How Dead Can You Be?

Abstract

Life and death are defined in terms of function. Four groups of abnormal cases of death are specified and differentiated from normal cases. Murder, active euthanasia and cessation of artificial respiration are differentiated on the basis of the interested party, the cause of death and the purpose of the act. Juridical acceptance of this differentiation and terminology makes cessation of artificial respiration lawful, provided the patient had validly refused this treatment or is irreversibly comatose and also respirator-dependent. This would make it unnecessary to redefine death in terms of coma in order to solve legal and practical problems. Such a redefinition is against current usage (coma presumes life) and is the first step on an extremely slippery road; it is only admissible if done by the legislator after extensive public discussion. Disagreement among doctors about the definition and diagnosis of death causes distrust among the public, aggravates the shortage of donor organs and makes legal security an illusion. Three diagnostic ‘schools’ are compared: the Anglo-American (using Harvard's criteria), the French (using Mollaret's coma dépassé) and the Austro-German (using absence of intracranial blood circulation). On grounds of logic only the Austro-German diagnosis is reliable; it is not based on a statistically irreversible absence of outwardly perceptible manifestations of brain function, but proves and documents with certainty the total and irreversible impossibility of brain function. At present this has to be done by bilateral angiography of both carotid and vertebral arteries; if negative concerning the intracranial part, this proves death. In normal cases the traditional criteria may be used; in abnormal cases where no infringement of the body is foreseeable death need not be a certainty in order to stop therapy, provided the patient is irreversibly comatose and also respirator-dependent; in abnormal cases where an infringement is foreseeable death should be proved and documented to make the infringement lawful, apart from other conditions such as consent. Proof can be obtained by the Austro-German method or by discontinuing resuscitation during at least 15 consecutive minutes where this is legally permissible. Most German and Dutch lawyers concerned share this view.