Ethics in Science & Medicine. Vol. 3. pp. 95-105. Pergannon Press. 1976. Printed in Great Britain.

THE CONCEPTS OF DEATH AND EMBODIMENT GEORGE I. AGICH

Teaching Assistant, Institute for the Medical Humanities, The University of Texas Medical Branch, Galveston, TX 77550, U.S.A.

Abstract-The medical problem of the "definition" of death is empirical. It consists in specifying the operational criteria in terms of which the death of a person can be clinically ascertained. The ethical (as well as the legal) basis for medical practices associated with the determination of death, e.g. discontinuing intensive care procedures, disconnecting resuscitative machinery, and removing organs for transplantation, hinge on understanding "death" to mean the death of a person. Since the definition of death as the death of a person is conceptual and not operational, it is not a matter for empirical medicine to decide. In order to clarify and amplify this point, this paper discusses two important medical statements on brain or cerebral death: the report of the Harvard Committee on brain death and the report of the American Electroencephalographic Society Committee on EEG determination of cerebral death. The conclusion reached in this paper is that medical criteria for determining brain or cerebral death can be operationally specified. However, operational definitions of death presume, rather than establish, the definition of death as the death of a person. In addition to the operational definition, a conceptual definition of death is required. This definition need not lay out the full sense of personhood, but only those factors which conceptually connect the operational criteria for brain death to the full sense of "death" as the death of a person. Therefore, this analysis focuses on the essential conditions necessary for the embodiment of persons. The most important of such conditions is that the person must be embodied somewhere in the world of physical objects if action is to take place. The brain and the central nervous system as understood by the neurosciences is the factual realization of this essentially necessary condition of the embodiment of persons. For this reason, the clinical determination of brain death is tantamount to determining the death of a person. The connection between brain death and the death of a person is here articulated conceptually. It is articulated in such a way that the factual character of clinical medicine is preserved, but the essential character of the meaning of death is made clear.

Medical discussions of the problem of death usually involve two distinct questions: "what are the criteria for saying when death has occurred'?" and "what is the meaning of death which helps morally to legitimate actions such as discontinuing life-support measures and removing organs for transplantation after death has been pronounced?"[ I] As we shall see, the question of criteria amounts to asking for what has been called an operational definition of death;[2] here empirical matters are at stake and scientific knowledge is adequate to them. The second question, however, asks for a conceptual definition and it involves considerations of meaning, not fact.[3] This question has to be raised, and is implicit in the medical discussion of the "definition of death", because the problem of determining criteria for death has ethical ramifications for the practice of medicine. Though they are empirical, the medical-scientific criteria for determining death gain significance in moral judgments in virtue of the essential character of the conceptual definition. The conceptual definition lays out what it means to be a living (and correlatively a dead) person. Moral significance is gained since the special responsibility of the physician to the dying patient can be said to end once the patient is no longer present, i.e., once the patient is dead.[4] Thus, in addition to the question of the criteria for determining death, i.e., the question of fact, there is the question of meaning. Or, to use the more widely accepted rubric, there is a conceptual definition in addition to the operational definition.

The physician is generally regarded as having a special competence to determine when death has occurred. The recognition of the physician's competence can be illus-trated in several ways. The Black's Law Dictionary (fourth edition, 1951), for instance, defines death as

The cessation of life: the ceasing to exist; defined by physicians as a total stoppage of the blood. and a cessation of the animal and vital functions consequent thereupon, such as respiration. pulsation. etc.

The important thing about this definition is not the way in which the Dictionary says that physicians do define death. since the clinical states noted have come under attack

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by physicians. but rather the recognition that it is the physician who can offer criteria of death. In addition, the law of the United States and all the fifty states treats the question of death as a question of fact to be determined in every case; when doubt exists about the time or cause of death. courts seek expert medical testimony. Thus, the law regards the physician as having a special competence to determine when and how death has occurred in specific instances.[5]

However, physicians often construe their competency in broad terms to include speci-fying the meaning or the conceptual definition of death. In this regard, two discussions and reports are especially significant: the first is important because it illustrates the confusion between the conceptual and operational definitions of death and the second because its altogether adequate construal of the operational issue points to the need for a conceptual definition which only philosophy, and not medicine, can give. They are the Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death[6] and the Report of the Ad Hoc Committee of the American Electroencephalographic Society on EEG Criteria for Determination of Cerebral Death.[7]

The Harvard Committee Report characterizes itself as offering a "definition of irrevers-ible coma" and a "definition of death". It matter-of-factly takes the clinical determination of irreversible coma to be unproblematic and equivalent in meaning to the death of a person as if this equivalence were factual and non-problematic. It does not even give arguments using clinical and experimental evidence to justify the proposed criteria as criteria of brain death. Instead, the Report gives a hypothetical argument that "if the characteristics [of irreversible coma] can be defined in satisfactory terms, translatable into action ... then several problems will either disappear or will become more readily soluble." (p. 337) As the argument is developed in the Report, it is really only rhetorical in character in that reasons are not given. It may be summarized as follows.

