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This is an excellent paper and Dr. Lizza very cogently demonstrates
that the presence of intracranial neurological function, however it is
going to be defined, is the only criterion for life. The practical
application of any other definition produces results that are incoherent
with respect to universally accepted concepts of human life and death.
It is therefore puzzling that Dr. Lizza has elsewhere defended u...
It is therefore puzzling that Dr. Lizza has elsewhere defended using
the cessation of circulation as a criterion for death in the case of non-
heart beating organ donation(1). The Waldo thought experiment reveals
the problems not only with the use of this criterion, but also with his
use of potential in determining death.
Assume that Waldo's head was attached to a machine that provided
circulation (oxygenated blood). One could turn the machine off, leave it
off for a period of time (thus depriving Waldo of circulation), and then
turn it on again. The time period could be a few seconds or an hour. If
it was only a few seconds, Waldo would not lose any neurological function.
If it was an hour and no steps were taken to protect Waldo's brain, he
would irreversibly lose all neurological function. If it was an hour, and
steps were taken to preserve Waldo's brain (medications, hypothermia), he
would again not lose any function(2). Regardless of the time period,
circulation could be restored. Assuming that we agree that a
neurologically intact Waldo is alive, and if Waldo has irreversibly lost
neurological function he is dead, the circulatory status is entirely
incapable of determining Waldo's life and death status. Lack of
circulation is useful only if it successfully predicts a concomitant loss
of neurological function. In the modern era of medicine, circulation
status is no longer an independent predictor of life and death. It is a
vestige of a model of body interdependence which is no longer accurate.
In situations where the neurological and circulatory determinations
differ, the neurological findings are controlling. Therefore, organs can
be harvested from a non-heartbeating patient only when the lack of
circulation has resulted in irreversible cessation of neurological
Use of circulation as a criterion for death also leads to discussions
of potential versus irreversibility(or, permanent versus irreversible to
use Bernat's formulation). Until there is necrosis of the blood vessels,
circulation can always be provided by machines, even in a body that all
agree is dead. To avoid this problem, Dr. Lizza allows that
circumstances, including a patient's wishes, can limit the potential for
irreversibility. There a number of problems with this approach.
Assume that Waldo is a conscious thinking head attached to a pump
supplying oxygenated blood. We have already agreed that a conscious Waldo
is alive. He has specifically stated that if the pump stops, he does not
want it to be turned on again. If the pump is turned off, he will still be
conscious for at least 10 seconds or more. However, according to Dr.
Bernat(3), Waldo is dead the moment the pump stops . According to Dr.
Lizza, Waldo is dead because, having stated his wishes which must legally
be obeyed, he has lost the potential for circulation. The position
therefore lacks coherence since it provides a circumstance where a
conscious person is labeled as dead.
The life or death status of a human being is an intrinsic quality of
that human being's body. The label of life or death that we apply to that
body should reflect as best as possible, that intrinsic characteristic of
the body. Therefore that label should not be affected by conditions
extrinsic to the body. Perhaps aside from liver function, neurological
function is the only function of the body that cannot be approximated with
machines to some extent. Irreversible cessation of neurological function
is something that can be determined. It is only the usage of the
circulatory criterion that requires employing
Death should be irreversible, and 'recovery' from death should be a
rare occurrence due only to mistakes in the determination of facts. Under
Dr. Lizza's construct, 'recovery' from death could occur by disobeying the
law and/or violating the patient's wishes. In fact resuscitation has been
done on patient's who have been declared dead and some have regained some
neurological function(4). While this is obviously quite the exception, it
is reasonable to expect that criteria to determine death would eliminate
this possibility as much as possible.
By making the concept of irreversibility dependent on a patient's
wishes, the patient, under certain circumstances, is deciding if he is
dead or not. Admittedly Dr. Lizza has restricted the patient input to
defining potential of reversal. But it is still very much different than
deciding if resuscitation should be done or not. While I admire his
struggle with how to deal with issues of potential, in the case of
determining death it results in incoherence. Waldo has shown that.
1.Lizza, JP. Potentiality and Persons at the Margins of Life.
Diametros nr 26 (grudzie? 2010): 44-57
2. Hypothermic cardiac arrest has been successfully used in surgery
for up to 72 minutes.
3. Bernat's concept is that permanent cessation of circulation is
death. Permanent is defined as a situation where the circulation will not
spontaneously restart, and a decision has been made that outside power
will not be used to restart it. Obviously the pump is off and will stay
off unless an outside power turns it on.
4. See case histories here: http://www.alcor.org/ a patient was
declared dead based on cessation of circulation. The cryopreservation
protocol called for chest compression and ventilation to preserve the
brain until the preservatives could be injected and cooling begun. Not
surprisingly, at least one patient was noted to resume 'agonal