By B. Holly Vautier
Reprinted with permission from Theology Matters, Volume 3, #3 - May/June 1997
Reprinted with permission from Dignity and Dying: A Christian Appraisal (Grand Rapids: Eerdmans, 1996), pp.96-104.
Definitions and Declarations
Modern technology has compelled society to re-evaluate classical definitions of death. Now that it is possible to mechanically sustain cardiac and respiratory functions, traditional criteria for determining death no longer retain their previous meaning. New ambiguities have necessitated new definitions.
While the Danish Council of Ethics has opted to retain the classical cardiac activity standard,1 most contemporary criteria for death involve some form of brain death determination.2 Two major versions of brain death ––whole-brain and higher-brain (neocortical) –– have been proposed.
The Uniform Determination of Death Act is representative of the whole-brain definition. Based on the 1981 President’s Commission Report, it has now been endorsed legislatively or judicially by forty-five states.3 The UDDA defines death as follows:
either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.4
In the United Kingdom, on the other hand, official criteria for death leave room for higher-brain interpretations. The current indicators of death –– irreversible unconsciousness and irreversible apnoea –– are considered controversial and unacceptable by many religious groups and some physicians. Nevertheless, a person who physiologically fits this description can be declared legally dead.5
The choice of either the whole-brain or higher-brain definition is significant, since it involves a philosophical position as well as an empirical formulation.6 While establishing the criterion for death is primarily a medical concern, defining death may be regarded as a philosophical task.7 When a patient is determined to be ‘dead’, for example, may depend more on the observer’s definition of such terms as ‘person’, ‘human being’, and ‘alive’ than on specific biological indications. Advocates of the whole-brain perspective tend to hold inclusive views of personhood, pointing out that what is essential to being a person varies widely both within individual societies and interculturally.8 Alexander Capron cites only one requirement for personhood ––‘live birth of the product of a human conception’. 9 On the other hand, proponents of the neocortical position restrict personhood to human beings whose cognitive functioning is intact. John Lizza argues that to be a person one must be conscious and sentient.10 Robert Veatch proposes that an individual’s moral standing within the human community should end ‘when it is reasonable to deduce that there has been a break-down of the link between bodily integrity and mental and social capacity’. 11 It is evident, then, that one’s definition of death involves one’s declaration of the meaning of ‘personhood’.
Roots and Fruits
Divergent views of the meaning of personhood are not new. Origins of both the inclusive (whole-brain) and the cognitive (higher brain) understandings of personhood are apparent in history and philosophy.
At the root of the inclusive declaration of personhood is a tradition which acknowledges the human being as a single entity having both a material body and an immaterial soul. This unified concept is evident in the Torah and the New Testament, as well as in the writings of Aristotle.12 The Judeo-Christian perspective points to the Genesis account of creation (Gen. 2:7) as indicative of this unity. Berkhof describes the twofold complex of personhood as follows:
Every act of man is seen as an act of the whole man. It is not the soul but man that sins; it is not the body but man that dies; and it is not merely the soul, but man, body and soul, that is redeemed by Christ.13
In De Anima, Aristotle affirms the unity of body and soul. 14
On the other hand, the roots of the cognitive declaration of personhood are evident in the writings of Plato and Descartes. Unlike Aristotle, Plato regards the body as evil –– merely an impediment to the progress of the soul. Descartes retains a mind/body dualism that reduces the status of the human body to that of a disposable piece of machinery.l5 While the unified concept attributes goodness to the body, this view robs the body of all significance.
