Brain Death and Technological Change:
Personal Identity, Neural Prostheses and Uploading
James J. Hughes
Prepared for the Second International Symposium on Brain Death
Second International Symposium on Brain Death
Havana Cuba * February 27-March 1, 1995
Contents
The death at issue in the brain death debate is not an empiric reality,
but a social category, "social death." It is a question of which bodies we are
comfortable using and disposing of in certain ways, and not comfortable giving
medicine or food as if they were "alive." Until recently both mind and body
stopped functioning at the same time, and this "death" and "social death" were
generally seen as one phenomenon. There were important exceptions, however, in
many cultures where particular diseases and disabilities earned a social death
definition before the physical death had occurred.
In the modern world, whole brain definitions of death arose as a result of the
technological deconstruction of death as a unitary phenomenon. The whole brain
definition was at the outset a compromise between those who prefer a
neocortical definition, and those who prefer the whole body definition. This
paper argues that the whole brain definition of death is an unwieldy,
historical compromise which will unravel as 21st century technologies permit
the repair, replacement and manipulation of body, and especially brain, tissue.
These technologies will present anomalies to the whole brain definition which
will force us towards, and then beyond, a neocortical definition of death. New
biological and cybernetic technologies will make clear that social life is
properly attributed to any biological system with a particular set of
subjective experiences - personhood. These technologies will also create
tremendous material incentives for the living to stop treating the permanently
unconscious as socially alive.
- For everyday purposes we know and can say whether an animal is alive or
not. But upon closer inquiry, we find that this is, in many cases, a very
complex question, as the jurists know very well. They have cudgeled their
brains in vain to discover a rational limit beyond which the killing of the
child in its mother's womb is murder. It is just as impossible to determine
absolutely the moment of death, for physiology proves that death is an not
instantaneous, momentary phenomenon, but a very protracted process.
(Engels,1880, Socialism: Utopian and Scientific)
Soon after the proposal of a brain death standard of death (Beecher 1968), a
debate began as to how much of the brain must be destroyed for a patient to be
declared dead. Veatch (1975) opened the debate by arguing that human beings
should be declared dead once they had lost the ability to meaningfully interact
with others. Veatch was soon joined by a small, vocal group of
"neo-corticalists" (Green and Wikler 1980) (Brody 1983) (Youngner and Bartlett
1983) (Gervais 1986) (Cranford and Smith 1987). In response, "whole-brainers"
(Black 1978a; Black 1978b) (Bernat 1989) have defended a standard requiring
complete brain death, and this standard was eventually endorsed by the
President's Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research (1981), and written into most state laws.
(See Appendix One for my summary of the arguments against the higher-brain
standard and their rebuttals.)
The debate in the 1970s and 1980s made clear that, although there were some
arguments advanced as to the ethical superiority of a whole-brain standard, the
real advantage of the whole brain standard was pragmatic: it was easier to
operationalize, it conservatively erred on the side of life, and it was seen as
the most radical that the public would tolerate. The whole brain definition was
at the outset a compromise between those who preferred a neocortical
definition, and those who preferred the somatic definition. As Botkin and Post
(1992) put it:
"It is our own conviction that the whole brain death standard probably best
balances the conflicting needs within our society, despite the confusion it
generates. This is based largely on utilitarian considerations." (Botkin and
Post 1992)
This paper argues that the whole brain definition of death is an unwieldy,
historical compromise which will unravel as 21st century technologies permit
the repair, replacement and manipulation of body, and especially brain, tissue.
These technologies will present anomalies to the whole brain definition which
will force us towards, and then beyond, a neocortical definition of death.
I begin by endorsing the view of some neocorticalist writers who argue that
this standard is best articulated in a dualist mind-body framework (Brody 1988;
Wikler 1988; McMahan 1995), which distinguishes between social and biological
life and death. This is contrasted to the whole-brain partisans and "unitarian"
neo-corticalists (Youngner and Bartlett 1983) who argue that there can only be
one death. I then pursue the thought-experiments of previous writers as to how
future technological advances may force further clarification in the definition
of social death, focusing on emerging brain repair strategies. Finally, I
discuss how some of these technologies may challenge even the neo-corticalist
model to evolve towards a personhood centered definition.
