Courtney Thomas Barnes
Philosophy 347: Neuroethics
Dr. Glick
12/16/201
Dignitas: Neocortical Death and the Right to Die with Dignity
The notion that a person could be physiologically living: physically able to self- sustain heartbeat and respiration, but have ceased to be a person is central to the argument for a neocortical standard of death. Locke’s assertion is that a person is “an intelligent being that has the cognitive capacity for reason and also for reflection, and can consider itself the same thinking being in different times and places.” The controversy is that a person can be technically alive but without consciousness or the expectation that they will ever regain consciousness to the extent that they could meet the definition for “personhood.” In the case of this dilemma, the question seems to be: “Does it indeed compromise the right to die with dignity of someone who no longer fits the definition of personhood with all that entails; for medical professionals to keep them alive on life support indefinitely. And if so would it honor their dignity more fully to allow them to physiologically die, not taking measures to unnaturally sustain them in a vegetative state? My thesis is that the neocortical death theory affords a person the right to die with dignity, at or around the time of the point at which their brain ceases to function and the time that they are no longer conscious and doctors have determined that regaining consciousness with cognitive functioning is unlikely.
According to Bernat (1998), death is defined as a permanent cessation of the critical functions of the organism as a whole. Due to both the rising costs of keeping people who have suffered critical damage to areas of the brain involved with higher brain function, consciousness and cardiopulmonary function on life support indefinitely and the need to harvest organs in a timely way from those who have prior to their death decided to register as organ donors; the three theories of death are of prime importance when determining when a person has ceased to live.
The cardiopulmonary theory of death encompasses the view that death occurs with the irreversible loss of cardiopulmonary function. Cardiopulmonary function is the capacity for the body to sustain respiration and heartbeat without assistance. This view was the standard used until the 1950s and embraced by the Roman Catholic Church regarding its views on death. In the 1950s a mechanical ventilator was invented that could keep people alive to the cardiopulmonary theory’s standards by sustaining both heart and lung functions mechanically. The advantage of the cardiopulmonary view of death is that it would advocate the implementation of life support measures in cases of brain death, persistent vegetative state and minimally conscious states; under which a person would not meet the criterion for cardiopulmonary death. The disadvantage of cardiopulmonary view of death is that it may justify keeping a person alive indefinitely, without consideration of whether the person would ever again be conscious, regain cognitive function or be able to survive independent of life support.
The whole brain theory of death defines death as occurring with the irreversible loss of the brain’s ability to perform critical, life-sustaining function. A test used to confirm whole brain death is PET (positron emission tomography) a form of nuclear medicine in which radioactive isotopes are injected into the body and then a scan is performed of the brain to detect and assess critical brain function. Another test used to confirm brain death is an EEG in which leads are attached with paste to the scalp in order to detect and measure electrical impulses in the brain. An advantage of the whole brain theory of death is that it seems to agree with organismic death which is defined as a loss of critical functioning. This encompasses a loss of discernible integrated function. This view allows for the prompt harvesting of viable organs and makes fiscal sense as it allows for costly life-support measures to be turned off. The disadvantages of the whole brain theory of death according to Jeff McMahan is that the death of the whole brain isn’t necessary or enough to prove the death of the organism, (ie) person. An example of this phenomenon would be someone on artificial respiration who may be brain dead, but the rest of the body remains alive. Those in a persistent vegetative state are not considered dead according to the whole brain theory of death.
