Philosophy 383 SFSU Rorty Lecture 8: Death (Oct 20)When is someone dead?There are at least three answers to that question: the legal answer, the medicalanswer, and the social answer. The ethical issues arise when negotiating the three.Legally, we have the UDDA (1980): “An individual who has sustained either irreversible cessation ofcirculatory and respiratory functions, OR irreversible cessation of allfunctions of the entire brain, including the brain stem, is dead.”Medically, physicians are required to abide by the parameters of the UDDA.But they are also designated by our society as the interface between thelaw and the society.And socially, things are much more complicated. People have views about death—ofvarious sorts—that don’t necessarily correspond with either the legal or the medicalviews.1. The legal viewThe articles, on pp. 339-360 of our text, discuss the transition in the course of thelast century from the traditional determination of death by the cessation of respiration andheart beat to a more technologically determined standard: the death of the whole brain,as determined by neurological tests. (=”brain death”) This transition to a technological determination has been made because oftechnological advances: because ventilators can substitute for the organism in keepingthe blood circulating, the stopping of the heart is not the first or even necessarily the bestway of knowing whether the person is still alive or not. But the brain is indispensable inkeeping the organism integrated and in keeping all the organic functions going. So if itcan be determined whether the brain is still working or not, it can be determined whetherthe person is dead, or merely unconscious.The brain-dead individual has no electrical activity in the brain (as measured byelectroencephalogram); no response to pain; no pupillary reflex (=if you shine a light intothe eye, the pupil does not narrow), and no spontaneous respiration. Officialdetermination of death by neurological criteria typically requires examinations anddeclarations by two physicians, and flat EEGs (electroencephalograms) 24 hours apart. (The Bernat article on p. 353 talks about some of the tests for brain death.)There are states of unconsciousness (pvs, minimally conscious state) where theindividual has no conscious activity, but the brain stem still survives to provide some ofthe functions of the autonomic nervous system. That person is not (legally) dead. Thatperson may be in PVS or in a minimally conscious state; and can remain in such a statefor up to 35 years, if life supporting treatments (ventilator, ANH) are continued.The typical scenario involves a severe injury (trauma or deprivation of oxygen fora period of time). The individual is raced to an ER and then to an ICU and put on allOct 20, 2009 Class Lecture: week 8 page 1Philosophy 383 SFSU Rorty available means of life-support to see if the heart will start beating again, or if the personwill begin to breath spontaneously. The three most common causes of brain injury aretrauma, bleeding into the brain, and anoxia—deprivation of the brain of oxygen, fromcessation of breathing or low blood pressure. Neurologists check to see the pupillaryreflex and other reflexes; there are several well-established tests for brain stem injury. Ifit looks bad, the patient is declared dead and removed from life support.There is some controversy about brain death on both ends. (1) Some people do not accept any criterion for death other than the cessation of heartand breath. Those people are allowed by law in two states (and by convention andsympathy almost everywhere else) to refuse to accept the declaration of death byneurological criteria. The formulation of the 1982 Uniform Determination of Death Actexplicitly includes this as one of two definitions. (Removing all life support quicklyprovides evidence of death by those more traditional criteria as well.) (2) Other people, including some in our readings for this week, wish to move to what iscalled the “higher-brain” standard: A person is dead when cerebral activity ceases—when they are no longer conscious, interactive, responsive—no longer able to remembertheir past, anticipate their future, or perceive their present. This ‘higher-brain’ standardis compatible with some (but not much) brain stem activity; and with the survival ofisolated cells in the brain which may generate electrical impulses visible on EEG. Thiscontroversy dovetails into our discussion last week of personal identity. We are not justanimals, mere animals; we are persons, as well, and the sustaining (or failure to sustain)of our animalian selves is a reproach or injustice to our human selves. The UDDA and the President’s Commission: The “Harvard criteria” for braindeath were codified in a model statute in 1980 which has been adopted in some versionby 50 states and (according to Bernat) about 80 foreign countries. There’s an interesting category of federal activity: model statutes, which thefederal government recommends that states adopt. We have seen one in action: thePatient Self-Determination Act, by virtue of which health care providers are legallysupported in NOT treating patients, despite the socially-designated function of health careproviders and institutions, if the patients refuse treatment. We see another in theUniform Determination of Death Act, by which the traditional definition of death issupplemented by a definition of brain death.2. The medical viewMedicine at its best is concerned with healing, curing—a temporary interruptionof life as usual, which then resumes, returning people to their studies, their work, theirfamilies. Our health system, our healers and curers, encounters people in extremity, anddoes its best for them. This is the modern medicine which we all love; the sunny side ofmodern medicine.But what is best for the patients that are the object of medicine?Oct 20, 2009 Class Lecture: week 8 page 2Philosophy 383 SFSU Rorty Sometimes people in extremity cannot be returned to health, to their ordinary lives. --After all, all men are mortal-- So we need to look a bit at the inevitable end of that life-as-usual, death—and consideredthe question of-- what is best for the dying? It’s best for them sometimes that they not suffer intractable pain, or be forced tocontinue to face a life that is in their judgment not worth living. What can the living do to choose the time