coverage end?
When will life-insurance death-benefits be paid?
When will any marriage of the patient be over?

    Veatch suggests some individual choice about the ending of marriage.
Perhaps the surviving spouse
should be permitted to declare the marriage over
when the patient has become permanently unconscious,
even if the patient is maintained on life-supports for some reason.
If it has been confirmed that the patient will never have
another conscious thought or feeling,
then every form of interpersonal interaction has ceased forever.

    Veatch suggests that spouses of individuals in PVS
should be allowed to establish new marriages.
Socially the PVS spouse is dead,
even if the unconscious body is maintained by feeding-tubes, etc.

    Some people have philosophical and/or religious reasons
for staying married to a spouse in persistent vegetative state.
The loving commitment to that former person can be maintained
while the spouse who is still a full person moves on in life.
This is what Michael Schiavo did after his wife Terri Schiavo
had been in PVS for some years:
He started a new marriage-like relationship
and even had children with his new 'spouse'
while he was still officially married to Terri.
When Terri was finally disconnected from life-supports,
Michael married his second wife.
(Michael Schiavo's book, Terri, The Truth,
is reviewed in another bibliography:
Books on the Right-to-Die:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/B-RTDIE.html

    Veatch points out that having different definitions of death
in different states might create the following nightmare scenario:
What if the patient/corpse is taken by ambulance to another state,
where different criteria of death are in force?
If a patient is declared dead in one state,
does this status also apply in all other states?

    Presumably under any permissive set of optional definitions,
there would be only one declaration of death for each individual.
Once death is declared by a physician at the bedside,
all changes that normally follow death will begin:
Health-care for preserving the life of the patient will cease.
Life-support systems will be disconnected,
unless they are needed to preserve organs in good condition for donation
or even to gestate a fetus not yet ready to be born.
Life-insurance benefits will be paid.
Marriage will be over.
Social security and other pension benefits will end
—or shift to a spouse or other survivors.

    Veatch does raise the possibility that some individuals might be kept 'alive'
so that their relatives will continue to receive generous pension benefits.
There are no such reports, but it is a theoretical possibility.
If the family is receiving thousands of dollars a month
from some form of annuity, pension, or social security,
they do not want to kill the goose that is laying the golden eggs,
even if there are no other reasons for keeping the patient on life-supports.
Does this sort of thinking actually take place?
Exactly when should pension-benefits terminate for the not-quite-dead?

    On the other hand, inheritance is a benefit
that takes place only after death is declared.
Assets would pass to the heirs at an earlier date
if higher-brain criteria were used to declare death.
But the same kind of abuse by greedy relatives could occur
when the rich individual is being supported by machinery.
Premature withdrawal of life-supports could happen.
So far no such cases have been established.
But we need to be alert for the possibility that some life-ending decisions
are being taken to achieve an earlier pay-out of some kind of benefits.
Here are some safeguards for protecting patients from greedy relatives:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-GREED.html

    Sometimes people such as the Pope, a president, or a king
remain in that office until death is declared.
But now that we can keep individuals 'alive' by means of life-supports
even after they become permanently unconscious,
we need ways to replace such individuals if they enter PVS.

    Sometimes care-givers such as nurses and doctors
might be troubled by more liberal definitions of death.
They might not agree to 'pull the plug' for a patient in a coma
even if that patient has been officially declared dead.
But this problem is not unique to the definition of death.
Terminating medical treatment is always a lawful choice,
even if the doctors and nurses do not agree with this course of action.
If the patient dies as the result of withdrawing life-supports
or terminating other forms of medical care,
death will not be declared
until after the body shows the accepted signs of death.

    Veatch suggests the initiative for adopting an unusual concept of death
should belong to the family and/or the proxies.
Whenever they have unusual medical ethics or philosophical beliefs,
it is their responsibility to make those views known.

