The Higher-Brain Concept of Death: A Christian Theological Appraisal

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In the practice of Critical Care Medicine, an all-too-frequent scenario involves the care of a patient who is progressing toward a possible state of whole brain death (WBD). Clinical energies which have hitherto been focused on saving life are shifted to confirming what is held to be, by law, a state of actual death, and by law, the regional Organ Procurement Organization (OPO) must be contacted, who will in turn determine the donor-potential of the patient. The OPO is concerned with not just one patient, but hundreds, and many of these will die, should they fail to receive an organ transplant.¹ Much, and for many, hangs on the determination of death.

The significant “supply-demand” imbalance for transplantable organs has generated a number of initiatives designed to make available for transplantation an optimum number of maximally viable organs. One such proposal is to broaden the current criteria that establish brain death to include a determination of death based on the loss of so-called “higher-brain” function, whereby a person, typically a patient in persistent vegetative state (PVS) who has permanent loss of consciousness but continues to breathe unassisted, could be pronounced dead and their organs potentially made available.

The purpose of this essay is to explore the higher-brain death (HBD) criterion, to identify arguments supporting and opposing the proposal, and to locate this proposal, broadly speaking, within the contemporary brain death debate. Finally, the essay will engage the question of how the proposal might be viewed in Christian thought, and whether it may be endorsed from a Christian standpoint.

In this endeavor, it is necessary to acknowledge the inevitable inconsistency of terminology among the concepts of “spirit,” “soul,” and “mind” across philosophical presuppositions and across history. For the purposes of this appraisal, we will employ a concept of “mind” as articulated by J.P. Moreland: “The mind is that faculty of the soul that contains thoughts and beliefs along with the relevant abilities to have them. . . . The spirit is that faculty of the soul through which the person relates to God.”²

Less than a year after the first successful human heart transplant, the medical community foresaw the inevitable need for more organs. In 1968, the Journal of the American Medical Association (JAMA) published the report of the Harvard Ad-Hoc committee on the definition of irreversible coma;³ the stated intent of the report was to make hospital beds available, and to increase the number of organs which might be made available for donation. There followed in 1981 the President’s Commission Report on Defining Death, which concluded that death could be established by either a cardio-respiratory or a whole-brain death criterion.⁴ The Commission’s recommendations were codified in the Uniform Definition of Death Act (UDDA); the “dead donor rule” which followed is a philosophical synthesis of the UDDA and homicide law, and establishes that no organ may be procured from anyone who is not dead by one of these criteria.⁵

In 2009, The President’s Council on Bioethics (PCB) issued a White Paper Report on Controversies Surrounding the Determination of Death, which, acknowledging difficulties associated with the concept of WBD, reaffirmed that the diagnosis of death may be made either by WBD, designated by the Council to be “Total Brain Failure” (TBF), or by cardio-respiratory criteria.⁶  The Council affirmed the essential ‘unified organism status’ of human life, the biological single-event nature of death, and the inevitability of death.⁷ This construct is ascendant in philosophy, law, and medical practice, and provides the necessary starting point for this discussion. Current practice is prescribed in the PCB 2009 report.⁸ The council acknowledged but rejected alternative brain death criteria proposals, including HBD.

To be sure, the WBD/TBF formula is not without controversy. Critical Care practitioner and ethicist Robert Truog summarizes the obvious “questions about whether patients with massive brain injury, apnea, and loss of brain stem reflexes are really dead. After all . . . these patients [when supported by mechanical ventilation] look very much alive: they are warm and pink; they digest and metabolize food, excrete waste, undergo sexual maturation, and can even reproduce.”⁹ More substantively, D. Alan Shewmon articulates the confusion inherent in brain death language and terminology, well known to intensive care physicians.¹⁰ Further, he delineates the flawed scientific methodology whereby TBF as a concept was developed, and calls into question the reliability and therefore the ethical acceptability of the apnea test, which is the definitive diagnostic test for WBD/TBF.¹¹

Robert Veatch is arguably the premier advocate for a change in practice and policy to a HBD criterion. Agreeing with Shewmon, Veatch’s argument hinges on the notion that the “whole” brain criterion cannot possibly be “whole,” given that, despite the irreversible loss of consciousness and of brainstem function, neuroendocrine cells within the brain necessarily continue to be active in patients declared to be brain dead; hence the aforementioned physiological homeostasis. This inconsistency of concept and terminology invites Veatch to opine, “If one is to retain a neurologically based concept of death, it is terribly implausible to insist that all functions of the brain must be lost irreversibly. Every reasonable defender of brain-based death pronouncements must exclude some functions, opening up the question of just which functions should be excluded.”¹²

