On a Cosmopolitan Definition of Death

Most traditional mythologies have equated life to breath. Breath was considered to be something more than respiration, linked -in a tradition that goes back to myths of Anima Mundi- to some sort of universal life. In this context, death was the departure of such transcendental airy entity towards fabulous scenarios of different kinds. The link of breathing and the capacity for speech contributed for a further metaphysical development of the physiological act of oxygenation. The Parmenidean tradition in Greece, but especially the Aristotelian philosophy, linked life more to intelligence than to any other physiological action. In fact, in the Metaphysics, Aristotle declares life to be some sort of intelligence. This double link, to breathe and to intelligence, in their transcendental or materialistic interpretations, gave for centuries a cornerstone for the definitions of life. Even, in the practice of modern medicine up to the 1960’s, it was the loss of the capacity to breathe (together with the loss of blood flow) the key property for the definition of death. The definition of death elaborated by the Academy of Medical Royal Colleges in 2008, declares death as the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe. Here, the concept consciousness merely describes a physiological process that would be better described as a state of vigilance, opposed to sleep, coma or anesthesia, but in any case, implies the expression of intelligence in its more basic terms. Thus, according to this definition death is a combination of an irreversible loss of any state (process) of vigilance and the capacity to breathe.

Irreversibility of functional performance seems at first a good indicator for death, especially irreversible loss of critical systems which lead to a general collapse of the body, like it used to be the loss of capacity to breathe or to pump blood. However, the invention of mechanical ventilators during the 1960’s changed the conceptual scene and patients with massive brain destruction could maintain with the help of machines a relatively healthy functioning of other systems. David Cole has convincingly argued that irreversibility is not an absolute concept in relation to the medical definition of death, for it is conditioned both by the state of the medical technology and by the scenarios where the death situation may occur (it is not the same a massive heart attack in a hospital that in a camping in the mountains). If we consider the changes in medical science, we may induce that what today is not irreversible may be reversed tomorrow, so it seems futile to try to give final definitions and limits for such a dynamical field of knowledge in which biomachines may alter radically the way we look today to the functioning of human organs.

All that is needed is a working definition which can be used in the context of the main legal and ethical frames (Human Rights Declaration, etc.) to avoid abuses and violations of human rights. The common ground for ethics and medicine is not the performance of a particular organ or a system of them, but the social persona. Therefore, irreversibility has to be measured in relation to that persona, and in many cases it means that there are irreversible loses even in situations when no major organs have been affected but a general impairment ends with the life of the patient as s/he knew it. This problem would need to be addressed and complemented in relation to the questions of assisted suicide and the property which the individual has over his or her body. Since human beings are symbolical, the symbolical emergent dimension has to be added to the physiological one. The symbolical approach can be so different as the materialistic one of physiology in relation to the transcendental one which speaks about resurrections. In fact, the discrepancies affect to the social persona, for while science speaks of the persona in terms of the political legal system in which it is developed, religion speaks of a transcendental persona beyond the political one. How to harmonize such a complex symbolical scenario? One possible solution is a plain appeal to consistency of action: medicine treats the socio-political persona according to the general legal frames, while leaves the metaphysical person as a private question of the patient. But this implies that religion also does not interfere with the clinical practice (beyond its conditionings in the general beliefs which are gathered in the ethical codes of the group). A person would be clinically dead when its body functions where so impaired as to impede any psycho-social communication. Such an assessment needs a careful and thorough examination of each individual case and has to be independent of considerations in relation to organ donation, unless previously specified by the patient in actual statements and reports. We would need databases with patient decisions in relation to different health scenarios which could affect them.

Some References

Academy of Medical Royal Colleges [2008] A Code of Practice for the Diagnosis and Confirmation of Death. http://www.aomrc.org.uk/doc_view/42-a-code-of-practice-for-the-diagnosis-and-confirmation-of-death.

Bosnell, Rose and Madder, Hilary.[2011] Concepts of brain death. Surgery (Oxford). Volume 29, Issue 7, July 2011, Pages 289–294.

Cole, D. J. (1993), Statutory Definitions of Death and the Management of Terminally

Ill Patients Who May Become Organ Donors After Death, Kennedy Institute of Ethics

Journal, 3: 145–55.

Youngner, Stuart J. The Definition of Death. [2007] In The Oxford Handbook of Bioethics. p.p. 285-303. Oxford University Press. 2007.

The five normative postulates of Evidence Based Medicine

Evidence Based Medicine (EBM) is rooted in five linked ideas [Davidoff, Haynes, Sackett  & Smith, 1995]:

1.     Clinical decisions should be based on the best available scientific evidence.

2.     The clinical problem-rather than habits or protocols-should determine the type of evidence to be sought.

3.     Identifying the best evidence means using epidemiological and biostatistical ways of thinking.

4.      Conclusions derived from identifying and critically appraising evidence are useful only if put into action in managing patients or making health care decisions.

