ABP AMERICANBIOETHICS PROJECT

By the 1960s, intensive-care medicine had created clinical states that did not fit comfortably within traditional understandings of death.

In 1968, an ad hoc committee at Harvard Medical School proposed criteria for what it called “irreversible coma.” The report became a landmark in the development of neurological criteria for death.

The practical concerns were substantial. Clinicians needed guidance for patients whose brains had irreversibly ceased functioning while machines maintained other bodily processes. Organ transplantation made the timing and determination of death especially consequential.

Yet the controversy was never only technical.

Were neurological criteria simply a better way of recognizing that death had already occurred? Or did they represent a change in what medicine meant by death? If circulation could continue and organs could remain biologically active, why should irreversible loss of brain function mark the death of the human being as a whole?

No laboratory test could answer that philosophical question by itself.

Ventilators, dialysis, artificial nutrition and hydration, cardiopulmonary resuscitation, and intensive care could sustain patients through illnesses that had once been rapidly fatal.

Karen Ann Quinlan's case brought that problem into public view.

After her family obtained permission to withdraw mechanical ventilation, Quinlan continued breathing on her own and lived for years.

That fact matters.

Withdrawing life-sustaining treatment was not the same thing as declaring her dead.

Medicine now had to distinguish a decision that treatment need not continue from a determination that the patient had already died.

The President's Commission addressed the problem directly in its 1981 report Defining Death.

The Commission recommended recognizing death through either the irreversible cessation of circulatory and respiratory functions or the irreversible cessation of all functions of the entire brain, including the brain stem. A similar formulation became influential through the Uniform Determination of Death Act.

The framework did not end philosophical disagreement.

Critics questioned whether a body diagnosed as dead by neurological criteria had truly lost all forms of biological integration. Others argued that irreversible loss of brain function marked the destruction of the organism as an integrated whole. Still others emphasized consciousness or capacities associated with personhood.

The controversy demonstrated that determining which biological facts matter requires more than collecting biological facts. It requires an account of why those facts should mark the boundary between life and death.

A patient need not be dead for continued treatment to become ethically unnecessary.

A competent patient may refuse a ventilator even when it would prolong life. A surrogate may sometimes decline burdensome treatment for an incapacitated patient. Clinicians may conclude that an intervention cannot achieve its intended physiological purpose.

These judgments generated enduring disputes about withholding and withdrawing treatment, medical futility, and the difference between killing and allowing to die.

The language of futility seemed to offer a technical answer, but often concealed disagreement about goals. A treatment may successfully maintain blood pressure or respiration while failing to restore consciousness. Whether that treatment is “futile” depends partly upon what outcome is being sought.

The deeper distinction remained:

When has this person died? And when is medicine no longer obligated to postpone this person's death?

Nancy Cruzan suffered severe brain injury in a 1983 automobile accident and remained in a persistent vegetative state. Her family eventually sought removal of artificial nutrition and hydration.

In Cruzan v. Director, Missouri Department of Health (1990), the Supreme Court recognized a constitutionally protected liberty interest related to refusing unwanted medical treatment while allowing Missouri to impose evidentiary requirements for decisions on behalf of an incapacitated patient.

Cruzan was not legally dead.

Her case concerned the obligations owed to a living patient who could no longer communicate and whose prospects for recovering consciousness were extremely poor.

Questions about death can determine when obligations to a living patient end because the patient has died. Questions about treatment limitation ask what obligations remain while the patient is still alive.

New technology created these disputes, but technology could not resolve them.

Families and clinicians can disagree about prognosis. Religious communities may reject neurological criteria for death. Disability advocates have challenged assumptions that profound dependence, unconsciousness, or severe impairment necessarily makes continued life less valuable.

Even the vocabulary remains contested.

“Quality of life” may describe outcomes important to a patient, or become an outsider's judgment about whether another person's life is worth sustaining. “Futility” may identify an intervention incapable of producing a physiological effect, or conceal disagreement about which effects matter.

Medicine became increasingly capable of describing what a body was doing. That did not automatically determine what should be done for the person whose body it was.

Neurological criteria reshaped the legal and clinical determination of death. Decisions about withholding and withdrawing treatment became part of ordinary intensive-care practice. Advance directives and surrogate decision-making developed partly in response to fears that patients might be sustained by treatments they would not have wanted. Ethics committees became increasingly involved in disputes that technical expertise alone could not resolve.

Medicine's ability to postpone death created genuine goods. It also made the boundary between saving life and prolonging dying more difficult to discern.

The power to postpone death is not the power to defeat it.

1. 1968

   Harvard Ad Hoc Committee, “A Definition of Irreversible Coma”

2. 1969

   Henry K. Beecher and the developing debate over death

3. 1976

   In re Quinlan

4. 1981

   Defining Death

5. 1981

   Uniform Determination of Death Act

6. 1990

   Cruzan v. Director, Missouri Department of Health