Veatch correctly points out that the definition of death, which he considers to be a matter of philosophy, religion, and public policy, must be distinct from the medical criteria that establish death;¹³ but in proposing possible answers to his question, Veatch makes a subtle but important shift from a biological to a “personhood” rationale.¹⁴ He lists several options for what might constitute personhood: (1) the capacity for rationality, (2) self-awareness of personal identity, (3) the capacity to experience, and (4) the capacity for social interaction.¹⁵ The first of these he rejects on the observation that “babies are living in a human sense, in spite of the fact that they have never executed reasoning function.”¹⁶ On similar grounds he rejects the second option.

But in a synthesis of the third and fourth options (capacity to experience and to have social interaction), Veatch finds his answer. “We opt for the general formulation that a human is dead when there is irreversible loss of embodied capacity for consciousness. This would make those who have lost all functions of the entire brain dead, of course; but it would also include those who lack consciousness, which includes the permanently comatose, the permanently vegetative, and the anencephalic infant to the extent that these groups can be identified.”¹⁷ And, for these patients, ‘death behaviors’ (grieving, burial, etc) may commence.¹⁸ Veatch has linked his HBD construct to organ procurement, by way of advance directive- or surrogate-mediated consent.¹⁹ Finally, Veatch endorses a ‘conscience clause,’ that is, the freedom of individuals to select, also by advance directive or surrogate consent, which criteria for death (circulatory, WBD/TBF, or HBD) they wish to have applied to themselves,²⁰ and more recently has proposed wording for a change in public policy and law to make such an option available.²¹

Others have embraced Veatch’s HBD formula, albeit with some variation of rationale. Jeff McMahan endorses HBD on the basis of arguments from ‘nonorganism’ and from ‘dicephaly.’ In the first instance, McMahan asserts, “Whether we are organisms is . . . not an ethical question. It is a metaphysical one.”²² He denies a human’s biologic status as an organism, based on the hypothetical transplant of his own cerebrum, leaving his own brainstem and body (i.e., his organism) behind. “Since I can thus in principle exist separately from my organism that is now mine, I cannot be identified with it.”²³ In the second instance (dicephalic individuals), the question is to which of the ‘persons’ does the organism of the body belong? Because he cannot assign ‘organism’ status to individuals, he proposes that we are, instead, embodied minds. “What is important to determine is when we die in a nonbiologic sense—that is, when we cease to exist. If we are embodied minds, we die or cease to exist when we irreversibly lose the capacity for consciousness . . . .”²⁴

John Lizza moves the argument more definitively into the ‘personhood’ arena. Indicting the Commission’s assertion that there is no philosophical consensus on what constitutes personhood,²⁵ Lizza, citing Aristotle’s contention that “‘rationality’ is an essential property of man,”²⁶ invokes a litany of philosophers who actually agree in “the belief that some type of cognitive function is necessary for something to be a person.”²⁷ Lizza also disputes the PCB’s rejection of the HBD formula: “[I]t is important to distinguish the question of whether the higher brain formulation can be clearly articulated from the question of whether we have adequate medical criteria for determining whether someone has died under that formulation. The formulation that death has occurred [by HBD criteria] is itself, quite clear.”²⁸ Implicit in Lizza’s argument are the notions that the diagnosis of PVS can be made with certainty, that it is certain that these patients lack any capacity for conscious awareness, and that his philosophers’ ‘consensus’ of what constitutes personhood is normative.

Lizza subsequently has developed his HBD construct.