These two dissimilar traditions naturally yield fruits in keeping with their roots. The fruit of the unified concept of personhood is the acknowledgment that all human beings are persons. In traditional western society, this assumption of inclusivism has resulted in a linkage of justice and the value of human life. There has been a prevalent conviction that regardless of an individual’s condition, characteristics, or merits, every human being ought to be granted equal right to and protection of one’s life.l6 On the other hand, the fruit of the fragmented concept of personhood is the acknowledgment that only certain human beings qualify as persons. In current pluralistic society, this assumption of exclusivism has resulted in indifference with regard to the value of some human life. There is confusion about which categories of human beings are morally entitled to rights to and protection of their lives.17
The Past: Perils of Non-Personhood
In Ethics at the Edges of Life, Paul Ramsey warns his readers that a nation’s social policy will ultimately be based on its institutional assumption of who has moral standing within the human community. He convincingly demonstrates how legal, medical, and ethical decisions intersect to determine who will (and who will not) receive legal protection and life-saving or life-sustaining medical care. The treatment one receives will be contingent on the moral ethos prevalent within the society.l8
The prevailing moral ethos includes the value a culture places on individual human life. Where a strong Judeo-Christian ethic is evident, for example, life is regarded as a gift and a trust.19 It is seen as an intrinsic rather than merely an instrumental good. This is why, according to Bleich, ‘. . . it is possible to discern a reinforcement of values in the preservation and prolongation of life even if that life appears to be bereft of value in conventional or social terms.’ 20 This sense of the sanctity or dignity of all human life has been influential in maintaining traditional western prohibitions against abortion, suicide, euthanasia, and hazardous medical experimentation on human subjects.
When an ethic which endorses life for all persons is replaced by an ethic of selective personhood, people are valued on conditional terms. Those who qualify for personhood (such as healthy, competent adults) retain their valued status in society. But those who fail to qualify for personhood (fetal life, disabled infants, incompetent adults, individuals who have lost their neocortical functions, for example) lose their status as valued members of the society. When loss of personhood is equated with worthlessness, depersonalization can too easily constitute a license to kill.
The ‘euthanasia’ murders in Germany (1920s-1940s) were a heinous example of the result of depersonalization. This killing of an estimated 275,000 mental patients was deliberately planned and enthusiastically executed by the psychiatric elite –– within the context of a technologically advanced, ‘humane’ medical community. 21
The scientific rationale for these outrageous acts was the concept of ‘life devoid of value’. This idea, published in the writings of Professor Karl Binding and Doctor Alfred Hoche in 1920, served to justify the destruction of lives ‘not worth living’. 22 Binding included social factors (such as the burdens ‘worthless persons’ place on their families) as reasons for killing.23 Hoche used economics as a rationale for murder. He categorized ‘worthless persons’ according to their disabilities in order to demonstrate how much the continued existence of each group would cost society. His calculating fiscal argument included the statement that ‘. . . it is easy to estimate what incredible capital is withdrawn from the nation’s wealth for food, clothing, and heating –- for an unproductive purpose.’ 24
The Present: Failing The Personhood Test
What, one may ask, do the past perils of non-personhood have to do with current America? Wildes has observed that the once-dominant moral ethos of western society is ‘fundamentally broken’. Considerable controversy already exists about who has moral standing within the community.25
Abortion is legal. The fiction of non-personhood, as urged by Marks, has reached even beyond Roe v Wade.26 It has extended into the special care nursery, where Drs. Duff and Campbell have practiced involuntary euthanasia for disabled newborns. These physicians have publicly justified allowing death as a ‘management option’ when ‘the hope of meaningful personhood’ is absent.27 Fetal life has failed the personhood test. No legal statute has removed the Fourteenth Amendment rights of disabled infants. They have simply failed the personhood test by default.
At the opposite edge of life, Dr Jack Kevorkian has continued to resist the law and persist in ‘assisted suicides’. Is he preparing the terminally ill to fail the personhood test?
Writers in American journals are proposing that the designation of ‘dead’ be applied to persons whose potential for cognitive functioning has ceased. 23 This idea sounds strangely similar to a British statement that a PVS patient ‘cannot be a person’ 29 and the Danish position that loss of cognitive functioning means ‘the extinction of the person’.30 A recent article in the Annals of Internal Medicine carries this proposition to its practical conclusion. Halevy and Brody state:
We feel that medical care, including artificial nutrition and hydration, can be unilaterally withdrawn from vegetative patients. Organs may be harvested from eligible donors when the standard clinical tests are satisfied.
