Towards a Pragmatic Definition of Death

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Towards a Pragmatic Definition of Death

• Brendan Leier PhD
• Clinical Ethicist, UAH/Stollery
• Assist. Clinical Professor
• John Dossetor Health Ethics Centre

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• When we exist, death is not.
• When death is, we are not.
• Death is nothing to us.
• -Epicurus-

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Why Define Death?
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Why Define Death?

• The Epicurean answer
• The effort to define death is really a means to
  address some other pressing concern or dread fear.

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Taphophobia
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Taphophobia
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Medical Definitions
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19th Century New York Bill

• First Permanent cessation of respiration and
  circulation.
• Second Purple discoloration of the dependent
  parts of the body.
• Third Appearance of blistering around a part of
  the skin touched with a red hot iron.
• Fourth The characteristic stiffness known as
  rigor mortis.
• Fifth Signs of decomposition

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Medical Definitions

• Cardio-Pulmonary Death (clinical death)

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Medical Definitions

• Cardio-Pulmonary Death (clinical death)
• Brain Death (permanent cessation of electrical
  activity)

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Medical Definitions

• Cardio-Pulmonary Death (clinical death)
• Brain Death (permanent cessation of electrical
  activity)
• Whole brain
• Higher brain

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Medical Definitions

• Cardio-Pulmonary Death (clinical death)
• Brain Death (permanent cessation of electrical
  activity)
• Disintegration

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Medical Definitions

• Cardio-Pulmonary Death (clinical death)
• Brain Death (permanent cessation of electrical
  activity)
• Disintegration
• Cardio-Pulmonary Death (again?)

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DCD A New Debate?

• See Ari Joffe -vs- Sam Shemie in Philosophy,
  Ethics, and Humanities in Medicine 2007

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Two false assumptions

• 1. That because there is a word death, there
  must be some true essential definition of that
  condition. Let us call this the essentialist
  assumption.

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Two false assumptions

• That because there is a word death, there must
  be some true essential definition of that
  condition. Let us call this the essentialist
  assumption.
• That it is the exclusive domain of the
  physician/scientist to determine this matter of
  fact and this determination should be the basis
  for public policy and legislation. Let us call
  this the domain assumption.

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Two false assumptions

• 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. Here one can accept the usual
  concept of complete and final separation of the
  soul from the body but in practice one must take
  into account the lack of precision of the terms
  and separation.
• 7 Pius XII, Prolongation of Life Allocution
  to the International Congress of
  Anesthesiologists (November 24, 1957), The Pope
  Speaks 4 (1958) 393-398.

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Two false assumption (modern)

• For all purposes within the jurisdiction of the
  Parliament of Canada,
• a person is dead when an irreversible cessation
  of all that persons brain functions has
  occurred
• the irreversible cessation of brain functions can
  be determined by the prolonged absence of
  spontaneous circulatory and respiratory
  functions
• when the determination of the prolonged absence
  of spontaneous circulatory and respiratory
  functions is made impossible by the use of
  artificial means of support, the irreversible
  cessation of brain functions can be determined by
  any means recognized by the ordinary standards of
  current medical practice (Report 15, p. 25)

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What is the meaning of meaning?
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Ludwig Wittgenstein on Meaning
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Wittgensteins Picture Theory
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Wittgensteins Meaning as Use

• Words do not have fixed meanings, nor do concepts
  have fixed eternal essences, rather they are used
  like tools and have many functions.

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Wittgensteins Meaning as Use

• Words do not have fixed meanings, nor do concepts
  have fixed eternal essences, rather they are used
  like tools and have many functions.
• The meaning of a concept is derived from its use
  in a particular context or game.

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Wittgensteins Meaning as Use

• Words do not have fixed meanings, nor do concepts
  have fixed eternal essences, rather they are used
  like tools and have many functions.
• The meaning of a concept is derived from its use
  in a particular context or game.
• A language game embodies the meanings and
  relationships of a particular activity.

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Form of Life
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Wittgensteins Meaning as Use

• How should we explain to someone what a game is? 
  
• If we don't have a common thread running through
  everything we call a game it seems very
  chaotic!  How on earth do we teach people to use
  this term game?
• I imagine that we should describe games to him,
  and we might add "This and similar things are
  called 'games' ". And do we know any more about
  it ourselves? Is it only other people whom we
  cannot tell exactly what a game is?
• Still, don't we teach this term games to
  children?  And don't they learn it?  Can it
  really be as difficult as all that if we manage
  to teach it so easily?  -But this is not
  ignorance.

