This is a very fine and scholarly challenge to what Lizza calls the 'biological paradigm' of death. The paradigm provides the theoretical grounding for our current acceptance of  'brain death' as death, and the clinical practice that goes along with it. Specifically, relatives and patients do not get to determine their own criteria for death. Matters are, instead, set out for them and given the stamp of strict biological objectivity. Patients and relatives may be involved in deliberations about when someone should be allowed to die, but not in deliberations about what it is for them to die. Lizza favors greater autonomy or, as he puts it, pluralism and choice.

The problematic biological paradigm is take to hold that death is a single biological concept that we use to understand a specific event (not process) that is the same across species. It is in no way socially constructed or value-laden. Any non-biological use of death, e.g. in talk about the death of a culture, is metaphorical. Death in the proper sense, refers to the cessation of an organism's life. There are no specifically human ways to die and technological changes do not open up the prospect of any new ways to die. Death is also irreversible and is one of two possible states for an organism to be in. There are no intermediate conditions between alive and dead.

Lizza argues convincingly that this paradigm contains commitments that are by no means obvious. Particularly, the idea that there is any single workable criterion that will cover all the relevant cases. Circulatory and respiratory criteria have traditionally been used to determine death. (Within some religious traditions they still are.) But respiration and circulation can now be artificially sustained in cases where we opinions about the status of the patient are likely to differ. (When, for example, a patient passes into a permanent vegetative state.)

Against the traditional option, we can go for an option that relies upon modern conceptual knowledge about brain structure. In making this shift, Lizza argues that we could acknowledge that what we take death to be has changed, or we could do what we actually do, which is to cover over the novelty of the biological paradigm. In this respect, the influence of Thomas Kuhn upon his understanding of paradigms is fairly clear but unobtrusively so. He notes the influence but doesn't overplay it. (Possibly a wise move given that Kuhn has his critics.) The history of the concept is rewritten or at least re-interpreted to allow that defining death as brain-death is presented as in no way a revision, but rather a clarification of what has gone before.

If we go for an equation of death with brain death we may highlight the failure of the whole brain, the functional failure of the brain-stem, or the cessation of higher brain functions required for consciousness. Any of these might in principle be maintained in the absence of either respiration or circulation. Similarly, the higher functions may not presuppose the lower ones. It is at least conceivable that they might be sustained even in the absence of a functional brain-stem.

What option we go for will depend, in part upon ontological commitments concerning what we take to be important about human life or personhood and whether, for example, a persons can die before the death of the associated human body. (And here, Lizza discusses the usual Lockean problems of personhood.) The account of death that we go for will not be read off of any neutral account of biology. The biological paradigm is quite wrong to contend otherwise.

The account of death we opt for will depend upon our value commitments, and these can shift and change or vary from person to person. The point at which we are prepared to accept that someone is dead and that it is legitimate to switch off any support or (if we oppose pre-mortem harvesting) use their organs for transplant, will depend upon what we think of as important.

Lizza happens to have his own view that consciousness is what matters, the concept of personhood is conceptually basic. (It cannot be broken down into anything else.) Persons are basic substances with corporeal and psychological characteristics. The account builds upon work by Peter Strawson and David Wiggins but it is not Lizza's claim that this is the correct account that should be imposed. In place of any single definition, Lizza appeals for pluralism and choice. Others will not value what he values.

Here, I want to query the interchangeable appeals that are made to pluralism and (more problematically) choice. Although Lizza makes a convincing case for recognizing that a definition of death will involve value commitments, it is not obvious (to me at least) that appeal needs to be made to the concept of choice as an alternative to the current norm.

In the closing passage of the book Lizza suggests that those who are 'committed to a Judeo-Christian understanding of the person as a substantial union of mind and body and think the irreversible loss of higher-brain functions would result in the destruction of this union could accept irreversible loss of higher-brain functions as a criterion of death.' Others, 'who believe a human organism that has lost all brain functions still retains its soul or spirit and thus has not lost its psychophysical integrity could accept only the loss of circulation and respiration as a criterion for determining death.'         Finally, those who 'believe a person's psychophysical integrity would be destroyed by the loss of all brain functions but not the loss of only higher-brain functions could accept a whole brain criterion of death.' (pp.179-180).

To treat such acceptance of one definition rather than another as a matter of choice in this way may be misleading. Lizza favors a process in which values are brought to bear upon this question and efforts are made to see which of a range of available options is consistent with the relevant values. Here, it may well be the case there really is one standpoint that is more consistent in the relevant sense. Accordingly, unless there are several options that are consistent with a set of values then the favored process may be more like accepting, finding out or discovering rather than choosing.

Be that as it may, this is a finely detailed, and closely argued philosophical study of the definition of death with well-articulated consequences for public policy and clinical practice. Lizza's volume is well worth a read for those in any relevant discipline.

© 2007 Tony Milligan

Tony Milligan is a Teaching Fellow with the School of Divinity, History and Philosophy at the University of Aberdeen. His doctoral research focused upon Iris Murdoch and his current research interests are in ethics and the emotions. 

Categories: Ethics, Philosophical