differences between deathand dying · although dividing an account ofdeath into three parts has...

Journal of medical ethics, 1995; 21: 270-276

Differences between death and dying

E T Bartlett Cleveland State University, Ohio, USA

AbstractWith so much attention being paid to the developmentand refinement of appropriate criteria and tests fordeath, little attention has been given to the broaderconceptual issues having to do with its definition or withthe relation ofa definition to its criterion. The task ofselecting the correct criterion is, however, virtuallyimpossible without proper attention to the broaderconceptual setting in which the definition operates as thekey feature. All of the issues I will discuss arise becauseof this lack of concern with conceptual matters. Suchproblems as incorrectly diagnosing a patient as deadprior to the harvesting of his or her organs, defending theidea that death is reversible, and advocating abrainstem criterion ofdeath, are all, I believe, errorsthat derive from this misplaced emphasis.

In a paper written a little over 13 years ago, Bemat,et al remarked that (1):

'Much of the confusion arising from the currentbrain death controversy is due to the lack of rigorousseparation and ordered formulation of three distinctelements: the definition of death, the medicalcriterion for determining that death has occurred,and the tests to prove that the criterion has beensatisfied'.

Not much has changed in the years since thoseremarks were first made. Although dividing anaccount of death into three parts has become moreor less accepted in the literature, what has notdeveloped is an equal appreciation and understand-ing of all components of an account. Instead, dis-agreements over which criteria are correct, forexample, brainstem versus whole brain, versushigher brain, versus cardiopulmonary, have receivedthe greatest amount of attention. This is no doubtbecause of the fear that ifwe get the criterion wrong,there is real danger of a misdiagnosis! It is, however,the converse of this attitude that is troublesome, ie, if

Key wordsDeath; definition; brain death.

we get the criterion right so that there are no falsepositives, nothing else much matters. With so littleattention being paid to conceptual niceties, it is, Isuppose, to be expected that questions such as thereversibility of death begin to gain credence!

Definitions of death have two components. One isformal and universal and the other material and par-ticular. The formal requirement is the same for everydefinition and, that is, irreversibility. This is truesimply as a matter of language. It is how we speakersof English have come to use the word 'death'. Thematerial part of the definition explains what, on aparticular view, death is said to be. It is in this areathat much of the current dispute ought to be occur-ring, for example, loss of the integrating function ofthe organism as a whole versus what is essentiallysignificant to the life of a person.

It is the criteria that contain the anatomical refer-ence needed to apply the ideas in the material com-ponent of the definition to a particular case. Thecollapse of that segment of the anatomy selected bythe criteria, as measured by the tests, provides uswith the proximate cause of death. In a consistentaccount, the cessation of the functions of the organsdesignated by the criteria, yield what is meant by'death' as explained by the material component ofthe definition. If the cessation of these functionsdoes not create a condition that actually constitutesdeath, then the account fails, either because thecriterion and the material portion of the definitiondo not coincide, or, because what they pick out is notwhat we mean by 'death'. Criteria are thus judged intwo ways. First they must fulfil the definition, ie,they must be an anatomical reflection of its materialcontent. Secondly, together with the definition, theymust properly correspond with ordinary use andordinary language. Even if they match perfectly, iftheir application required us to withhold the diagno-sis of death from previously clear cases and apply itto only novel ones, their consistency would notmatter.

Arguments that support the components of adefinition are conceptual and linguistic, whereasthose in support of criteria are primarily factual andempirically based. Whether or not, for example, 'the

copyright. on June 7, 2020 by guest. P

rotected byhttp://jm

e.bmj.com

/J M

ed Ethics: first published as 10.1136/jm

e.21.5.270 on 1 October 1995. D

ownloaded from

http://jme.bmj.com/

E TBartlett 271

destruction of the brain as a whole' is both necessaryand sufficient in order to end up with 'the loss ofintegrating function of the organism as a whole' is anempirical issue. Is there anything other than thedestruction of the brain as a whole that would, initself, result in the loss of the integrating function?The answer to that is dependent upon what isphysiologically true and one's knowledge of it.Whether or not loss of integrating function is whatwe mean by 'death' is not, however, an empirical buta linguistic question.