Wouldn't it be more appropriate to say that, even though (the PVS body) is
still alive, this patient is no longer a person, having lost, when her cortex
stopped functioning, the physiological base of what is crucial to personhood?
(Brody 1988)
The death at issue in the brain death debate is not an empiric reality,
but a social category, "social death." It is a question of which bodies we are
comfortable using and disposing of in certain ways, and not comfortable giving
medicine or food as if they were "alive." The operationalized "social death"
would tell us which bodies we can stop feeding, remove from life support,
remove organs from, and cremate. In other words, I would like to advance a
slightly more sociological version of the argument that other higher-brain
advocates have made for mind-body dualism (Brody 1988) (Wikler 1988) (McMahan
1995), as distinct from the whole-brain position, or the higher-brain unitarian
position, that irreversible loss of consciousness is the only death possible
for a human being.
Bernat and associates, in defending the whole brain death definition, have
asserted that there is a universally recognized standard for the recognition of
death. This may be true, though it may not be relevant to the our current
dilemmas. But I propose that there is also a near universal distinction between
social personhood and physical existence. In many cultures persons with
particular diseases and disabilities were treated as "socially dead" before
physical death had occurred. Social death has been used as a means of dealing
with newborns with anomalies and disabilities, with the elderly infirm, and as
punishment. Corpses are treated in some societies as being inhabited by the
vital principle for long after we would declare death, as for instance among
the Tibetans who continue to chant verse to the body and its listening spirit
for a week after respiration has stopped. And many societies invest greater or
lesser faith in the continued presence of the dead as members of the social
order, with rights and obligations.
Conversely, partum is not the universally recognized beginning of social life.
In some societies infants were not considered persons until one year of age
(Piers 1978) (Harris 1979). Some religions and cultures hold that social
personhood begins at conception, or before. Some societies recognize a
continuity of identity across individuals, on the grounds that one person can
or should assume the roles and obligations of another.
While we would be unsympathetic with most of the previous applications of the
principal of social life and death in simpler societies, these cases show that
there is no universally recognized "bright shining line" between social death
and life. Instead of a universal binary dead-alive recognition, cross-cultural
evidence would suggest more of a two-by-two table
Socially Alive Socially Dead
Biologically U.S.: All conscious U.S.: fetuses and whole brain
Alive adults dead, the PVS
some societies: outcasts, disabled, zombies
Biologically in some societies: corpses prepared for disposal
Dead ghosts, ancestors, gods
corpses still connected
to spirit
One of the frequent arguments against the higher-brain definition of death is
that it would be distasteful to bury a breathing body. Defining a body as dead
or socially dead does not remove all obligations to treat it "humanely." We
have many policies regarding the use and disposal of corpses, specifying what
we consider to be in good taste. We honor the wishes of the dead in regards the
disposal of their remains and their property. Similarly, the definition of the
permanently vegetative as being dead "socially" does not mean that we need to
allow surgeons to remove their organs, or morticians to bury or cremate them
while they are still breathing. We may be more restrictive about what can be
done with PVS bodies than what can be done with bodies that aren't breathing,
just as we may be more restrictive about what can be done with a body which is
being prepared for an open-casket wake versus one that will be cremated.
The social death concept asserts that citizenship, rights and value adhere not
to bodies, but to subjective persons. This means that we would charge someone
who removed the ventilator from a PVS patient with interfering with corpses
rather than murder. We would consider it absurd to spend social resources on
their maintenance. After social death there is no patient present, we would not
encourage health workers to talk to the permanently comatose (La Puma, 1988).
In this view, the body of the patient in persistent vegetative state is still
alive, and could remain so, but the patient is not. (Wikler 1988)
Most whole brain partisans are comfortable with family and health care
institutions having wide discretion to withhold and withdraw life support,
including food and fluids, from bodies in PVS on the grounds of advance
directives, surrogate decision-making, quality of life judgments, or resource
allocation. But the "social death" or operational death argument is that it is
not simply permissible to withhold food, fluids and medicine from the
PVS patient, but desirable that we soon stop the perfusion of this body, unless
some great important good can be obtained from doing so. It is wrong to
continue to treat them as if they are "alive."
