Respecting Choice in Definitions of Death

Abstract

The definition of death was clearer one hundred years ago than it is today. People were declared dead if diagnosed with permanent cessation of both cardio‐circulatory function and respiratory function. But the definition has been muddled by the development of new technologies and interventions—first by cardiopulmonary resuscitation and ventilators, which were introduced in the mid‐twentieth century, and now by extracorporeal membrane oxygenation, which creates the ability to keep oxygenated blood circulating, with or without a beating heart or functioning lungs. In Defining Death: The Case for Choice, Robert Veatch and I argue that the definition of death should focus on “what change in a human being is so fundamental that we can say the individual is no longer with us as a member of the human community bearing rights such as the right not to be killed.” We assert that this decision is a normative issue about which different stakeholders may believe that different changes are fundamental, and we therefore propose that the optimal policy solution may be to allow stakeholders to choose their own definition within a reasonable range of options. There are three caveats that need to be highlighted regarding this approach.

Death, dying and donation: community perceptions of brain death and their relationship to decisions regarding withdrawal of vital organ support and organ donation

“…This suggests that these decisions were not being made due to a lack of knowledge, but more likely that these opinions are representative of differing considerations of what it means to be declared dead. 16 Our findings suggest that the Australian public have a rather pragmatic view regarding 'life support' in severe brain injury, such that the formal determination of death is less important than the degree of brain damage and the corresponding impact that has on the likelihood of survival in determining whether a patient should be 'allowed to die'. The proportion of respondents agreeing to withdraw life support is similar to that reported from previous international surveys of general public opinion.…”

“…Respondents indicating they agreed that the patient was dead favoured functional reasons, such as the inability to breathe and loss of meaningful life without a living brain, whereas those considering him not dead favoured the ongoing presence of a pulse and/or breathing. This suggests that these decisions were not being made due to a lack of knowledge, but more likely that these opinions are representative of differing considerations of what it means to be declared dead 16 …”

Ethics in extracorporeal life support: a narrative review

“…Early works by Bartlett [ 3 ] and Lantos et al [ 10 ] describe how ECLS research is linked to its ethical prerequisites and consequences; Jaramillo et al [ 17 ] point out the rationality of deliberation in limiting ECLS; Carlisle et al [ 65 ] oppose the clear-cut understanding of futility; and in the face of the common utilitarian ECLS-prioritisation model advocated by Abrams et al [ 66 ], Supady et al [ 26 ] prefer the egalitarian approach of Norman Daniels, which is based on the right to participate in a fair and transparent allocation process. Finally, Ross [ 67 ] and Halpern et al [ 55 ] depict the notion of death as pragmatic and therefore alterable.…”

Challenges to Brain Death in Revising the Uniform Determination of Death Act

“…Without doubt, the most flexible public policy approach would be to allow patients the liberty to choose their own personal death criteria and to extend that right of choice to lawful surrogate decision-makers such as durable powers of attorney for health care. This libertarian approach, proposed in detail by Veatch and Ross, 57,58 holds that patients' constitutionally protected rights to consent and refuse treatment should encompass the ultimate right to be declared dead according to one's own choice of death criteria. Although permitting personal choice in medical conditions is appealing in a liberty-respecting society, the idea of personal choice in death criteria strikes me as difficult to implement in clinical practice and one that carries the potential for creating chaos in intensive care units.…”