Marking an irreversible episode is a necessary butcertainly not sufficient condition for an acceptabledefinition. It must also mark the right one, ie, it mustcapture what the public means when they recognizeinformally that someone is dead. For example,would we call someone 'dead' even though she dis-played some degree of integrating capability (2),and, even though a patient showed no capacity at allfor sustaining the integration of her systems, is theresome other consideration that might lead us to saythat she was, nevertheless, alive (3)?

Neurological criteriaThe application of a criterion of death to a particularcase is always the application of a relative standard.Even though criteria have more stability than tests,they never reflect more than where medicinehappens to be at the moment. Specifically, theircontent reflects what medical practice currentlybelieves to be the point of irreversibility. Prior tocardiopulmonary resuscitations (CPR), a cardiacarrest was appropriate material out of which to con-struct a criterion of death because people neversurvived them. But as CPR was developed, itbecame clear that an arrest was not necessarily irre-versible. Consequently, its status as a criterion waschallenged on the purely formal grounds of revers-ibility. If one recovered, clearly he didn't die, so thatwhatever had happened was not acceptable as acriterion of death. With the publication of theHarvardAd Hoc Committee Report and eventually thePresident's Commission's Defining Death, neuro-logical criteria have become today's irreversibleepisodes. In the United States, the irreversibledestruction of the brain as a whole marks the eventfrom which there is said to be no recovery. But,whether or not that is the correct criterion, there isno reason to believe that it must remain so for alltime. As medicine reverses conditions previouslythought to be irreversible, there is every reason tobelieve that this criterion too will have to undergochange.

Generally speaking, as long as an event or itemfunctions as a condition necessary for the occurrenceof the death, it may be included as a link in thecausal chain that ends in death. The very last link inthe chain is, however, special. It is always failure atthe physiological spot designated by the criterion of

death. What sets this link apart from any of the otherones is that, first, it must be present in every suchcausal chain, and second, its fulfilment constitutesdeath, ipso facto. In the United States where thedestruction of the brain as a whole is said to be thecriterion and 'integrating function of the organism asa whole' (4) is said to be the definition, we would saythat at the moment when the brain as a whole wasdestroyed the patient was dead. That is, the destruc-tion of the brain as a whole gives us, in itself, whatwe mean when we say that a person is dead. Unlikethe other links in the chain, this cause must actuallyconstitute its effect. Not only is it necessary for theoccurrence of death, it is sufficient as well. It must,of course, also mark what is currently the point ofirreversibility.

Contrast this sense of cause with, for example,saying that what caused the patient's death was abullet fired into his brain. Even though there is nodoubt that it will ultimately lead to death, what wemean when we say that someone is dead must beapplicable to absolutely anyone who has died in thepast or will die in the future. Clearly people havedied and will die without bullets in their brains. But,if the account being considered is correct, no oneever has or will die without his brain as a whole beingdestroyed, because that is what gives us what wemean when we say that someone is dead, ie, 'a loss ofthe integrating function of the organism as a whole'.

Christopher Pallis and those who accept his brain-stem view defend an account that is vulnerable tocriticism based on the above observations. In anargument designed to rebut the re-introduction ofthe cardiopulmonary criterion, Pallis chastises thosewho insist that 'the criterion of death should be thecessation of cardiac activity' because, he says, they'fail to grasp that it is an adequate blood flow ofoxygenated blood to "the brain as a whole" brain -

not cardiac function per se - that is of relevance' (5).The basis of this argument is the distinction betweenthose anatomical functions which, with respect todeath, are of importance in themselves, ie, they con-stitute death, as opposed to those that are importantonly as a means to something else, ie, they causedeath. Cardiac function is important, but only tosupport cerebral functions and not in itself. Pallis ismaking the same point here that I made moregenerally above. Failure of cardiac activity does not,in itself, constitute death. It is, potentially, a cause ofdeath but not in the constitutive sense required of anacceptable criterion.

The brainstem accountThe point I want to make is that this same argumentapplies, I believe, to the brainstem account. Pallisexpresses it as follows: 'If human death is defined asthe irreversible loss of the capacity for consciousnesscombined with the irreversible loss of the capacityto breath spontaneously (and hence to maintain a



e.bmj.com

/J M


e.21.5.270 on 1 October 1995. D

ownloaded from

http://jme.bmj.com/

272 Differences between death and dying

spontaneous heart beat) the death of the brainstemwill be seen to be the necessary and sufficient condi-tion for the death of the individual' (6).

