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University of Toronto St. George

PHL Jonathan Breslin, PhD — Practicing Healthcare Ethicist; Institute for Health, Policy, Management, & Evaluation W5 RW141 ▯ Lecture 1 — September 11 ▯ ▯ofT Joint Centre for Bioethics — largest in the world - Video — the Onion: Red Roof Inn - Canadian Hospital gets death threats over baby Joseph; worthless treatment versus worthless life - Physicians establishing a position and putting their foot down - Parents’s decision should be respected, regardless (keeping IC in mind) - Course: philosophical issues related to death and dying, with emphasis on ethical issues; intersection of theory and practice ▯ - Advanced Directives paper — write one, discuss with a loved one, write about the experience of doing that ▯ What is death? The million dollar questions: 1. What does it mean to say a person (or any organism) is dead? 2. How do we know when a person is dead? ▯ Death as an event versus Death as a process - Beginning of life - There is a point where nothing was there - End of life - Died versus ceased to exist - Decomposing buried body - Dusts - There is a moment in time that is death — death as an event (versus death as an (ongoing) process) - Hit by a car — killed “instantly” - well, not ceased to exist - Guillotine: heart stops breathing, brain works for a bit it doesn’t instantly die it stops getting oxygenated blood, but it takes a little time for all of them (brain cells) to die..moment of death can drag out over a period of time; if - ^ seems like there was a precise momenttops beating am I dead? ▯ - What’s going on inside the body: hard to identify precise moment of death ▯ - Cancer - 2 years to live, is the whole process death? - Death: The end of life. The cessation of life. (These common definitions of death ultimately depend on the definition of life, upon which there is no consensus). death - Irreversible loss of heartbeat --> death - Taken together these were reliable determinations of death - 1950s stuff changed: - Copenhagen polio epidemic 1952-3 new machine was introduced that reduced mortality: the positive-pressure ventilator - Gave us the ability to artificially replace the body’s damaged breathing mechanisms - Became widespread in 60s ushering in era of intensive/critical care ▯ - Birth of new group of patients with devastating brain damage, who would have previously died, now kept alive on ventilation - Transplant surgeons soon realized the potential for organ retrieval from these patients (why?) - Transplanting organs was still in the early stages...not very successful - Had to get organs from someone declared dead...the organs couldn’t stay alive long enough - Also the patients probably rejected ▯ - With d- According to established criteria for determining death (cardio-respiratory), they’re not dead - Transplant surgeons and people who recognized the benefits — pickle, group of patients who are being maintained on ventilators (doesn’t look like they are going to recover), but according to traditional criteria, they aren’t dead ▯ - Harvard Med — the Harvard Committee: developed criteria for the diagnosis of brain death in 1968 the introduction of neurological criteria for determining death - To this point brain death did not = death .. Now there is neurological criteria that can determine death of a person ▯ - Also in 1968, the World MedicalAssembly adopted the Declaration of Sydney - Death is a process - Practical death occurs when a threshold of irreversibility is crossed - Someone can be practically death even if they aren’t fully death (for all intensive purposes dead) - When devastating irreversible damage to the brain: crossed threshold - No way to recover/ point of no return ▯ - Back to Bernat Culver and Gert - Without the brain, the human body necessarily dis-integratesism 1981 ▯ - Cases: - Susan Torres - 26 y/o pregnant woman, collapsed in 2005 from brain cancer and progressed to brain death; husband requested she be maintained on ventilator until fetus reached viability - Her body survived for 3 months, until baby was delivered and then ventilator was removed - How is that someone could be declared dead, but body kept functioning well enough that it supported healthy growth of fetus and resulted in a healthy baby ▯ - Ronald Chamberlain 15 y/o teenager boy who suffered severe brain damage following an asthma attack; declared brain dead bu- He was maintained on vent for more than 7 mo when he suffered a cardiac arrest and “died” again - LuisAlvarado, infant declared brain dead; parents refused to allow physicians to withdraw ventilation - Was maintained for ~18 mo before the vent was withdrawn ▯ - Areview of the lit and media reports by Shewmon revealed 7 reported cases of brain dead patients surviving for at least 6 mo, the longest case being 14.5 years - The younger the patient, the longer he/she is likely able