Abstract
In celebration of the fortieth anniversary of the publication of Beauchamp and Childress’s Principles of Biomedical Ethics, a review is undertaken to compare the lists of principles in ...various bioethical theories to determine the extent to which the various lists can be reconciled. Included are the single principle theories of utilitarianism, libertarianism, Hippocratism, and the theories of Pellegrino, Engelhardt, The Belmont Report, Beauchamp and Childress, Ross, Veatch, and Gert. We find theories all offering lists of principles (or the equivalent) numbering from one to ten. Many of the differences can be reconciled, but some critical differences remain.
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When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: ...whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them.
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Under current law, it is not possible to procure a transplantable heart after cardiac death. Robert Veatch discusses two possible ways out ofthis dilemma.
Organ Donation after Cardiac Death
In this ...issue of the
Journal,
Boucek et al. (pages 709–714) report on three cases of heart transplantation from infants who were pronounced dead on the basis of cardiac criteria. The three Perspective articles and a video roundtable discussion at www.nejm.org address key ethical aspects of organ donation after cardiac death. Bernat and Veatch comment on the cases described by Boucek et al.; Truog and Miller raise a fundamental question about the dead donor rule. In a related Perspective roundtable, moderator Atul Gawande, of Harvard Medical School, is joined by George Annas, of the Boston University School of Public Health; Arthur Caplan, of the University of Pennsylvania; and Robert Truog. Watch the roundtable online at www.nejm.org.
Once, all transplantable organs were procured after a donor's heart had stopped irreversibly. Assuming that one accepted the dead donor rule, irreversible heart stoppage triggered organ procurement. Around 1970, the law gradually began to accept the declaration of death on the basis of irreversible loss of brain function. Today, physicians in all U.S. states may pronounce death and procure organs when brain function is determined to be permanently lost. Nevertheless, the more traditional heart-based pronouncement is accepted as an alternative.
The application of either brain- or heart-based criteria for pronouncing death is somewhat more complicated for infants and small children. . . .
The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to ...forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a "legal fiction." Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement.
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8.
Defining Death Veatch, Robert M; Ross, Lainie F
11/2016
eBook
New technologies and medical treatments have complicated questions such as how to determine the moment when someone has died. The result is a failure to establish consensus on the definition of death ...and the criteria by which the moment of death is determined. This creates confusion and disagreement not only among medical, legal, and insurance professionals but also within families faced with difficult decisions concerning their loved ones.
Distinguished bioethicists Robert M. Veatch and Lainie F. Ross argue that the definition of death is not a scientific question but a social one rooted in religious, philosophical, and social beliefs. Drawing on history and recent court cases, the authors detail three potential definitions of death - the whole-brain concept; the circulatory, or somatic, concept; and the higher-brain concept. Because no one definition of death commands majority support, it creates a major public policy problem. The authors cede that society needs a default definition to proceed in certain cases, like those involving organ transplantation. But they also argue the decision-making process must give individuals the space to choose among plausible definitions of death according to personal beliefs.
Taken in part from the authors' latest edition of their groundbreaking work on transplantation ethics,Defining Deathis an indispensable guide for professionals in medicine, law, insurance, public policy, theology, and philosophy as well as lay people trying to decide when they want to be treated as dead.
In response to the criticism of Schneiderman and colleagues (2017) that two recent policy statements of professional medical organizations referred to some medical treatment that were traditionally ...called "futile" by the terms "inappropriate" or "potentially inappropriate," this critique accepts their claim challenging these terms as being hopelessly ambiguous. However, this critique rejects the conclusion they all share that clinicians or hospitals should have the unilateral authority to refuse to provide treatments that will plausibly achieve the end that the patient or surrogate is pursuing. Although clinicians should be presumed authoritative in deciding to reject treatments that will not achieve the patient or surrogate's end, they should be obligated, provided five conditions are met, to provide those treatments that will achieve the patient or surrogate's end. The implications of honoring a physician's right to conscientious objection to treatments they deem "futile" are compared to physician claims of the right to refuse to provide contraceptive services on the same grounds.
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