    An Advance Directive for Medical Care is the most convenient place
for the patient and/or the proxies to make any such wishes known.
See this reviewer's Question 19 for comprehensive Advance Directives:
"Which definition for death should apply to you?":
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/YLY-Q19.html

~~~~~~~

Chapter 9: "The Unimportance of Death"
by Norman Fost, MD, MPH

    This author suggests that we give up trying to re-define death
but go ahead with organ-donation from bodies
that will be known as 'living donors'.
He does not think that we will ever have a single definition of death
that will be suitable for all purposes.

    Fost cites the practice of organ-transplantation in Wisconsin
before that state created its brain-death law.
For 10 years, transplant surgeons took the donor to the operating room,
turned off the life-support systems,
waited a few minutes for the heart and lungs to stop,
declared death using the heart-lung criteria,
restarted the life-support machines,
& proceeded to harvest and transplant the reusable organs.

    Sometimes this procedure of proving death by the traditional criteria
is still practiced where brain-death laws are in effect.
This might be more for the benefit of the family than anyone else.
The family is supposed to be reassured that the donor was really dead
because the heart and lungs stopped working.
But, as others have argued,
if the vital functions could be restored by the life-support machines,
then the patient was not really dead after all.

    This reviewer believes that it would be easier on the family
for the death to be declared on the basis of brain-functions.
This could take place, not in the operating room
just before the organs are harvested,
but in the normal hospital bed
where the patient received his or her terminal care.
And it could take place hours or even days
before any cutting for transplantation begins.

    The process of proving and certifying that brain-death has occurred
would not be rushed by the necessity of operating immediately
in order for the organs to be as fresh as possible.
Second opinions can be sought to make sure
that the first doctor was not mistaken
about the present and future state of the brain
of the patient who will become the donor.

    Once death has been officially declared
and the death-certificate completed and signed,
then the family will proceed with the next steps in their grieving process,
notifying all family and friends of the death,
proceeding with funeral or memorial service plans, etc.
There will be no further need for the family members to stay by the beside.
The costs of terminal medical care will end with the declaration of death.
After the patient has been declared dead,
the costs of maintaining the body for possible organ-transplants, etc.
will be billed as a small part of the cost of
organ procurement and the transplants that will follow.

    The delay made possible by declaring death using brain-criteria
will allow the transplant system to locate and prepare
the very best recipients of the organs to be harvested.
The organs will be removed from a body that has been officially dead
for a few hours or even a few days,
even tho all of the vital functions of that body
are being maintained by artificial means.

    Fost points out that even in France,
which has a presumed-consent law for organ-transplantation,
in actual practice the doctors still ask for the organs from the family.
And if the grieving family declines, the organs are not used.

    This means that presumed consent is not working.
If that law were working as written,
then the organs would automatically be available for transplant.
The family would be informed but there would be no process of asking.

    In most of the USA, we have required request laws.
This means that the medical personnel are required to ask for organs
from the usually-traumatized family.
But this has made little difference in practice
because there are no consequences for not asking.
Since there is no enforcement method,
the medical staff will simply follow their own feelings,
which often means that they do not ask the grieving family
for the organs of their soon-to-be-dead or newly-dead relative.

    Changing the law to allow more liberal definitions of death
will not make more organs available for transplant
unless those laws actually change
what happens at the bedside of the dead (or nearly-dead) patient.
Fost points out that where laws have been changed,
organ-donation has not increased.

    Also, new definitions of death
create confusion among doctors and laypersons alike.
It used to be easier to 'pull the plug' without worrying about the law.
But now lawyers might have to be brought into the process
to make sure that death was properly declared according to the new law.
Fost thinks that everything was easier for doctors
before the laws were changed
to permit brain-criteria to be used in declaring death.
Fost says that the legislatures should resist the temptation
to resolve philosophical and religious issues by creating new laws.
To give another example,
legislators should not attempt to define when human life begins.

    Even tho brain-based definitions of death
have initially created more confusion than clarity,
this reviewer believes that we can only go forward
toward more freedom in defining death
rather than going back to relying only on the traditional criteria.
And we should even welcome as liberal a test
as permanent unconsciousness to be chosen as a definition of death
by those patients and families who see the advantages of such a definition.

    Dr. Fost here raises the issue of babies born without any upper brains.
He does believe that such anencephalic infants
should be used as organ donors to save the lives of other infants.
But they should not be defined as born dead.
He considers these bodies without upper brains as living donors.
The parents would be told that their babies died
when their organs were harvested.

    This reviewer suggests that it would be easier for all concerned
to prove that these infants were born permanently unconscious.
Because the parts of the human brain that are the seat of consciousness
are completely missing from these infants,
they will never have a conscious thought or feeling.
Their 'lives' will be reflexes controlled by their brain-stems.
If we ourselves were ever to decline into such a state
of biological life without the possibility of conscious thinking or feeling,
we would probably prefer that the last vestiges of 'life' be terminated.
But when the organs of permanently unconscious human bodies
can be used to extend the lives of babies and adults
who can live full human lives,
then it seems wiser to harvest the organs
than to allow those organs to die with their original owners.

    Dr. Fost wants to resolve this problems in a different way:
Instead of redefining death using brain-criteria,
he wants infants and adults without higher-brain functions
to be considered alive until the moment their bodies die
because vital organs were removed for transplant.

    Accordingly, most organ-donors would be living donors.
Their date and time of death
would be when the heart (for example) is removed.
It seems to me this would create more problems than it solves.
What transplant-team wants to operate on living donors,
who will be declared dead only when their organs are removed?
What family would consent to 'killing' their loved ones for their organs?
The dead-donor rule is now universally accepted:
Organs are only harvested from cadavers.
The transplant-team should not begin the process of harvesting
until after death has been officially declared by an independent doctor.

    Dr. Fost is quite liberal in practice,
even tho he takes a different philosophical point of view.
He even favors organ 'donation' from patients in persistent vegetative state:
When PVS patients are going to be disconnected from life-supports anyway,
they have no further interests or rights
that will be violated by harvesting their organs.
But his understanding would define PVS donors as living donors.
And, again, death would be declared after the vital organs are removed.

    Even more radical, Dr. Fost would permit terminally-ill patients
to donate their organs to save other lives.
Under present law and practice,
living donors are only allowed to donate paired-organs or parts of organs,
when such donations will not result in their own deaths.
Under Dr. Fost's proposal,
laws would have to be modified to make certain
that the transplant surgeon could never be charged with murder
for removing vital organs that resulted in the donor's death.
The donor might be alive and fully-functioning in every sense.
He or she might be able to give fully-informed consent
for the removal of his or her organs
with full knowledge that death would result from such harvesting.

    While this extreme conclusion might follow from Dr. Fost's premises,
it does not seem likely to this reviewer
that any such practice would ever be condoned.
The main worry would be that terminally-ill patients
were being killed for their organs.
Even with the best safeguards to prevent mistakes and abuses,
the general public would not agree
to allow terminally-ill patients to 'donate' their organs.
There will always be the doubt that the donor might have been saved.

    The option of a liberal definition of death
(such as permanent unconsciousness)
would allow this altruistic terminally-ill patient
to donate his or her organs so that others might live:
After all are satisfied that the safeguards have been fulfilled
so that no premature death will be involved,
the donor could be made permanently unconscious
by the most appropriate medical means.
Then the donor could be declared officially and permanently dead
on the basis of the final loss of consciousness
—without the possibility of consciousness ever returning.
If it seems wise, this donor could be certified to be brain-dead
before any consideration of organ-donation begins.
Only some time after official death has been certified,
after the death-certificate has been completed and signed,
would any cutting for transplant begin.
This would not violate the dead-donor rule.
The donor would be a cadaver at the time of the donation.

    This is how I would like to donate my own remains.
After I am finished with my body,
I want it to be used as a 'living cadaver'.
And if my body and/or organs are used in this way after my death,
I will have become a dead-donor.
Thus, it is critical that permanent unconsciousness
be accepted as a new (perhaps optional) definition of death.
Or perhaps it would be appropriate to insist
that brain-death be officially determined and declared.

    But we can still extend our thanks to Dr. Fost
for his creative attempts to solve the same dilemma in a different way.

