Brain Death and Technological Change [Brain Death Resources] Brain Death and Technological Change: Personal Identity, Neural Prostheses and UploadingJames J. HughesPrepared for the Second International Symposium on Brain Death Second International Symposium on Brain DeathHavana Cuba * February 27-March 1, 1995 Contents Abstract Introduction Social Death: Operationalizing the Death Concept Technological Change, and Changes in Social DeathDiagnostic AdvancesNeural Tissue Transplants and Chemical StimulationNeural-Computer Prostheses Cryonics and Nanotechnological Repair and Replacement Material Interests and Death RedefinitionPost-Biological Definition of Death: Personhood and BeyondAppendix One: A Quick Review of the Principal Arguments For and Against a Neo-Cortical Standard of DeathAppendix TwoBibliography AbstractThe death at issue in the brain death debate is not an empiric reality,but a social category, "social death." It is a question of which bodies we arecomfortable using and disposing of in certain ways, and not comfortable givingmedicine or food as if they were "alive." Until recently both mind and bodystopped functioning at the same time, and this "death" and "social death" weregenerally seen as one phenomenon. There were important exceptions, however, inmany cultures where particular diseases and disabilities earned a social deathdefinition before the physical death had occurred.In the modern world, whole brain definitions of death arose as a result of thetechnological deconstruction of death as a unitary phenomenon. The whole braindefinition was at the outset a compromise between those who prefer aneocortical definition, and those who prefer the whole body definition. Thispaper argues that the whole brain definition of death is an unwieldy,historical compromise which will unravel as 21st century technologies permitthe repair, replacement and manipulation of body, and especially brain, tissue.These technologies will present anomalies to the whole brain definition whichwill force us towards, and then beyond, a neocortical definition of death. Newbiological and cybernetic technologies will make clear that social life isproperly attributed to any biological system with a particular set ofsubjective experiences - personhood. These technologies will also createtremendous material incentives for the living to stop treating the permanentlyunconscious as socially alive. Introduction For everyday purposes we know and can say whether an animal is alive ornot. But upon closer inquiry, we find that this is, in many cases, a verycomplex question, as the jurists know very well. They have cudgeled theirbrains in vain to discover a rational limit beyond which the killing of thechild in its mother's womb is murder. It is just as impossible to determineabsolutely the moment of death, for physiology proves that death is an notinstantaneous, momentary phenomenon, but a very protracted process.(Engels,1880, Socialism: Utopian and Scientific) Soon after the proposal of a brain death standard of death (Beecher 1968), adebate began as to how much of the brain must be destroyed for a patient to bedeclared dead. Veatch (1975) opened the debate by arguing that human beingsshould be declared dead once they had lost the ability to meaningfully interactwith others. Veatch was soon joined by a small, vocal group of"neo-corticalists" (Green and Wikler 1980) (Brody 1983) (Youngner and Bartlett1983) (Gervais 1986) (Cranford and Smith 1987). In response, "whole-brainers"(Black 1978a; Black 1978b) (Bernat 1989) have defended a standard requiringcomplete brain death, and this standard was eventually endorsed by thePresident's Commission for the Study of Ethical Problems in Medicine andBiomedical and Behavioral Research (1981), and written into most state laws.(See Appendix One for my summary of the arguments against the higher-brainstandard and their rebuttals.)The debate in the 1970s and 1980s made clear that, although there were somearguments advanced as to the ethical superiority of a whole-brain standard, thereal advantage of the whole brain standard was pragmatic: it was easier tooperationalize, it conservatively erred on the side of life, and it was seen asthe most radical that the public would tolerate. The whole brain definition wasat the outset a compromise between those who preferred a neocorticaldefinition, and those who preferred the somatic definition. As Botkin and Post(1992) put it:"It is our own conviction that the whole brain death standard probably bestbalances the conflicting needs within our society, despite the confusion itgenerates. This is based largely on utilitarian considerations." (Botkin andPost 1992) This paper argues that the whole brain definition of death is an unwieldy,historical compromise which will unravel as 21st century technologies permitthe repair, replacement and manipulation of body, and especially brain, tissue.These technologies will present anomalies to the whole brain definition whichwill force us towards, and then beyond, a neocortical definition of death.I begin by endorsing the view of some neocorticalist writers who argue thatthis standard is best articulated in a dualist mind-body framework (Brody 1988;Wikler 1988; McMahan 1995), which distinguishes between social and biologicallife and death. This is contrasted to the whole-brain partisans and "unitarian"neo-corticalists (Youngner and Bartlett 1983) who argue that there can only beone death. I then pursue the thought-experiments of previous writers as to howfuture technological advances may force further clarification in the definitionof social death, focusing on emerging brain repair strategies. Finally, Idiscuss how some of these technologies may challenge even the neo-corticalistmodel to evolve towards a personhood centered definition.SocialDeath: Operationalizing the Death ConceptWouldn't it be more appropriate to say that, even though (the PVS body) isstill alive, this patient is no longer a person, having lost, when her cortexstopped functioning, the physiological base of what is crucial to personhood?