Supplementing this view is the one expressed byGillonjn an editorial in this journal: '... if a humanperson is necessarily a unity of consciousness andbody, and if consciousness (and a capacity andpotential for consciousness) has ceased to exist, thenthe human person has ceased to exist' (7).

Crucial to both expressions is the conjunction ofconsciousness together with integrating functions asthe two constituents of human existence, both ofwhich have their seat in the brainstem. Although Iwould take issue with this view because of thedualism that it embraces, for the purpose of this dis-cussion I want to focus on just the matter of causeversus constituent part as a way of sorting throughcriterial candidates (8).

Although the brainstem provides importantsupport for consciousness, it does so only causallyand not as a constituent. Just as in Pallis's ownexample of the 'heartless' Barney Clark, a patientwith an infarcted brainstem may do well enough, ie,be alive, on a respirator and in intensive care. It istrue that the reticular activating system (RAS) doesexercise control over consciousness, but, like theheart, its importance lies in the support that itprovides to another structure, the cortex, and not initself. Cortical failure is a constituent part of deathwhile RAS failure is merely one of its many causes.In this regard failure of the RAS is the same ascardiac failure in that it causes but does not consti-tute death. But, in another regard, it is not even asclosely connected to death as is cardiac failure.When the heart stops, autolysis soon destroys thecells of the cortex. In the absence of the RAS, thecortex, intact, just never gets turned on. Although itis unlikely that the cortex could get turned on via adifferent circuit that bypassed the RAS, as long as itremains intact as the seat of consciousness, thepossibility remains, if only as a theoretical one.

A mindless organismThe other half of this pair, the integrating functions,for example, neuroendocrine control, do actuallyconstitute much of '... the human organism func-tioning as an integrated whole' (7). What this meansis that when the brainstem - exclusive of the RAS -fails, this failure gives us what we mean when wespeak of the failure of the organism as a whole. Theonly way in which one could argue, however, thatthe destruction of the brainstem constituted deathwould be by defending a straightforward brainstemdefinition of death in which the material content ofthe definition promoted just these integrating func-tions. This would mean that the absence of thesefunctions alone would give us what we mean whenwe say that a person is dead. That is, I believe,manifestly false. What these integrating functions

constitute is a mindless organism - nothing recog-nizable as a human being (9). In summary, bothcomponents of the brainstem account fail because ofrequirements of the relationship between criteriaand definition. The failure of the RAS causes butdoes not constitute the irreversible loss of conscious-ness and while the loss of the integrating functiondoes indeed constitute the destruction of theorganism's functioning as a whole, the absence ofthose functions does not make up the death of whatis recognizably a human being.

Startling claimIn a very different area of the same conceptual arena,David Cole makes the rather startling claim that theordinary concept of death is the concept of areversible state. In an article entitled 'The reversi-bility of death' he argues against what he calls thestrong construal of irreversible: 'The first construalof irreversibility, on which it is for all time and notrelative to the present, has the counterintuitive con-sequence that one cannot possibly come back to life.Death is defined as irreversible for once and for all -but this surely conflicts with the ordinary concept'(10).

I confess to intuitions totally opposed to the oneshad by Mr Cole. Consequently, if we are to avoidgridlock, we need to find something other than ourrespective hunches. One of the things that makes aresolution difficult is Cole's conception of the'ordinary concept' of death. Concepts which requiresupport by divine, presumably omnipotent interven-tion, or 'esoteric' (magic) techniques seem to me farfrom ordinary. Because they are extra-ordinary ormiraculous occurrences, they are the sort ofconcepts to be contrasted with rather than illustra-tive of ordinary ones. Perhaps what misleads Cole isthe fact that these unusual ideas are sometimesentertained by very ordinary people. If, however, anidea violates both the laws of logic and nature, then,even if it is entertained by a large number of other-wise very ordinary folk, it remains, nonetheless, anextra-ordinary concept. The idea that death mightbe reversible violates the laws of both sorts.