5.     Performance should be constantly evaluated.

The five normative postulates express a program for medical practice which has been widely and enthusiastically accepted by the medical community.

Postulate one is a call for continuous formation on the part of the physician, the acknowledgement of the rapid and continuous development of life sciences and the imperative need for theoretical and practical updates in the fields of those sciences: medical education is an ongoing process. One major problem with this sound proposal is the availability and transparency of scientific information: human health is an industry and information is restricted by market conditions. Besides this social objection to the implementation of the postulate, we meet an epistemological one: the concept of medical evidence is problematic.  The problem is subsumed under the belief in the unquestionable validity of the randomized controlled trials, but the statistical efficacy of a treatment, per se, is not sufficient for its implementation: statistical evidence needs also theoretical integration, i.e., has to be understood in a wider reference frame if we want to have some control over possible perverse effects (using Merton’s trerminology) unforeseen in statistical conceptual frames. In the health sciences, it is now a commonplace that both mechanistic and probabilistic evidence are required to substantiate causal claims [Russo and Williamson, 2007]. The history of medicine presents many cases in which causal claims made solely on the basis of statistics have been rejected until backed by mechanistic or theoretical knowledge [Russo and Williamson, 2007].

Postulate two expands what was said in postulate one, it is basically a call against inertia and mechanic medical action. Its implementation encounters several economic problems.

Postulate three is an epistemological declaration: the medical method should be mainly statistical. As we just said, biostatistics by itself is not enough for medical practice: without a theoretical frame, statistics is nothing but uninterpreted data. On the other hand, the implementation of a health program not fully understood is a plea for what the social sciences call perverse effects.

Postulate four is an ethical demand for the EBM program: the purpose of the medical practice is to cure patients. In this sense, is not a dehumanized practice as its opponents advocate. On the other hand, we could not say that EBM expresses a humanistic approach, for it has not an anthropological perspective upon the medical practice as a social action.

Finally, postulate five extends the ideas expressed in P1 and P2.

References

Davidoff, F., Haynes, B., Sackett, D., and Smith, R. Evidence-based medicine. [1995]. British Medical Journal, 310, 1085–1086.

Russo, Federica, and Williamson, Jon.  Interpreting Causality in the Health Sciences. [2007] International Studies in the Philosophy of Science. Vol. 21, No. 2, July 2007, pp. 157–170.

EthoMedical Leaves: Treatment choices when the patient is incapacitated

David Wendler and Annete Rid’s [2011]study on surrogates treatment decisions has shown that at least one third of the surrogates experienced a negative emotional burden as the result of making the choice. Rid, Wendler and others have proposed the use of a Patient Preference Predictor (PPP) -an actuarial model for prediction- that gathers particular information about the treatment preferences of a population sample and produces the treatment option that an individual patient would be most likely to prefer.

One question: What about asking patients about their own choices for most common scenarios and preparing files well in advance, when signing health insurance policies? The collected database would certainly improve the actuarial model of prediction for all those cases where there is not an opportunity to ask the patient.

References

Wendler, David and Rid, Annette. The Effect on Surrogates of Making Treatment Decisions for Others. [2011]. Ann Intern Med. 2011;154(5):336-346.

Feeding the gods: the market of human organs

In the Samoan myths of the afterlife, the soul of the poor is food for the soul of the noble and rich [Frazer, 1922]. Are we living in the Samoan afterlife? Well, for some of our unfortunate contemporaries the situation is not so different. Simon Rippon has discussed the issue in an interesting paper on the Journal of Medical Ethics, where he analyzes the thesis of the moral and economic benefits for the poor which provides the free market of live donor organs. He expresses the thesis of the Laissez-Choisir  (LC) argument in three premises.

P1. People in poverty who would choose to sell their organs if a free market existed must regard all other options open to them as worse.

P2. If we take away what some regard as their best option, we thereby make them worse off, at least from their own perspective.

P3. If a policy makes some worse off from their own perspective, it would be paternalistic for us to judge otherwise and to implement the policy on their behalf. We ought not to be paternalistic in this way. Therefore, we ought not to prohibit organ markets for the supposed good of those in poverty who would choose to sell their organs if a free market existed.

LC has been subscribed by Julian Savulescu [2003] and by Gerald Dworkin [1994] on the grounds of the freedom of choice of the sellers and the paternalism of any attempt to regulate the market. Janet Radcliffe Richards [Radcliffe et al.,1998], on the other hand, has subscribed LC on the grounds of a worse scenario if the prohibition is reinforced. Rippon’s paper refutes LC's claims on the grounds that sometimes you may hurt people by giving them an option that they would be better off taking: the addition of the option makes it more difficult or costly to perform the reasoning necessary to reach the best decision. His argumentation refutes P2, but fails to address what from my point of view is at the center of this moral problem: hypocrisy, or put in ethical terms, the inconsistency between the moral values of society and its actions.