(Brody 1988)The death at issue in the brain death debate is not an empiric reality,but a social category, "social death." It is a question of which bodies we arecomfortable using and disposing of in certain ways, and not comfortable givingmedicine or food as if they were "alive." The operationalized "social death"would tell us which bodies we can stop feeding, remove from life support,remove organs from, and cremate. In other words, I would like to advance aslightly more sociological version of the argument that other higher-brainadvocates have made for mind-body dualism (Brody 1988) (Wikler 1988) (McMahan1995), as distinct from the whole-brain position, or the higher-brain unitarianposition, that irreversible loss of consciousness is the only death possiblefor a human being. Bernat and associates, in defending the whole brain death definition, haveasserted that there is a universally recognized standard for the recognition ofdeath. This may be true, though it may not be relevant to the our currentdilemmas. But I propose that there is also a near universal distinction betweensocial personhood and physical existence. In many cultures persons withparticular diseases and disabilities were treated as "socially dead" beforephysical death had occurred. Social death has been used as a means of dealingwith newborns with anomalies and disabilities, with the elderly infirm, and aspunishment. Corpses are treated in some societies as being inhabited by thevital principle for long after we would declare death, as for instance amongthe Tibetans who continue to chant verse to the body and its listening spiritfor a week after respiration has stopped. And many societies invest greater orlesser faith in the continued presence of the dead as members of the socialorder, with rights and obligations. Conversely, partum is not the universally recognized beginning of social life.In some societies infants were not considered persons until one year of age(Piers 1978) (Harris 1979). Some religions and cultures hold that socialpersonhood begins at conception, or before. Some societies recognize acontinuity of identity across individuals, on the grounds that one person canor should assume the roles and obligations of another. While we would be unsympathetic with most of the previous applications of theprincipal of social life and death in simpler societies, these cases show thatthere is no universally recognized "bright shining line" between social deathand life. Instead of a universal binary dead-alive recognition, cross-culturalevidence would suggest more of a two-by-two table TableOne: Social and Biological Life Socially Alive Socially Dead Biologically U.S.: All conscious U.S.: fetuses and whole brain Alive adults dead, the PVS some societies: outcasts, disabled, zombies Biologically in some societies: corpses prepared for disposal Dead ghosts, ancestors, gods corpses still connected to spiritOne of the frequent arguments against the higher-brain definition of death isthat it would be distasteful to bury a breathing body. Defining a body as deador socially dead does not remove all obligations to treat it "humanely." Wehave many policies regarding the use and disposal of corpses, specifying whatwe consider to be in good taste. We honor the wishes of the dead in regards thedisposal of their remains and their property. Similarly, the definition of thepermanently vegetative as being dead "socially" does not mean that we need toallow surgeons to remove their organs, or morticians to bury or cremate themwhile they are still breathing. We may be more restrictive about what can bedone with PVS bodies than what can be done with bodies that aren't breathing,just as we may be more restrictive about what can be done with a body which isbeing prepared for an open-casket wake versus one that will be cremated.The social death concept asserts that citizenship, rights and value adhere notto bodies, but to subjective persons. This means that we would charge someonewho removed the ventilator from a PVS patient with interfering with corpsesrather than murder. We would consider it absurd to spend social resources ontheir maintenance. After social death there is no patient present, we would notencourage health workers to talk to the permanently comatose (La Puma, 1988).In this view, the body of the patient in persistent vegetative state is stillalive, and could remain so, but the patient is not. (Wikler 1988)Most whole brain partisans are comfortable with family and health careinstitutions having wide discretion to withhold and withdraw life support,including food and fluids, from bodies in PVS on the grounds of advancedirectives, surrogate decision-making, quality of life judgments, or resourceallocation. But the "social death" or operational death argument is that it isnot simply permissible to withhold food, fluids and medicine from thePVS patient, but desirable that