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Wittgensteins Meaning as Use

• Cont.
• We do not know the boundaries because none have
  been drawn. To repeat, we can draw a boundary-for
  a special purpose.
• Does it take that to make the concept usable? Not
  at all!  (Except for that special purpose.)
• No more than it took the definition 1 pace 75
  cm. to make the measure of length 'one pace'
  usable.
• And if you want to say "But still, before that it
  wasn't an exact measure", then I reply very
  well, it was an inexact one.-Though you still owe
  me a definition of exactness. 
• Philosophical Investigations 69

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Wittgensteins Meaning as Use

• Conclusion for our purposes
• If we want to understand the meaning of a
  concept, we are not interested in its definition.
• We must look and see how the word is used.

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The Current Problem
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The Current Problem

• Every essentialist (empirical) attempt to define
  death can be undermined by a skeptical response
  in either

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The Current Problem

• Every essentialist (empirical) attempt to define
  death can be undermined by a skeptical response
  in either
• an ontological form brain death is not really
  death

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The Current Problem

• Every essentialist (empirical) attempt to define
  death can be undermined by a skeptical response
  in either
• an ontological form brain death is not really
  death
• An epistemological form how do we know that this
  particular person is brain dead? PVS Zolpidem
  example.

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A Possible Pragmatic Solution

• Work towards the affirmation of a patient centred
  concept of death.

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A Possible Pragmatic Solution

• Work towards the affirmation of a patient centred
  concept of death.
• Cultural
• Religious
• Secular
• Existential

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A Possible Pragmatic Solution

• Embracing a patient-centred definition of death
  does not undermine the role of the clinician, on
  the contrary, it provides the means to affirm an
  individually tailored best interest standard.

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A Possible Pragmatic Solution

• Embracing a patient-centred definition of death
  does not undermine the role of the clinician, on
  the contrary, it provides the means to affirm an
  individually tailored best interest standard.
• Nor is this pragmatic approach inconsistent with
  the affirmation of similar legal/ethical patient
  decision-making roles (reproductive choice,
  withdrawal of treatment)

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A Possible Pragmatic Solution

• Embracing a patient-centred definition of death
  does not undermine the role of the clinician, on
  the contrary, it provides the means to affirm an
  individually tailored best interest standard.
• Nor is this pragmatic approach inconsistent with
  the affirmation of similar legal/ethical patient
  decision-making roles (reproductive choice,
  withdrawal of treatment)
• Nor does this approach rule out appropriate
  conventional definitions and standards.

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Protection of Roles in Healthcare
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What is the Real Challenge?
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Ivan Illich Death Under Intensive Care

• In many a small village in Mexico, I have seen
  what happens when social security arrives. For a
  generation people will continue in their
  traditional beliefs they know how to deal with
  death, dying, and grief.
• The new nurse and the new doctor, thinking they
  know better, teach them about an evil pantheon of
  clinical deaths, each one of which can be banned,
  at a price. Instead of modernizing peoples
  skills for self-care, they preach the ideal of
  the hospital death

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Ivan Illich Death Under Intensive Care

• Like all other major rituals of industrial
  society, medicine in practice takes the form of a
  game. The chief function of the physician
  becomes that of an umpire.
• He is the agent or representative of the social
  body, with the duty to make sure that everyone
  plays the game according to the rules.
• The rules, of course, forbid leaving the game and
  dying in any fashion that has not been specified
  by the umpire.
• Death no longer occurs except as the
  self-fulfilling prophecy of the medicine man.

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A Communication Strategy and Brochure for
Relatives of Patients Dying in the ICU NEJM
Volume 356469-478, 2007

• Value and appreciate what the family members
  said.
• Acknowledge the family members' emotions.
• Listen, to ask questions that would allow the
  caregiver.
• Understand who the patient was as a person.
• Elicit questions from the family members.

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Thich Quang Duc
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Thanks!

• Brendan
• bleier_at_ualberta.ca
• Brendan.leier_at_capitalhealth.ca
• Please check out Ethos, our new health-ethics
  resource page
• www.ethos.ualberta.ca