The alternative [i.e., HBD] to this medical or biological paradigm of death is to think that death is a metaphysical, ethical and cultural phenomenon in as equally a fundamental sense as it is a biological phenomenon. The definition and criteria of death are therefore as much matters involving metaphysical reflection, moral choice, and cultural acceptance as they are biological facts to be discovered. . . . It [the alternative paradigm] promotes an understanding of our nature as beings that are open ended rather than timelessly fixed, as having an active role in creating and determining the bounds of our being rather than being passive recipients of physical forces.²⁹

Against this backdrop, and liberated from a strictly biological definition of death, Lizza may then agree with Veatch and McMahan that death may be metaphysically assigned based on the ‘locus’ of personhood, namely, the capacity for consciousness. Their views are reminiscent of the “consciousness criterion” for personhood of John Locke. “For Locke,” says Providence College Professor Joseph Torchia, “personhood presupposes conscious awareness of self as self . . . personhood becomes the superogatory attribute that some individuals possess and others do not, depending on the quality of their conscious experience.”³⁰

Lizza continues, “Advocates of this [the HBD] view understand consciousness and other cognitive functions as dependent on or identical to certain higher brain functions, and when those brain functions cease, the human being or person dies. Individuals in a permanent vegetative state…are therefore considered dead.”³¹ He complains that Veatch, influenced by the “traditional Judeo-Christian concept of a human being as an essential union of mind and body,”³² has “explicitly avoided”³³ the inevitable conclusion of the higher-brain paradigm, that is, that it must reside either in a “Cartesian dualism” of mind and body,³⁴ or in a substantive concept of personhood.³⁵ “If there is some sense . . . to the existentialist idea that our nature is not fixed and that we can create, at least in part, who we are, then personhood and personal identity should be approached more as open-ended projects than as realities determined by factors independent of the choices we make.”³⁶ Lizza sums up what might be a ‘manifesto’: “We need to ask what it is we want to become. We need to be open to the possibility that, just as there are new ways in which we can live, there may be new ways in which we can die.”³⁷

Both McMahan and Lizza, then, invoke a mind-body hierarchical dualism—the self, as it were, may exist independently of the body and of bodily constraints, which, finally, are irrelevant to who the individual is or can become. For Lizza, the “factors independent of the choices we make” are necessarily biological. McMahan frankly denies that we require or possess “organism status” at all.

HBD proponents, then, despite some variations in rationale, resolutely insist that personhood is contingent upon, and is defined by, the ability to have consciousness. As St. Louis University Ethics Professor Jeffrey Bishop puts it, in the HBD concept, “persons occupy the space of the neocortex, or more abstractly, persons occupy the intangible space of neocortical function.”³⁸ All HBD proponents declare that persons who have permanently lost neocortical function, the ability to interact with their environment, to be dead, regardless of their ability to breathe. They “cease to exist.” Death behaviors may be embarked upon, and, with ‘proper’ consent, organs may be procured. Indeed, advocates of a shift in public policy and law favoring HBD assert that a person is autonomous over the remnant organism that once was theirs— autonomous to the point of choosing to let ‘it’ die or be killed.

Opponents of the HBD formula have argued on moral, biological, philosophical, and theological grounds. On the one hand, virtue ethicist Edmund Pellegrino opposed any formulation of brain death, including WBD/TBF, on grounds of lack of moral certainty.³⁹ On the other hand, utilitarian ethicist Robert Truog states, “Veatch argues that the crux of the issue is a moral decision about when patients can be treated ‘as if they are dead,’ [death behaviors, for example] rather than an ontological decision about whether or not they are dead.” And Truog rejects Veatch’s ‘conscience clause.’⁴⁰ Neurologist James Bernat acknowledges at least one concern raised by Shewmon: “We all agree that by ‘death’ we do not require the cessation of functioning of every cell in the body.”⁴¹ But he states that Veatch’s HBD formula “contains a fatal flaw . . . it is not what we mean when we say ‘death.’” He points out that no society, culture, or law understands patients with PVS to be dead. “Thus,” he says, “the higher-brain formulation fails . . . to make explicit our underlying consensual conception of death and not to contrive a new definition of death.”⁴² Bernat’s biological construct is strengthened by a provocative study in which neurologists, using advanced neurophysiologic imaging, detected awareness in a patient confirmed to have PVS,⁴³ a finding which, if confirmed, does violence to Lizza’s assertion of accuracy and the finality of this diagnosis.