(1) The law cedes to medicine the authority to decide the factual question of death. Our consideration of the legal view of the question of death supports this first premise, which is factual.

(2) "Responsible medical opinion is ready to adopt new criteria for pronouncing death to have occurred in an individual sustaining irreversible coma as a result of permanent brain damage." (p. 339) This premise is also factual and appears true from surveys of medical opinion. But even if true, the acceptance of new criteria is not itself evidence of the adequacy of the criteria since they may be accepted for correct or incorrect reasons. The Report does not consider this possibility.

(3) The question of death is for the law the question of the death of an individual, of a person before the law. This third premise is assumed in the Report, but has to be supplied if the appeal to the general legal situation is to have any logical status in the argument. This premise is also factual, but unlike the first two is a fact of the law. It is necessary for the argument for it enables the conclusion to follow.

(4) The criteria recognized by the medical community and accepted on that authority by the law are in effect criteria for the death of an individual. The conclusion has practical consequences for medicine insofar as the legal construal of the person as a bearer of rights and duties is implicit. When a bearer of rights and duties is no longer present, actions not previously permitted, such as disconnecting life-supporting equip-ment and removal of organs for transplantation, are allowed. But insofar as the argument of the Report does not deal with the medical question of fact per se, it has only rhetorical force.[8]

The Harvard Committee Report "defines" death by an interesting version of the infor-mal fallacy called "the argument from authority".[9] The argument from authority is informally fallacious in that it substitutes an appeal to an authority for reasons. The Harvard Committee Report is a peculiar version in that it argues on the basis of a lack of authority.

The law does not claim either the authority or the competence to determine the question of death, but recognized medicine's competence to decide the question as a

The concepts of death and embodiment 3

question of fact. Thus, the only authority that can warrant the criteria of irreversible coma as brain death is empirical medicine and its authority rests on empirical scientific evidence alone. The Report, however does not give such evidence,[10] but asserts its criteria in the absence of any other authority to do so. In addition, the Report offers no reasons for saying that brain death (or irreversible coma since the terms are taken as equivalent in the Report) is equivalent to the death of a person. What the Report does, however, is to argue that its criteria have the effect, i.e., the practical consequence, of determining the death of a person simply because the law permits such an inference. But no reasons are given to validate the inference from brain death to the death of a person.

The Report states that its concern is limited to "those individuals who have no discernible central nervous system activity." (p. 337) It offers four diagnostic characteristics of irreversible coma, characteristics which are criteria for pronouncing such comatose patients dead. The criteria are (1) unreceptivity and unresponsivity, (2) lack of movement and breathing, (3) absence of reflexes, and (4) flat electroencephalogram with the exclusion of two conditions, hypothermia (temperature below 90°F.) and presence of central nervous system depressants such as barbiturates. Evidence of the first three constitute satisfactory diagnosis, according to the Report, while the last provides confirmatory data. (pp. 337-8) Outside the rhetorical consideration that the criteria are practically (i.e., should be legally) equivalent to the death of an individual in that they permit one to act as if the patient were dead, the Harvard Committee Report does not argue medically for its criteria.

In the Harvard Committee Report the two issues we distinguished earlier, the opera-tional definition of death and the conceptual definition, are confused. Apparently the legal considerations, which bear on the problem of the conceptual definition insofar as the legal point is that death is the death of a person before the law and medicine is recognised as the authority capable of deciding the factual question of death, are regarded as superseding the purely medical problem of giving reasons for the adequacy of the criteria proposed. This is disturbing, because the proper issue for medicine is the operational definition which is logically independent of the legal situation though not logically independent of the problem of the conceptual definition as we shall see in due course.[11]

The question at this point is "are there strictly medical reasons for the criteria'?" The answer is yes and the Electroencephalographic Society Committee Report is instructive in this regard, because it makes clear that medical reasons will be empirical, clinical and experimental in nature. Also, theoretical conditions which might affect the adequacy of the criteria are considered. Therefore, the Electroencephalographic Society Committee regards what the Harvard Committee calls "irreversible coma" and it calls coma depasse to be a clinical state of affairs to be judged in accordance with medical data alone. The main problem for medicine thus consists in evaluating the evidence for and against the criteria.

According to the Electroencephalographic Society Committee Report coma depasse is a "definite clinical state in which the following are present: (1) coma with complete unresponsiveness; (2) cessation of spontaneous respirations, no muscle tone, and a flaccid paralysis; (3) absence of all reflexes (including fixed dilated pupils and absence of cephalic reflexes); (4) frequent inability to maintain circulation without artificial means; and (5) a linear EEG, unresponsive to any stimulation." (pp. 1506-7) These diagnostic indices are more exactly spelled out than those of the Harvard Committee Report. Further, the Electroencephalographic Society Committee Report does not treat this state as diagnostic evidence of brain or cerebral death when employed alone, but requires a special EEG reading to make these clinical observations significant for a diagnosis of cerebral death. This reading is called an "isoelectric trace" or "isoelectric EEG". The predominant concern of the Elect roencephalographic Society Committee is to establish the diagnostic, i.e., operational significance of this reading in determining cerebral death.

