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Revisiting the Persisting Tension Between Expert and Lay Views About Brain Death and Death Determination: A Proposal Inspired by Pragmatism

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Abstract

Brain death or determination of death based on the neurological criterion has been an enduring source of controversy in academic and clinical circles. The controversy chiefly concerns how death is defined, and it also bears on the justification of the proposed criteria for death determination and their interpretation. Part of the controversy on brain death and death determination stems from disputed crucial medical facts, but in this paper I formulate another hypothesis about the nature of ongoing controversies. At stake is a misunderstood relationship between, on the one hand, the nature of our lay (or our “manifest image”) views about death and, on the other hand, the nature of scientific insights (and related conceptual refinements) into death and its determination (the “scientific image”). The misunderstanding of this relationship has partly anchored the controversy and continues to fuel it. Based on a perspective inspired by pragmatism, which stresses the positive contribution of science to ethical and policy debates but also challenges different forms of scientism in science and philosophy found in foundationalist interpretations, I scrutinize three different stances regarding the relationship between lay and scientific perspectives about the definition of death: (1) foundational lay views, (2) foundational expert views, and (3) co-evolving views. I argue that only the latter is sustainable given recent challenges to foundationalist interpretations.

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Notes

  1. I am leaving aside the controversy over practical tests used to operationalize the two criteria of death determination.

  2. It is customary in debates about death and death determination to distinguish between different components of a “paradigm of death,” i.e., a set of assumptions made in debates about death determination. This paradigm includes: (1) the definition of death, (2) the criteria for death determination, and (3) the tests needed to ascertain that the criteria have been fulfilled (Bernat, Culver, and Gert 1981). This paper focuses on the definition of death and to some extent on its relationship to the death determination criteria (since not all authors clearly distinguish between them). As described in this paper, sometimes definitions are not provided and their discussion is solely based on criteria (e.g., in legislation), or in some other cases, the criteria are well applied but the understanding of the concept and the definition are poor (e.g., among some clinicians or the general public). This paper more specifically examines the relationship between the definition of death and a claim that this definition should make “explicit the consensual concept of death that has been confounded by technology” (Bernat 2006, 36). I argue that there is a more active, reconstructive task involved in the scientific definition of death than simply reflecting a pre-existing consensual definition of death. My analysis is consistent with the interpretation of the leading author in this debate, Dr. James Bernat, who writes that “much of the disagreement over our account of death result[ed] from the lack of acceptance by dissenting scholars of the ‘paradigm of death’” (Bernat 2006, 36). I present an analysis of why there has been such disagreement about the role of the reconstructive efforts to define death in an evolving scientific and technological context, notably because foundational claims have been made about pre-existing views on death.

  3. It should be clear from this paragraph that any “lay view” is shaped by historical context and can thus change in response to various factors (e.g., scientific knowledge, technological advances). In this paper, “foundational lay views” is essentially used to designate the character of primacy attributed to the cardio-circulatory criterion and the definition of death that is congruent with it.

  4. A previous version of the act, the 1978 Uniform Brain Death Act, did not mention the cardio-circulatory criterion, assuming further that this was not matter of debate (see http://www.uniformlaws.org/ActSummary.aspx?title=Determination%20of%20Death%20Act).

  5. In the United States, matters dealing with the teaching of biology and evolutionary theory have generated opposition not found in other Western nations (Coyne 2012). and therefore one could argue that U.S. legislatures have reflected this ambiguity and relativism regarding the value of biological sciences.

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Authors and Affiliations

  1. Neuroethics Research Unit, Institut de recherches cliniques de Montréal (IRCM), 110 avenue des Pins Ouest, Montréal, QC, H2W lR7, Canada

    Eric Racine

  2. Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada

    Eric Racine

  3. Department of Neurology and Neurosurgery, Experimental Medicine & Biomedical Ethics Unit, McGillUniversity, Montréal, QC, Canada

    Eric Racine

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Racine, E. Revisiting the Persisting Tension Between Expert and Lay Views About Brain Death and Death Determination: A Proposal Inspired by Pragmatism. Bioethical Inquiry 12, 623–631 (2015). https://doi.org/10.1007/s11673-015-9666-0

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