Ethics for the Pediatrician: Conceptual and Ethical Issues in the Declaration of Death

Abstract

1. Armand H. Matheny Antommaria, MD, PhD* 1. *Associate Professor, Division of Pediatric Inpatient Medicine; Adjunct Assistant Professor, Division of Medical Ethics and Humanities, University of Utah School of Medicine, Salt Lake City, Utah. After completing this article, readers should be able to: 1. Distinguish among the definition, criteria, and tests for death. 2. Contrast the whole and higher brain criteria of death. 3. Evaluate the major criticisms of and alternatives to the whole brain criteria of death. 4. Describe the controversy over when donation-after-cardiac-death donors are dead. Historically, death has been determined by the absence of breathing and circulation. The development of transplant and resuscitation technologies created practical problems for clinicians that the concept of “brain death” attempts to resolve. The persistent shortage of transplantable organs, however, has renewed interest in cardiac death. This article focuses primarily on the conceptual and ethical, as opposed to clinical, issues related to the determination of death. The discussion can be organized around the definition, criteria, and tests for death. Definitions state the necessary and jointly sufficient conditions for applying a word or concept correctly. Of note, some individuals contend that death is not definable. Criteria are measurable conditions and tests that are used by clinicians at the bedside. This article describes the current dominant paradigm of death, including the whole brain definition and the neurologic and cardiorespiratory criteria of death. The article also describes the major criticisms of this paradigm and proposals to revise or replace it. ### Definition The dominant definition of death contends that it is a single concept common to all organisms. This definition focuses on the organism rather than the organism's constituent parts because some of the parts may continue to function even after the organism is dead. Bernat and colleagues argue that death is “the cessation of functioning of the organism as a whole.” (1) This definition emphasizes the …