Written by Ibo van de Poel
In 1968 an ad hoc committee of the Harvard Medical School proposed criteria for brain death. Keulartz et al. (2002: 16) describe this introduction of the notion of ‘brain death’ as a redefinition of the notion of death with far-reaching moral consequences. Following Giacomini (1997), they ascribe the introduction of the new notion mainly to developments in transplantation medicine, and they argue that: “While the norm that organs may only be removed once the donor is dead did not change, the definition of death was altered drastically. Accepting the new definition changed the practice: organs could now be removed from patients who would previously not have been regarded as dead, without violating the norm” (Keulartz et al. 2002: 16). Others (e.g. Baker 2019) have attributed the introduction of the notion of brain death to the introduction of the mechanical ventilator, which made it possible to pump air into patients’ lungs and so to sustain heart activity. Some of these patients showed no brain activity, a fact that could be established due to the development of EEG (Electroencephalography) technology.
Whatever the exact historical explanation is for the introduction of brain death and the accompanying value change, it is clear from the historical record that this change did not occur overnight. Rather there was a period of 10 to 15 years in which there was, first ,moral uncertainty, for example, about how to deal with comatose patients that could be kept alive due to the mechanical ventilator, second, a range of more localized inquires about how to deal with the new situation, and, finally, the report of the Harvard Committee that let to a more-or-less authoritative and broadly accepted definition of brain death, even if this definition has been (and still is) also heavily criticized.
Moral uncertainty
In September 1967, Beecher, the later chair of the mentioned Harvard Committee, spoke in a letter to the dean of the Harvard Medical School about “ethical problems created by the hopelessly unconscious patent”, saying that “The individuals are increasing in numbers all over the land and there are a number of problems which should be faced up to.“ (cited in Belkin 2003: 327). The ethical problems that Beecher refers to arose well before 1967. Already in 1957 anesthesiologists turned to Pope Pius XII for an answer. At the world conference of anesthesiologists, the pope raised the question “[May] a patient plunged into unconsciousness … whose … blood circulation … is maintained through artificial respiration be considered de facto or even de jure dead?”, declining to answer that question, he stated that “it remains for the doctor and especially the anesthesiologist, to give a clear and precise definition of ‘death’ and the ‘moment of death’ of a patient who passes away in a state of unconsciousness” (cited in Baker 2019: page number#).
Typically, two American newspapers draw diametrically opposing conclusions from the words of the pope (Giacomini 1997: 1472): one saying that “Human life may linger after the heart stops, and medical sciences has the right to struggle with all its means to bring seemingly dead person back to life”(New York Times, 25 November 1957; cited in Giacomini 1997: 442), and the other reporting “Doctors may stop efforts to delay death … artificial methods of reviving life may be halted in order to allow a virtually dead patient to ‘die in peace’” (Boston Globe, 25 November 1957; cited in Giacomini 1997: 442). So the words of the pope do not seem to have reduced any (moral) uncertainty.
Although the pope placed the decision in the hands of the medical profession, many doctors at the time felt not able to answer the question and were in a state of great (moral) uncertainty. Belkin cites neurologist C. Miller Fisher who describes the situation in 1955 with respect to such comas as: “we had no language to describe them or rate them or anything … the examination of the sick [comatose] patient was chaotic” (cited in Belkin 2003: 343). Two years later, by 1957, Fisher felt the issue had been largely resolved and he “clearly recalls advising colleagues to turn off respirators, confident enough by then in his examination to predict irreversible ability of the central nervous system to maintain any cordial cortical activity of independent vegetative functions. With few exceptions, he recalls involving families in these decisions with little fanfare or controversy” (Belkin 2003: 343). Fred Plum, the author of the book The Diagnosis of Stupor and Coma together with Jerome Posner, had doubts for a much longer time, as shown by some striking differences between the 1966 (1st) and 1972 (2nd) edition of the mentioned book (Belkin 2003: 344). He explained the difference to Belkin by stating that in 1966 he was still worried that he could be wrong (Belkin 2003: 344).
Inquiry
As the above cases of Fisher and Plum (described by Belkin 2003) suggest individual doctors and teams (as well as others) undertook inquiries and investigations in the light of the new moral uncertainties. These seems related to three types of situations, one are situations of (seemingly) irreversible coma where it was the questions whether patients should be kept ‘alive’ (with mechanical ventilation); a second was the (uncertain) meaning of a flat EEG, and a third type of situations related to transplantation. The three were related in the sense that a flat EEG was often seen if not as a sign of (brain) death, then at least as predictor of non-survival, and transplantation was only permitted if a clear and uncontroversial determination could be made that someone was dead.
Even if these three types of situations are somehow related, different inquiries focused on different aspects of them and different people perceived their relation differently. Beecher, the chair of the later ad hoc committee, was mainly concerned about what Belkin (2002) calls bed-side concerns about how to deal with patients in a (seemingly) irreversible coma. Schwab, a neurologist on the committee, had a long-standing interest in the “physiological parameters of the definition of death” (Belkin 2003: 332). Already in 1941 he carried out EEG tracings of a patient in the emergency ward and concluded from this experience that the electrocardiogram is a better indicator of the exact time of death than heartbeat (Belkin 2003: 332-333). Indeed, a larger community of neuroscientific researchers became convinced in the next two decades of the relation between EEG measurements and consciousness (Belkin 2003: 333-340). However, the implications of these insights for bed-side considerations were not obvious, as (Belkin 2003: 340) points out: “[w]ell into the 1960s the ‘flat line’ of the isoelectric EEG was still without clear meaning.” He cites the neurologist Henri Fischgold who stated in 1961: “ ‘flat EEG trace’ does not signify death of brain … but does have prognostic significance if it persists for hour or days in a subject which is at normal body temperature in the absence of anesthesia” (cited in Belkin 2003: 341).