Ethicist David DeGrazia similarly affirms a biologic, or ‘organismic,’ definition of death; additionally, he offers philosophical arguments against the personhood and moral cases for HBD. “I submit that the patient [for example, with PVS] is alive, because it seems that the organism as a whole—as an integrated unit of interdependent subsystems—continues to function, despite the loss of consciousness.”⁴⁴ DeGrazia points out, contra Lizza, that the capacity for consciousness is “necessary but not nearly sufficient for personhood.”⁴⁵ Additionally, he notes internal inconsistency in Veatch’s claim that death carries moral duty—‘death behaviors.’ “A more promising view is that death is primarily a biological concept that, at least in the human case, is morally very salient due to a relatively stable background of social institutions and attitudes.”⁴⁶

The HBD/WBD/TBF and its interface with formulations of personhood are merging in the public sphere in the literature of organ procurement and transplantation. The public is understandably confused over terms and concepts.⁴⁷ Given the gravity of the issue of defining death and the immense need of potential organ recipients, the matter is of urgent practical concern.

Clearly, the issues surrounding the definition of death and its relationship to personhood are of significant theological and pastoral moment. How must the concept of higher-brain death be regarded in Christian thought? Let us look first at currently available ethical guidelines before exploring their metaphysical and theological backdrop.

Roman Catholic and Protestant organizations do not recognize patients in PVS to be dead. On the contrary, the Ethical and Religious Directives (ERD) for Catholic Healthcare Services endorse the ongoing care for these patients including the provision of nutrition via feeding tube,⁴⁸ and the Christian Medical and Dental Association (CMDA), a predominantly Protestant organization, holds PVS patients to be “neither dead nor less than human.”⁴⁹

The higher-brain criterion does, however, find adherents among certain Eastern Orthodox writers. Orthodox Protodeacon Basil Andruchow, in an educational article for Orthodox lay readers, states that “the criterion for life is brain activity within the cerebral cortex. It is activity in that region of the brain that defines the human condition.”⁵⁰ Orthodox priest Fr. John Breck, in a text covering Orthodox Christian bioethics for a lay public, states that PVS is “often referred to as brain death . . . the death of the cerebrum indicates that the soul, in liturgical language, has ‘left the body,’ and the person as such is dead.”⁵¹ Similarly, Stanley Harakas, Professor Emeritus of Orthodox Theology at Holy Cross Greek Orthodox Seminary, states in a multi-faith series on healthcare decisions, “Generally, the Orthodox recognize death as the cessation of higher human capacities concurrent with the demise of the cerebral cortex, even though lower brain stem activities may remain.”⁵²

It would seem, therefore that some Orthodox writers differ from Catholic and Protestant ethicists on this particular issue.

Ethicist Gilbert Meilaender of Valparaiso University articulates what is likely a more widespread Christian understanding as he consolidates philosophical and Christian arguments against a ‘personhood’ construct that would be typical of HBD. While not mentioning HBD specifically, he does allude to the dualistic thinking that is foundational to McMahan’s and Lizza’s arguments. He is intrigued that such thinking has a following today. “In an age supposedly dominated by modes of thought more natural and historical than metaphysical, we have allowed ourselves to think of personhood in terms quite divorced from our biological nature or the history of our embodied selves.”⁵³ Biological life, however disabled, is not able to be separated from who we are, and who we are meant to become, that is, from our ‘personhood.’ “To live the risen life with God is, presumably, to be what we are meant to be. It is the fulfillment and completion of one’s personal history.”⁵⁴ That history is manifest during this fallen biological life “. . . before we are conscious of it and, for many of us, continues after we have lost consciousness of it.”⁵⁵ Further, Meilaender identifies the connection between a dualistic personhood construct and the ‘pretention’ and contradictoriness of autonomy,⁵⁶ whereby an autonomous ‘self’ presumes to dictate parameters of life and death onto the ‘other’ of the organism.

A Christian appraisal of HBD will hinge, in the obvious absence of specific Biblical texts, on that which may be inferred from the tenets of creedal orthodoxy under metaphysical and systematic theological doctrines of anthropology and Christology. Pre-suppositional for Christians are the biological life of Adam—humankind—and the biological life of God the Son in His Incarnation. But Meilaender has correctly located additional grounds on which one must engage the question of HBD. Since Lizza, McMahan, and, by implication, Veatch, have invoked a hierarchical dualistic construct of personhood, a Christian evaluation must address this very construct. We turn to the Church’s understanding of personhood, from antiquity.