~~~~~~~

    There are several other chapters not reviewed here.
If interested, check the Internet for a complete table of contents.
This collection has presented several different points of view,
from different professions, countries, religions, & generations.
More such conferences should continue the discussion
of the definitions of death.

2. Richard Zander, editor

Death: Beyond Whole-Brain Criteria

(Dordrecht, NL: Kluwer Academic Publishers, 1988)
(ISBN:            )
(Library of Congress call number: not given)
(Medical call number: W820D2853 1984)

    Based on a conference in 1984, the contributors to this volume
are divided—some advocating whole-brain definitions of death
and others advocating higher-brain definitions
or even the death of the person.
As of the time of this conference,
no clear consensus among the experts had yet emerged.
And they knew that the general public would take even longer
to comprehend the higher-brain definitions of death.

    But if we call it the death of the person or the end of conscious life,
then lay people should be able to grasp that easily and quickly.
This reviewer believes that each individual
should be empowered to specify in advance
which definition of death should be applied to him or her.
In some cases, this would permit an earlier declaration of death,
which would be very important for organ-donation
and other possible uses of a brain-dead body.

    The first chapter gives a good history of concern for defining death.
In the past, many worried that patients might be wrongly declared dead.
Medicine discovered how to resuscitate people who seemed to have died.
And medicine discovered how to keep tissue alive outside its host-body.
Premature burial was a wide-spread worry in the 19th century
—even tho no modern cases of being buried alive were ever proven.

    In recent years, the main problem has been keeping the body 'alive'
even after the death of the person.
We now worry about being wrongly declared alive.

    Whole-brain-death became the standard in medical practice in 1968,
because a wide consensus could be achieved about that definition.
But from the beginning, some experts advocated a higher-brain standard.
However, no reliable tests could prove permanent unconsciousness.
And it had become increasingly easy to keep a body 'alive'
without any of the higher functions of the human brain.

    Part of the difficulty in defining death is the assumed need
for an either/or definition of death:
Either this body is alive or this body is dead.
But should we be content to describe the various stages of dying?
Should the permanent loss of consciousness define death?
Without consciousness, our lives as persons have come to an end.
A human person has: consciousness, memory, language, & autonomy.
These are phenomena that every layperson can evaluate.
No technology is needed to determine sleep.
But we do need professional opinions to evaluate the possibility
that the patient might awaken at some time in the future.

    The second chapter argues forcefully
that once the upper surface of the brain (the gray matter) is dead,
that person is forever dead
—even if the brain-stem can keep the heart beating and the lungs breathing.
After the upper brain tissue is definitely dead, it never regenerates.
And consciousness has never been known to return to such a brain.
Thus, it seems wise and compassionate the stop the heart and the lungs,
to declare death, and to proceed with the other activities that follow death.

    Many laws require a sharp line between life and death.
A spouse of a patient in persistent vegetative state
would not be permitted to remarry until the patient is declared dead.
Inheritance does not pass until the grantor is legally dead.
Homicide is no longer possible if the patient was already dead.

    In general, the legal profession and the state laws
have left it to the medical profession to decided when to declare death.
And brain-death statutes grant legal permission
to use whole-brain criteria as sufficient for declaring death.
We might leave all determination of death to the medical profession
(presumably using criteria and tests doctors generally accept)
rather than changing the state laws
to embody every new advance in medical practice.
A good-faith declaration of death by a licensed physician
following accepted medical practice
should be sufficient to certify that a person is dead.

    David Smith recommends neocortical death as the definition.
When certain criteria are met, the person would be declared dead.
A PET scan could determine when a patient's neocortex is dead.
But additional methods have probably been developed since this writing,
which answer with ever greater confidence this question:
"Will this patient ever regain consciousness?"

    Once the patient has been declared dead, the family or the estate
could keep the biological functions going at their own expense.
But the public should not be expected to pay for such maintenance.
This would be parallel to the practice of freezing a body after death,
in the remote hope that a cure for the cause of death would be discovered
and the body could be brought back to life.
Any such freezing takes place after the declaration of death.
The cost of maintaining the frozen body is paid by the estate or the family,
just as the cost of burial or cremation would be borne by the family.