It is an insult not only to the specific individual, but to human beings in
general, to confuse someone who is deceased with a living individual. (Veatch
1992)
Wikler (Wikler 1988) points out that this argument risks circularity. We
cannot simply define those bodies as "dead" which we wish to withhold treatment
from, and then withhold treatment from the "dead." This underlines the
importance of the social death concept, which allows us to distinguish between
the socially dead and other categories of patients. The socially dead are those
bodies lacking personhood, and thus any possibility of interests or rights in
medical care or nutrition.
Most participants in this debate assert that the public and the medical
profession would be shocked at defining bodies in PVS as "dead" (Tresch et al.
1991), and use this as either an argument against the neo-cortical standard or
for greater public education (Youngner et al. 1989). Yet there is some
evidence that both the public and physicians are ready to discuss whether it is
right to continue treating bodies in PVS as alive.
Results of a survey conducted out the Center for Clinical Medical Ethics
support the contention of an emerging consensus among bioethicists as to the
status of PVS patients. The survey was mailed out to 240 medical ethicists in September 1992 and all surveys were
received back by December 1992. The response rate was 60% (155 of 260).
[The sample of medical ethics-related individuals was
composed of about half Ph.D.s in philosophy and related social science and
humanities, two dozen students with interests in medical ethics issues, as well
as about 20 physicians, ten directors or staff at health policy organizations,
a handful of priests and nuns, and several nurses and lawyers. The occupations
of the medical ethics-related sample included ethics consultants at hospitals,
the directors of academic programs in philosophy, medical ethics or policy, and
the staff of lobbies for AIDS funding, national health insurance, drug
legalization, senior concerns, alternative medicine, and for and against
abortion.]
Two parallel sets of questions were included addressing whether a family should
be allowed to withdraw life-sustaining treatment for newborns and currently
unconscious 70 year-old women in a variety of conditions (the questions are in
Appendix Two). The graph above shows the ethicists' responses to the different
scenarios.
This sample is by no means representative of American bioethicists, but
nonetheless supports the general contention that American bioethicists consider
the permanent loss of mental capacity to be as much a reason for the
withholding of life-sustaining treatment as immanently terminal disease.
More to the point, there is a growing acceptance of the higher-brain definition
of death. Also in 1992, Payne and Taylor (1993) surveyed 500 neurologists; half
believed that PVS patients should be considered dead, and 94% thought they
would be "better off dead." Less than half thought that any PVS patients'
illnesses should be treated aggressively, and more than three-quarters thought
that a universal health care plan should discontinue payment for PVS patients'
treatments. About nine out of ten believed it was ethical to withdraw and
withhold hydration and nutrition, and two-thirds believed it was ethical to use
the patients' organs for transplantation.
Some have said that the 1968 Harvard Committee's report is little more than an
addendum to instructions on how to use a respirator. (Gervais 1986)
Most histories of bioethics assert a generative force to medical technology.
Technology is described as having "created" dilemmas, from the impact of
in-vitro fertilization (IVF) in creating beginning of life dilemmas, to
ventilators in creating end-of-life dilemmas. But I agree with those who argue
that technology does not create new ethical dilemmas (Emanuel 1991: 11-13), but
makes us aware of dilemmas already present which we had hitherto ignored. One
of the effects of technology is to "denaturalize" (Bayertz 1992) things which
we had taken for granted as unitary.
An example is IVF and the "deconstruction" of parenting (Stanworth 1988). IVF
did not create a dilemma of conflicts between birth parents and social
parents; that conflict has existed since prehistory as a result of adoption. On
the other hand, IVF did make possible the conflict between genetic mothers and
birth mothers, two roles which had previously been unitary.
In the same way, the on-going redefinition of death and social death is the
result of the technological deconstruction of dying. Instead of a relatively
instantaneous process, death is now more like a "syndrome" (Botkin and Post
1992), a cluster of related attributes. This disaggregation requires that we
decide how many of these attributes are required before we begin treating
someone as "dead," just as physicians must decide how many psychiatric traits
are required before making a diagnosis of "schizophrenia." In the case of brain
death, ventilators did not create the question, but forced us to face it once
ventilation disaggregated brain injuries and somatic death.