The appeals to freedom of choice are a mockery: freedom of choice is always limited by initial conditions and only possible in a system with perfect flow of information, i.e., is just an ideal condition, a convenient narrative of domination which justifies many abuses. The sellers of organs do not know the full scenario but simply get into further trouble, buying themselves, at best, some extra-time: we are offering to the person a floating device so s/he can be saved to be properly eaten lately by the sharks. When we appeal for the freedom to decide upon our own body, we forget that such a right is denied at large throughout the world, as we see in the relation to the free use of drugs, or in war situations, or in terminal diseases: the restrictions on the freedom of choice for the individual in these three scenarios is inconsistent with the approval of a free live donor market. We have to decide, the body belongs to the individual or it does not. But even if we reach the civilized point of letting the individual decide upon his (her) life and body, the idea of a free market does not necessarily follows. Why should there be market conditions for human transplanting? The still on-going belief on the supernatural capacities of the invisible hand of the market, the old Laissez Faire, is an old superstition linked to other supernatural beliefs and has no grounds on economic data: market crisis are paid by the population at large through public funds.

There are not easy and straightforward rational solutions when ontologies are involved, especially when those are otherworld valuations. The live donor market problem has, nonetheless a solution based on human valuations. If we value life and freedom of choice we cannot interfere in the free donation of organs, but it seems rather perverse and human degrading the idea of solving (or even alleviating) poverty through merchandizing human body parts. Although prostitution reaches beyond the sex domain into realms of manipulation and domination, when we are dealing with body parts, nobody would sell a part of his/her body if the need for survival was not urgent. The control of the organ market by society will force other solutions for poverty, more permanent and consistent with the values that we are teaching to our children and write in our Constitutions, the values that can hold a community as a human social contract. From my point of view, our own life cannot be maintained at any price. We have reached to this point of social evolution precisely by standing against barbarisms and abuses. The ridicule and shallow proposals for a human life based only on money valuations, are an insult against intelligence, and therefore, against life.

References

Dworkin G. [1994]Markets and Morals. In: Dworkin G, ed. Morality, Harm and the Law.

Oxford: Westview. 1994. 155–61.

Frazer, James. [1922]. The Belief in Immortality and the Worship of the Dead. Vol. 2.  MacMillan and Co., London.

Radcliffe Richards J, Daar A, Guttmann R, et al. [1998] The case for allowing kidney sales. Lancet. 1998. 351:1950–2.

Rippon, Simon. [2012] Imposing options on people in poverty: the harm of a live donor organ market. JME. Med Ethics 2014;40:145–150.

Savulescu J.[2003] Is the sale of body parts wrong? JME 2003;29:138–9.

What is the purpose of prolonging life in painful terminal diseases?

Let us examine the problem from the point of view of a rational ethics based on anthropological grounds. By rational, I mean a discourse whose statements are not contradictory among themselves, and by anthropological grounds I mean a non-transcendental valuation of life, a human axiology. Particularly, I will use two anthropological ethic principles:

P.1 Principle of life preservation: We have to preserve human life.

P.2 Principle of primacy of the public interest: the life of the group has preference over the life of the individual. Human individual life is conditioned by the life of the group and subsumed to its needs. Not only my actions are rightful when they do not imply any sort of harm to others, but they cannot be autonomous when there is an urgent need of society: we work and die for the group whenever is needed. And since the needs of society are always urgent, life preservation is limited by public interest, as has always been the case with wars.

In relation to our question, we can imagine, at least, the following scenarios for a dying patient in pain:

1     The patient is sustained by public funds.      

           a. Society denies further sustenance for it is an incurable disease and cannot benefit from the              situation. 
      b. Society agrees to sustain the patient despite the non-economic benefits of the situation.

1.   The community wants the person to live longer in pain.

2.  The community wants the person to live longer but not in pain.

3.  The community leaves the choice to the individual.

2       The patient is self-sustained.

a.   Still the society wants to exercise the control.

1.    Society wants the individual to suffer.

2.    Society wants the individual to live longer but not to suffer.

b.  Society declares the case to be a private choice.

In the case 1.a, when the patient is sustained by private funds and society denies further sustenance, we are dealing with a rational choice according to principles 1 and 2, for P1 cannot be enacted (is a terminal disease), and there is nothing positive for the patient (supposing that s/he is driven by the principle of avoiding pain) in the situation. The rational action is assisted death.