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An "isoelectric trace" or "isoelectric EEG" is a technical term meaning "a linear EEG with no evidence of brain activity over 2 pV between electrode pairs 10 cm or more apart." (p. 1506) This term is proposed to replace the older term "flat EEG" which is subject to considerable misunderstanding since the voltage measured may vary from 3-20 pV. The term is replaced because its range of variance has little clinical importance in determining cerebral death. The Electroencephalographic Society Committee Report instead offers the term "isoelectric EEG", because its operational significance in assessing the permanent cessation of cerebral activity[12] has been established. As evidence the Electroencephalographic Society Committee Report points out that patients measured at voltages higher than the isoelectric reading, i.e., from 3 pV and higher, have recovered, but none have recovered from a true isoelectric reading when complicating conditions were excluded. Thus, the isoelectric trace seems to be an index of cerebral death based on correlations of survival and isoelectric readings. But for it to be properly accepted as the significant index, complicating conditions have to be excluded, and to be excluded they must first be identified. They, too, are identified empirically, by clinical and experimental means.

The Electroencephalographic Committee Report gives two conditions which parallel those given in the Harvard Committee Report: hypothermia and anesthetic or barbiturate induced isoelectric trace. Hypothermia, which the Harvard Committee treated as a clinically significant exception, is treated by the Electroencephalographic Society Committee as a theoretical exception only. Experiments on animals with a temperature reduced to 62`F. showed an isoelectric trace, but the animals recovered. Also, it is noted that one member of the Committee "has observed a spontaneous hypothermia in patients with coma depasse, but never low enough to account for the absence of EEG activity." (p. 1507) Anesthetics have also been shown clinically and experimentally to produce periods of isoelectric activity in the EEG and patients in coma from massive barbiturate intoxication have had isoelectric EEG recordings, though some have recovered electrically and clinically with special treatment such as dialysis. (p. 1506) Therefore, the empirical evidence at this time is that the isoelectric EEG is a necessary but not sufficient index for cerebral death when the complicating conditions are excluded. [ 13]

Members of the American Electroencephalograph ic Society who responded to a survey conducted by the Committee unanimously agreed that "the EEG alone cannot be used to diagnose cerebral death, that the electroencephalographer, per se, does not have the function to declare this, but only to declare that the EEG is isoelectric, or, as the committee suggests, indicative of electrocerebral silence." (p. 1508) There are two reasons for the reluctance to declare that cerebral death has occurred on the basis of EEG evidence alone. The first reason is procedural and legal, namely it is the attending physician who is responsible for making the diagnosis of brain death and not the electroencephalographer. The second reason, however, is the more important, namely that there is insufficient evidence to say that isoelectric EEG readings, even in the absence of complicating conditions, are a sure indication of cerebral death.

The evidence is inadequate even though the Report summarizes 1665 cases of patients with linear EEG's. Of these only three survived. Two of these survivors suffered from barbiturate induced coma and one from coma due to a meprebamate overdose. Nevertheless, it was not clear that in every one of the 1665 cases the EEG was truly isoelectric. There were considerable differences in the measuring techniques used and in the instrument amplification. Until the practice of using proper techniques to achieve a truly isoelectric trace is followed uniformly,[14] the clinical adequacy of the trace as an index of brain death will remain uncertain. As the Report puts it: "The value of increased amplification in differentiating the low voltage `flat' record from the truly isoelectric record should be emphasized." (p. 1507)

Further, the question of how long the state of electrocerebral silence must be present before one may reasonably conclude that there is cerebral death is still undecided. The Report suggests that time requirements may differ according to the case of the

The concepts of death and embodiment 5

coma (p. 1509), but the answer to the question of duration has yet to be worked out satisfactorily either clinically or experimentally. Since patients have recovered from coma depasse and from isoelectric EEG recordings, the Electroencephalographic Society Committee concludes that "neither the neurologic character of coma depasse alone nor electrocerebral silence by itself is a certain indicator of cerebral death, but together they constitute strong presumptive evidence that such is the case, provided that depressant drugs in anesthetic levels as a cause are eliminated, as well as the theoretical situation of hibernation." (p. 1509)

The Electroencephalographic Society Committee Report responds well to the medical need for clinical and experimental evidence to justify the move from criteria for coma depasse to cerebral death. It proposes that the Committee serve as a body to gather data and to promote the study of patients in isoelectric coma. "The objective of this study would be to define more precisely, for different causes of the comatose state, the moment for the outside limits of reversibility," (p. 1509) The specialized techniques for this study are also proposed. These proposals are entirely consistent with the needs of clinical medicine. But by stressing the empirical nature of the medical operational definition of death, the import of the conceptual definition of death can be brought to the fore.

