Volume 7 Number 2 July 2006 - JICS - The Intensive Care Society

Volume 7 Number 2
26
Original Articles continued
paradoxically, made identifying a point of death even
harder. In the natural process of dying, the final
elements of the closing down process come fairly
close together; but we can now draw out those
different elements, often independently, while
monitors allow us to watch what is going on in
previously impossible detail. The range from
which to choose the point of death has expanded
immeasurably.
The resulting controversies about the point of death
can become passionate, because holders of different
views regard their opponents as doing serious,
unjustified harm. People who accept the brain stem
criterion, for instance, think that innumerable organs
are lost to slow deterioration while ventilators
maintain cardiopulmonary function, or monitors show
the last flickers of cortical activity, in a patient
already dead. Others with more conservative views
– including many potential donors and their families
– think their opponents are recommending the
murder of dying patients.
The only way out of this impasse involves
recognizing a much more fundamental point: that
science cannot establish a point of death. The
traditional view is that there is an objective fact
about the matter: death is the final departure of
some undetectable soul or élan vital. But if such
things exist, science has no way of observing them.
If, on the other hand, life is – as scientists
increasingly believe – a function of the organization
of material parts, there simply is no point of
transition between life and death. Trying to pin it
down is like trying to determine the point at which
red becomes orange on a spectrum. On the
traditional account, the question of when death
occurs in the closing down process is scientifically
unanswerable; on the more recent one, it is
meaningless. Either way, it should be abandoned.
The whole problem can then be approached from a
different direction. Why are we so anxious to know
whether someone is alive or dead? The reason,
obviously, is our concern to treat the living and the
dead appropriately.
Instead of trying to keep the familiar categories and
force the transitional states into them, we should
address directly the problem of how people in those
states should be treated. This question is not
scientific, but moral. Science can tell us what states
people are in and (with different degrees of certainty,
and subject to change) whether those can be
stabilized or reversed. It cannot answer the moral
question of how we should treat people in those
states.
Traditional believers in an objective point of death
will probably answer the moral question by
maintaining an absolute prohibition on active
hastening of death, and always presuming life in
case of uncertainty. But for anyone who accepts
that there is no definite point of death, but only a
shading between clearly alive and clearly dead,
moral judgments will need a different basis. The
most plausible view is that what matters is people’s
interests.
This kind of idea, when followed through, has
radically different implications from those of the
traditional view. They can overlap in many areas,
but in the penumbra between life and death, the two
approaches come apart. When patients reach the
point of having no interest in further treatment to
reverse or delay the closing down process, they
usually have no interest in whether it is further
delayed, or accelerated, or redirected. From their
point of view, accelerating the closing down process
beyond the point of their interests is no more killing,
in any morally relevant respect, than is accelerating
the closing down of hair growth by cremation. At the
same time, other people may have considerable
interest in how the process happens – not only
because of transplants, but because of the
enormous resources that currently go into end-of-life
care. From their point of view it matters a great deal
whether we treat the dying according to their
interests as we understand them, or rule out certain
possibilities altogether until some (highly elusive)
objective point of death.
Law and professional practice already give great
weight to patients’ interests, and most doctors would
say those interests were the purpose of their work.
But much of what is legally required and actually
done has nothing to do with interests, and may
actually work against them, because of ancient
assumptions about an objective point of death and
its moral relevance.
Since every day extends our ability to separate and
draw out the different elements of the closing down
process that is death, it is essential to replace the
anachronistic, apparently scientific debate about
when death really occurs with the explicitly moral
debate that it should be.
J Radcliffe Richards
Centre for Biomedical Ethics and Philosophy UCL
July 2006
The Journal of the Intensive Care Society