One can adopt one of four positions towards the advance of technology and
ethical adaptation. The first position would be the ethically significant
changes in medical technology will never occur. Predictably, some whole-brain
partisans adopt this view, and reject the idea that technological change will
encourage further specification of death definitions (Bernat 1992). The second
position would be that ethical categories and logic that are adequate today
should be maintained, while new logics could be adopted later, when necessary.
This appears to be the argument of other whole-brain partisans; a whole-brain
definition may be inadequate in the future, but it is a good, conservative
standard given today's technology. A third position would be that any thought
experiment which shows the superiority of one view over another should be
accepted.
The position I advance here is a compromise; we are not obliged to entertain
all thought experiments, no matter how implausible, but if technology will make
our current ethical views inadequate within some finite, foreseeable period of
time, we should adjust our thinking, and law, to a more solid footing. In the
case of the personal identity literature, not all the technologic thought
experiments are plausible. For instance the physicist David Allen Batchelor, in
his The Science of Star Trek, discusses the technical constraints on
the teleportation device used in the Star Trek series, and discussed in some of
the personal identity literature, and concludes that this would be virtually
impossible within our current scientific framework. But many of the thought
experiments, such as brain transplants, are possible eventually.
Below I briefly review some of the emergent technologies which will likely
force a specification of social death definition from the whole-brain standard
to the neo-cortical standard and beyond.
One of the principal drawbacks of the higher-brain definition of death,
acknowledged by both proponents and opponents, is that the diagnosis of whole
brain death is technically possible, while the diagnosis of irreversible
cessation of cerebral function is more difficult or impossible. Without
reviewing technical issues beyond my competency, I will note that Veatch (1992)
has written an extensive review of the technical ambiguity of the whole-brain
diagnosis. Conversely, advances in PET scanning and other imaging techniques
should make it easier to diagnose someone as having irreversible damage to the
cerebral cortex, without having to wait for months.
Because technology can substitute for many brain functions (spontaneous
respiration, cardiovascular support, and neuroendocrine regulation), a more
refined definition that emphasizes functions that cannot be replaced through
technology may be appropriate. In fact, we are replacing brain stem functions
with ever-increasing success. (Youngner and Bartlett 1983)
Future medical technology may enable us to keep the brain stem alive or
replace it entirely, thus preventing brain-stem death. (Ray 1991)
The British brain death policy requires only that the brain stem has been
destroyed to declare death, and many commentators have noted that it is
technically possible to substitute for brain stem function with intensive
monitoring (Youngner and Bartlett 1983)). Prolonged survival of a patient with
a mechanical brain stem, but otherwise intact cognition, would show the
inadequacy of a brain stem definition, and perhaps also of the whole brain
definition which implicitly asserts the pivotal role of the brain stem.
The remediation of damage to the cerebral hemispheres is currently beyond our
abilities, but the discovery of the special malleability of fetal brain tissue,
and the ability to stimulate neural cell growth and division with neurotrophic
chemicals or gene therapy, raises the possibility that patients with extensive
brain damage, sufficient to currently be considered dead, at least by
higher-brain standards, may be able to returned to some degree of function
(Tuszynski and Gage 1995; Valouskova and Galik 1995; Olson 1993). Of course,
they will probably continue to be disabled in many ways, and have lost much of
their memory. The question these technologies may raise is how much of one's
motor skills, memory and cognition one may lose to be treated as dead,
"socially dead" or "sick enough to not require further medical treatment or
feeding," if those abilities can eventually be restored. McMahan asserts
that the complete replacement of the cerebral tissues would constitute a new
person:
Replacement of the (cerebral) tissues through the transplantation of new
hemispheres might make consciousness possible, but this would not count as
receiving the same mind, even if the new hemispheres were perfect duplicates of
those destroyed. There would be a new and different mind. (McMahan 1995: 105)
The subjective experience of such a person would presumably be the same as an
infant; the slow creation of meaning, acquisition of linguistic skills, and
construction of a self-concept.
We might deal with such eventualities the way we deal with brain dead pregnant
women, from whom we also have the possibility of bringing forth new life if we
continue to maintain their socially dead bodies. Generally, in the United
States, we would honor prior expressed wishes of such women to be maintained to
term, and some would support the rights of husbands to make this decision
without their wives' prior expressed wishes. On the other hand, we also honor
the patient's or surrogate's request to perform an abortion on pregnant women
in PVS on the grounds that the rights of the real or prior persons trump those
of the potential persons. Since potential people don't have rights, the former
person or their surrogates could request that the remediative techniques not be
used to develop a new potential person.