Simply because we commonly believe that deathis not reversible does not mean that all talk of'reversibility' is always out of place. Everyoneaccepts the fact that we are able to reverse the dyingprocess in a large number of patients whose caseswould have been viewed as hopeless in the past.Reversibility can be sensibly discussed withouthaving to revert to magic, science fiction, or divineintervention. Clearly it is a relative, context-depen-dent term, whose proper application will varyaccording to the conditions that obtain at the time.But the conditions whose reversibility may be arguedare not now and never have been, the conditions thatconstitute death. Even though in the past there wasnothing to be done to save a patient's life after



e.bmj.com

/J M


e.21.5.270 on 1 October 1995. D

ownloaded from

http://jme.bmj.com/

E TBartlett 273

having suffered, for example, a cardiac arrest orkidney failure, the patient was, at the time of thefailure, dying and not dead. What could have beenreversed was not, strictly speaking, death but ratherthe dying process (11).

Death does not occur, however, until that processhas been fully completed. Only then do we properlysay that the patient is dead. Even though, at anearlier point, it would have been correct to say of adying patient that her condition was irreversible,meaning that there was no longer any medical optionavailable to reverse her dying, when it is now said, atthe moment of death, it has a very different use anda very different type of supporting argument.Whether or not a dying process is reversible is alwaysan arguable issue, depending on who and what isdeemed appropriately available. After that processhas come to its natural conclusion, however, and thepatient is dead, the use ofthe word 'irreversible' restson a matter of definition. The 'irreversibility' of thedying process is a matter of the empirical facts of thepatient's condition relative to available capabilitiesand goals of those present. All of these factors makejudgments of irreversibility contingent and thus,even when entirely true, subject to denial withoutfear of formal contradiction.

A conditional statementA part of what makes this confusing is the apparentabsolute finality and certitude involved in saying thatdeath is, by definition, irreversible. No real, empiri-cal certitude, however, is a part of that claim. Whatfollows as a matter of logic is a conditional state-ment. Ie, if someone has been properly pronounceddead, then it is logically impossible for his conditionto be reversed. No matter of fact follows from this. Itmerely means that if someone has been pronounceddead, and if, mirabile dictu, that person then rises upand asks to see the morning paper, it follows, as amatter of logic, that the pronouncement of deathwas in error. Whether or not such an event isreasonable or just silly, medically possible or entirelyimprobable is an entirely different issue havingnothing to do with the matter of logic.Tom Tomlinson also takes David Cole to task for

his view on irreversibility, but does so, in myopinion, for some questionable reasons. Tomlinsongives the following argument: 'I believe that Colegets off on the wrong foot by assuming that "death"is essentially and solely an ontological categoryrather than irreducibly an ethical one as well. Let'srestore that ethical perspective by asking a questionthat Cole never tries to answer: Why would anyonethink that the determination of death should be thedetermination of the irreversible?' (12).

Restoring an ethical perspective means, appar-ently, recognizing the enormous changes that occurin our moral relationship to the patient when hiscondition changes from being ill to being dead. We

no longer need to be concerned about, for example,his treatment needs, as they cease when he does.Although it is important to recognize that the bodyof a former patient has a different moral statusfrom what it had when the patient was ill, it doesnot follow that the determination of the corpse'sirreversible condition is to be established by any sortof moral insight.

Tomlinson's argument is the following: 'Thus, ifdeath has these ethical implications for the demise ofour obligations to the deceased, [then] its determi-nation must include a judgment of irreversibilitysufficiently secure to warrant the ethical judgmentsthat follow' (13). My objection to this statement isnot because, viewed as discrete claims, I believe anyof its components to be false. My objection arisesbecause I believe Tomlinson to be saying that theantecedent of the above conditional provides suffi-cient reason for believing in the truth of its con-sequent. In other words, death must be irreversiblebecause of the radical change that occurs in ourmoral relationship once it has been established.

