By Brendan Abel, JD, MMS Legislative and Regulatory Affairs Counsel
Fifty years ago, 20 miles from the Medical Society’s headquarters, a group of physicians was tasked with redefining the most essential concept in the practice of medicine: death. Their revised definition of death, driven by technological advances, was subsequently codified into law.
Today, physicians and ethicists are again debating concepts of death. Brain imaging technologies are challenging our long-held concepts of “total brain death.” Some are pushing for a more stringent, holistic concept of brain death, while others lean in the opposite direction, focusing on concepts of irreversible consciousness.
If anything seems absolute, if any state of being seems fixed, it is death. But, like everything else in medicine, death evolves, reminding us that bioethics is not confined to hypertechnical matters, such as gene editing or nanotechnology. Bioethics extends to matters that will affect every one of us — including how our life and death will be defined.
Implications of Technology
The definition of death illustrates the paramount importance of bioethics to the practice of medicine, now and in the future. Technological advances will continue to
displace longstanding tenets of medicine. Bioethics will continue to be an essential tool as the medical community addresses these issues in the name of upholding the highest ethical standards for patients and for the profession.
Until the 1970s, the definition of death had seemed simple. A person died when they stopped breathing, their heart stopped beating, and their body turned blue and cold. Two converging technological advances — ventilators/life support and organ donation — challenged this.
Life support could keep a patient’s heart beating into perpetuity, creating a quandary: “living” patients whose hearts pumped blood through their warm bodies, but whose brains had ceased to function. And organ transplantation, which was premised upon the ethical tenet that a patient must be dead before an organ could be obtained for donation, suddenly put a keen importance on the precise moment of death. In this new world, death needed to be redefined.
Harvard’s Definition of Death
A committee of physicians and researchers at Harvard Medical School convened for that purpose. The Ad-Hoc Committee
of Harvard Medical School to
Examine the Definition of Brain Death issued a report that, for the first time in the United States, proposed a new concept: brain death. “A Definition of Irreversible Coma” was published in JAMA in 1968. Patients could
now be determined dead by either the traditional definition — cessation of cardio-pulmonary function — or the new criterion of a “permanently nonfunctioning brain.”
It took some time for the Ad-Hoc Committee’s definition of brain death to become law. In 1980, a physician in Washington who defined death via the Committee’s standard was sued for advising that medical intervention end in the case of a brain-dead patient. This prompted all 50 states to codify in law the bi-definitional concept of death, affirming a place in bioethical history for
the Ad-Hoc committee.