    In the donation-plans of this reviewer,
after the declaration of death based on permanent unconsciousness,
my body would become the property of the medical institution,
which could use it for any medical, scientific, or educational purposes.
This would be much better than keeping my body 'alive'
as a 'living memorial' to the person I once was.
These views are explored more fully in an on-line essay entitled:
"The Living Cadaver: Medical Uses of Brain-Dead Bodies".

~~~~~~~

    A chapter entitled:
"Human Death and the Destruction of the Neocortex"
by Edward T. Bartlett & Stuart J. Younger

    In creating a new definition of death, we need three elements:
a concept, medical criteria, & objective tests.
The first formulation of whole-brain death
did not separate these elements very well.

    In fact, much of the early, informal presentation of 'brain-death'
really referred to the higher-brain functions such as:
sentience, memory, personality, conscious life, uniqueness,
judging, reasoning, acting, enjoying, & worrying.

    However, the formal definitions referred to
the integrating functions of the brain-stem: such as regulating
heart-beat, breathing, body-termperature, & blood-pressure.
These are all functions that continue while we are asleep.
But the distinctively human and personal functions
only happen while we are awake.

    Whole-brain definitions of death would also apply to all animals.
But our higher-brains provide the functions that make us persons
—which is more than mere living biological organisms.
From the human and personal point of view,
we care more about the disintegration of ourselves as persons.

    The deaths of our human selves or persons take place some time
before the final deaths of our bodies as biological organisms.
We might want to draw the line between living persons and dead persons.
And we might add a new category: former persons.
These would be individuals who have permanently lost
most of the capacities that constitute personhood:
consciousness, memory, language, & autonomy.
How would we want to be treated if we become former persons?
These four criteria of personhood
are explored more deeply in a small book by the present reviewer:
When Is a Person? Pre-Persons and Former Persons.
This book contains about 200 questions that can be asked by laypersons
in evaluating the levels of personhood in someone they know.

    The whole-brain definition of death was proposed
because it would be acceptable by various groups in the public,
even if they have different philosophical concepts of life and death.

    But there are some conservative religious groups
that will be very slow to accept any changes in the concept of death.
Whole-brain death was acceptable because without mechanical support,
the body would soon be completely dead
by the traditional criteria of the loss of breathing and heart-beat
—which have been the definition of death for thousands of years.
When religions are founded on texts
written hundreds or even thousands of years ago,
it will be difficult for the present believers to make adjustments
for advances in medical science and technology.

    But the following is one possible direction for new religious thinking:
Religious people are very concerned about the spiritual condition
of the patient whose death is being determined.
Religions sometimes speak of the departure of the soul or spirit.

    Perhaps modern thinkers based in ancient religious traditions
will be able to notice that spirituality was usually found in living minds.
When thinking has ended permanently,
perhaps all spiritual activities of that person are also at an end.
When the death of the body immediately followed the death of the brain,
there was little reason to wonder about the departure of the soul.
When the breathing stopped, the soul departed:
Spiritual life within this earthly body was over.
But what about a body in persistent vegetative state?
Does the soul or spirit still exist within a body in a coma?
Or has the spiritual life of that living person come to an end?

    The present reviewer believes that we do have spiritual capacities,
such as self-transcendence, freedom, creativity, & love.
But all of these capacities of our human spirits depend on consciousness.
See an on-line series entitled WHAT IS SPIRITUALITY?

    Other persons who believe in 'spirit' take different points of view.
For some, spirit means primarily the capacity to exist beyond death.
But all who think about spiritual matters should ask themselves:
What is the spiritual condition of a former person in a coma?

    Some authors in this collection have begun the process
of re-thinking death as the death of the person,
which would anatomically be associated with the death of the neocortex.
If we are certain that the upper parts of the brain are permanently dead,
then we can be confident in declaring that person dead.
But it might be some decades before this concept
of the death of the human person is accepted by the general public.

    Laypersons are more familiar with consciousness
and the end of consciousness.
Each of us experiences the temporary loss of consciousness
every night when we go to sleep.
We know that sleep was temporary when we awake in the morning.
And when we observe others who have lost consciousness,
we can keep hoping that they will wake up again.
But after a reasonable time, if consciousness does not return on its own,
we should consult neurologists to discover
the causes of what appears to be permanent unconsciousness.

    If medical science tells us that consciousness will never return,
then we should consider what to do next.
The most conservative choice would be
to keep the body 'alive' for as long as possible,
using whatever life-support systems are appropriate.
The course suggested by standard medical care
is to wait for an agreed-upon length of time
to see if any efforts can bring this upper brain back to life.
And if nothing helps, then the life-supports are disconnected,
allowing the patient to die a natural death.
The most liberal (and still controversial) choice
would be to declare the patient to be dead
when it has been well-established that consciousness will never return.

    Death of the neocortex or death of the person
would allow the body to be used for organ-transplant
and other medical procedures and education.
But all medical personnel involved in such further use
of the permanently unconscious body
will have to be convinced that this patient is really dead.
If death has been officially declared and accepted by all concerned,
then what remains can be treated as a dead body.

    The public will be slow to accept
the death of the upper brain as the death of the person.
For example, what about the 10,000 patients in persistent vegetative state,
who are being kept 'alive' by various means of life-support?
The public will not easily allow these patients to be declared dead.
The case of Terri Schiavo amply illustrates this:
Most public opinion (including most of the U.S. Congress)
did not believe that Terri should be disconnected from life-supports,
which in her case was mainly a feeding-tube.

    We need careful discussion of the most appropriate
options of care for patients in PVS.
Should they be described as "former persons"?
Should we automatically keep all PVS patients
on life-supports as long as possible?
Should other options be accepted by the medical profession
as well as the general public?

    How will resistance to 'pulling the plug' be overcome?
It might take decades of discussion and re-thinking.
Perhaps other high-profile cases will galvanize new dialog.
The ever-increasing number of patients in PVS
will mean that more families will confront this problem.
And some individuals will make their own decisions
about how death should be defined in their own cases,
which will stimulated others who know about such choices