Whether or not a patient's condition is irreversibleis in no way a function of the moral consequences thatwould follow! That these consequences would have tobe rejected should this condition turn out not to besatisfied, is enough to cause us to look carefully at aposition such as Cole's. But the statement: 'Death isirreversible because if it were not we would be wrongin neglecting the interests of the corpse' is a nonsequitur. The issue with Tomlinson is not whether ornot death is reversible. The issue is what constitutes agood reason for saying that it is. My point is thatunpalatable moral consequences are not, in them-selves, a good reason for drawing a conclusion abouta statement whose foundation rests unassailed in bothfact and language. We might just as well argue thatbecause the organs are so badly needed we will justsay that the patients are dead! No one would seriouslypropose a utilitarian theory of truth.

Tomlinson makes the preceding argument withinthe context of explaining a protocol developed by theUniversity of Pittsburgh (14). This protocol allows fororgans to be harvested from a previously inaccessiblegroup of patients, the non-heart-beating cadavers. Itcontains, however, some disturbing procedures whichraise questions about whether or not the patient isdead at the point at which the surgeons open him/herup to remove the organs. The requirements of theprotocol reported in the literature are these. 'For cer-tification of death, the prompt and accurate diagnosisof cardiac arrest is extremely important. Procurementof organs cannot begin until the patient meets thecardiopulmonary criteria for death, ie, the irreversiblecessation of cardiopulmonary function' (15).

Irreversible cessationYoungner and Arnold go on to say that: 'Theprotocol specifies that irreversible cessation of



e.bmj.com

/J M


e.21.5.270 on 1 October 1995. D

ownloaded from

http://jme.bmj.com/


cardiac function will be demonstrated when pulsepressure is zero (as measured via femoral arterialcatheter) and when the patient is apneic andunresponsive and has one of the following electro-cardiographic criteria: (1) 2 minutes of ventri-cular fibrillation; (2) 2 minutes of electric asystole(ie, no complexes, agonal baseline drift only);or (3) 2 minutes of electromechanical dissociation'(16).The preceding determinations are made in the

operating room so that after the two-minute waitingperiod, the patient's chest can be opened up and hisorgans removed before warm ischaemia has caused aproblem. Tomlinson says of such a procedure that:'An essential element of the present context is thatthe non-heart-beating donor under the Pittsburghprotocol has volunteered to donate organs only afterhaving exercised his right to refuse any further life-prolonging treatments aimed at resuscitation fromcardiopulmonary arrest. To refuse to withdraw thelife prolonging respirator therapy or to institute otherlife prolonging treatments would be a violation of thedonor's wishes and of his rights, and so not ethicallyacceptable' (17).

Active, voluntary euthanasiaI have no problem with Tomlinson's argument. Itseems to me to be appropriate, sound, and sufficientto do the job of justifying the procedure. Eventhough, however, I am persuaded by it, I take seriousexception to his analysis of what the argument isbeing applied to. What this argument justifies isactive, voluntary euthanasia. These patients arealive. As long as there are no serious doubts aboutthe medical possibility of reviving these patients aftertwo minutes of asystole (18), the condition of thesepatients is clearly reversible, and therefore cannotconstitute death. This follows as a matter of logicfrom the accepted definition of death together withthe fact of their reversibility.

Continuing the case for the Pittsburgh group,Youngner and Arnold observe that: 'There is littlediscussion in either the President's commissionreport, Defining Death, or the report of its medicalconsultants, Guidelines for the Determination ofDeath,regarding what is meant by irreversible' (19).

It is true that there is absolutely no discussion ineither of those publications about the meaning of 'irre-versible', but that is because, in all likelihood, no oneever dreamt that there might be anything to discuss!'Irreversible' is a common term in ordinary languagewhose meaning is straightforward, unambiguous, andon the tip of everyone's tongue. It means, notreversible, that is, not capable of being reversed orreversing (20). The conclusion that the patients in thisprotocol are not dead then follows, as a matter oflogic, from the definition of death as an irreversiblestate together with the assumption of fact that theircondition is reversible.

Although it is true to say that these publicationsnever discussed the meaning of the word 'reversible',it is also true that they devoted almost all of theirattention to a determination of the conditions underwhich one could make an actual diagnosis ofirreversibility. It would be a serious misrepresenta-tion, therefore, to imply that they neglected such animportant issue. Quite the contrary, they focused onthe only aspect of the issue which is important andthat is a determination of the actual conditions underwhich a diagnosis of irreversibility can be safely made.The sense of reversible invoked in the protocol is

something like 'auto-reversibility' meaning, Ibelieve, the capacity of the patient, unaided by anyoutside support, to reverse his own condition.Tomlinson says: 'The procedures then go on tospecify how this "irreversible" cessation will bedetermined - namely by a set of tests designed todetermine that the cessation would be irreversible byauto-resuscitation' (21).