The second choice has, in turn, three scenarios. The first one, 1.b.1 is not as rare as it would seem. Such is the case with criminals or by religious motives in which the valuation of pain extends beyond this life to other worlds. There are religious ethical values which consider suffering as a way for purgation in a context of otherworld scenarios. Here, is not the principle of life preservation what is at work, but a principle of punishments and rewards on a transmundane scale, which is contrary both to any anthropological principles and to the structure of most of our legal systems. Since this punishment does not serve any practical purpose for the community, beyond sadistic morbid satisfactions, it obeys only non-rational valuations, therefore are not part of a rational ethics.

The second scenario of the second choice, 1.b.2, when the community wants the person to live his/her final days without pain, does not affect the principle of life preservation, for life cannot be preserved in this case, and also conforms to the public interest principle, which in this case is to alleviate the patient’s pain. The rational action is the alleviation of pain whether by the increase of medication for relieve, or by the shortening of the condition of pain. If pain cannot be alleviated, the rational outcome of the scenario is assisted death, for since P1 cannot be accomplished and the choice is not to suffer, it can only be obtained by shortening the duration of pain.

The third scenario, 1.b.3, is to leave the choice to the patient, which will decide therefore either to continue his/her suffering to the very end or to suicide. None of these decisions is contrary to the ethical principle of life preservation nor to the one of public interest, for life cannot be prolonged and the community has passes the choice to the patient, i.e., has given the ownership of life to the individual. This case is equivalent to 2.b, and both are rational actions.

The case 2.a. 1, when the patient is self-sustained and society still wants to control the life of the individual for it wants him to suffer (for whatever ethical or metaphysical reasons) is equivalent to the 1.b.1, and therefore, is not a choice of rational ethics. On the other hand, the case 2.a.2, is analogous to 1.b.2, and represents a choice of rational ethics which developed to its consequences leads to assisted death.

Therefore, pain can only be prolonged in terminal disease cases under non-rational ethical principles, whether those corresponding to the personal choice of the individual or the group.

Medical Ethics

The prevention and treatment of illnesses is conditioned not only by our biological knowledge but also by the effective integration that we have of other sciences and our control of the physical environment. Medicine is obviously linked to the rest of human knowledge but, being the science of human life, is also determined by the particular social forms in which our life develops, by the economical conditionings in which health and sickness find an additional restriction. In this sense, medicine is a social science and a social action, not a mere biological knowledge of the physiological functions of the human body.

The social action of medicine, the self-care and self-preservation performed by human societies, is not the result of the efforts and ideas of a single generation but a vast cultural endeavor. For that reason, it cannot come as a surprise that beyond the evident success of our survival as species, the accomplishments and failures of the medical practice have not been measured with an identical rod, and the very same biological actions of life and death have been ethically valuated differently according to diverse axiological systems. Medical actions have not a simple biological valuation but a symbolically complexified domain which gives them a particular axiological tension. Such encounter of disparate forces –common to other life sciences- demands from medicine a continuous critical thinking in which theoretical reflections cannot lose sight of its everyday praxis, the resolution –urgent most of the times- of cases in which a concrete human being fights with death in unbearable pain. Medical ethics is the result of this critical thinking, covering a wide domain of problems, from the moral decisions of the clinical practice to the questioning of concepts like health, sickness, person, life and death, providing philosophical frames for their definitions. On the other hand, medical ethics examines critically the cutting edge research of the biological sciences, taking care that the main international political and ethical agreements are honored, and that the human being is treated within the ideals of respect, equality and dignity.

Medical ethics, like any other ethical action, is a ground for continuous disagreements and conflict at the individual and collective level. The differences of ethical codes are founded on different metaphysical values linked to ways of life, leaving little room for philosophical argumentation. Today, human ethical valuations range from those of the Anima Mundi groups and nations, to mixtures of different kind of universalisms of the laws and gods, passing through the materialistic valuations of modern science. In this global milieu, if there is going to be any general reference frame for ethics it has to be the consensual international conventions and declarations where the social person of the human being is put, at least ideally, at the center of any medical action. The Universal Declaration of Human Rights proclaimed by the General Assembly of the United Nations on 10 December 1948, the Conventionfor the Protection of Human Rights and Fundamental Freedoms of 4 November 1950, the Conventionon the Rights of the Child of 20 November 1989, are today the pillars for any medical ethics, not as a final charts, but as starting points for further development.

When we talk about medical ethics we are therefore talking about a praxiological action (ethical and political) with epistemological consequences. The definitions of life, death, person, human being, sickness, health, pain, individual consciousness, etc., -according to our present knowledge of the universe- determine intellectual frames of reference that will produce new emotional and cognitive horizons. Such an expansion is not ethically easy. Medical ethics needs to be expressed through non-contradictory critical argumentations and not simply by sterile appeals to religious or political authority. To this methodological axiom, I would add the inspiring role of two ethical values which underlie not only the Hippocratic Oath, but also Aristotle’s works on ethics: love for life and valor.