to reconsider how they would like to be treated at the end of their lives,
especially if they might have a long period of unconsciousness at the end.

    This reviewer recommends that all patients in PVS
be evaluated at least once every month.
And just because a decision was once made to put them on life-supports
should not prevent changing that decision
after a longer period of time without the return of consciousness.

    Permanent unconsciousness might become an optional definition of death:
New laws could be written that would allow a physician qualified in neurology
to declare a former person dead
if that patient has been unconscious for a year or more
and is never likely to regain consciousness.
And if the patient has given permission for such a definition
in an Advance Directive for Medical Care,
this will make such a declaration easier.
The family and the proxies might also agree with such a determination.
If the patient has received neurological care and evaluation for one year,
there can be a high degree of confidence
if all the neurological tests say that this upper brain
will never again have another moment of consciousness.

    Similar laws allow a missing person to be declared legally dead
if he or she has been missing for seven years.

    Death: Beyond Whole Brain Criteria was one of the earliest attempts
to go beyond the whole-brain definitions of death.
What was basically lacking when it was written
(and might still be basically absent)
is a clear set of tests for 'neocortical death'.
Only after medical science has reached a good consensus
about the end of consciousness and the death of the person
can the general public be expected to follow suit.

    Using higher-brain criteria for death
would allow patients to be declared dead
when they become permanently unconscious.
When our conscious lives have irreversibly come to an end,
we could permit a declaration of death,
which would then allow all the after-death events to begin.

    This is the choice I make for myself now.
Even if my body still has a heart-beat and is still breathing,
I grant my permission to be declared dead
if I will never again have a moment of conscious thought or feeling.
I would like to donate my body as a 'living cadaver'.
This is a new concept for medicine and for the general public.
But such an intermediate state might become more common.
For all purposes (medical, social, legal, etc), such a body is dead.
(As linked earlier, these views are explored more fully in an on-line essay entitled:
"The Living Cadaver: Medical Uses of Brain-Dead Bodies")

    Many of the authors in this book also raised the question
of defining what it means to be a person,
but none offered very elaborate definitions and tests for personhood.
They merely referred to such common-sense activities as
thinking, feeling, acting, communicating, relating, etc.
This reviewer thinks that we need more careful criteria
to decide that a certain individual has stopped being a person.
See When Is a Person? Pre-Persons and Former Persons.

    Even tho this book—Death: Beyond Whole-Brain Criteria—
is a few decades old, the issues have still not been resolved.
And new books along this line are definitely needed.

3. Michael Potts, Paul A. Byrne, & Richard G. Nilges, editors

Beyond Brain Death:
The Case Against Brain Based Criteria for Human Death

(Dordrecht, NL: Kluwer Academic Publishers, 2000)       270 pages
(ISBN: 0-7923-6578-X; hardcover)
(Library of Congress call number: not given)
(Medical call number: W820P871b 2000)

    Brain death has been widely accepted since the 1980s.
But this group of doctors and philosophers raise doubts about this practice.
Most of them come from Roman Catholic backgrounds,
but their objections are still based in science more than metaphysics.

    The definition of brain-death was developed
mainly to facilitate organ-transplantation.
But are we sometimes declaring people death too soon
in order to keep the organs in good condition for their next owners?

    Laypersons will always have problems with declaring their relatives dead
when they see their bodies still breathing (perhaps aided by machines),
their hearts still beating, & their bodies still warm to the touch.
Even if they are told that all brain functions have ceased
without the possibility of ever returning,
laypersons sometimes hold to their common-sense perception
that this body is still alive.

    And before the 20th century,
all doctors would have agreed that such bodies are still alive.
But almost all states in the USA now permit a new definition of death:
If all functions of the whole brain have ceased,
that person may be declared dead.

    But what about vestiges of consciousness in the upper brain
when the brain-stem is dead
and its functions have been taken over by machines?
If we take organs from such a body,
are we removing them while the donor is still alive?

    Being on the way towards death is not the same as being dead.
Fatal diseases or conditions are not sufficient to declare death.
Drugs can sometimes cause all functions of the brain to cease.
And if these bodies are not supported by medical technology,
all functions of those bodies will soon stop.
But in such cases, the loss of brain-function does not equal death.
Some people can be brought back from drug overdoses.

    This is the reason that there must be a waiting period
followed by re-testing before brain-death can be declared.
Drowning or drugs might have caused a temporary loss of brain-function.

    Religious beliefs about the soul inside the body
create some problems for the brain-death criteria.
According to most religious beliefs,
as long as the body is breathing, the soul is still there.

    Such religious beliefs might have to be adjusted for the new reality
of bodies being supported by high-tech machines.
When these beliefs emerged, breathing bodies were always alive.
And the departure of the soul was identified with the last breath.
People who believe in a soul will have to re-examine their beliefs
with respect to bodies sustained by life-support machinery:
If the patient is brain-dead,
—excluding the possibility of consciousness ever returning to this body—
has the soul already departed?
Can there be spiritual functions in a brain
after consciousness is no longer possible?

    What about a patient who spends years in persistent vegetative state?
Is the soul of such a patient still waiting within the body?
Will the soul 'depart' only after the life-supports are disconnected?
This reviewer believes that all spiritual functions depend on consciousness.
After my consciousness is over forever, so are all my spiritual functions.
But other forms of belief might reach different conclusions.

    And medical ethics should allow all forms of religious faith,
unless there is a serious conflict with scientific medicine.
Some people might want to consult their religious advisors
before deciding which definition of death to use.
Brain-death has been accepted by the scientific community,
but it might be a long time before religious authorities accept brain-death.
And this book has collected the views of a few people
who do not agree that a brain-dead patient is really dead.

    Because some countries have been slow to adopt brain-death,
a patient might be declared dead in one country but not in another.

    These differences will gradually be resolved
as universal standards and tests are accepted
for defining brain-death everywhere on the Earth.

    If we wish to harvest the organs of donors kept 'alive' by life-supports,
we must first define them as dead.
Death must be officially declared by a doctor
before any transplant surgeon will begin the operation
to remove reusable organs from the donor.
From this perspective, the potential donor must be either alive or dead.
If brain-death criteria and tests are to be used,
the family members must be brought along with this process.