It is important at this stage to be very careful aboutwhat is at issue. Mixed up in this protocol are somevery powerful moral arguments about what is mostimportant, appropriate and proper to do. None ofthese are being criticized here because the point isthat none of them is relevant. At this stage we areengaged in a factual process of classification, ie, dowe have before us necessary and sufficient reasons forsaying that the patient is no longer dying but is nowdead? The answer is absolutely, no! Surely no onewould seriously argue that the condition of a patient,two minutes post-arrest, who is unable on his own toreturn to a normal rhythm, is, ipso facto, dead. If thatwere true then we should now refuse CPR on similarpatients because they are dead! This is not to beconfused with the reasonable claim that in similarcases such patients should not get CPR because theyare the subjects of Do Not Resuscitate (DNR)orders. The issue here is not whether there are per-suasive reasons to resuscitate them but whether ornot they are dead. If we continue to insist that theyare dead, then we have by dint of this small piece ofverbal legislation, ie, by interpreting 'irreversible' tomean 'not-auto-resuscitatable', vastly increased thepool of potential organ donors to include everyonewho, without medical assistance, is going to die! Themeaning of the word 'reversible' is clear and is clearlynot the same as 'auto-resuscitatable' (22).The difficulties with this protocol do not stop with

just the ill-advised analysis of 'reversible' (23). Thereare difficulties in the manner in which they speakabout the cardiopulmonary criteria. These difficul-ties are not, however, the special creation of thisparticular protocol. They are another example of theloose ends that the President's Commission did nottie up (24). There is no supporting argument thatwould allow one to flip-flop between cardio-pulmonary and neurological criteria of death asthough either one would do the same job just as wellas the other. What might have been merely a



e.bmj.com

/J M


e.21.5.270 on 1 October 1995. D

ownloaded from

http://jme.bmj.com/

E TBartlett 275

theoretical annoyance when the Guidelines were pub-lished and the Uniform Determination of Death Actwas promoted has become, with the development ofthe Pittsburgh protocol, a serious issue.

Crucial factorOne crucial factor in evaluating an anatomical regionas a potential criterion of death is its relationship tothe definition. If we accept 'the irreversible loss ofintegrating function' as the definition of death, then'the irreversible destruction of the brain as a whole'and 'the irreversible destruction of the cardio-pulmonary system' have two very different relation-ships to the definition that they are supposed toinstantiate. As I argued earlier, satisfaction of theneurological criteria, gives us, in itself, a conditionthat constitutes death. As Pallis correctly arguedearlier, satisfaction of the cardiopulmonary condi-tions does not do that. It merely sets into motion aseries of events which, all other things being equal,result in 'the irreversible loss of the integratingfunction' (5). The difficulty with the Pittsburghprotocol is that it jumps into the middle of the dyingprocess and so prevents all of the other things fromever becoming equal. Normally, if a DNR patienthas a cardiac arrest nothing is done so that the lackof blood-flow to the brain begins its irreversibledestruction. But it takes time, and until it hashappened the patient is not dead but dying.Practically, in an ordinary clinical situation, thepatient would be dead soon enough. Because of thedifficulties of warm ischaemia, the conditions oforgan harvesting are not normal, and the surgeonsopen him up before he is dead. A cardiac arrest is agood predictor of death. It fails, however, as acriterion of death because its occurrence does notgive us what we mean by death. It is a mistake there-fore to declare these patients dead by either criteria -neither neurological nor cardiopulmonary will dothe job.

AcknowledgementI would like to thank my colleague and fellowinstructor Stewart Youngner, MD and the studentsof Case Western Reserve University School ofMedicine for providing the occasion and stimulusfor this paper. The inspiration is theirs and the errorsmine.

E T Bartlett, PhD, is Associate Professor of Philosophy,Cleveland State University and Adjunct AssistantPIrofessor of Medicine, Cape Western Reserve UniversitySchool ofMedicine, Cleveland, Ohio, USA.