Perhaps similarly we could add another layer of complexity to advance
directives, asking if patients would want their brains to be used by a new
tenant. The legal question is whether this successor would be the owner of the
previous tenant's property, be married to their successor's spouse, be liable
for the successor's crimes, and so on. The social life and death concept
advanced above suggests they should not be held to be the same person.
Any sufficiently advanced technology is indistinguishable from magic.
Arthur C. Clarke
Research is also being conducted on the creation of computer chip matrices into
which nerves can grow, and which could permit two-way communication between
neurons and computers (Agnew and McCreery
1990) (Banks 1995) (Seabrook 1994) (Kovacs et al. 1995) (Compston 1994). Such
computer-brain interfaces raise the possibility that computer technology may
also be developed to remediate neural capacities. These technologies are
currently only being applied to peripheral nerves, and the control of
prosthetic devices, but in conjunction with neurotrophic growth factor and
neurotrophic gene therapy, they may eventually be applied to cerebral tissue.
Already advances are being made in electronic prosthetics for sight and
hearing, from cochlear implants to optic nerve interfaces. Computer engineers
are also developing biological computing and storage media3, and software that
learns, suggesting a future convergence between organic computing, neural
network software and neural-computer interfaces.
Youngner and Bartlett (1983) address the possibility of future mechanical
remediation of brain injuries, and accept that such remediation would be
unproblematic for brainstem functions, but they go to great lengths to reject
the possibility of mechanically-mediated cognition.
It is, however, easy to imagine a patient's integrated vegetative functions
being fully assumed by complex machines or well-trained health professionals.
Any problems in such a takeover would be of a purely technical nature. In
contrast, conceptual problems surround the replacement of a patient's
consciousness and cognition. We believe it is impossible for a person's
thoughts and feelings to be replaced by a mechanical device and still retain
their essential nature. If the replacement is successful, the thoughts and
feelings would no longer be those of a human; if they remained essentially
unchanged, the replacement was not successful. This point shows the essential,
conceptual connection between higher brain functions and the continued life of
the person. No comparable problem arises with the replacement of vegetative
operations...If a living person is to exist, the thoughts and conscious
processes must be those of a human, not a machine. (Youngner and Bartlett
1983)
Dr. Youngner's rejection of the possibility of personhood in a cybernetic
medium is a common, but minority, position in the field of artificial
intelligence and cognitive science. Most cognitive scientists accept the
materialist assertion that mind is an emergent phenomenon from complex matter,
and that cybernetics may one day provide the same requisite level of complexity
as a brain. Of course, those who embrace the possibility of self-aware machine
minds do not necessarily want to see them be developed, or grant them "human
rights" once they do develop.
Perhaps what Dr. Youngner was suggesting is something akin to the brain
transplant thought experiments in the personal identity literature (Wikler
1988). If the brain tissue that gave rise to a person is destroyed, and
replaced by brain tissue or cybernetics which give rise to a new person, it
would not be correct to consider this new person as identical with the previous
one. The dilemma that such cerebral remediation techniques might pose however
is that the new person might regain some of the memories and other
characteristics of the previous person. Even a wholly dead brain, and certainly
a neo-cortically dead brain, probably retains some structures of memory and
personality which could be reactivated by these techniques.
Another technology that may eventually challenge our death concepts is cryonic
suspension, the freezing of heads, or whole bodies, for eventual reanimation.
All diagnostic protocols for the determination of brain death call for ruling
out hypothermia, but what if the brain is being intentionally and permanently
frozen. Our current concepts of death don't very well address the status of a
person who might eventually be brought back to life.
Unfortunately for those who wish to undergo this procedure, American law
requires that they be pronounced clinically dead first. Cryonicists believe
that future reanimation will be more successful if they could initiate the
freezing before somatic death, and certainly before cerebral death. Cryonics
firms have already been accused (and acquitted) of murder for having failed to
have a physician pronounce death before they began the suspension procedure. In
1993, the California Supreme Court ruled that a man with a terminal brain tumor
could not have his head removed before he died. Like the
Non-Heart-Donor-Protocol, the cryonicists, or rather the physicians present,
are forced to make a rapid diagnosis of death, and then initiate suspension.