we soon stop the perfusion of this body, unlesssome great important good can be obtained from doing so. It is wrong tocontinue to treat them as if they are "alive."It is an insult not only to the specific individual, but to human beings ingeneral, to confuse someone who is deceased with a living individual. (Veatch1992)Wikler (Wikler 1988) points out that this argument risks circularity. Wecannot simply define those bodies as "dead" which we wish to withhold treatmentfrom, and then withhold treatment from the "dead." This underlines theimportance of the social death concept, which allows us to distinguish betweenthe socially dead and other categories of patients. The socially dead are thosebodies lacking personhood, and thus any possibility of interests or rights inmedical care or nutrition.Most participants in this debate assert that the public and the medicalprofession would be shocked at defining bodies in PVS as "dead" (Tresch et al.1991), and use this as either an argument against the neo-cortical standard orfor greater public education (Youngner et al. 1989). Yet there is someevidence that both the public and physicians are ready to discuss whether it isright to continue treating bodies in PVS as alive.Results of a survey conducted out the Center for Clinical Medical Ethicssupport the contention of an emerging consensus among bioethicists as to thestatus of PVS patients. The survey was mailed out to 240 medical ethicists in September 1992 and all surveys werereceived back by December 1992. The response rate was 60% (155 of 260).FigureOne: Percent of Ethicists Who Were Willing to Agree to Families WithdrawingLife-Sustaining Treatment [The sample of medical ethics-related individuals wascomposed of about half Ph.D.s in philosophy and related social science andhumanities, two dozen students with interests in medical ethics issues, as wellas about 20 physicians, ten directors or staff at health policy organizations,a handful of priests and nuns, and several nurses and lawyers. The occupationsof the medical ethics-related sample included ethics consultants at hospitals,the directors of academic programs in philosophy, medical ethics or policy, andthe staff of lobbies for AIDS funding, national health insurance, druglegalization, senior concerns, alternative medicine, and for and againstabortion.]Two parallel sets of questions were included addressing whether a family shouldbe allowed to withdraw life-sustaining treatment for newborns and currentlyunconscious 70 year-old women in a variety of conditions (the questions are inAppendix Two). The graph above shows the ethicists' responses to the differentscenarios.This sample is by no means representative of American bioethicists, butnonetheless supports the general contention that American bioethicists considerthe permanent loss of mental capacity to be as much a reason for thewithholding of life-sustaining treatment as immanently terminal disease.More to the point, there is a growing acceptance of the higher-brain definitionof death. Also in 1992, Payne and Taylor (1993) surveyed 500 neurologists; halfbelieved that PVS patients should be considered dead, and 94% thought theywould be "better off dead." Less than half thought that any PVS patients'illnesses should be treated aggressively, and more than three-quarters thoughtthat a universal health care plan should discontinue payment for PVS patients'treatments. About nine out of ten believed it was ethical to withdraw andwithhold hydration and nutrition, and two-thirds believed it was ethical to usethe patients' organs for transplantation.TechnologicalChange, and Changes in Social DeathSome have said that the 1968 Harvard Committee's report is little more than anaddendum to instructions on how to use a respirator. (Gervais 1986) Most histories of bioethics assert a generative force to medical technology.Technology is described as having "created" dilemmas, from the impact ofin-vitro fertilization (IVF) in creating beginning of life dilemmas, toventilators in creating end-of-life dilemmas. But I agree with those who arguethat technology does not create new ethical dilemmas (Emanuel 1991: 11-13), butmakes us aware of dilemmas already present which we had hitherto ignored. Oneof the effects of technology is to "denaturalize" (Bayertz 1992) things whichwe had taken for granted as unitary.An example is IVF and the "deconstruction" of parenting (Stanworth 1988). IVFdid not create a dilemma of conflicts between birth parents and socialparents; that conflict has existed since prehistory as a result of adoption. Onthe other hand, IVF did make possible the conflict between genetic mothers andbirth mothers, two roles which had previously been unitary.In the same way, the on-going redefinition of death and social death is theresult of the technological deconstruction of dying. Instead of a relativelyinstantaneous process, death is now more like a "syndrome" (Botkin and Post1992), a cluster of related attributes. This disaggregation requires that wedecide how many of these attributes are required before we begin treatingsomeone as "dead," just as physicians must decide how many psychiatric traitsare required before making a diagnosis of "schizophrenia." In the case of braindeath, ventilators did not create the question, but forced us to face it onceventilation disaggregated brain injuries and somatic death. One can adopt one of four positions towards the advance of technology andethical adaptation. The first position would