Some religious family members might object to declaring death
on the basis of the cessation of all brain functions.

    Such dilemmas can be prevented by the patient
(while still a fully-functioning person)
deciding exactly which definition of death should be applied to him or her.
And such a practice would permit very liberal potential patients
to select even more controversial definitions of death,
such as the permanent loss of consciousness.
Such permissions could be embodied in
comprehensive Advance Directives for Medical Care.
For example, Your Last Year by the present reviewer
asks the following open-ended Question:
"Which definition of death should apply to you?"

    One author included in this volume—David Albert Jones, OP—
objects to all heart-transplants for the following reason:
Being almost dead is not the same as being completely dead.
If the heart can be re-started, then the donor was not dead after all.
Even if the heart was observed not beating for two minutes
—as required by some protocols—
the fact that it could be re-started in the body that receives the heart,
shows that the heart was not really dead.
Thus the donor was not dead because the heart could be re-started.
In Jones' view this donor is a living donor
because the heart was still beating
before it was stopped by removing the life-support systems.
And we do not permit living patients to donate vital organs such as hearts.
We do not want even the suspicion
that living donors have been killed for their organs.

    This raises the very valid question of just when to declare death.
If the patient has given permission in advance
for a liberal definition of death,
then there should be no reluctance on the part of the declaring doctor
to certify that this patient is officially dead.
Brain-death is the most common such situation:
All functions of the whole brain have permanently ceased.
A doctor—not part of the transplant team—declares the donor dead.
Then the dead body may be used for organ-transplantation.
But if the patient has given advance permission,
even something as liberal as permanent unconsciousness
could be accepted as a definition of death.
This might be required for using the body as a 'living cadaver'.

    Michael Potts points out that some people who oppose abortions
nevertheless permit brain-death criteria to be used for declaring death.
Some claim that a fetus is a person even tho it has no consciousness.
So why do they not maintain that an individual who is brain-dead
has a similar status to a fetus before consciousness emerges?
Some thinkers place the beginning of personhood
when a fetus can live outside its mother's womb.
Some say that personhood depends on being a unified organism,
controlled by a brain.

    The present reviewer defines personhood as having
(1) consciousness, (2) memory, (3) language, & (4) autonomy.
Under this definition, neither a fetus
nor an adult who is permanently unconscious
would qualify as a human person.
A fetus would be a pre-person.
And a permanently-unconscious adult would be a former person.

    Two chapters deal with Japan,
where brain-death has been slow to be adopted.
The basic worry is that a donor will be declared dead
before he or she is really dead
in order to harvest his or her organs for another individual.

    Whenever the real status of the donor is in doubt,
more and better testing is called for.
And this will often require more than simple, bedside tests
that can be performed by any physician.
Neurologists with special equipment and specific tests
should be employed for doubtful cases of brain-death.

    Some authors represented in this book
believe that we should always err on the side of caution:
Instead of allowing bodies to be declared dead
when all functions of the brain have ceased forever,
we should wait for all signs of death to be present,
including the end of heart-beat and breathing.
We would not do an autopsy on a warm, breathing body.

    At least one author says that the soul is present in the body
from the moment of conception.
Can a single cell have a soul?
And he does not know exactly when the soul leaves the body.
Therefore he will insist on the centuries-old definition of death.

    These are valid religious beliefs.
And those who embrace such statements of faith should say so
in their Advance Directives for Medical Care.
Also they might explicitly rule out organ-donation
because of the remote possibility
that they might be declared dead prematurely.

    Since this book was published in 2000,
there does not seem to have been any movement to overturn
the practice of declaring death using the brain-death criteria.
But the cautions embodied in this book
do need to be taken into account.
And laypersons, especially, need to be 'brought up to speed'
with current practices so that they will not hesitate of donate organs
if and when a sudden tragedy strikes the family.

4. D. Scott Henderson

Death and Donation:
Rethinking Brain Death as a Means of Procuring Transplantable Organs

(Eugene, OR: Pickwick Publications; www.wipfandstock.com, 2011)
(ISBN: 978-1-60899-622-3; paperback )
(Library of Congress call number: R725.56D36 2011)
(Medical call number: W820H496d 2011)

    This author gathers all evidence and testimony from people
who do not believe that brain-death should be used as the condition
for declaring death in order to allow organ-transplantation.
Even tho the practice has now been well-established for at least 3 decades,
there are some people who question its wisdom.

    The author raises serious doubts about the various definitions of brain-death
and the various tests that might be used for determining brain-death.
When brain-death has been defined in state laws,
problems and ambiguities always arise.

    Likewise, different sets of tests might be used in different locations,
which could mean that a patient is dead in one location but not in another.

    Everyone who wishes to advance organ-donation
should take into account the objections and problems raised by this book.
But this reviewer does not foresee many changes in current practice:
When a doctor has declared a patient to be dead on the basis of brain-death,
then transplantation of re-usable organs will be permitted.

    Ever-better definitions and tests for brain-death
will emerge over the next 1,000 years,
but we will never go back to requiring the heart to stop beating
and/or the lungs to stop breathing
before we can declare that a patient has reached the end of his or her life.

    Patients who wish to donate their organs after death
might make the situation easier for all concerned
if they were to set forth in writing (well before death)
their personal view that brain-death should be counted as death
at least as far as their own bodies are concerned.

    And they might even endorse a more liberal definition of death:
When their minds can no longer have a moment of consciousness,
then the death of the person can be declared,
following by whatever next steps might be required
for complete death to be declared in that time and place.

    Why would we keep a permanently-unconscious individual 'alive'
when meaningful human life is completely over?
That individual's organs could be transplanted into other patients
who will soon be dead because their original organs are failing.
When we compare the obvious benefits to the theoretical harms,
almost everyone says: Let the organs to given to living persons
who can make good use of them.

    Seven people might be saved from immediate death
by the donation of the organs of one individual
whose human, personal life has ended.

    Some people will always resist and reject brain-death.
And under most current laws, it is their right to deny organ-donation.
But for the vast majority of educated people,
it makes more sense to declare (or even facilitate) brain-death
so that the healthy organs can be given to someone else.
