Reexamining the definition and criteria of death.

Abstract

The whole-brain criterion of death was first formally proposed by the "Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death" in a "Special Communication" published in JAMA in 1968. Since then, all states in the United States and many western countries have endorsed this definition of death. The strongest defense of the concept of "brain death" was provided by Bernat, Culver, and Gert in a series of papers published in the early 1980s, emphasizing the important distinctions between the definition and the criteria of death and the tests for death. Careful analysis, however, demonstrates that brain-related criteria of death are inconsistent with traditional concepts of death. Thus, although death is properly understood as a biological phenomenon, "brain death" is a social construct created for utilitarian purposes, primarily to permit organ transplantation. The best definition of death is "the event that separates the process of dying from the process of disintegration" and the proper criterion of death in human beings is "the permanent cessation of the circulation of blood." Nevertheless, because brain-related criteria of death have been widely accepted, and because our society has demonstrated a strong commitment to organ transplantation, abandoning the concept of brain death would create serious political problems. Abandoning the "dead donor rule" would solve the problem of obtaining organs for transplantation, but would create different, equally serious, political problems. Preserving the concept of brain death as a social construct, as a "legal definition of death," but distinct from biological death, is also problematic, but may be our most acceptable alternative.