be the ethically significantchanges in medical technology will never occur. Predictably, some whole-brainpartisans adopt this view, and reject the idea that technological change willencourage further specification of death definitions (Bernat 1992). The secondposition would be that ethical categories and logic that are adequate todayshould be maintained, while new logics could be adopted later, when necessary.This appears to be the argument of other whole-brain partisans; a whole-braindefinition may be inadequate in the future, but it is a good, conservativestandard given today's technology. A third position would be that any thoughtexperiment which shows the superiority of one view over another should beaccepted. The position I advance here is a compromise; we are not obliged to entertainall thought experiments, no matter how implausible, but if technology will makeour current ethical views inadequate within some finite, foreseeable period oftime, we should adjust our thinking, and law, to a more solid footing. In thecase of the personal identity literature, not all the technologic thoughtexperiments are plausible. For instance the physicist David Allen Batchelor, inhis The Science of Star Trek, discusses the technical constraints onthe teleportation device used in the Star Trek series, and discussed in some ofthe personal identity literature, and concludes that this would be virtuallyimpossible within our current scientific framework. But many of the thoughtexperiments, such as brain transplants, are possible eventually.Below I briefly review some of the emergent technologies which will likelyforce a specification of social death definition from the whole-brain standardto the neo-cortical standard and beyond.DiagnosticAdvancesOne of the principal drawbacks of the higher-brain definition of death,acknowledged by both proponents and opponents, is that the diagnosis of wholebrain death is technically possible, while the diagnosis of irreversiblecessation of cerebral function is more difficult or impossible. Withoutreviewing technical issues beyond my competency, I will note that Veatch (1992)has written an extensive review of the technical ambiguity of the whole-braindiagnosis. Conversely, advances in PET scanning and other imaging techniquesshould make it easier to diagnose someone as having irreversible damage to thecerebral cortex, without having to wait for months. NeuralTissue Transplants and Chemical StimulationBecause technology can substitute for many brain functions (spontaneousrespiration, cardiovascular support, and neuroendocrine regulation), a morerefined definition that emphasizes functions that cannot be replaced throughtechnology may be appropriate. In fact, we are replacing brain stem functionswith ever-increasing success. (Youngner and Bartlett 1983) Future medical technology may enable us to keep the brain stem alive orreplace it entirely, thus preventing brain-stem death. (Ray 1991) The British brain death policy requires only that the brain stem has beendestroyed to declare death, and many commentators have noted that it istechnically possible to substitute for brain stem function with intensivemonitoring (Youngner and Bartlett 1983)). Prolonged survival of a patient witha mechanical brain stem, but otherwise intact cognition, would show theinadequacy of a brain stem definition, and perhaps also of the whole braindefinition which implicitly asserts the pivotal role of the brain stem.The remediation of damage to the cerebral hemispheres is currently beyond ourabilities, but the discovery of the special malleability of fetal brain tissue,and the ability to stimulate neural cell growth and division with neurotrophicchemicals or gene therapy, raises the possibility that patients with extensivebrain damage, sufficient to currently be considered dead, at least byhigher-brain standards, may be able to returned to some degree of function(Tuszynski and Gage 1995; Valouskova and Galik 1995; Olson 1993). Of course,they will probably continue to be disabled in many ways, and have lost much oftheir memory. The question these technologies may raise is how much of one'smotor skills, memory and cognition one may lose to be treated as dead,"socially dead" or "sick enough to not require further medical treatment orfeeding," if those abilities can eventually be restored. McMahan assertsthat the complete replacement of the cerebral tissues would constitute a newperson:Replacement of the (cerebral) tissues through the transplantation of newhemispheres might make consciousness possible, but this would not count asreceiving the same mind, even if the new hemispheres were perfect duplicates ofthose destroyed. There would be a new and different mind. (McMahan 1995: 105)The subjective experience of such a person would presumably be the same as aninfant; the slow creation of meaning, acquisition of linguistic skills, andconstruction of a self-concept. We might deal with such eventualities the way we deal with brain dead pregnantwomen, from whom we also have the possibility of bringing forth new life if wecontinue to maintain their socially dead bodies. Generally, in the UnitedStates, we would honor prior expressed wishes of such women to be maintained toterm, and some would support the rights of husbands to make this decisionwithout their wives' prior expressed wishes. On the other hand, we also honorthe patient's or surrogate's request to perform an abortion on pregnant womenin PVS on the grounds that the