The conception and the determination of brain death continue to raise scientific, legal, philosophical, and religious controversies. While both the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in 1981 and the President’s Council on Bioethics in 2008 committed to a biological definition of death as the basis for the whole-brain death criteria, contemporary neuroscientific findings augment the concerns about the validity of this biological definition. Neuroscientific evidentiary findings, however, have not yet permeated discussions about brain death. These findings have critical relevance (scientifically, medically, legally, morally, and religiously) because they indicate that some core assumptions about brain death are demonstrably incorrect, while others lack sufficient evidential support. If behavioral unresponsiveness does not equate to unconsciousness, then the philosophical underpinning of the definition based on loss of capacity for consciousness as well as the criteria, and tests in brain death determination are incongruent with empirical evidence. Thus, the primary claim that brain death equates to biological death has then been de facto falsified. This conclusion has profound philosophical, religious, and legal implications that should compel respective authorities to (1) reassess the philosophical rationale for the definition of death, (2) initiate a critical reappraisal of the presumed alignment of brain death with the theological definition of death in Abrahamic faith traditions, and (3) enact new legislation ratifying religious exemption to death determination by neurologic criteria.

Ben Saunders claims that actual consent is not necessary for organ donation due to 'normative consent', a concept he borrows from David Estlund. Combining normative consent with Peter Singer's 'greater moral evil principle', Saunders argues that it is immoral for an individual to refuse consent to donate his or her organs. If a presumed consent policy were thus adopted, it would be morally legitimate to remove organs from individuals whose wishes concerning donation are not known. This paper disputes Saunders' arguments. First, if death caused by the absence of organ transplant is the operational premise, then, there is nothing of comparable moral precedence under which a person is not obligated to donate. Saunders' use of Singer's principle produces a duty to donate in almost all circumstances. However, this premise is based on a flawed interpretation of cause and effect between organ availability and death. Second, given growing moral and scientific agreement that the organ donors in heart-beating and non-heart-beating procurement protocols are not dead when their organs are surgically removed, it is not at all clear that people have a duty to consent to their lives being taken for their organs. Third, Saunders' claim that there can be good reasons for refusing consent clashes with his claim that there is a moral obligation for everyone to donate their organs. Saunders' argument is more consistent with a conclusion of 'mandatory consent'. Finally, it is argued that Saunders' policy, if put into place, would be totalitarian in scope and would therefore be inconsistent with the freedom required for a democratic society.

m o n g some faculty and administration in higher education, the position hat students are our customers" has b e c o m e a form o f " a c a d e m i c orthodoxy," from which dissent is t h o u g h t to be "irresponsible." Obviously, such a claim has practical consequences, from the way that faculty teach their courses to the role that student evaluations play in the process of evaluating faculty. Paul Gottfried notes that in many colleges and universities, "Professors see themselves, or are urged by administrators to do so, as purveyors of customer service, while academic m a n a g e m e n t routinely refers to students and their parents as consumers or customers. "~ I have heard such claims m a d e by some of my own colleagues, and not only those from the business department. Although not all my colleagues agree with that position, it remains prevalent a m o n g faculty and administrators, not only at small colleges placing a prem i u m on enrollment, but also in large, well-endowed universities.

Alan Shewmon's article, 'The brain and somatic integration: Insights into the standard biological rationale for equating "brain death" with death' (2001), strikes at the heart of the standard justification for whole brain death criteria. The standard justification, which I call the 'standard paradigm', holds that the permanent loss of the functions of the entire brain marks the end of the integrative unity of the body. In my response to Shewmon's article, I first offer a brief summary of the standard paradigm and cite recent work by advocates of whole brain criteria who tenaciously cling to the standard paradigm despite increasing evidence showing that it has significant weaknesses. Second, I address Shewmon's case against the standard paradigm, arguing that he is successful in showing that whole brain dead patients have integrated organic unity. Finally, I discuss some minor problems with Shewmon's article, along with suggestions for further elaboration.

Conflating physician-assisted death with palliative care is a growing concern in medicine. Palliative care is symptommanagement medical care without actively shortening the end-of-life trajectory of a terminal illness. Physician-assisted death intentionally shortens the dying process to bring about preplanned death as the means of relieving suffering. Physician-assisted death may be conflated with palliative care where this practice is illegal, eg, France. The Revised French Code of Medical Ethics states that when the decision to withdraw or withhold treatment is made in accordance with applicable law, and even if the patient has brain damage precluding an assessment of suffering, physicians must use the treatments, including analgesics and sedatives, to maximize the quality of end of life, safeguard the patient's dignity, and comfort relatives. This revision, which in France has the force of law, appears to uphold the Hippocratic Oath to alleviate suffering and deliver compassionate care. Additional analysis raises questions: (1) what type of treatment is being withdrawn or withheld? (2) What type of brain damage or neurological disability might preclude the assessment of suffering? (3) What type of suffering (eg, physical, psychosocial, existential, etc.) must be treated? (4) What measure of proportionality is applicable to ensure that sedatives and analgesics will not be the proximate causation of death? The legislation assumes potential suffering from treatment withdrawal which disrupts the current ethical paradigm on withdrawing versus withholding treatment. This legislation also applies to neurologically disabled patients incapable of requesting euthanasia but for whom a treatment limitation decision has been made. Re-evaluation of the double-effect principle, intention, and causation of death precludes using the term palliative care. The two-step process (ie, treatment withdrawal and administration of sedatives and analgesics) should be considered physician-assisted death in some neurologically disabled persons. The revision implicitly paves the way to organ donation euthanasia in neurological disorders.

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The current practice of organ transplantation has been criticized on several fronts. The philosophical and scientific foundations for brain death criteria have been crumbling. In addition, donation after cardiac death, or non-heartbeating-organ donation (NHBD) has been attacked on grounds that it mistreats the dying patient and uses that patient only as a means to an end for someone else's benefit.Verheijde, Rady, and McGregor attack the deception involved in NHBD, arguing that the donors are not dead and that potential donors and their families should be told that is the case. Thus, they propose abandoning the dead donor rule and allowing NHBD with strict rules concerning adequate informed consent. Such honesty about NHBD should be welcomed.However, NHBD violates a fundamental end of medicine, nonmaleficience, "do no harm." Physicians should not be harming or killing patients, even if it is for the benefit of others. Thus, although Verheijde and his colleages should be congratulated for calling for truthfulness about NHBD, they do not go far enough and call for an elimination of such an unethical procedure from the practice of medicine.

The “standard position” on organ donation is that the donor must be dead in order for vital organs to be removed, a position with which we agree. Recently, Robert Truog and Walter Robinson have argued that (1) brain death is not death, and (2) even though “brain dead” patients are not dead, it is morally acceptable to remove vital organs from those patients. We accept and defend their claim that brain death is not death, and we argue against both the US “whole brain” criterion and the UK “brain stem” criterion. Then we answer their arguments in favour of removing vital organs from “brain dead” and other classes of comatose patients. We dispute their claim that the removal of vital organs is morally equivalent to “letting nature take its course”, arguing that, unlike “allowing to die”, it is the removal of vital organs that kills the patient, not his or her disease or injury. Then, we argue that removing vital organs from living patients is immoral and contrary to the nature of medical practice. Finally, we offer practical suggestions for changing public policy on organ transplantation.