Their rationale is economic –– ‘the appropriate use of social resources’.3l PVS patients are beginning to fail the personhood test.
The Future: Inclusivity or Utility?
As our medical technology advances, there will be increasing temptation to depersonalize individuals and groups under the aegis of social needs. How we resolve the issue of personhood will determine when our social obligations to individuals begin and end. A social policy that reinforces the inclusive view of personhood will strive to deal justly with the distribution of limited resources; it will recognize both the intrinsic value of human life and the right of individuals to live. On the other hand, the classification of human beings as non-persons opens the door to a utilitarian ethics in which medical treatment is granted or denied on the basis of quality of life or economic criteria. Since a non-personhood policy implies that individual life is dispensable, it could also lead to the sanctioning of the procurement of donor organs from dying patients,32 the legalization of mercy killing, and the eventuality of involuntary euthanasia. St Martin has noted that the designation of certain groups as non-persons can predispose them to death selection. 33
As noted above, tacit legal, ethical, and medical policies have already converged to predispose Americans to accept non-personhood status for several groups within society. Ramsey has warned that ‘talking about a non-personhood policy in a normless context is a way to promote its sooner actualization’.34 Daniel Callahan, for example, has already strongly stated his intention to change social consensus to adopt ‘a new policy that would refuse reimbursement’ for comatose patients who are not likely to regain consciousness.35 In our increasingly normless culture, we cannot afford to ignore the admonition of Arthur Dyck:
If a society withdraws its defenses of its most defenseless members, the question arises whether it is in the interest of persons to enter into covenant with such a society. 36
Death, Personhood, and Life
There is a sobering interconnection between definitions of death, the meaning of personhood, and the value of human life. For this reason, it is vital that societies continue to endorse a single, uniform definition of death which retains the status of all human beings as persons. Any designation of non-personhood invites revisions in medical and legal standards which lead to the devaluing of human life.
There is still some uncertainty as to when the moment of death occurs. 37 Hans Jonas has observed that ‘since we do not know the exact borderline between life and death, nothing less than the maximal definition of death will do’.38 And Helmut Thielicke thoughtfully concludes:
It is conceivable that a person who is dying may stand in a passageway where human communication has long since been left behind, but which nevertheless contains a self-consciousness different from any other which we know. 39
Criteria for death should be based on the state of the patient and not on the need for transplantable organs or the cost of continued therapy.40 People must not allow a combination of Cartesian thinking and increasing cost/ratio panic to legitimize society’s disposing of human beings in the same way that we dispose of material objects. Barry Bostrom has insightfully stated:
...law, medicine and health care should be designed to err, if at all, on the side of the preservation of life and the establishment of rational principles for the protection of the most vulnerable persons in society –– those who are medically dependent and disabled. 41
Jewish law astutely recognizes that the worth of every human being:
...is the indispensable foundation of a moral society.42 . . .One seemingly innocuous inroad into the inviolate sanctuary of human life may threaten the entire ethical structure of society.43
Aware of the past perils of non-personhood, alliances of German citizens are now protesting against what they see as the potential for future bioethical crimes against humanity.44 Yet other Western nations remain complacent –– seemingly indifferent to the moral and ethical danger signals.
The issues of the sanctity of life and the right to live have particular relevance in the field of gerontology. America is ageing. Public policy in such areas as resource allocation, cost containment, organ transplantation, and euthanasia will directly impact the increasing population of ‘oldest old’ (aged 85+). On the other hand, if they are knowledgeable and motivated, older persons may have the political potential to influence public policy.