The competence of medicine extends, in the matter of death, to the question of fact. In the case of coma depasse the concept of death is defined in wholly empirical, i.e., clinical and experimental, terms. The evidence for saying that the state of coma depasse is equivalent to brain death is empirical and is based on the adequacy of the isoelectric EEG reading in diagnosing permanent cessation of brain activity. In these terms the most we can say is that the clinical neurologic character of coma depasse together with the isoelectric EEG comprises the best available presumptive evidence that death has occurred in a comatose patient. Medicine as a practical science, however, must act on the basis of the best available evidence. But, importantly, in the case of the definition of brain death, the best available evidence is presumptive in two different senses.

The first sense in which the evidence is presumptive has to do with the actual state of medical knowledge, namely that there is not yet sufficient data to support coma depasse and isoelectric EEG readings as conclusive indices of brain death. The Electroen-cephalographic Society Committee sees this clearly and does not muddle matters by offering rhetorical arguments from the law to support its criteria for brain death. But there is, in addition, a second sense in which the evidence is presumptive, a sense which has nothing to do with the lack of adequate empirical data. This sense refers us to the conceptual definition.

Conceptual definition was contrasted with operational definition. An operational definition sets out criteria in virtue of which we can tell when we have an instance of a thing. In operational terms the criteria of coma depasse together with an isoelectric EEG reading would tell us that there is brain death if sufficient empirical data were available to establish the adequacy of the criteria. The conceptual definition, on the other hand, tells us what kind of thing an object is, namely it gives us the essential characteristics which make an object the kind of thing it is. Since the issue of the definition of death has great practical import for medicine, the operational definition offering criteria for determining brain death presupposes that brain death is tantamount to the death of a person.

This point was noted in connection with the Harvard Committee's attempt to justify the practical consequences of its criteria for brain death by an implicit appeal to the legal understanding of death as the death of a person before the law. That appeal fails because it substitutes one set of facts, medical facts, for another, namely facts of the law, when what is needed is not facts but an essential definition of death as the death of a person. Essential characters saying what it means to be a person are required. These characters would be the necessary and sufficient conditions for personhood. The empirical determination that any of the essentially necessary conditions

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are permanently absent would provide an adequate ground for pronouncing the comatose patient dead and for actions such as disconnecting life-supporting equipment and removing organs for transplantation. These actions can be argued for ethically on the grounds that whatever good ensues from them does not come at the expense of any harm to the comatose patient since the patient as person is dead. Thus, the conceptual definition of death involves the delineation of the meaning of the embodiment of persons, i.e., the relation between "brain" and "mind," and "mind" and "person." This relationship is complex, to say the least, but its significant features can be sketched to illustrate how the medical concept of death relies on the conceptual definition of death.

The relevant features of the conceptual definition of death for medicine are those bearing directly on the function of the brain and central nervous system in the embodi-ment of persons. The operational definition offered in the Reports presumes that the brain and central nervous system, unlike other organs, is a necessary somatic condition for the embodiment of persons, but neither of the two Reports says why this is so.[15] The conceptual definition of death will thus have to make clear the function of the brain in the embodiment of persons.

Employed scientifically the term "brain" means an organ which integrates neurophysiologic functions; it also means the locus of the functional integration of consciousness. As a neurophysiologic organ the brain is a part of the world of physical objects and is bound up in the nexus of physical causality. As such, the brain and its functions can be measured and identified by scientific means. However, "brain" also means the locus of the integration qr consciousness within the animate body. Consciousness, however, is not so clearly measurable and determinable by scientific tests. The processes of consciousness, though apparently localized in the brain, are processes of "mind." Therefore, the key conceptual problem in connection with brain or cerebral death is to trace out the conceptual connections between the brain as a concept of neurophysiology (and empirical science in general) and the brain as the locus of processes of consciousness, particularly the higher level processes of consciousness having to do with personhood. The conceptual definition of death thus turns toward the problem of the embodiment of persons.

Any treatment of the embodiment of persons has to take note of the seminal ambiguity in the term "body". This ambiguity includes the tripartite distinction between an alive body and a dead body or corpse and a mere body. We often use the term "person" for "lived-body" and so distinguish persons from corpses. "Corpse" thus means a body which is not a person, though at one time it was a person or a lived-body; it is a body which is dead in that a person no longer lives it, but is not yet a mere body in that there may be some life-cellular, tissue life-in it.