The organs will be much more useful to the recipient
than any possible value they might have to the brain-dead donor.

    Whenever we are uncertain about the condition of the potential donor,
we should seek a more complete and accurate description
of what is actually happening inside that individual body and brain.
Wrestling with definitions, words, & laws
will not be as productive and/or meaningful as
examining the actual patients who might become donors
and the actual patients who might receive their organs.

5. Franklin G. Miller & Robert D. Truog

Death, Dying, and Organ Transplantation:
Reconstructing Medical Ethics at the End of Life

(New York: Oxford University Press: www.oup.com, 2012)       196 pages
(ISBN: 978-0-19-973917-2; hardcover)
(Library of Congress call number: R726.M5525 2011)
(Medical call number: WB60M647d 2012)

    Philosophical questions about modern medical ethics:
How valid are the criteria for declaring brain-death?
Should organs be harvested before the donor is dead?

    Chapter 1 argues that withdrawing life-supports is a cause of death,
because the patient would have continued to live with the supports.
But modern medical practice affirms
that the underlying disease or condition is the cause of death,
even when life-supports were used for some period prior to death.
This confusion might be resolved by separating
the causes of death from the methods of dying.
A dead former-patient who was once sustained
by a breathing-machine or a feeding-tube
will have a death-certificate listing as the cause of death
the physical condition that first required the life-support system.
Discontinuing the life-supports was definitely a life-ending decision.
But the death-certificate should name the underlying problem
rather than the fact of disconnecting specific life-supports.
This distinction becomes even more obvious
when the "life-sustaining treatment" is an array of drugs.
No one would say that the cause of death
was the lack of drugs to control heart rate.
Here the cause of death is the underlying heart problem.
And the live-ending decision was giving up specific drugs.

    Here is an explicit provision for the proper recording of deaths:
"The Proper Recording of Voluntary Deaths and Merciful Deaths".

    Chapter 2 deals with the many variations of
'euthanasia' and 'physician-assisted dying'.
Whenever a life-ending decision is dubbed "euthanasia",
negative connotations become dominant.
Only a few countries allow lethal injection,
which would be the most common form of 'euthanasia'.
If patients have a right to refuse treatment,
does this give them a right to request 'euthanasia'?
Death is the result in either case.
But the professional ethics of the doctor
apply to these two different actions:
Doctors are not permitted to kill, but they can allow death.

    Doctors do in fact become involved in many end-of-life medical decisions.
And only a few of these are called "euthanasia" or "assisting suicide".
The authors do approve of some help at the end of life.

    Chapter 3 raises doubts about the definition of "brain-death".
Many functions of the body can be maintained
long after the brain has lost most of its functions.
In practice, this is only troubling in the case of organ-donation:
If the heart is still beating and the lungs are still breathing,
is this donor dead enough to harvest organs for others?
Without immediate medical intervention,
the patient whose brain stops working
will soon be dead in every sense of the word.

    The authors seek a satisfactory definition of brain-death.
In a few words, we must be able to separate the living from the dead.
A more open question would ask for a full description
of all of the facts about this particular patient.
Then the proxies could decide for themselves
what should be the next steps in caring for this patient.
While the philosophers discuss certain words and phrases,
the family must decide what to do next.
The criteria and tests for brain-death will continue to evolve,
but each patient's life or death must be decided right now.

    Chapter 4 continues the discussion of how to define death
by considering the "higher brain standard of death".
We cannot easily locate consciousness in one part of the human brain.
Therefore human death cannot be defined by loss of the 'higher brain'.
Even in PVS patients, there might be some elements of consciousness.
And many people would not agree to define a patient in PVS as dead.

    Also, can we speak of the "death of the person"
some meaningful time before the obvious death of the body?
Should consciousness (how measured?) be the main mark of personhood?

    The practical answer might be for each individual or family
to define for themselves what constitutes death for a specific patient.
When considering life-ending decisions,
what dimensions of personhood would be sufficient
to keep this patient 'alive' on life-supports?
Could death be declared somewhat sooner
for the purpose of organ-donation?
If no further meanings can be achieved in this human life,
should we 'pull the plug' and declare death?
That would allow the re-usable organs to be given to other human beings,
whose meaningful lives are most obviously not yet finished.

    Chapter 5 explores problems with organ-donation,
even using the traditional heart-and-lungs definition of death.
Sometimes hearts that have stopped spontaneously re-start themselves.
And the fact that the heart can be re-started in the body of the recipient
proves that this heart was not irreversibly dead.
If we wait too long to prove that the donor is permanently dead,
then the organs will become useless for transplant.
When the donor is being sustained by a heart-lung machine,
when and how should the donor be declared dead?
Becoming dead as soon as the heart is removed
would not be enough to satisfy the dead-donor rule.

    Exceptions to the dead-donor rule might be appropriate
when the complete situation is taken into consideration:
The donor is definitely on the way towards death.
Nothing can restore the donor to ordinary life.
And those who are waiting for organs in nearby operating rooms
will greatly benefit from the organs that can be harvested
from the dying donor.
Everyone agrees that good motives and good behaviors
are seen on all sides.
So why not go ahead,
even if the process might violate the dead-donor rule?

    Another way to fulfill all requirements would be to permit
permanent unconsciousness to be the criterion of death.
Then the doctors could give sufficient drugs
to prevent any return of consciousness.
The donor could be declared dead
because of the irreversible loss of consciousness.
And the donation could proceed with the organs all functioning well.

    Perhaps the transplant doctors would be even safer
if other doctors intentionally caused brain-death
—with the permission of everyone concerned.
Then they would declare the donor to be officially dead,
even while the body is maintained by 'life-support' machinery.
And the transplant surgeons could proceed to harvest
and transplant all of the useful organs
into patients waiting in adjoining operating rooms.

    Chapter 6 proposes a dramatic departure from current practice:
Might it be possible for living donors
who are known to be on the downward pathway towards death
to donate their organs as part of a set of life-ending decisions?
The patient and/or the proxies for the patient
officially decide to terminate all life-support systems.
This is known by all to be a life-ending decision:
The patient will inevitably die as a result of such withdrawal.
But on this pre-determined date of death,
the patient and/or the proxies also authorize
the harvesting of all transplantable organs
—before the official moment of death is declared.
The donating patient is completely and permanently unconscious
from the beginning of the whole medical process.
This donor will never have another thought or feeling.