rights of the real or prior persons trump thoseof the potential persons. Since potential people don't have rights, the formerperson or their surrogates could request that the remediative techniques not beused to develop a new potential person.Perhaps similarly we could add another layer of complexity to advancedirectives, asking if patients would want their brains to be used by a newtenant. The legal question is whether this successor would be the owner of theprevious tenant's property, be married to their successor's spouse, be liablefor the successor's crimes, and so on. The social life and death conceptadvanced above suggests they should not be held to be the same person.Neural-ComputerProsthesesAny sufficiently advanced technology is indistinguishable from magic.Arthur C. Clarke Research is also being conducted on the creation of computer chip matrices intowhich nerves can grow, and which could permit two-way communication betweenneurons and computers (Agnew and McCreery1990) (Banks 1995) (Seabrook 1994) (Kovacs et al. 1995) (Compston 1994). Suchcomputer-brain interfaces raise the possibility that computer technology mayalso be developed to remediate neural capacities. These technologies arecurrently only being applied to peripheral nerves, and the control ofprosthetic devices, but in conjunction with neurotrophic growth factor andneurotrophic gene therapy, they may eventually be applied to cerebral tissue.Already advances are being made in electronic prosthetics for sight andhearing, from cochlear implants to optic nerve interfaces. Computer engineersare also developing biological computing and storage media3, and software thatlearns, suggesting a future convergence between organic computing, neuralnetwork software and neural-computer interfaces. FigureTwo: The Neural-Computer Chip Interface Developed by the INTER Consortium  Youngner and Bartlett (1983) address the possibility of future mechanicalremediation of brain injuries, and accept that such remediation would beunproblematic for brainstem functions, but they go to great lengths to rejectthe possibility of mechanically-mediated cognition.It is, however, easy to imagine a patient's integrated vegetative functionsbeing fully assumed by complex machines or well-trained health professionals.Any problems in such a takeover would be of a purely technical nature. Incontrast, conceptual problems surround the replacement of a patient'sconsciousness and cognition. We believe it is impossible for a person'sthoughts and feelings to be replaced by a mechanical device and still retaintheir essential nature. If the replacement is successful, the thoughts andfeelings would no longer be those of a human; if they remained essentiallyunchanged, the replacement was not successful. This point shows the essential,conceptual connection between higher brain functions and the continued life ofthe person. No comparable problem arises with the replacement of vegetativeoperations...If a living person is to exist, the thoughts and consciousprocesses must be those of a human, not a machine. (Youngner and Bartlett1983)Dr. Youngner's rejection of the possibility of personhood in a cyberneticmedium is a common, but minority, position in the field of artificialintelligence and cognitive science. Most cognitive scientists accept thematerialist assertion that mind is an emergent phenomenon from complex matter,and that cybernetics may one day provide the same requisite level of complexityas a brain. Of course, those who embrace the possibility of self-aware machineminds do not necessarily want to see them be developed, or grant them "humanrights" once they do develop.Perhaps what Dr. Youngner was suggesting is something akin to the braintransplant thought experiments in the personal identity literature (Wikler1988). If the brain tissue that gave rise to a person is destroyed, andreplaced by brain tissue or cybernetics which give rise to a new person, itwould not be correct to consider this new person as identical with the previousone. The dilemma that such cerebral remediation techniques might pose howeveris that the new person might regain some of the memories and othercharacteristics of the previous person. Even a wholly dead brain, and certainlya neo-cortically dead brain, probably retains some structures of memory andpersonality which could be reactivated by these techniques. Cryonicsand Nanotechnological Repair and ReplacementAnother technology that may eventually challenge our death concepts is cryonicsuspension, the freezing of heads, or whole bodies, for eventual reanimation.All diagnostic protocols for the determination of brain death call for rulingout hypothermia, but what if the brain is being intentionally and permanentlyfrozen. Our current concepts of death don't very well address the status of aperson who might eventually be brought back to life.Unfortunately for those who wish to undergo this procedure, American lawrequires that they be pronounced clinically dead first. Cryonicists believethat future reanimation will be more successful if they could initiate thefreezing before somatic death, and certainly before cerebral death. Cryonicsfirms have already been accused (and acquitted) of murder for having failed tohave a physician pronounce death before they began the suspension procedure. In1993, the California Supreme Court ruled that a man with a terminal brain tumorcould not have his head removed before he died. Like theNon-Heart-Donor-Protocol, the cryonicists, or