Torchia states, “The dichotomies between soul and body, spirit and matter, are largely alien to the creation accounts of the Old Testament, where God creates the whole human being. . . . This emphasis on human unity carries over into the New Testament as well.” Regardless, he says, there is a considerable ‘spiritualistic emphasis’ found in both gospel and epistle. “A Christian account of our humanness bears the special burden of navigating between two worlds [that is, the spiritual and the bodily], so to speak, and thereby uphold the unity of every human person.”⁵⁷

It is widely appreciated that St. Augustine of Hippo (AD 354-430) was heavily influenced by the Neoplatonism of his day, and struggled in his early thought with the notion that the mind, or soul, was “closest to God among created things.”⁵⁸ However, even in his early writing, he does articulate a unitary concept of personhood. He states in De Moribus, “although they are two things it might happen that one of these would be looked upon and spoken of as man.”⁵⁹ In his mature writing, Augustine had adapted the composite view of man, which is a “‘harmonious union’ of the inner man of the spirit and the outer man of the flesh,” and according to which neither soul nor body is ascendant in this composite.⁶⁰ Augustine illustrates: “. . . is it neither the soul by itself nor the body by itself that constitutes the man, but the two combined, the soul and the body each being part of him but the whole man consisting of both? This would be analogous to applying the term ‘pair’ to two horses yoked together . . . we do not call either of them . . . a pair, but only use that term of the two in combination.”⁶¹

St. Thomas Aquinas (d. 1274) also recognized a composite view of soul and body, endorsing Augustine’s assessment in City of God.⁶² “In keeping with the general thrust of Pauline anthropology, Aquinas stresses a unitary conception of our humanity . . . he defines humans as composites of the formal principle of the soul and the material substrate of the body. The soul is thus conjoined with the body in an inextricable union comprising one substantial reality.”⁶³

Most pertinent to the issue at hand, Torchia observes,

In contemporary terms, Aquinas’s understanding of humans as substantial unities of soul and body implies that the soul cannot be confined to (or localized in) some part of the body (e.g., the brain) or bound up exclusively with physiological processes (e.g., brain wave activity, consciousness, or receptivity to feelings of pleasure or pain). For him, however, rationality . . . defines the parameters of our humanity. In this regard, rationality is not viewed as a behavioral characteristic. . . . Rather, it assumes a definitional significance, as a means of designating those who are spiritual and intellectual beings by their very nature, regardless of the quality of their rational output. Aquinas by no means views rationality in the exclusionary sense of contemporary thought, whereby one who lacks the complete use of reason is somehow barred from the moral community and emptied of intrinsic value. One cannot lose what one is by definition as a human being.⁶⁴

Aquinas’s thought has informed centuries of Catholic thought. The Second Vatican Council attests to the essential union of body and soul:

Though made of body and soul, man is one. Through his bodily composition he gathers to himself the elements of the material world; thus they reach their crown through him, and through him raise their voice in free praise of the Creator. For this reason man is not allowed to despise his bodily life, rather he is obliged to regard his body as good and honorable since God has created it and will raise it up on the last day.⁶⁵

More recently, Pope John Paul II affirmed both a “universal human nature” and “that each human person” remains a remarkable psychophysical unity.”⁶⁶ At no point in the documents of the Second Vatican Council or in John Paul II’s thought is there invoked a hierarchical metaphysical relationship of soul (or mind) over body.

The ancient consensus of personhood as a body and soul composite is shared also by the Reformed tradition, was articulated by John Calvin in 1536,⁶⁷ and developed, among others, by Herman Bavinck, who contends that the whole person is the image of God. Regarding the doctrine of human creation, he states, “[I]t follows . . . that this image extends to the whole person . . . and he is such totally, in soul and body, in all his faculties and powers, in all conditions and relations.”⁶⁸ “Man has a spirit (pneuma),” he says, “but that ‘spirit’ is psychically organized and must, by virtue of its nature, inhabit a body. It is of the essence of humanity to be corporeal and sentient.”⁶⁹ Notably, he points out that of body and soul, the body was formed first, and into it the breath of life was breathed (Gen 2:7).⁷⁰ As Thiago Silva observes, “[B] ody and soul are so intimately connected with each other that both are part of and belong to the image of God in human beings.”⁷¹ Bavinck articulates this intimacy in a way that has bearing on the issue at hand:

It is so intimate that one nature, one person, one self is the subject of both and of all their activities. It is always the same soul that peers through the eyes, thinks through the brain, grasps with the hands, and walks with the feet. Although not always present in every part of the body in its full strength . . . it is nevertheless present in all parts in its whole essence . . . . It is one and the same life that flows throughout the body but operates and manifests itself in every organ in a manner peculiar to that organ.⁷²

It is necessary to return briefly to the Eastern Orthodox approach to personhood. Despite the endorsement of a HBD construct among some Orthodox ethics writers, other Orthodox theologians are more cautious, arguing that such positions are out of keeping with the moral theological tenets of an Orthodox anthropology. As we begin, physician, ethicist, and Eastern Orthodox believer H. Tristram Engelhardt reminds us of how far the East is from the West on matters of theological approach: “Western Christianity and Western secular moral thought have in great measure sought to articulate morality and bioethics as if they could be adequately understood on the basis of experience and reflection outside a life rightly aimed at God.”⁷³ He traces this philosophical tendency to Augustine and to a “mid-second-millennial confidence in secular discursive reasoning that spanned from Scholasticism to the Enlightenment.” An Orthodox morality, he suggests, bypasses much of the influence of the philosophical enquiry of this period, and appeals directly to Holy Scripture and to the Church Fathers, given their historical, cultural, and spiritual proximity to Christ and the apostles themselves.⁷⁴

As to the specific concept of personhood, Orthodox theologian Vladimir Lossky cautions against reading that very ‘second millennial’ philosophy into the Fathers:

I would have had to ask myself . . . to what degree this wish to find a doctrine of the human person among the Fathers of the first centuries is legitimate. Would this not be trying to attribute to them certain ideas which may have remained unknown to them and which we would nevertheless attribute to them without realizing how much, in our way of conceiving the human person, we depend upon a complex philosophical tradition . . . very different from the one which could claim to be part of a properly theological tradition?⁷⁵

With this background, Hilarion Alfeyev, Bishop of the Moscow Patriarchate, explains that according to Orthodox thought, human beings, created in the image of God, are in fact hypostases, patterned after the eternal Hypostases (that is, the three Persons) of the Holy Trinity. John Zizioulas, late Metropolitan of Pergamon states that whereas the term ‘hypostasis’ originally was never related to the term ‘person,’ it came over time to embrace what the West now calls personhood, but in continuity with what constitutes the substance (ousias) of human beings generally. “From this endeavor came the identification of hypostasis with person.”⁷⁶

Both Zizioulas and Lossky do ‘overhear’ an anthropology in Patristic thought that is fundamentally tied to humankind’s hypostasis being the inevitable creative work and manifestation of the Trinitarian hypostasis. Since the hypostases of the Triune God are distinguished by their internal relationship one to another, and not by characteristics or qualities, a hypostasis of personhood is to be understood relationally, and not confined to any particular characteristic, quality, or anatomic locus.

Professor Christos Yannaras of Panteon University in Athens agrees:

What man is, then, his hypostasis, cannot be identified either with his body or with his soul. It is only given effect, expressed and revealed by its bodily or spiritual functions. Therefore no bodily infirmity, injury or deformity and no mental illness, loss of power of speech or dementia can touch the truth of any man, the inmost I which constitutes him as an existential event.⁷⁷

Similarly, Professor Daniel Varghese of St. Vladimirs Seminary states that, according to Eastern Orthodox thought, all human beings are created in God’s image “irrespective of the development of organs. Consequently Orthodoxy could reject the arguments for denial of personhood based only on biological or cognitive capabilities . . . . The intellect or reason is not the dominant factor to determine whether a being is a person or not.”⁷⁸

The consensus that the human person is the intimate, composite, psychosomatic hypostasis of body and soul is thus deeply and widely held throughout Eastern and Western Christian thought and across Christian history, reflecting the clear teaching of Holy Scripture in Old and New Testaments. From the mature thought of Augustine, through Aquinas, and to the present, “personhood” is constituted by what Calvin Seminary professor John Cooper refers to as a holistic dualism,⁷⁹ to which the idea of a mind-over-body-hierarchical relationship is foreign. Christ’s bodily resurrection is the final seal of a fundamental union of body and soul.

The practice of organ transplantation itself is embraced by most Christian traditions,⁸⁰ as is the WBD/TBF formula. Pope John Paul II affirmed the concept and practice of WBD in 2000;⁸¹ it is endorsed by Protestant and Reformed,⁸² Eastern Orthodox,⁸³ and Coptic⁸⁴ traditions.