But biologically speaking, the donor's body is still alive.
After all usable organs have been removed from the donor's body,
any remaining life-support systems are switched off and detached.
And then the donor is declared officially dead.

    This is a direct violation of the dead-donor rule:
Only donors who are already dead may have their organ harvested.
Or it might be characterized as an exception to the dead-donor rule.

    This reviewer expects medical ethics and public opinion
to be more receptive to a liberalized definition of death:
The anesthesia given to the donor can guarantee
that consciousness will never return to this brain.
Then the donor can be officially and legally declared dead
—either on the basis of brain-death or permanent unconsciousness.
This would be especially reasonable
if the donor approves in advance this new definition of death.
A peaceful and painless death is achieved by one team of doctors
—following all relevant safeguards for life-ending decisions.
Once the donor has been officially and legally recorded as dead,
then the transplant team can take possession of the body
and begin the process of harvesting organs that can save other lives.

    The forms and degree of harm to the donor is almost non-existent
if this donor was clearly already on the road towards death.
Sometimes the donor is not quite dead.
With fully-informed prior consent from the donor and the proxies,
it should be possible to donate living organs from the almost-dead donor.
Blood circulation has not been proven to have ceased irreversibly.
Even if brain-death has been declared,
some signs of life might still be detected in this brain.
Nevertheless, these authors believe
that we can ethically remove living organs for transplant.

    Even if transplant clinicians were able to accept not-quite-dead donors,
because of their deep knowledge of the inevitability of this death,
the general public will probably not accept the subtle distinctions
argued effectively in this book.
Laypersons will more strongly insist on the dead-donor rule.
Because of the science-fiction worry about killing people for their organs,
the general public wants each donor to be officially and legally dead
before any cutting begins to harvest organs to save other lives.

    Chapter 7 explores 'legal fictions' in making end-of-life decisions.
The authors believe that both brain-based
and circulation-based definitions of death are legal fictions
—similar to saying that a corporation is a person.
They hope that these convenient falsehoods will eventually be replaced
by their own ethical principles that would allow organ-donation
from patients who are as good as dead.

    But the authors also acknowledge that the dead-donor rule
has been used so widely and consistently in organ-transplantation
that it does not seem likely to be replaced by their re-thought system
of allowing almost dead individuals to donate their organs before death.
It will make no difference in practice,
but a few specialists might approve the thinking presented in this book.

6. Dick Teresi

The Undead:
Organ Harvesting, the Ice-Water Test, Beating-Heart Cadavers
—How Medicine is Blurring the Line between Life and Death

(New York: Pantheon Books: www.pantheonbooks.com, 2012)       350 pages
(ISBN: 978-0-375-42371-0; hardcover)
(Library of Congress call number: not given)
(Medical call number: W820T316u 2012)

    A science writer and journalist explores
the dark world of brain-death and organ harvesting.
He interviewed many people in creating this book.
Thus the conclusions are based on expert opinion
rather than doubts raised by lay-persons
thinking about death for the first time.

    Surprisingly, there are many moments of humor in this book.
Funny things can happen on the way towards death.

    This book belongs with the others opposing liberal definitions of death
because of the suspicion that the donor is not quite dead yet.
Should the donor be put under anesthetic before organs are removed?
Even some transplant doctors believe so.
They want to prevent the body from having any reflexive movements
when the viable organs are harvested.

    This reviewed agrees with the dead-donor rule:
The donor must be officially declared dead
by an independent doctor before any organs are removed.
Sometimes re-testing will make certain that the donor is dead,
especially when brain-death needs to be proven.
This would be especially important when the cause of death is not known.

    But when specific medical methods of dying have been applied,
then there should be no ambiguity about the death:
The patient and/or the proxies have made a life-ending decision.
And possibly they have agreed in advance to donate all usable organs.
Perhaps the method of dying was selected by the doctor
specifically to facilitate organ-donation.
When this is a chosen death, no elaborate testing and re-testing is required.
The declaring doctor can say ahead of time exactly what signs of death
will prove that the donor is completely dead.

    The doctor who declares death
can have the death-certificate filled out in advance.
Only the exact time of time will be filled in when death is declared.
The declaring doctor will sign the completed death-certificate.
And then the transplant team can accept the cadaver
and begin their process of removing the organs
that will give many more years of service in their new owners.

    If you are already an organ-donor,
do not allow this book to change your mind.
Affirm your preferred definition of death in your Advance Directive.
And say which organs (if any or all) you wish to donate after death.

7. John A. Lizza

Persons, Humanity, and the Definition of Death

(Baltimore, MD: Johns Hopkins University Press: www.press.jhu.edu, 2006)
(ISBN: 0-8018-8250-8; hardcover)
(Library of Congress call number: RA1063.L59 2006)
(Medical call number: W820L789p 2006)

    Biological death is well understood in modern biology.
All the same definitions and tests that apply to other animals
also apply to the human bodies.
But human death is more personal and social than animal death.
This book explores the extensive philosophical discussion
of just what constitutes the death of a human person.

    Consciousness and the end-of-consciousness
are very important for discussing the deaths of human persons.
We would not keep a permanently unconscious animal alive.
But some human bodies have been maintained for years
after the last sign of conscious life had disappeared.

    Some of the important issues covered:
persistent vegetative state, brain-death, higher-brain death,
personhood, allowing alternative definitions of death.

    This book offers a comprehensive review of thinking up to 2006.
But it does not offer any new, original insights or suggestions
for making death-bed decisions about people who might be dead.
As such, it is holds more interest for philosophers
than for patients and their doctors,
who must determine death every day in our hospitals.

Created 11-2-2007; 11-7-2007; Revised and expanded 12-8-2007; 12-15-2007; 12-18-2007;
2-26-2009; 4-18-2009; 5-30-2010; 9-11-2010;
5-19-2013; 5-21-2013; 5-24-2013;7-7-2013; 7-8-2013; 7-28-2013;
5-29-2015; 3-2-2018;

Here is the complete list of bibliographies related to death:

A. Death—The Best Books

B. Preparing for Death

C. Best Books on Terminal Care (from the Doctor's Point of View)

D. Books on Hospice Care

E. Advance Directives for Medical Care —The Best Books

F. The Right-to-Die—Best Books

G. Books Opposing the Right-to-Die

H. Safeguards for Life-Ending Decisions—Best Books

I. Definitions of Death

J. Books on Voluntary Death

K. First Books on Voluntary Death by Dehydr ation

L. Medical Methods of Choosing Death

M. Books on Helping Patients to Die

N. Books Describing Merciful Deaths

O. Best Books on Cancer for Laypeople

P. Is There Life After Death?—Best Books

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