Attitudes that are merely theoretical today can become the laws, ethics, and medical practice of tomorrow. Paul Ramsey reminds us:
Eternal vigilance is the price public conscience must pay for law that sustains and does not further erode the moral fabric of this nation. 45
For most of America’s history the ‘moral fabric of this nation’ has been fashioned by the Hippocratic tradition and supported by the biblical ethic of covenant. This outlook upholds the value of human life, produces the fruit of compassion, reinforces the related theological concepts of charity, mercy, and agape, and culminates in care based on need. The Mount Sinai covenant, for example, requires the Israelites to accept compassionate responsibility for widows, orphans, strangers, and the poor. In the New Testament, Jesus attributes worth to the most marginalized persons in society and equates righteousness with the provision of their care.46 Biblical passages such as Psalm 139:14-16 and Matthew 10:29-31 speak eloquently of the uniqueness and dignity of each human being.
Indeed, ‘eternal vigilance’ is required in order to prevent further erosion of traditional moral and ethical foundations. The health plan proposed by U. S. President Clinton is an example of how changing attitudes toward the care of society’s most vulnerable members can influence national health policy. At the core of the Health Security Act is a philosophical shift away from the ethic of giving treatment priority to seriously ill individuals and toward a policy of the greatest good for the greatest number. Instead of care based on need and motivated by covenant values and Christian virtues, the new model is care based on social utility (including quality of life criteria) and motivated by the bottom line. ‘For too long,’ the Act contends, ‘public health funds have been sapped to pay for individual care. 47
As the Clinton Plan demonstrates, today’s theory can all too easily become tomorrow’s practice. In the United States, neocortical definitions of death may currently be only theoretical. But if higher-brain declarations become socially acceptable, increasing categories of human beings are likely to fail the personhood test. In a social climate obsessed by cost containment and captivated by utilitarian thinking, it would be tempting to depersonalize those whose care is the most expensive. Higher-brain definitions of death are compatible with exclusive views of personhood. Non-personhood policies open the door to revisions in medical and legal standards which are conducive to the further devaluing of human life.
Arthur Dyck summarizes the pivotal ethical issue as follows:
All of us in our daily lives are confronted by arguments based on expediency, and appeals to the greatest good for the greatest number, to the most desirable results, to a new ethic, and the like. The limitations of these simple and superficially plausible modes of reasoning need to be recognized and alternatives proposed and understood. A community that fails to do this will fail properly to distinguish good and evil in thought, and also in practice.48
The future of medical ethics will be shaped by the way in which public policy defines death. Such definition will in turn depend on how we understand the meaning of personhood and the intrinsic value of human life.
B. Holly Vautier, an ordained Presbyterian minister, is co-pastor of the First Congregational Church of Clinton, MA. She has suffered from a chronic, disabling illness for 26 years.
1. B A Rix, ‘Danish Ethics Council Rejects Brain Death as the Criterion of Death’, Journal of Medical Bioethics 16 (1990), p.5.
2. Amir Halevy and Baruch Brody, ‘Brain Death: Reconciling Definitions, Criteria, and Tests’, Annals of Internal Medicine 119 (1993) p.519.
3. John P Lizza, ‘Persons and Death: What's Metaphysically Wrong With Our Current Statutory Definition of Death?’, The Journal of Medicine and Philosophy 18 (1993), p.352.
4. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death: A Report on the Medical, Legal and Ethical Issues in the Determination of Death (Washington, DC: U.S. Govt. Printing Office, 1981).
5. John F Catherwood, ‘Rosencrantz and Guildenstern are "Dead"?’, Journal of Medical Ethics 18 (1992) p.34.
6. Alexander M Capron and Leon R Kass 'A Statutory Definition of The Standards For Determining Human Death: An Appraisal And A Proposal', in Dennis J Horan and David Mall (eds.), Death, Dying, And Euthanasia (Frederick, MD: University Publications of America, 1980), p.47.