The neocortical theory of death explains that death occurs with the irreversible loss of higher brain function. Two examples of this phenomenon would be anencephalic infants and people in a vegetative state due to severe brain injury. The advantages of the neocortical theory of death are that a person seems to go when their higher brain function ceases. Thus a person can die before their body shuts down. This view makes it easier to harvest organs from vegetative patients, salvaging vital organs for those most in need of transplants who otherwise would die without them. The disadvantage of the neocortical view of death is that the neocortical death view can’t be a completely scientifically reliable measure at this point. Since we aren’t able to accurately test for consciousness, this does raise concerns due to the ambiguity of neural correlates. We aren’t able to determine, beyond a shadow of a doubt, at what point higher-brain function is irretrievable. The major caution amongst medical professionals stems from the fear of misdiagnosing someone as meeting the criterion for neocortical death.. One grey area within the theory of neocortical death is the question of whether a person in a minimally conscious state is indeed dead. However, a person in a persistent vegetative state would be considered dead according to the neocortical theory of death.
The brain death standard came to be invented through legal means with the Uniform Declaration of Death Act in 1981, which is based on two criterion: the first standard is irreversible cessation of circulatory and respiratory functions; or the second standard, which is irreversible cessation of all functions of the entire brain, including the brain stem. Due to the second criteria “brain dead” patients can be considered dead due to the fact that the brain is no longer capable of sustaining life independently. Organ harvesting is of primary concern and the harvesting of viable organs for transplant in a timely way is one reason for this view.
I’m going to argue that the neocortical theory of death is the most humane of the theories, as it is a balanced viewpoint that takes into consideration the point at which a person loses both the ability to function and to sustain their own vital processes such as heartbeat and breathing, higher brain functions, and also when a person becomes unresponsive due to a persistent vegetative state. I believe that this theory, which takes into consideration that a person at some point may be “gone,” unable to respond, unable to make decisions, lack consciousness, and be unable to survive without medical interventions such as expensive life support measures such as a ventilator; is merciful. This perspective may prevent potential pain and suffering for the person who has diminished function and no to limited likelihood of recovery, and it also minimizes financial burden to the family and the health care system as it expedites the emotional closure that families need in order to fully grieve the loss of their loved one. The neocortical theory also expedites harvesting of viable organs for transplant for people who are in desperate need of a heart, lung, liver, or kidney transplant. These harvested organs can make the difference between a fully conscious and cognizant person’s survival, or imminent death. It makes sense to prioritize the life of a person who is conscious and depending on a transplant in order to survive over a person who is technically so brain damaged that they will at best minimally recover and likely suffer the rest of their life.
I acknowledge that several objections can be made to refute the idea that neocortical theory is a merciful and dignity preserving option. A family may argue that their loved one may one day regain consciousness and brain function, emerging from their comatose state even when the neurologist believes this to be improbable. This may be the case particularly in the instance of a survivor of a traumatic brain injury who is in a minimally conscious state. Since the neocortical view of death does not clearly state that a person in a minimally conscious state is dead, this leaves a question of when to determine that a person in a minimally conscious state is so damaged that recovery is unlikely at best. Currently the tests for brain death: to check for a reaction to pain stimuli and for reflexes controlled by the brain stem such as pupil dilation and gag reflex may not be comprehensive. We cannot currently test for consciousness, this means that a person in a brain damaged state may or may not be conscious when taken off of life support due to meeting criteria for neocortical death. So taking this person off life-support may in itself cause several minutes of suffering as their body dies. This may be the most valid argument against implementation of the neocortical theory of death as criteria for declaring a person legally dead. However I believe it is still more compassionate to allow a potentially conscious person who has no measurable higher brain function left to suffer for a few minutes, as opposed to indefinitely on life support.
The neocortical theory of death is the most inherently compassionate option, as it allows the family closure, and the chance to grieve the loss of their loved one. Secondarily, the family of the deceased will not be burdened with the high cost of life-support, which can exceed two thousand dollars a day. Thirdly the organs of those who are registered organ donors can be promptly harvested and given to those in need of heart, lung, liver, kidney and cornea transplants in a timely way. The neocortical theory of death is perhaps most importantly humane to the patient who may or may not be conscious and suffering. As there is no reliable standard test for consciousness, this ensures that a patient who is comatose does not suffer unnecessarily by being kept alive in a state where higher brain function has ceased and is unlikely to ever resume.