Meanwhile, similar issues were debated by transplant surgeons. Giacomini (1997: 1467) describes the 1966 Ciba Foundation symposium as “[p]robably the most thorough interdisciplinary scrutiny of death”. It included “20 physicians … , five legal scholars, a journalist and a theologian” (Giacomini 1997: 1467). Questions discussed included “For how long should ‘life’ be maintained in a person with irrevocable dame of the brain?” and “When does death occur in an unconscious patient dependent on artificial aid to circulation and respiration?” (Giacomini 1997: 1467). There was no agreement on whether dead should be redefined, and if so what the signs of death should be, and some warned that death should be not be redefined for the sole purpose of facilitating transplantation.
The Harvard committee
The Harvard committee consisted of thirteen members; most of them were from the medical profession, but the committee also included a law professor, a history of science professor and a social ethics professor (Baker 2019: footnote 135). The committee saw it as their “primary purpose to define irreversible coma as a new criterion of death” (Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death 1968: 337) Two reasons have been cited for this need for a definition, namely the problem of comatose patients that could be kept ‘alive’ with mechanical ventilation which lead to a “[great] burden … on patients who suffer permanent loss of intellect, on their families, on the hospitals, and on those in need of hospital beds already occupied by these comatose patients” (ibid.), and, second, “[o]bsolete criteria for the definition of death can lead to controversy on obtaining organs for transplantation” (ibid.)
The committee stressed that it looked for criteria that were “translatable into action” (ibid) and it stressed that “[m]ore than medical problems are present. There are moral, ethical, religious and legal issues” (ibid). The committee then went on to propose four characteristics of irreversible coma: 1) unreceptivity and unresponsitivity; 2) no movement or breathing, 3) no reflexes 4) flat EEG. It stated that the first three were satisfactory to diagnose irreversible coma and that the fourth “provides confirmatory data, and when available it should be utilized” (ibid.) It also stressed that all “tests shall be repeated at least 24 hours alter with no change” (ibid: 338).
The deliberations of the committee witnessed the coming together of different lines of investigation and inquiry alluded to before, as can be seen from analyses of draft versions and conversations between the committee members (see Belkin 2003, Giacomini 1997). For example, there was debate whether the committee should propose criteria for irreversible coma without redefining death, or should propose criteria for brain death, or should just propose a redefinition of death. Although the report of the committee is usually seen as introducing the notion of brain death, it contains phrasings that are reminiscent of all three perspectives.
Another important point of discussion was the relation was transplanation concerns. Although the committee was careful to avoid in its final advice any suggestion that the formulation of the criteria was in any sense motivated by transplantation concerns, it is clear that some committee members linked both issues and wanted criteria that would not be too stringent with respect to transplanation, while others seem to have rejected any connection.
The criteria formulated by the committee, and similar criteria proposed by quickly became authoritative and more or less broadly accepted, although that certainly does not mean that they were – and are (or their updates) – uncontroversial.1 They have for example been (heavily) criticized for being too much motivated by utilitarian concerns for transplanation, as well as for being philosophically and ethically shallow when it comes to the understanding of ‘death’ and it moral implications.
Parts of this text have been used in the article Nickel, P. J., Kudina, O., & van de Poel, I. (2022). Moral Uncertainty in Technomoral Change: Bridging the Explanatory Gap. Perspectives on Science, 30(2), 260-283. doi:10.1162/posc_a_00414. This is a longer text that was written in preparation of that article.
Notes
- The World Medical Association’s Committee on Ethics in Sydney Australia addressed the issue around the same time. For a comparison of similarities and differences with the Harvard committee, see Machado et al. (2007).
References
Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. 1968. “A Definition of Irreversible Coma: Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death.” JAMA 205 (6):337-340. doi: 10.1001/jama.1968.03140320031009.
Baker, Robert. 2019. The structure of moral revolutions : studies of changes in the morality of abortion, death, and the bioethics revolution, Basic bioethics. Cambridge, MA: The MIT Press.
Belkin, Gary S. 2003. “Brain Death and the Historical Understanding of Bioethics.” Journal of the History of Medicine and Allied Sciences 58 (3):325-361. doi: 10.1093/jhmas/jrg003.
Giacomini, Mita. 1997. “A change of heart and a change of mind? Technology and the redefinition of death in 1968.” Social Science & Medicine 44 (10):1465-1482. doi: https://doi.org/10.1016/S0277-9536(96)00266-3.
Keulartz, Jozef, Michiel Korthals, Maartje Schermer, and Tsjalling Swierstra. 2002. “Ethics in a technological culture. A proposal for a pragmatist approach.” In Pragmatist ethics for a technological culture, edited by Jozef Keulartz, Michiel Korthals, Maartje Schermer and Tsjalling Swierstra, 3-21. Dordrecht: Kluwer Academic Publishers.
Machado, C., J. Korein, Y. Ferrer, L. Portela, M. de la C. García, M. Chinchilla, Y. Machado, Y. Machado, and J. M. Manero. 2007. “The Declaration of Sydney on human death.” Journal of medical ethics 33 (12):699-703. doi: 10.1136/jme.2007.020685.