7. Charles M Culver and Bernard Gert, Philosophy in Medicine (New York: Oxford University Press, 1982), p.180.
8. President's Commission, p.39.
9. Ibid., p.8.
10. Lizza, p.363.
11. Robert M Veatch, A Theory of Medical Ethics (New York: Basic, 1981), p.245.
12. Patrick G Derr, ‘The Historical Development of The Various Concepts of Personhood’, in Russell E Smith (ed.), The Twenty Fifth Anniversary of Vatican II: A Look Back and A Look Ahead (Braintree, MA: The Pope John Center, 1990), p.26.
13. Louis Berkhof, Systematic Theology (Grand Rapids: Eerdmans, 1939), p.192.
14. Derr, p.20.
15. Ibid., p.23.
16. Arthur J Dyck, On Human Care: An Introduction to Ethics (Nashville: Abingdon, 1977), p.l03.
17. Kevin Wildes, ‘Moral Authority, Moral Standing, And Moral Controversy’, The Journal of Medicine and Philosophy 18 (1993), p.349.
18. Paul Ramsey, Ethics-at the Edges of Life (New Haven: Yale University Press, 1978), preface.
19. Ibid., p.146.
20. J David Bleich, ‘Life as an Intrinsic Rather Than Instrumental Good: The "Spiritual" Case against Euthanasia’, Issues In Law and Medicine 9 (1993), p.149.
21. Fredric Wertham, ‘The Geranium In The Window: The Euthanasia Murders’, in Horan and Mall (eds.), Death, Dying, and Euthanasia, pp.603-607.
22. Karl Binding and Alfred Hoche, ‘VERBATIM: Permitting the Destruction of Unworthy Life: Its Extent and Form’, translated by Walter E Wright, Issues in Law & Medicine 8 (1992), p.244.
23. Ibid., p.249.
24. Ibid., pp.260-261.
25. Wildes, p.348.
26. Ramsey, pp.247-249.
27. Raymond S Duff and A G M Campbell, ‘Moral and Ethical Dilemmas In The Special-Care Nursery’, in Horan and Mall (eds.), Death, Dying, And Euthanasia, pp.96-97.
28. Lizza, p.351.
29. Raanan Gillon, ‘Death’, Journal of Medical Ethics 16 (1990), p.4.
30. Rix, p.6.
31. Halevy and Brody, p.524.
32. Rix, p.6.
33. Thomas St Martin, ‘Euthanasia: The Three-In-One Issue’, in Dennis J Horan and David Mall (eds.), Death, Dying, And Euthanasia, p. 600.
34. Ramsey, p.249.
35. Daniel Callahan, ‘Pursuing a Peaceful Death’, Hastings Center Report 23 (1993), p.37.
36. Dyck, p.102.
37. Halevy and Brody, p.519.
38. Hans Jonas, Philosophical Essays: From Ancient Creed to Technological Man (Englewood Cliffs, NJ: Prentice-Hall, 1974) p.130.
39. Helmut Thielicke, The Doctor as Judge of Who Shall Live and Who Shall Die (Philadelphia: Fortress, 1970), p.18.
40. David Lamb, ‘Wanting It Both Ways’, Journal of Medical Ethics 16 (1990) p.9.
41. Barry A Bostrom, ‘Euthanasia in the Netherlands: A Model for the United States?’, Issues In Law & Medicine 4 (1989), p.486.
42. David M Feldman and Fred Rosner (eds.), Compendium On Medical Ethics: Jewish Moral, Ethical, and Religious Principles in Medical Practice (New York: Federation of Jewish Philanthropies of New York 1984), p.l3.
43. Ibid., p.107.
44. Daniel Wikler and Jeremiah Barondes, ‘Bioethics and Anti Bioethics in Light of Nazi Medicine: What Must We Remember?’, Kennedy Institute of Ethics Journal 3 (1993), p.53.
45. Ramsey, p.26.
46. William F May, The Physician's Covenant (Philadelphia: Westminster, 1983), p.124.
47. The President's Health Security Plan (New York: Times Books, 1993), p.78.
48. Dyck, p.172.
Theology Matters is a publication of Presbyterians for Faith, Family and Ministry.