Viewed biologically and physiologically, an alive-body grades into a dead body so that a corpse may yet be alive in some minimal sense and so is not a mere inanimate piece of matter. This scientific fact has, however, been mistaken to mean that the com-monsensical distinction between a person and a corpse-which is analogous but not equivalent to the distinction between an alive-body, i.e., a body containing physiological and metabolical functions and processes, and a mere body, i.e., a body which is not biological and so is physiologically and metabolically non-functional-is without justifi-cation.

Robert Morison, for instance, has argued that death is a process and not an event since bodies viewed biologically and physiologically are only more or less alive at any time correlative to being more or less dead at the same time. Death is here understood solely in physiologic terms, and since this scientific perspective does not unequivocally inform us about the death of persons, the declaration of death is said to be an arbitrary matter without any conceptual or logical validity.[16]

However, it is possible to insist commonsensically that a corpse is a body which is not a person since it is dead. even though there are physiological grounds for saying that there is life in such a body. Similarly, a body which appears alive to clinical observation and perhaps to common sense. i.e.. the body of a comatose patient, may

The concepts of death and embodiment

not be alive in the sense of being the embodiment of a person. In other words, though the gross signs of life (respiration and heartbeat, for instance) continue even if machine sustained, there may not be personal life. In such a case an alive body would really be a corpse. But it would be a conceptual confusion, though one which is natural owing to the language, to say that such bodies are dead. They are dead only in the sense of no longer embodying persons; it is, to be precise, the person which is dead. In this regard Dallas High has pointed out "an organ does not die but only persons die." (p. 448) The aliveness of such bodies is the reason why they are of great interest for organ transplants and medical research.[17]

The problem which any medical definition of death in terms of brain death faces (in light of resuscitative technology) involves determining the empirical limits of the possible existence of persons, i.e., the clinical signs, the duration of such signs, and the complicating conditions which constitute the factual outer limits of the life of a person. The full solution of the problem must not entail the conceptual reduction of life of a person (and hence the death of a person) to the level of physiological processes, though the thrust of the medical discussion is rightly toward empirical, physiological and neurological, criteria. These criteria which are criteria for brain death or cessation of cerebral activity, however, have to be tied conceptually to the notion of a person in order to validate the necessary inference from brain death to the death of a person. In short, a consideration of the meaning of person, mind, and brain in embodiment is required to make out the connection between brain death and the death of a person.

Usual treatments of the interrelationships are factual, that is to say, they adduce reasons explaining the interrelationship of person, mind, and brain by presuming the factual existence of these as given in natural science or metaphysics. The interrelation-ships thus adduced are comprehended as only factually necessary, i.e., necessary given the contingent existence of things we call "persons," "minds," and "brains." Any changes in the factual conditions of the possibility of embodiment: developments in organ trans-plantation, prosthetic devices attached to skeletal muscles, and artificial organs, for example, requires a corresponding reconsideration of the interrelationships by natural science and metaphysics and, perhaps, a re-evaluation of the employment of terms such as "person," "mind," and "brain."

Two general alternatives present themselves: Either these entities are regarded as separate and distinct and the problem is to explain the nature of the connections. Or, they are regarded as identical, i.e., one is reduced to another, so that the problem of the interrelationship is dissolved by denying the conceptual difference, i.e., the difference in meaning between "person," "mind," and "brain." Since the conceptual difference is what gave rise to the problem of the medical definition of death, the second solution is unacceptable. The first alternative is equally unacceptable if the nature of the connection between these entities is specified factually, that is, in terms of the state of affairs of the world. In light of this situation, a treatment not committed to the viewpoint of natural science or metaphysics is required. Such a treatment has to elucidate the essential, i.e., conceptual, meaning of "person," "mind," and "brain" in embodiment prior to and independent of scientific and metaphysical explanation.[18] This method of treatment will avoid the problems engendered by a metaphysical reification of things and their interrelationships by examining only the meaning of things and the meaning of their interrelationships without constructing theories to explain the phenomena.[19]

In light of these points, our treatment of the embodiment of persons, it is easy to see, must focus. on the lived-body. The lived-body is a complex set of meanings ranging from basic to higher, more complex levels of embodiment founded upon these. The common-sense distinction between a corpse, an alive body, and a person will find expression in terms of these levels of significance.

The lived-body is paradoxically hoth an external, extended object and a place of localized sensation, i.e., a place where sensations are "on" and "in".[20] In other words, the lived-body itself is at once a physical object belonging to the world of objects

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and the field or general organ of the experience of such objects. The lived-body, in short, has the double meaning of object and subject.

On the one hand, as an object, i.e., as part of the spatio-temporal causal nexus, the lived-body brings mind into the world of things and into contact with physical objects and, on the other hand, by not being merely an object the lived-body serves as the field wherein physical processes become sensations, that is to say, wherein objects of the world are experienced. Though they belong to consciousness or mind and not to the physical world beyond experience, sensations or the material component of experience anchor consciousness in the world of physical objects. They do so, because the lived-body has the correlative senses of "physical object" and "the field of experience of physical objects."