rather the physicians present,are forced to make a rapid diagnosis of death, and then initiate suspension.Cryonicists acknowledge that the freezing process results in the rupture ofmany cellular membranes, and that micro-cellular repair will be the principalchallenge of future reanimators. Cryonicists have therefore enthusiasticallyembraced the new field of nanotechnology (Drexler 1986; Drexler and Peterson1991) (Regis 1995), which promises to eventually create microscopic,self-replicating robots capable of moving through frozen tissue without furtherdisrupting cell walls, identifying damaged tissue, and repairing it.Cryonicists expect this level of nanotechnology to be available within the nexthundred years. Of course, nanotechnology holds promise in all fields of medicine and industry,not just for the reanimation of the frozen. Nanotech visionaries predict theconvergence of molecular medicine, genetic therapy and nanotechnology to createtools to treat any disease, and immune system boosters capable of identifyingand eliminating disease before it occurs. In combination with theneural-computer trends discussed above, increasing numbers of nano-enthusiastsbelieve that the brain structures and activities can eventually be replacedentirely by nano-machines, and/or read into new media. This is known in sciencefiction and cyber-culture as "uploading" (Dery, 1996). MaterialInterests and Death RedefinitionWhen and if these remediative technologies come available, there will betremendous material interests at stake. These technologies will develop just asthe industrialized world shifts to increasing proportion of elderly. Thenumber of people with brain death and PVS will expand from the current 10,000,at any one time in the United States, to many times that number as technologyis increasingly successful at keeping them alive. The number with dementia sosevere that they are functionally equivalent to PVS may reach the hundreds ofthousands.The technologies discussed above will be very expensive, at least at theoutset, and their distribution and use will be very controversial. The persons,biological and cybernetic, that emerge from their application will be equallycontroversial. It seems most likely that a society with many expensivetechnologies to choose from, and faced with the disposition of the property andrelationships of new persons in old bodies, will explicitly forgo the expensiveremediation of sudden and complete cerebral destruction on the principle of"one body - one shot at personhood." On the other hand, the gradual applicationof these modalities in cases of progressive neurological disease, such thatthey maintain a continuous sense of personal identity, will probably beaccepted at a desirable contribution to the quality of life. It will probablybe obligatory that we attempt neurological resuscitation in cases of diagnosticuncertainty, unless otherwise forbidden by the person's advance directives,even though this may give rise to a new person. Post-BiologicalDefinition of Death: Personhood and BeyondBarring the end of civilization as we know it, technology will eventuallydevelop the capacity to remediate severe brain injuries, and perhaps eventranslate human thought into alternative media. In anticipation of thesetechnologies, even if only accepted as thought experiments, we can begin to seethe outlines of further changes in our definition of death. First, with theremediation of the brain stem and other body regulating structures, we will beforced to acknowledge that the destruction of the "integrative" functions ofthe body is an inadequate definition of death, since the social person willremain intact. Once we begin to remediate cerebral cortex injuries I believe we will be forcedbeyond a neo-cortical definition of death to one focused on the continuity ofsubjective self-awareness. Those who have a continuous sense of self-awareness,in whatever media, will be considered social persons, with attendant rights andobligations. Finally, these technologies will begin to fundamentally challenge the conceptof continuous, unitary personhood itself. This challenge was made to the fieldof personal identity literature by Derek Parfit (Parfit 1984), and has not yetbeen seriously grappled with in any area of philosophy, including bioethics.Now empirical research is beginning to offer the same disturbing result, asnoted in a recent Time magazine review of cognitive science:Despite our every instinct to the contrary, there is one thing thatconsciousness is not: some entity deep inside the brain that corresponds to the'self,' some kernel of awareness that runs the show, as the 'man behind thecurtain' manipulated the illusion...in The Wizard of Oz. After morethan a century of looking for it, brain researchers have long since concludedthat there is no conceivable place for such a self to be located in thephysical brain, and that it simply doesn't exist. (Nash, Park and Wilworth,1995) When we get to the point where neurological functions can be controlled,designed and turned on and off, the illusory sense of continuous self-identitywill become more obvious. Once we cast off this fundamental predicate ofEnlightenment ethics, the existence of an autonomous individual, we are beyondthe ethical frameworks of contemporary bioethics. To be sure, there are ethicalworldviews that do not have the autonomous individual at their core, fromtheocracy to Communism. Let us hope that, if we begin to take these thoughtexperiments serious