In recent decades, medical and legal communities have taken “Whole Brain” death to be synonymous with the death of the human being. This standard, formalized in the 1981 Uniform Determination of Death Act (UDDA), defines death as the irreversible cessation of all brain activity. Yet, problematically, this definition misunderstands the hylomorphic nature of man. It neglects, in other words, that man is composed of both soul and body.
For “Whole Brain” death to accord with a metaphysically sound anthropology, it must be death simpliciter — death without qualification. But years of philosophical reflection suggest that “Whole Brain” death, and it’s more recent “partial brain” variations, such as the gravely concerning 2023 UDDA amendment, does not demonstrate the absence of life and should not be taken as evidence of the death of the human being.
In their 1981 report, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (PC) accepted the proposed “Whole Brain” death formulation upon the conjecture that without the brain, the organism ceased to be a unified whole. The distinction, they purported, between living and nonliving comatose patients rests on the assumption that “when the mask created by the artificial medical support is stripped away what remains is not an integrated organism but ‘merely a group of artificially maintained systems.’”
This assertion wrongly presupposes that the function of the brain is fully responsible for somatic integration, or in other words, making it a functioning whole (a living body) out of what is otherwise a disassociated mass of parts.
This position further presumes that the brain has a necessary relationship to organismal life. As Doyen Nguyen stresses, this “equates the death of the patient with the loss of function of one organ.” And as illustrated by St. Thomas Aquinas, it is contrary to reason to say that the soul inhabits “just one part of the body…it must exist in the whole body and in each part of the body…(because it is) the form and actuality not only of the whole but also of each part.” To assert otherwise is to conform to a dualistic-material logic that separates in theory what is undivided in reality: body and soul.
The findings of pediatric neurologist D. Alan Shewmon provided impressive evidence suggesting the biological inadequacies of this “Whole Brain” formulation, and convincingly indicate that most bodily integration is not facilitated by brain activity. Shewmon argued, in a 2008 President’s Council on Bioethics that clinicians should err on the side of life when faced with a patient who is in a prolonged comatose state: “[I]n the face of such persistent uncertainty, the only ethically valid course of action is to consider and treat such a patient as a still-living human being.”
This position was refuted by the majority of the second PC’s members, who found that “the loss of the impulse to breathe and the total loss of engagement with the world as the cessation of the most essential functions of the organism as a whole” provides reasonable evidence for the proclamation of death.
This erroneous conflation of death with the loss of specific biological functions is presented in an exaggerated form in the 2023 UDDA revision. To suggest that death can be identified merely upon “permanent coma” disregards the long-held notion that death is a biological event with physical signs. And while, as noted, this amendment was rejected, not only is the fact of its proposal concerning, but also (and perhaps more so) the ULC’s expressed interest in aligning the law with current clinical standards.
Under its current formulation, the UDDA requires proof that the “irreversible cessation of all functions of the entire brain, including the brain stem” has occurred. This presents a problem for clinicians because they are sometimes unable to prove complete cessation of all functions, and an accurate definition of death (read: a legal one) is not ascertainable. But inadequate clinical standards do not justify evading the law and abandoning reason. As several ethicists have noted, the appropriate response to false positives is to “improve testing, not change the definition of the disease.”
Life and death are binary and absolute. There is neither a third option nor a sliding scale. As St. John Paul II stated: “A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man.”
It is incumbent upon physicians to ensure that the care they provide to their patients is care — that concerns the good of the person. In the ever-evolving landscape of modern medicine, this assurance is complicated by technological interventions that confuse once-established boundaries. Still, the emerging inability of medical professionals to conform to what we have always known to be true is not an acceptable justification for malpractice.
As I noted in part one of this article, when assessing sensitive bioethical issues, we must proceed with prudence and charity, and when it comes to brain death, in dubio pro vita.
Until clinical standards are improved, medical professionals should, at least, proceed under the assumption that patients who do not meet the accepted standards are still living human beings. And following the rejection of the revised amendment, ethicists, clinicians, and researchers alike should take this as an opportunity to further evaluate the brain death criteria as a whole.