Bishop has detailed extensively the political, economical, and philosophical forces which were strategic in establishing the practice of organ transplantation as the practice of WBD/TBF unfolded.⁸⁵  Recognizing that “standards of research are relative to their historical circumstance,”⁸⁶ he locates the entire evolution of the definition of death in the setting of an organ procurement agenda. Within a greater context, he says, is the paradox that medicine—while serving the preservation of life—is largely unable to accomplish this outside of death itself dictating the terms.⁸⁷ One cannot, for example, obtain life from certain transplants unless someone else dies.

But the organ supply-demand gap remains wide, and is very much in the public eye. The question of what constitutes personhood has been brought into the fray.

Lizza and McMahan deploy a concept in which personhood itself is distinct from the physical body, or organism. The organism, McMahan contends, may continue to live, but the person is dead. Although Veatch does not articulate such a dualism in terms quite so extreme, his conclusions, especially regarding ‘death behaviors,’ necessarily embrace this very notion. Finally, under the HBD theory of these three authors, the ‘late’ person is able, by advanced or surrogate consent, to execute biological life-ending authority over the living, breathing body. It is on these points that Christians must pause.

Holy Scripture and Church tradition affirm the absolute sacredness of every human life. The prohibition of taking life is established in Genesis, codified in Mosaic Law, and affirmed and interpreted in its fullest by Christ Himself. This very sacredness is never to be subjected to the assignment, by any temporal authority, of a philosophically derived construct of “personhood,” not to mention the assignment of a putative anatomic-physiologic locus of such a construct. This is, of course, precisely what Veatch and others have attempted. Under the HBD agenda, human sacredness becomes, in one group (those in PVS) relatively less sacred than the sacredness of another group (those in need of an organ transplant). Those in PVS, according to Veatch, may be declared dead—which is another way of saying, in the face of majority opinion across Christian traditions, that such patients have lebensunwertes leben, life not worth living.

The inevitable implication of the HBD view is the endorsement of a mind-overbody dualism that permits the determination of death, under Veatch’s conscience clause, based on a false appropriation of autonomy. By autonomous choice, a patient may request that he be declared dead by advance or surrogate decision, even if he is yet alive. The resulting action may be assisted death, with or without the procuring of organs. Regarding this question of autonomy, Georgetown University ethicist Edmund Pellegrino has stated,

[I]n ethics generally and medical ethics in particular, autonomy, freedom, and the supremacy of private judgment have become moral absolutes. On this view, human freedom extends to absolute mastery over one’s life, a mastery which extends to being killed or assisted in suicide so long as these are voluntary acts . . . . For the Christian, this is a distorted sense of freedom that denies life as a gift of God over which we have been given stewardship as with other good things.⁸⁸

Christians, then, must reject the higher-brain criterion for death as articulated by Veatch and others. The assertion of autonomy presumes to usurp God’s sovereignty over life, which is the inevitable outworking of Veatch’s, McMahan’s and Lizza’s dualism in HBD. One may agree with Bishop that the entire history of the concept of brain-death has been driven and tainted by an organ procurement agenda. However, it may be argued that Christians may in good faith affirm organ transplantation as a practice, along with currently practiced WBD/TBF formulations.

The currently accepted practice of declaring death by traditional circulatory criteria or by whole brain criteria holds in balance the deep needs and sacredness of the patient awaiting an organ transplant as well as the sacredness of the patient who may become an organ donor. This practice holds at bay the menace of a manmade personhood dualism of mind over body. For Christians to embrace a higherbrain criterion for death requires the embrace of a lethal anthropological heresy, the inevitable outcome of which is that sacredness of human life becomes relative rather than absolute, and that living persons become subject to exploitation and death.

Note: I am indebted to Professor Gilbert Meilaender for his advice in the preparation of this manuscript.