In the lived-body the field of sensation is basically a tactile field, a field in which objects (including the lived-body itself) are experienced through specific sensations of firmness, warmth, and softness, etc. In integrating these sensations the lived-body experiences itself through kinesthetic sensations. An object feels warm to the touch of my hand. I feel the warmth and the hard surface with my hand and correlatively feel the movement of my arm and hand upon the object. The kinesthetic sensations of the arm and hand are correlated to the sensation of warmth and the hardness and smoothness of the surface felt by the hand. Kinesthetic sensations enable the lived-body to experience not only physical objects but itself as the agency of the experience of physical objects.[21] The lived-body is thus uniquely differentiated in experience from all other physical objects through kinesthetic sensations which give to the lived-body a sense of "interiority" not present in the experience of merely physical objects.

The main importance of kinesthetic sensations for our purpose is that they are corre-lated to the higher level functions of mind, especially willing. Another term for agency or the author of agency is "person." Through kinesthetic sensations the lived-body is experienced as the bearer of actions (of the will). The exercise of the will is experienced through the lived-body by means of kinesthetic sensations which are foundational for tactile ones. In other words, I act and then experience objects, i.e., have sensations of physical objects, correlative to the action kinesthetically experienced. That is to say, the person who acts must be able to experience his actions.[22].

This points to an integration of sensation within the lived-body, the sense of which involves some organ of integration in embodiment. The brain or some such organ is essential to embodiment, because, if there are to be sensations for consciousness, physical processes have to be correlated with sensations. Further, the integration of sensation in experience must also be constituted as part of the world of physical objects. In this regard, "brain" means the factual realization of the integrative function of the livedbody which is essential to embodiment.

Embodiment essentially requires that consciousness be in the world for there to be integration of sensation.[23] The brain (and central nervous system) is, according to science, the factual realization of this essential necessity. So, the existence in the world of a functioning brain and central nervous system. is a necessary condition of embodi-ment, i.e., for being alive within the world.[24] Thus, the brain and its states underlie all consciousness which involves sensation. That means that higher level functions of mind, such as willing, which require sensations are essentially dependent on the brain. This dependency, however, does not entail a reduction of higher level functions of mind to the brain. The dependency is a relation essential to the meaning or sense of embodi-ment. In other words, if a body is to be a lived-body, the higher level functions of mind will have to be embodied in a functioning brain and central nervous system. The medical concept of brain or cerebral death can now be interpreted in terms of the conditions essential for embodiment.

Brain death, when adequate empirical criteria are established for ascertaining it, is tantamount to the death of a person, because the brain is the essential condition for embodiment. When the body can no longer satisfy the essential requirement that sen-

ti b i t t d h i th ld it t b d i d A d h

The concepts of death and embodiment 9

the essential conditions for embodiment are empirically determined to be absent, the person is justifiably pronounced dead. The person is dead, because the condition necessary for life. a functioning brain, is no longer present. Thus, embodied existence ends and the lived-body becomes a corpse or mere body.

In this way, the conceptual definition of death justifies the specifically medical definition of death as brain death. The problem of the adequacy of the criteria for ascertaining brain death-the problem dealt with in the Electroencephalographic Committee Report-is preserved as a purely medical, empirical issue. The sense of the medical definition of brain death is elucidated while its proper empirical nature is underscored. Thus, the ethical problem of organ transplantation and the disconnection of life-support equipment becomes relatively clear. If no person is present, i.e., if the essential condition for the embodiment of the higher level functions of mind is permanently absent, then no harm or injury can be inflicted upon the patient as person. The value considerations which are left are, therefore, legal and social.

REFERENCES 1. Two well-known discussions of the definition and meaning of death are Robert S. Morison's Death: process or

event'? Science, N.Y. 173, 694-98, 1971; and Leon R. Kass reply in the same issue Death as an event: a commentary on Robert Morison, pp. 698-702. For Morison the definition or concept of death as an event is an instance of what Whitehead called the "fallacy of misplaced concreteness". Death is a continuous process of disolution and not an event. Ethical questions about death cannot be answered definitively, because death really never is since it is a mere process of becoming. Kass, in his response to Morison, notes that he confuses two issues: -6) When, if ever, is a persons life no longer worth prolonging'? and (ii) When is a person in fact dead'?" (p. 699) Morison is only concerned with the first point. In this regard Kass points out: "regardless how one settles the question of whether and what kind of life should be prolonged, one will still need criteria for recognizing the end." (Ibid.)

2. "An operational definition of a term states that the term is applied to a given case if and only if the performance of specified operations in that case yields a specified result." Irving M. Copi, Introduction to Logic, p. Ill. 3rd edition, MacMillan, New York, 1968. The term "operational definition: was first used by P. W. Bridgman in The Logic of'Modern Physics (1927) in connection with issues in the philosophy of science.