to be maintained on a vent after being declared dead by neurological criteria ▯ - If the brain isn’t the great integrator we thought what do we do with our concept of brain death> what about organ donation? - Option 1: Truog’s Proposal - Abandon DDR and return to the common sense cardiorespiratory criteria for determining death - Allows us to directly confront the important issues rather than fiddling with the definition of death - Patients should be allowed to donate organs if they become permanently unconscious or imminently dying - In essence, patients could be organ donors without actually being declared dead! ▯ - Option 2: Veatch’s “higher brain” criteria - Death: a complete change in the status of a living entity characterized by the irreversible loss of those characteristics that are essentially significant to it - What is essential to being human is our capacity for consciousness; loss of consciousness = death - He’s referring to higher brain, i.e. higher than brain stemoose the definition of death that is meaningful to them - Definition of death that people want to die by..conscience clause New Jersey has this — someone may believe in cardiorespiratory criteria: you can take my organs after cardiorespiratory death: total brain death, higher brain death, cardiorespiratory death should be ways to die by you can choose from ▯ - Challenge: are PVS patients really dead? - Video: Terry Schiavo anorexic --> cardiac arrest --> PVS - Autopsy: after 11 years of being PVS had atrophied to size of softball: clear that nothing functionally going on - wasn’t actually understanding: open your eyes ▯ - Option- 2008: President’s Council on Bioethics released a white paper entitles: Controversies on the Determining of Death - Replaced brain death with total brain failure - Defended ethical foundation DDR - Rejected higher brain criteria - Rejected the integrative unity rationale - Death is a condition of the organism as a whole (not any particular part of an organism) - The brain is not the integrator of vital functions - Death: when the organism ceases to do the “fundamental work of a living organism - the work of self-preservation, achieved through the organism’s need-driven - 2 forms of environmental commerce: - Loss of both = deathousness - Total brain failure is a sign that a human is no longer able to engage in the essential work of a living organism; - Shewmon’s criticism: they don’t clarify what they mean by breathing - drive to breach or act itself - Shewmon’s issues: - Is self-preservation achieved through need-driven commerce with the surrounding world the only fundamental vital work of a living organism - Neither cessation of breathing nor consciousness alone signals death, so why does cessation of both? - If neither on its own is sufficient, why does the combo of them - Counter-examples: i.e. Human fetuses are undeniably alive but don’t breath and aren’t conscious Discussion: - What’s the right approach? - Status quo: continue with whole-brain criteria (on either integrative unity or PC rationale) and organ donation, even though- Brain death isn’t a settled issue - it’s controversial - Follow Truog: get rid of death by neurological criteria altogether and abandon the DDR to continue with organ donation? - Follow Veatch: adopt higher-brain criteria for determining death? ▯ - Something else? ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ ▯ Notes f- Resuscitate: to restore to life. Derived from the Latin resuscitare, to reawaken. (medicinenet) - Brain dead person: dead versus moribund (at the point of death) and irreversibly comatose - 1968 Harvard Committee’s socio-medico-legal revolution: reformulation of death in terms of brain function -equated with death was legal utility: it would free up beds in intensive care units and facilitate organuld be transplantation - Ushered a brief era of wild transplantation -diagnostic criteria for irreversible cessation of all brain functions, but also of any generally accepted philosophical rationale for why irreversible non-function of the brain should constitute death - By 1978 over 30 different diagnostic criteria had been published, none of them validated -the remaining 23 states that had not yet revised their death statutes to include brain based criteriona model for - It’s medical consultants proposed a set of diagnostic criteria that instantly became the standard for the US - It articulated a then plausible rationale for equating the irreversible cessation of all brain function with death - - Argued that the brain is the body’s central integrator, without which the body necessarily and imminently disintegrates and succumbs to asystole despite all technological interventions - Asystole: cardiac standstill with no cardiac output and no ventricular depolarization; it eventually occurs - President’s commission also claimed that brain death and ordinary death are physiologically