The Evolution of Death and Dying Controversies

Abstract

When Institute of Society, Ethics and Life Sciences (now The Hastings Center) began its death and dying work in 1970, first task was to disentangle definition of death from decisions to forgo life support. We were still in an era when it was often assumed that if one was alive, then health professionals should launch a full-court press to preserve life. The members of Institute's Task Force on Death and Dying went to work teasing these two questions apart. The first major public product contributed to making this basic distinction. A symposium at American Association for Advancement of Science (AAAS) in December 1970 included papers directed at clarifying definition of death. Authors included task force members Robert Morison and Henry Beecher, who was also chairman of Ad Hoc Committee of Harvard Medical School that established definition of brain death. In a debate between them and their commentators (Leon Kass and me), issues were whether death was a process or a momentary event and whether any support remained for a cardiac definition of death. The process/event debate was published in Science. (1) The clear result was recognition that while dying is a process (one that is extremely hard to differentiate from chronic illness), death itself is a momentary event, a bright line marking boundary between being a member of human community of living and those formerly living. Early on, we recognized crucial public, social, psychological, and legal significance of a categorical distinction between life and death. This distinction must be clear to decide whether spouses count as widows or assaults as homicides, for example, or whether life-insurance policies should pay off and assassinated presidents be succeeded by their vice presidents. If one accepts what is called donor being dead is a necessary condition for legitimately procuring life-prolonging organs. We also recognized that cluster of issues traditionally associated with death might be disaggregated so that some of conditions could be separated from pronouncement of death. Under special circumstances, for example, life insurance might pay off while one was still alive, such as in programs in which terminally ill are allowed to collect their insurance (at a discounted rate) in order to pay medical and other bills. One of conditions that The Hastings Center disaggregated early on was forgoing life support. With forty years of hindsight, it is remarkable how simple definition-of-death debate seemed back then. We recognized only two options at that time: one died either when circulatory function ceased irreversibly or when all brain functions stopped irreversibly, and most of us thought brain function option was more rational, modern view. Moreover, no one questioned dead donor rule, although many realized that a lot more was at stake in debate over definition of death than just procurement of organs. The early work of task force (eventually called research group) led to a consensus in favor of a whole-brain-based definition of death. The position was endorsed by entire group (although some of more thoughtful, provocative members pressed hard about potential dangers of abandoning cardiac definition). (2) This effort led two group members to propose a carefully crafted whole-brain definition that eventually shaped work of President's Commission for Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. (3) Toward Greater Complexity In retrospect, this simple two-option choice was already in jeopardy by time of AAAS meeting. Henry Beecher's unpublished presentation contained a hidden challenge. (4) In defending critical role of brain, he argued that the individual's personality, his conscious life, his uniqueness, his capacity for remembering, judging, reasoning, acting, enjoying, worrying, and so on, reside in brain, and . …