Cryonicists acknowledge that the freezing process results in the rupture of
many cellular membranes, and that micro-cellular repair will be the principal
challenge of future reanimators. Cryonicists have therefore enthusiastically
embraced the new field of nanotechnology (Drexler 1986; Drexler and Peterson
1991) (Regis 1995), which promises to eventually create microscopic,
self-replicating robots capable of moving through frozen tissue without further
disrupting cell walls, identifying damaged tissue, and repairing it.
Cryonicists expect this level of nanotechnology to be available within the next
hundred years.
Of course, nanotechnology holds promise in all fields of medicine and industry,
not just for the reanimation of the frozen. Nanotech visionaries predict the
convergence of molecular medicine, genetic therapy and nanotechnology to create
tools to treat any disease, and immune system boosters capable of identifying
and eliminating disease before it occurs. In combination with the
neural-computer trends discussed above, increasing numbers of nano-enthusiasts
believe that the brain structures and activities can eventually be replaced
entirely by nano-machines, and/or read into new media. This is known in science
fiction and cyber-culture as "uploading" (Dery, 1996).
When and if these remediative technologies come available, there will be
tremendous material interests at stake. These technologies will develop just as
the industrialized world shifts to increasing proportion of elderly. The
number of people with brain death and PVS will expand from the current 10,000,
at any one time in the United States, to many times that number as technology
is increasingly successful at keeping them alive. The number with dementia so
severe that they are functionally equivalent to PVS may reach the hundreds of
thousands.
The technologies discussed above will be very expensive, at least at the
outset, and their distribution and use will be very controversial. The persons,
biological and cybernetic, that emerge from their application will be equally
controversial. It seems most likely that a society with many expensive
technologies to choose from, and faced with the disposition of the property and
relationships of new persons in old bodies, will explicitly forgo the expensive
remediation of sudden and complete cerebral destruction on the principle of
"one body - one shot at personhood." On the other hand, the gradual application
of these modalities in cases of progressive neurological disease, such that
they maintain a continuous sense of personal identity, will probably be
accepted at a desirable contribution to the quality of life. It will probably
be obligatory that we attempt neurological resuscitation in cases of diagnostic
uncertainty, unless otherwise forbidden by the person's advance directives,
even though this may give rise to a new person.
Barring the end of civilization as we know it, technology will eventually
develop the capacity to remediate severe brain injuries, and perhaps even
translate human thought into alternative media. In anticipation of these
technologies, even if only accepted as thought experiments, we can begin to see
the outlines of further changes in our definition of death. First, with the
remediation of the brain stem and other body regulating structures, we will be
forced to acknowledge that the destruction of the "integrative" functions of
the body is an inadequate definition of death, since the social person will
remain intact.
Once we begin to remediate cerebral cortex injuries I believe we will be forced
beyond a neo-cortical definition of death to one focused on the continuity of
subjective self-awareness. Those who have a continuous sense of self-awareness,
in whatever media, will be considered social persons, with attendant rights and
obligations.
Finally, these technologies will begin to fundamentally challenge the concept
of continuous, unitary personhood itself. This challenge was made to the field
of personal identity literature by Derek Parfit (Parfit 1984), and has not yet
been seriously grappled with in any area of philosophy, including bioethics.
Now empirical research is beginning to offer the same disturbing result, as
noted in a recent Time magazine review of cognitive science:
Despite our every instinct to the contrary, there is one thing that
consciousness is not: some entity deep inside the brain that corresponds to the
'self,' some kernel of awareness that runs the show, as the 'man behind the
curtain' manipulated the illusion...in The Wizard of Oz. After more
than a century of looking for it, brain researchers have long since concluded
that there is no conceivable place for such a self to be located in the
physical brain, and that it simply doesn't exist. (Nash, Park and Wilworth,
1995)
When we get to the point where neurological functions can be controlled,
designed and turned on and off, the illusory sense of continuous self-identity
will become more obvious. Once we cast off this fundamental predicate of
Enlightenment ethics, the existence of an autonomous individual, we are beyond
the ethical frameworks of contemporary bioethics. To be sure, there are ethical
worldviews that do not have the autonomous individual at their core, from
theocracy to Communism. Let us hope that, if we begin to take these thought
experiments serious now, we will have developed adequate frameworks based on
our cherished liberal democratic values, when they are urgently needed.
