The point of death

The Guardian yesterday reported the death of the man who had been so tragically shot in Antigua, with his wife, three weeks after their wedding. It began like this:

"Ben Mullany, the newlywed who was shot on honeymoon in Antigua in an attack that killed his wife, Catherine, died in hospital in Wales yesterday after his life support machine was switched off.  The 31-year-old trainee physiotherapist, who had suffered a fractured skull and had a bullet lodged in the back of his head, was flown back to Britain while in a coma on Saturday. Tests carried out when his condition stabilised after the 24-hour journey established he was brain dead." 

This is a familiar way of describing such happenings, even among clinical professionals.   Brain death is pronounced, so the life support machine is switched off, and the patient dies.   The clear implication is that brain death is not death.  The machine is still keeping the patient alive, and it is switching off the machine that causes real death. 

This was not the intention of the people who introduced the concept of brain death.  Their intention was to offer an alternative means of diagnosing death as such.   For a very long time doctors had used the cardio-pulmonary criterion (cessation of breathing and heartbeat) to establish death, but the development of the mechanical ventilator (‘life support machine’) meant that many patients whose brains were no longer functioning, and who had no chance whatever of recovering either consciousness or spontaneous breathing, were still, by these criteria, alive.  This caused many difficulties.  These were particularly acute for the developing transplantation programme, which needed donors that were dead but organs that were kept fresh by the ventilator.  But it had wider implications of many kinds, such as in the enormous cost of keeping people on ventilators in intensive care when there was no chance of their ever recovering. 

So it was proposed in 1967, and has since been widely accepted, that brain death should be accepted as a criterion for death as such.  But of course by the original cardiopulmonary criterion ventilated brain-dead bodies should still count as alive – as in many parts of the world, and to a considerable extent in both popular and medical intuition, they still do.  Which of these views, and the variations on them, is right?
This fundamentally important point is that this problem is not one that can possibly be solved by science or technology.  Science can tell us, with increasing accuracy, what state any body is in, and what chance there is for reversal of any declining function.  But that does not amount to telling us which of those states is really death.

This is true whatever you think death actually is. If, as many people believe, the essence of life is the presence of an immaterial soul, death occurs when that soul finally leaves the body;  but as science cannot detect souls, it cannot determine when that is.  If, on the other hand, life is a complex organization of physical parts and nothing further, then when you know everything there is to know about the physical state of the body you know everything there is to know.  There simply is no further, objective question of whether the person is really dead.   Some parts or aspects may be dead while others continue, and the question is which we are going to count as constituting overall death.

Either way, then, the question of when death occurs is not a scientific one;  and this means the problem needs to be understood in a different way.   The reason why the diagnosis of death has mattered so much is that the difference between life and death is traditionally of enormous moral importance, and the problem we are faced with now must be recognized as a moral one.  Rather than a decision about the true moment of death, we need a decision about the morally appropriate treatment of people at the different stages of the closing down process that everyone recognizes as dying.

To people who think there is an objective point of death, even though we cannot be sure when it occurs, it may seem that the only acceptable course is the traditional one of waiting until there can be no possible doubt. (How?)  To those who think there is no more to human life than a complex arrangement of physical parts, however, the problem is to determine which aspects of the individual are the ones that are morally significant.  The proposal of the brain death criterion depended on the idea that what mattered was personhood.  The idea was that when brain function had finally gone, along with consciousness and all that went with it, the ventilator was pumping blood around an empty shell rather than a person. 

But although the brain death criterion is now widely accepted, the personhood idea makes the life/death distinction very uncomfortable around the margins, because by that standard people should probably be declared dead when their upper brains are so damaged as to preclude any possibility of consciousness or its return,, even though the brain stem is still intact and spontaneous breathing continues.   (This is the case with many patients in the state known as PVS, ‘persistent vegetative state’, who are still counted as alive and who can be maintained for many years by artificial feeding.)

When all this is fully understood, it raises serious doubts about whether we should recognize a sudden change of moral status between life and death at all.  Perhaps there needs to be a penumbral morality, to go with the penumbral states between the clearly alive and the clearly dead – before what is clearly death, but after the individual’s interests have finally gone.

From the press reports, it sounds as though it was clear soon after the shooting that Mr Mullany’s brain had been comprehensively and irretrievably damaged, and that there was no chance of his ever becoming again the same person – or any person – again.  This seems to have been recognized even before he was declared (brain) dead, and before his being returned to the UK for continued treatment.  His continuation on the ventilator did him no harm, but it did him no good either.   It gave his parents some kind of hope because he had not actually been declared dead – but hope of what?   Was it morally worthwhile to devote enormous amounts of skill and money to maintain his circulation and other bodily functions while flying him back to the UK?  Doing so was a natural and understandable response to a great tragedy, but was it the right one?

Given the ever increasing powers of technology to keep some parts and aspects of the body functioning when others have been irretrievably lost, and given the colossal expense involved in making use of this technology, it is morally essential to recognize these question of life and death for what they are.   But it will be very difficult to dislodge the idea that we must make a sharp moral dividing line between life and death.