now, we will have developed adequate frameworks based onour cherished liberal democratic values, when they are urgently needed.AppendixOne: A Quick Review of the Principal Arguments For and Against a Neo-CorticalStandard of DeathArguments Against the Neo-cortical Responses Standard Yuck factor Treating people who move Treating breathing, heart-beating and have their eyes open as dead bodies as dead also violates common violates common sense and moral sense and moral feeling, and yet it is feeling. This would be too great a the majority view in the medical and challenge to the public. bioethics community. Making the policy ethically logical is only slightly more challenging for the public. On the other hand, most surveys show that most people would not want to live in PVS. Self-Interest Since organ donation All bioethical definitions and would benefit from a neo-cortical decisions affect material interests standard, the effort is tainted by material interests Epistemological We can't know for Nor can we know for certain when the certain when the cortical functions of whole brain has been destroyed, and the brain have been permanently yet we accept a small margin of error. destroyed. The best diagnostic is In any case, the difficulty in time, and it is distasteful to have to determining mental status does not wait for months to determine if the invalidate our ethical position in patient is dead. regards that status. Future diagnostic techniques may make this moot. Discrimination If we accept the Most severely demented and retarded neo-cortical standard, we are obliged people have more personhood than the to deprive the severely demented and PVS patient. When they don't, similar retarded of their right to life. standards probably should apply. Slippery Slope If we accept the If we make correct, defensible neo-cortical standard, it will lead to definitions of what rights and our tolerating euthanasia of other obligations adhere to different humans and animals degrees of sentience, it will prevent slippage Pluralism A pluralistic society Despite diverse public views, social cannot impose such an extreme policy policy must specify what constitutes on publics that do not agree. murder, and what medical treatments must be provided. Although some flexibility is also possible, some group will always disagree with the limits specified. Disposal It would be distasteful to All societies have procedures for bury or cremate a breathing body. preparing bodies for burial. Ours includes stopping respiration and circulation. AppendixTwoQuestions included in the bioethics survey I conducted out of the Center forClinical Medical Ethics in 1992. Do you believe that parents, A 70 year-old person, who has not consulting with their pediatrician, previously expressed an opinion should be permitted to discontinue towards whether s/he would want to be medical treatments that may preserve kept alive, has fallen into a coma. the life of a week-old newborn, if: Should the person's relatives be permitted, in consultation with a doctor, to discontinue medical treatments that may preserve the person's life, if: * the newborn has a normal brain, but * the person may awake from the coma, has severe physical deformities that but has a terminal illness that will will cause death within several months cause death within several months * * Yes * No Yes * No * the newborn has a normal brain, but * the person may awake from the coma, has severe physical deformities that but will be paralyzed below the neck will cause death within several years for the rest of his or her life * Yes * Yes * No * No * the newborn has a normal brain, but has severe physical deformities that will cause death within twenty years * Yes * No * the newborn has a normal brain, and * the person may awake from the coma, will live a normal life span, but has but have severe and disabling severe and disabling disfigurement of disfigurement of the face, arms and the face, arms and legs * Yes * No legs * Yes * No * the newborn has an able brain and * the person may awake from the coma, body, but has a condition that will but will be in constant pain for the cause constant pain for the rest of rest of his or her life * Yes * No his or her life * Yes * No * the newborn has an able body, but * the person may awake from the coma, has such severe brain damage that s/he but will have such severe brain damage will only learn a few words and simple that they will only re-learn a few tasks, such as how to feed themselves words and simple tasks, such as how to * Yes * No use a spoon * Yes * No * the newborn has an able body, but * the person may open their eyes and has such severe brain damage that s/he move, but have such severe brain will never learn any tasks or how to damage that they will never re-learn communicate * Yes * No any tasks or how to communicate * Yes * No * the newborn has an able body, but * the person will not awake from the has such severe brain damage that s/he coma, and will always require a will never wake up, and will always feeding tube * Yes * No require a feeding tube * Yes * No BibliographyAgnew, William F., and Douglas B. McCreery. 1990. "Neural Prostheses:Fundamental Studies." Prentice Hall Advanced Reference Series.Banks, Danny. 1995. "Development of an Insertable Neural Signal Transducer forPeripheral Nerve." in Biological Engineering Society Symposium.University of Strathclyde, UK.Batchelor, David Allen. 