Updated Tradition – Cardiopulmonary Death
Traditionally, death is defined as ‘irreversible cessation of function in the heart and lung’. However, advances in medical technology have complicated the definition of death. Transplantation of vital organs further intensified the debate over life and death. In 1968, Harvard Medical School Ad Hoc Committee put forth a new criteria and redefined death as ‘irreversible coma’ based on brain standard. This new definition has achieved public acceptance along with prevalence of organ donation and transplantation. Nevertheless, whether brain death should be or could be a sufficient criterion of death ought to be more carefully examined. The controversies facing the brain death criteria give rise to a proposed return to tradition: an updated cardiopulmonary approach.
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One of my prime objection to Harvard Report lies in its purpose of redefining death. The Committee stated the direction of their reasoning by pointing out “that ‘obsolete’ criteria for the determination of death were aggravating the shortage of organs available for transplant.” Surely, we would all agree that, at some point, ‘plugging out’ stands for the interests of the dying patients and their grieved relatives. But what is more important is whether the decision is being made because somewhere else one is looking for a kidney or a beating heart rather than the patient is suffering from great burden. It seems like the Committee approached the redefinition of death with a desired conclusion – a justifiable way to increase the available organ supply – already in mind. Just as how Singer argues against this kind of moral reasoning: “if…we build up our description of the universal aspect of ethics so that it leads us ineluctably to one particular ethical theory, we shall be accused of smuggling our own ethical beliefs into our definition of the ethical.”(Practical Ethics) In this sense, the redefinition is unacceptable and immoral as it seeks a particular result in the attempt to unduly influence ascertained ethical truth.
Another primary objection comes from the contradiction of the criteria itself. The Harvard Medical School claims that, “The burden is great on patients who suffer permanent loss of intellect…”. However, if a person is already dead, it would be then impossible for him to feel any kind of psychological burden. Also, the phrase ‘irreversible coma’ is a confusing and misleading expression. From our previous knowledge, coma is a condition of a living person and death is beyond coma (President Ronald Reagan,1981). Others question the report because it did not, at all, “define” death but only listed a series of neurological signs. It didn’t in fact settle the problem as it hadn’t distinguished persistent vegetative state and death, therefore raised controversies in several hard cases, i.e. Terri Schiavo case.
Difficulties that the brain standard faces have contributed to the renewed interests in the traditional but updated cardiopulmonary definition. This new standard suggests death as the ‘irreversible cessation of circulatory-respiratory function’. According to this advanced approach, certain functions should also be portrayed as central. Tradition is correct to regard circulation and respiration as essential; however, circulation does not simply equal to a working heart and respiration isn’t limited to the lung function. Both organs, after all, can be artificially replaced and the organism of a patient can maintain integrated functioning with the assistance of medical science.
The chief advantage of this updated traditional standard is that it best and most adequately distinguishes the difference between life and death. Recent scientific research indicates that brain death is not automatically followed by immediate cessation of all other body functions: “It was found that the mean persistence of cardiac function after brain death was 8.20 days and the median survival time was 6 days.”(Al-Shammri S.a 2003;49:90–93) It would be controversial and emotionally difficult to declare an individual still breathing and with remained heartbeat as ‘dead’. Unlike brain death, loss of respiration and circulation leads undoubtedly to the breakdown of cells, tissues, organs and eventually the whole organism. Moreover, the cardiopulmonary approach would handle cases of locked-in and PVS patients more plausibly in terms of organismic functioning. It would provide more accuracy in clinical practice and wider consensus of the determination of death.
Contrary to the brain death criterion, the rather traditional definition can avoid some conceptual problems when it comes to the important implications for abortion and personhood. “According to the materialist viewpoint of brain death, when the brain is ‘dead’, what is left is merely a collection of organs but not a human person. This would raise further dispute for the endowment of personhood to adult patients.” (The Definition of Death,2007) The definition of death also has direct implications to the beginning of life. If consistent to the brain standard, a fetus without full development of brain couldn’t be regarded as a living human. In contrast, the cardiopulmonary approach evites the unnecessary linkage of certain brain functions and a person’s value, therefore avoids disputes by respecting a living as a whole.
It is inevitable that there will be many challenges confronting the updated traditional criteria. The main concern may still be the shortage of usable organ for transplantation. However accordingly, the practice of DCD (donation after cardiac death) contributes greatly to the above proposal. A patient who suffers severe brain injury but hasn’t met brain death determination can be considered as a donor of vital organs if his/her family has decided to withdraw care. At this stage, organs recovered from a donor after cardiac death retain some degree of oxygen deprivation and are therefore viable for transplantation. Thus, this provides a positive possibility to deal with the controversies about organ donation by optimizing conversations between family member, organ donation personnel and physicians.
Other questions may also come along with the readaptation of the definition of death. For instance, it will contradict with the current legal definition of death as the brain standard has already been broadly adopted. Nevertheless, there is no reason to refuse more adapted reform despite all the difficulties that we may encounter. As changing medical technology continuingly poses new problems related to our standard of death, we might well force ourselves to examine the consistency of death and what we actually value in a person, hopefully in a way that will better prepare us to address the unpredicted future.