Arguments Against the Neo-cortical Responses
Standard
Yuck factor Treating people who move Treating breathing, heart-beating
and have their eyes open as dead bodies as dead also violates common
violates common sense and moral sense and moral feeling, and yet it is
feeling. This would be too great a the majority view in the medical and
challenge to the public. bioethics community. Making the policy
ethically logical is only slightly
more challenging for the public. On
the other hand, most surveys show that
most people would not want to live in
PVS.
Self-Interest Since organ donation All bioethical definitions and
would benefit from a neo-cortical decisions affect material interests
standard, the effort is tainted by
material interests
Epistemological We can't know for Nor can we know for certain when the
certain when the cortical functions of whole brain has been destroyed, and
the brain have been permanently yet we accept a small margin of error.
destroyed. The best diagnostic is In any case, the difficulty in
time, and it is distasteful to have to determining mental status does not
wait for months to determine if the invalidate our ethical position in
patient is dead. regards that status. Future diagnostic
techniques may make this moot.
Discrimination If we accept the Most severely demented and retarded
neo-cortical standard, we are obliged people have more personhood than the
to deprive the severely demented and PVS patient. When they don't, similar
retarded of their right to life. standards probably should apply.
Slippery Slope If we accept the If we make correct, defensible
neo-cortical standard, it will lead to definitions of what rights and
our tolerating euthanasia of other obligations adhere to different
humans and animals degrees of sentience, it will prevent
slippage
Pluralism A pluralistic society Despite diverse public views, social
cannot impose such an extreme policy policy must specify what constitutes
on publics that do not agree. murder, and what medical treatments
must be provided. Although some
flexibility is also possible, some
group will always disagree with the
limits specified.
Disposal It would be distasteful to All societies have procedures for
bury or cremate a breathing body. preparing bodies for burial. Ours
includes stopping respiration and
circulation.
Questions included in the bioethics survey I conducted out of the Center for
Clinical Medical Ethics in 1992.
Do you believe that parents, A 70 year-old person, who has not
consulting with their pediatrician, previously expressed an opinion
should be permitted to discontinue towards whether s/he would want to be
medical treatments that may preserve kept alive, has fallen into a coma.
the life of a week-old newborn, if: Should the person's relatives be
permitted, in consultation with a
doctor, to discontinue medical
treatments that may preserve the
person's life, if:
* the newborn has a normal brain, but * the person may awake from the coma,
has severe physical deformities that but has a terminal illness that will
will cause death within several months cause death within several months *
* Yes * No Yes * No
* the newborn has a normal brain, but * the person may awake from the coma,
has severe physical deformities that but will be paralyzed below the neck
will cause death within several years for the rest of his or her life * Yes
* Yes * No * No
* the newborn has a normal brain, but
has severe physical deformities that
will cause death within twenty years
* Yes * No
* the newborn has a normal brain, and * the person may awake from the coma,
will live a normal life span, but has but have severe and disabling
severe and disabling disfigurement of disfigurement of the face, arms and
the face, arms and legs * Yes * No legs * Yes * No
* the newborn has an able brain and * the person may awake from the coma,
body, but has a condition that will but will be in constant pain for the
cause constant pain for the rest of rest of his or her life * Yes * No
his or her life * Yes * No
* the newborn has an able body, but * the person may awake from the coma,
has such severe brain damage that s/he but will have such severe brain damage
will only learn a few words and simple that they will only re-learn a few
tasks, such as how to feed themselves words and simple tasks, such as how to
* Yes * No use a spoon * Yes * No
* the newborn has an able body, but * the person may open their eyes and
has such severe brain damage that s/he move, but have such severe brain
will never learn any tasks or how to damage that they will never re-learn
communicate * Yes * No any tasks or how to communicate *
Yes * No
* the newborn has an able body, but * the person will not awake from the
has such severe brain damage that s/he coma, and will always require a
will never wake up, and will always feeding tube * Yes * No
require a feeding tube * Yes * No
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