3. In the article cited in Ref. 1, above, Leon Kass contrasts a "conceptual 'definition' or meaning" with an "operational 'definition' or meaning". Aside from making a terminological point, that the phrase "definition of death" is more appropriately used with respect to the first, and the phrase "criteria for determining that death has occurred" for the second--which is in fact what the terms "conceptual definition" and "operational definition" mean-Leon Kass does not clearly specify the ground of the distinction between the two. The ground of the distinction between the two is that the conceptual definition involves questions of meaning or essence while the operational definition involves questions of fhct. For an important discussion of the fact/essence distinction see Edmind Husserl. Ideas: General Introduction to Pure Phenomenology, Part l, Ch. 1. Section 1-16, pp. 45-71. (Translated by W. R. Boyce Gibson) Collier. New York, 1967. For a discussion of specific problems associated with giving a conceptual definition of death in the medical context. see Dallas M. High, Death: its conceptual elusiveness, Soundings 438-58, 1972.

4. The "special responsibility" of the physician to his patient is here understood as a moral responsibility inherent in the patient---physician relationship. The ethical dimension of medicine largely derives not from this social relationships as such, but from the conception of the patient as person fundamental to it. Once the patient is dead that special relationship of the physician to the patient ends. Of course. the physician may have non-medical responsibilities to the dead patient if. for instance. he made promises to the patient. This latter sort of responsibility, however, is outside the context of medical ethics.

5. There have been statutory "definitions" of death. The first of which was the Kansas Statute which gives alternative definitions, the first of which is the standard definition in terms of vital functions, those recognized in the Black's Law Dictionary, and the second is a definition based on the "absence of spontaneous brain function." Kansas Statutes Annotated, Ch. 77-202. For a good discussion of the relation of criteria for determining death and the law. see Alexander Morgan Capron and Leon Kass, A statutory definition of the standards for determining human death: an appraisal and a proposal University ql Pennselvaniu Luw Review, 121, 87-118, 1972.

6. A definition of irreversible coma. J. Am. Med. Ass. 205, 337-40. 1968.

7. Cerebral death and the electroencephalogram. J. Ain. Med. Ass. 209, 1505--10, 1969.

8. Even having satisfactorily answered the medical question of fact, the conceptual question (which gives ethical force to the operational definition) is presumed and needs to be asked.

9. Irving M. Copi, pp. 66-7.

10. It should be noted that Henrv Beecher, chairman of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death in effect discussed the medical evidence by considering the literature on the problem of determining criteria of death in comatose patients in an earlier article: Ethical problems created by the hopelessly unconscious patient, New Engl. J. ol, :bled. 278, 1425-30; (cf. especially pp. 1426-28) 1968.

11. Beecher notes in "Ethical Problems Created by the Hopelessly Unconscious Patient" that "the moment of death can have legal importance. but the criteria by which death is established must depend upon

104 GEORGE J AGICH

medical evidence." (p 1425) The evidence reviewed in the article, in the form of the literature on the criteria for determining death, however, leads to the inescapable conclusion that medicine can give no good reason either for saying when death has occurred-"what usually matters is not the time of death, but the time when a physician undertook to declare the patient dead." (p. 1426)-or for saying what death is. Noting the complexity in the meaning of death, i.e., "death occurs at several levels" because "life exists at several levels" (p. 1426), Beecher takes "death" to mean the cessation of physiologic life--"our basic concern is with the presence or absence of physiologic life, especially neurologic life." Yet, the implication of criteria for determining such death is to determine the cessation of the existence of a person. Beecher does not see this as an inference which needs to be argued for, but plays on the ambiguity in the terms life/death, i.e., physiologic, on the one hand, personal, on the other. This ambiguity is even present in the title of the article. Thus, the death of a person is reduced to lower level physiologic facts without any argument to legitimate the reduction. Cf., D. High's argument against just such a reduction, pp. 445-457.

12. This point has to be stressed. For the lack of brain activity to be definitive in the pronouncement of death, the absence must be permanent in the double sense that it will not be able to resume in fact but should activity resume it would be insufficient to embody the person as before the cessation.

13. The necessity at stake here is a factual necessity stemming in part from the very operations used in ascertaining brain death and in part from the factual, i.e., contingent. nature of the existence of embodied persons.

14. Cf. pp. 1507-8 and 1510 for a discussion of the technical aspects of measuring brain activity.

15. The Harvard Committee Report. in fact, observes that "An organ, brain or other, that no longer functions and has no possibility of functioning again is for all practical purposes dead." (p. 338) The point in the definition of brain death, however, is that the brain is not just like any other organ. In this regard. Dallas High points out that "an organ does not die but only persons die;' (p. 448) The death of the brain is significant only insofar as it indicates the death of a person. That much is clear. What is not clear is the nature of the relation between the condition in terms of which we determine "brain death" or "brain life" and conditions of embodiment. In this regard. Robert Veatch has recently argued (Tlie Whole-Oriented Concept of Death: An Outmoded Philosophical Formulation, J. Thanatol. 3, 13-30. 1975] that the condition in terms of which we now determine brain death do not determine the cessation of the conditions of embodiment.

