[Brain Death Resources]

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 




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.

Social Death: Operationalizing the Death Concept

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


Table One: Social and Biological Life

                  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).

Figure One: Percent of Ethicists Who Were Willing to Agree to Families Withdrawing Life-Sustaining 


[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.

Technological Change, and Changes in Social Death

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.

Diagnostic Advances

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.



Neural Tissue Transplants and Chemical Stimulation

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.

Neural-Computer Prostheses

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.


Figure Two: The Neural-Computer Chip Interface Developed by the INTER Consortium

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.


Cryonics and Nanotechnological Repair and Replacement

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).


Material Interests and Death Redefinition

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.

Post-Biological Definition of Death: Personhood and Beyond

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.

Appendix One: A Quick Review of the Principal Arguments For and Against a Neo-Cortical Standard of Death

Arguments Against the  Neo-cortical      Responses                                
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    
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    
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        

Appendix Two

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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