1995. "The Science of Star Trek." at:http://www.gsfc.nasa.gov/education/just_for_fun/startrek.html.Bayertz, Kurt. 1992. "Techno-Thanatology: Moral Consequences of IntroducingBrain Criteria for Death." Journal of Medicine and Philosophy17:407-417.Beecher, Henry K. 1968. "A definition of irreversible coma: report of theHarvard Medical School Comm to examine the definition of brain death."Journal of the American Medical Association 205:85-88.Bernat, James. 1989. "Ethical issues in brain death and multiorgantransplantation." Neurologic Clinics 7:715-728.Bernat, James L. 1992. "How Much of the Brain Must Die in Brain Death?"Journal of Clinical Ethics. 3:21-26.Black, Peter M. 1978a. "Brain Death (First of Two Parts)." New EnglandJournal of Medicine 299:338-344.Black, Peter M. 1978b. "Brain Death (Second of Two Parts)." New EnglandJournal of Medicine 299:393-401.Botkin, Jeffrey R., and Stephen G. Post. 1992. "Confusion in the Determinationof Death: Distinguishing Philosophy from Physiology." Perspectives inBiology and Medicine 36:129-138.Brody, Baruch. 1988. "Ethical Questions Raised by the Persistent VegetativeState." Hastings Center Report :33-40.Brody, Howard. 1983. "Brain death and personal existence: A reply to Green andWikler." Journal of Medicine and Philosophy 8.Compston, A. 1994. "Brain repair: an overview." Journal of Neurology242:S1-4.Cranford, Ronald E, and David Randolph Smith. 1987. "Consciousness: The MostCritical Moral (Constitutional) Standard for Human Personhood." AmericanJournal of Law and Medicine 13:233-248.Dery, Mark. 1996. Escape Velocity: Cyberculture at the End of theCentury: Grove Press.Drexler, K. Eric. 1986. Engines of Creation: Doubleday.Drexler, K. Eric, and Chris Peterson. 1991. Unbounding the Future: TheNanotechnology Revolution: Morrow.Emanuel, Ezekiel J. 1991. The Ends of Human Life: Medical Ethics in aLiberal Polity: Harvard University Press.Gervais, Karen G. 1986. Redefining Death. New Haven, CT: Yale UniversityPress.Green, Michael, and Daniel Wikler. 1980. "Brain death and personal identity."Philosophy and Public Affairs 9:105-133.Harris, Marvin. 1979. Cultural Materialism: Vintage Books.Kovacs, Gregory T.A., Todd K. Whitehurst, Nadim I. Maluf, and Christopher W.Storment. 1995. "Stanford/DVA Neural Interface Project." : Stanford University:http://www-cis.stanford.edu/cis/research/LabProjects94/StanfordDVA.html.La Puma, John, David L Schiedermayer, Ann E Gulyas, and Mark Siegler. 1988."Talking to comatose patients." Arch Neuro 45:20-22.McMahan, Jeff. 1995. "The Metaphysics of Brain Death." Bioethics9:91-126.Nash, J. Madeline, Alice Park, and James Wilworth. 1995. "Glimpses of theMind." Time :44-52.Olson, L. 1993. "Reparative strategies in the brain: treatment strategies basedon trophic factors and cell transfer techniques." Acta Neurochirurgica -Supplementum 58:3-7.Parfit, David. 1984. Reasons and Persons. Oxford: Oxford Univ. Press.Payne, Kirk, Robert Taylor, Carol Stocking, and Greg Sachs. 1993. "A NationalSurvey of Physicians' Attitudes Regarding the Care of Patients in PersistentVegetative State." in MacLean Conference on Clinical Medical Ethics andPatient Care, 5th Annual .Piers, Maria. 1978. Infanticide. NY: Norton & Co.President's Commission for the Study of Ethical Problems in Medicine andBiomedical and Behavioral Research. 1981. Defining Death: Medical, Legal andEthical Issues in the Determination of Death: Supt. of Doc.Ray, Joel. 1991. "The Body without a Mind: An Examination of Cognitive BrainDeath." Humane Medicine 7:29-34.Regis, Ed. 1995. Nano: The Emerging Science of Nanotechnology: LittleBrown.Seabrook, Richard. 1994. "The Brain-Computer Interface: Techniques forControlling Machines." :http://www.student.nada.kth.se/~nv91-asa/Trans/richard.seabrook.brain.computer.iterface.txt.Stanworth, Michelle. 1988. "Reproductive Technologies and the Deconstruction ofMotherhood." Pp. 10-35 in Reproductive Technologies: Gender, Motherhood, andMedicine, edited by Michelle Stanworth: University of Minnesota Press.Tresch, Donald D, Farrol H Sims, Edmund H Duthie, and Michael Goldstein. 1991."Patients in a persistent vegetative state attitudes and reactions of familymembers." Journal of the American Geriatrics Society 39:17-21.Tuszynski, M. H., and F. H. Gage. 1995. "Bridging grafts and transient nervegrowth factor infusions promote long-term central nervous system neuronalrescue and partial functional recovery." Proceedings of the National Academyof Sciences of the United States of America 92:4621-5.Valouskova, V., and J. Galik. 1995. "Unilateral grafting of fetal neocortexinto a cortical cavity improves healing of a symmetric lesion in thecontralateral cortex of adult rats." Neuroscience Letters 186:103-6.Veatch, Robert. 1975. "The whole-brain-oriented concept of death: An outmodedphilosophical foundation." Journal of Thanatology 3:13-30.Veatch, Robert M. 1992. "Brain death and slippery slopes." Journal ofClinical Ethics 3:181-7.Wikler, Daniel. 1988. "Not Dead, Not Dying? Ethical categories and persistentvegetative state." Hastings Center Report :41-47.Youngner, Stuart, and Edward Bartlett. 1983. "Human death and high technology:the failure of whole-brain formulations." Annals of Internal Medicine99:252-58.Youngner, Stuart, Seth Landefield, Claudia J. Coulton, Barbara W Juknialis, andMark Leary. 1989. "'Brain Death' and Organ Retrieval: A Cross-sectional Surveyof Knowledge and Concepts Among Health Professionals." Journal of theAmerican Medical Association 261:2205-2210. |
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