identical states, only in the former case the equivalence is masked (by artificial ventilation and circulatory support) - New clinical data (over the 2 decades following 1980s) have made it (increasingly) clear that patients with total brain failure were not physiologically identical to non-heart-beating corpses and they did not necessarily dis-integrate despite all the tech support; moreover, rare longer-surviving ones exhibited holistic properties: homeostasis, proportional growth (child), teleological repair, and general ability to survive outside a hospital setting with relatively little support (ventilator, tube feedings and nurse care — much less than many sick patients in ICUs require who are nevertheless clearly living organisms) - Still: mainstream rationale - “brain-dead” patients are being “kept alive” by machines or “dying” when the ventilator turned off — consider brain-dead as dad or better off dead but not yet really dead - Many who regard as dead do so on the grounds of loss of personhood (by virtue of permanent unconsciousness) - From biologically still living organism grounds that would classify patients in vegetative states as dead - Philosophers and bioethicists have become increasingly unconvinced by the organismic unity rationale, many preferring instead some variation of the personhood rationale - Some experts: “brain death” is not death after all, but that it doesn’t matter anyway for ethical organ harvesting - “Brain death as death: began as a utilitarian legislative decree and has remained a conclusion in search of a justification ever since; a conclusion clung to at all costs for the sake of the transplantation enterprise that quickly came to depend on it - White Paper: - Brain death - specific terminology: total brain failure - Upholds Kantian prohibition against using human beings merely as a means to an end and not also as an end in themselves thereby excluding any relaxation of the dead donor rule and warning of the ethical dangers inherent in relying on non-heart-beating donors - Reject Harvard Committees’s 1968 social construct approach - Ultimately: there is no sound biological justification for today’s neurological standard or position 2: a more compelling account of wholeness that would support the intuition that after total brain failure the body is no longer an organismic whole and hence no longer alive - Determining whether an organism remains a whole depends on recognizing the persistence or cessation of the fundamental ▯ Lecture 3 — September 25 ▯ - What’s wrong with killing? - Some key distinctions: - Killing v. Letting die - Intention v. Foresight ▯ - Scenario: - Abe & - Why was is wrong?shoots her so she can’t testify against him - What is it aboutAbe’s killing of Betty that was morally wrong? - Harm-based argument: killing is morally wrong because it inflicts harm on the victim - You’re doing something really bad to someone; harming them in the worst way - Harm-basedArgument 1. Death is bad for a person 2. Killing someone imposes the badness of death on that person 3. Imposing badness on someone inflicts harm on that person 4. Inflicting harm on another person is morally wrong Therefore: killing is morally wrong - Logically valid argument; accept premisses as true, conclusion follows ▯ - Why is death bad for someone? - It deprives a person of future good - People dying at young ages; don’t get to experience things/don’t get to look forward to good things - It deprives a person of time alive - Life is intrinsically good; death reduces the goodness - Death frustrates a person’s hopes, aspirations, dreams, projects, etc. - Death is a total disability (Sinnott-Armstrong & Miller, 2013) - Unique way of looking at the harm of killing - Complete inability to control body and mind - PVS - think about the badness of the state; total disability: worst state you can be in - What’s bad about death - you’re totally disabled ▯ The Epicurean Problem - Didn’t like that people were stressed about death - Wanted to convince people why they shouldn’t be anxious or stressed about death 1. Astate of affairs is bad for P only if P can experience the badness at some time a. Have to be able to experience it at some time for that happening to be bad 2. P can experience a state of affairs at some time only if it begins before P’s death 3. P’s being dead is not a state of affairs that begins before P’s death a. Dying, death, being dead - how people actually respond to death/what they’re stressed about ▯ - P’s being dead is not bad for P - i.e. You can’t experience something as bad if you don’t exist to experience it - What you’re dead you no longer exist as something able to experience anything - We can assume, you no longer exist as an experiencing being - So how can being dead be bad if you’re no longer in a state that can experience the badness of being d
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