16. Morison says, for instance: "Death does not come by inevitable appointment. in Samarra or anywhere else. He must sit patiently in the waiting room until summoned by the doctor or nurse." (p. 695) And also, that "The nervous system is, of course, more closely coupled to personality than are the heart and lungs (a fact that is utilized in developing the new definitions of death), but there is clearly something arbitrary in tying the sanctity of life to our ability to detect the electrical potential charges that managed to traverse the impedance of the skull." (p. 696) In light of the "arbitrariness" of such criteria. Morison proposes pragmatic considerations but not the need for conceptual analysis. This line of thought has rightly come under criticism. Dallas High has argued that biological and physiolo-gical considerations alone are insufficient to elucidate the significant meaning of death which is not the cessation of mere biological or physiological functions (necrosis). but the cessation of the existence of a person. (p. 449) High suggests that comprehensive considerations be employed in determining death. (p. 450) Such considerations are at least logically prior to physiological and other empirical indices of the death of a per,on. but it is not clear what efficacy "comprehensive" criteria would have for medicine. The problem is, however. as High rightly argues, one of determining the death of a person. (453 ff.). This can be done. sve will argue. by conceptually tying down the empirical criteria of brain death to the death of a person.

17. Willard Gaylin, Harvesting the dead, Harpers Maga_zine, 249. 23--30, 1974.

18. The method of treatment of embodiment will be phenomenological; that is to say. the meanings of "person," "mind," and "brain" will be elucidated without regard to theory. The classic formulation of the phenomenological method is to be found in Edmund Husserl's Ideas (cited in note 3, above), Part Three, Chapter 7, Section 63-75, pp. 171-193. Pill simply. the phenomenological method of exposition is a rigorous c\plication of the meaning of phenomena as experienced. Hence. our characterization of embodiment should be understood simply as an analysis or exposition of the meaning of "person." "mind," and "brain" in embodiment independent of any theoretical explanation.

19. The use of the term "meaning" in this paper corresponds with the Husserlian notion of Sinn. sense or meaning. This usage, simply put, commits us only to explication, not explanation of the embodiment of persons and the function of the brain therein. The explication prescinds from any commitment to natural science or metaphysics except to note that if the brain and central nervous system is the central organ C (cf. Note 24. below), and that is a matter for empirical science to decide, then the relation between "person," 'mind," and-

brain" (or the factual instance of the organ essential for embodiment) holds essenriallr. i.e.. holds according to the meaning of "person." "mind." and "brain."

20. Edmund Husserl Ideen :u einer reinen Phanomenologie utul phiinomenologischen Philosophie, Zweites Buch, Section 36, p. 145 (Edited by Marly Biemel) Martinus Nijhof. The Hague, 1952.

21. This point is analogous to that of Kant: "A person is the subject whose actions are capable of being imputed. Accordingly. moral personality is nothing but the freedom of a rational being under moral laws (whereas psychological personality is merely the capacity to be conscious of the identity of one's self in the various conditions of one's existence).... A thing is that which is not capable of any imputation. Every object of free choice that itself lacks freedom is therefore called a thing (res corporalis)". The Aletaphi'sical Prirwiples of Virtue: Part Il of The Metaphysics of .Morals. p. 23 (Translated by James Ellingtonl Bobbs-Merrill. New York. 1964.

22. In Husserl's terms. the lived-body is the organ of the will (Willen.sorgan) and the bearer of free movement or action (Tr6ger lreier Be«'egung). Ibid., p. 151.

The concepts of death and embodiment 12

23. Or, as Husserl puts it; "data of sensation can only appear if there are 'in objective reality' sense organs, nervous systems, etc." And, "if things are to be able to appear as harmonious actualities in a consciousness located in an intprsubjective nexus of understanding, then data of sensation must belong to the appearances and if they are to be able to be there, then animate organisms must also be able to appear and must have their physical actuality." (p. 289)

24. Or, in Husserl's terms: "Consciousness of the world is constituted in appearances, more precisely in somatic appearances. Sensations occur in particular apprehensions. in certain intersubjective regulations. And here especially the regulation conforms to the Objective actuality of those hidden somatic organs which we call the central organ C, nerve centers, sensory nerves, etc. And the occurrence of each sensation E in my consciousness 13m, that is, in a determinate individual consciousness e„, (of human M), should be dependent upon the portion of that regulation, that then is called the state C';." of my (of the respective individual M) Cm. Insofar as the sensations enter in other subjective processes of consciousness as constitutive moments, these would all be dependent on C", and its states." (pp, 290-