References and notes(1) Bernat J L, Culver C M, Bernard Gert. Annals of

internal medicine 1981; 94: 389-394.

(2) Evans D W, Hill D J. Catholic medical quarterly 1990;4: 113-121 and, same authors. Critical care medicine1991; 20: 1705-1713.

(3) Bartlett E T, Youngner S. Human death and thedestruction of the neocortex. In: Zaner R, ed. Death:beyond whole brain criteria. The Netherlands: KluwerAcademic Publishers, 1988: 205 ff for discussion oflocked-in syndrome.

(4) See reference (1): Gillon: 390.(5) Pallis C. J7ournal of medical ethics 1990; 16: 11.(6) See reference (5): 10. See also Pallis C. British medical

journal 1983; 285: 1409-1412. See also, Gillon R.J7ournal of medical ethics, 1990; 16: 3-4.

(7) See reference (6): Gillon: 4.(8) If the structure of the claim is really that of a conjunc-

tion, then that conjunction will fail (ie, the person willbe dead) if only one conjunct is false even though theother one remains true. So, on this view, either theirreversible loss of consciousness or the loss ofintegrating function would be sufficient for a diagnosisof death. This is not what the brainstem folk are after.What they want is for the standard for declaring deathto be both the irreversible loss of consciousness andintegrating function together. For that to work,however, the definition of death would have to be dis-junctive. Ie, human death would be either irreversibleloss of consciousness or integrating function. It seemsto me, however, that there are persuasive reasons forrejecting the integrating function.

(9) See reference (3): 207 ff. Bemat et al do come close tosubscribing to this view when they deny that 'persons'die. What dies, they argue, is some kind of organism.See reference (1): 390.

(10) Cole D J. The reversibility of death. J7ournal of medicalethics, 1992; 18: 28.

(11) If there is one key to unlock the variety of confusionsin Cole's arguments, it is his failure clearly to differ-entiate between what is true about dying from what istrue about being dead. I think that this distinctiontraces back to the admonition by Bemat et al to dis-tinguish between criteria and definitions. See, forexample, reference (10): 27: 'But were the world tochange in certain ways, death might become bothavoidable and reversible'. The avoidable and revers-ibility of death depend on two vastly different sets ofcircumstances.

(12) Tomlinson T. Kennedy Institute ofEthics journal 1993;3:161.

(13) See reference (12): 161. And, also 157:"'Irreversible" in this context is best understood notas an ontological or epistemic term, but as an ethicalone. Understood in that way, the patient declareddead under the protocol is "irreversibly" so, eventhough resuscitation by medical means is still possible' [myemphasis].

(14) Tomlinson T. UPMC policy. Kennedy Institute ofEthics journal 1992; pages A l-Al 5.

(15) Youngner S J, Arnold R M. J7ournal of the AmericanMedicalAssociation 1993; 269: 2769-2774.

(16) See reference (15): 2771.(17) See reference (12): 162.(18) See, for example, reference (12): 157: 'Thus, under

the protocol, a patient whose cardiopulmonary arrestmight well be reversible by means of standard CPR orother medical means could nevertheless be declareddead for the purpose of organ removal'.

(19) See reference (15): 2772.



e.bmj.com

/J M


e.21.5.270 on 1 October 1995. D

ownloaded from

http://jme.bmj.com/


(20) Webster's ninth new collegiate dictionary. Springfield,Mass: Mirriam-Webster, Inc, 1983: 1010, entryunder 'reversible'.

(21) See reference (12): 157.(22) What is very different, and quite reasonable, is to

present the lack of 'auto-reversibility' as marking apoint at which it would be morally permissible to stopmedical therapy and to proceed to operate on a dying

(thus alive) patient. Clearly this violates the deaddonor convention - so be it.

(23) It is unclear to me what the relationship is between therationale actually accepted by the Pittsburgh group andthose who write in support of them in the KennedyInstitute ofEthics journal, vol 3, see reference (14).

(24) See reference (12): 163-164 for many of the sameideas.



e.bmj.com

/J M


e.21.5.270 on 1 October 1995. D

ownloaded from

http://jme.bmj.com/

differences between deathand dying · although dividing an account ofdeath into three parts has...

Documents