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• Christian Medical & Dental Associations Ethics Statement on Persistent Vegetative State, 1998, III:1
• Cooper, John W., Body, Soul, and Life Everlasting: Biblical Anthropology and the Monism-Dualism Debate Grand Rapids, MI, Eerdmans, 1989
• Coughlin, John J., “Pope John Paul II and the Dignity of the Human Being,” Harvard Journal of Law and Public Policy, 2003; 27(1):65-80
• DeGrazia, David, Persons, organisms, and death: a philosophical critique of the higher brain death approach, The Southern Journal of Philosophy, 1999: 37:419-440
• Engelhardt, H. Tristram, The Foundations of Christian Bioethics, Lisse: Swets & Zeitlinger Publishers, 2000
• Harakas, Stanley S., “The Orthodox Christian Tradition: Religious Beliefs and Healthcare Decisions,” as Part of the Religious Traditions and Healthcare Decisions handbook series published by The Park Ridge Center for the Study of Health, Faith, and Ethics, 1999
• Hall, Christopher A. Reading Scripture with the Church Fathers, Downers Grove, Illinois, Intervarsity Press, 1998
• Lizza, John, Persons and death: what’s metaphysically wrong with our current statutory definition of death? The Journal of Medicine and Philosophy, 1993; 18:351-374
• ______, Persons, Humanity, and the Definition of Death, Baltimore, Md: Johns Hopkins University Press, 2006
• Vladimir Lossky, In the Image and Likeness of God, Crestwood , New York, St. Vladimir’s Seminary Press, 1974; Chapter 6: “The Theological Notion of the Human Person”
• McMahan, Jeffrey, An alternative to brain death, in Symposium: Defining the Beginning and the End of Human Life, Journal of Law, Medicine, and Ethics, Spring 2006, p 47
• Meilaender, Gilbert, Tera es animata: on having a life, Hastings Center Report, July-August 1993, 25-32
• Moreland, J.P., The Soul, Chicago, Illinois, Moody Publishers, 2014
• Oliver, Michael, et al, Organ donation, transplantation, and religion, Nephrology Dialysis Transplantation, 2010, 1-10, Editorial Review
• Owen, Adrian, et al, “Detecting awareness in the vegetative state,” Science, 2006; 313, 1402
• Payne, Franklin, Biblical/Medical Ethics: The Christian and the Practice of Medicine, Milford, Michigan: Mott Media, Inc., 1985
• Pellegrino, Edmund, “Euthanasia and Assisted Suicide,” in John Kilner, Arlene Miller, and Edmund Pellegrino,
• Dignity and Dying: A Christian Appraisal, Grand Rapids, MI: William B. Eerdmans Publishing Company, 1996
• Presidents’ Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death: Medical, Legal, and Ethical Issues in the Determination of Death, Washington, DC, 1981
• Reardon, Patrick H., Christ in the Psalms, Ben Lomond, California, Conciliar Press, 2000, “Psalm 8.”
• President’s Council on Bioethics (PCB):  White Paper Report on Controversies Surrounding the Determination of Death; 2009, Washington DC
• Saint Augustine, City of God, XIX. 3, USA, Penguin Classics, 2003
• Second Vatican Council Gaudium et Spes, 14,1, “The Dignity of the Human Person,” http://www.vatican.va/archive/ hist_councils/ii_vatican_council/index.htm
• Seema Shah, Kenneth Kasper, and Franklin Miller, A narrative review of the empirical evidence on public attitudes on brain death and vital organ transplantation: the need for better data to inform policy, Journal of Medical Ethics 2015; 41:291-6
• Shewmon, D. Alan, “Controversies Surrounding Brain Death” in Steven Jensen, ed., The Ethics of Organ Transplantation, Washington, D.C.: The Catholic University of America Press, 2011
• Silva, Thiago, “Herman Bavinck’s Anthropology and the Recent Body-Soul Debate,” Puritan Reformed Journal 9(2), 2017: 226-240
• Siminoff, Laura, Mary Mercer, and Robert Arnold, Families’ understanding of brain death, Progress in Transplantation 2003; 13(3):218-224
• The United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Healthcare Services, 2009
• Torchia, Joseph, Exploring Personhood: An Introduction to the Philosophy of Human Nature, Boulder, Co., Rowman & Littlefield Publishers, 2008
• Truog, Robert and Franklin Miller, The dead donor rule and organ transplantation, New England Journal of Medicine 2008; 359(7):674-5
• Varghese, Daniel, “Personhood and Bioethics: An Eastern Perspective,” International Journal of Orthodox Theology 6:4 (2015)
• Veatch, Robert and Lainie Ross, Transplantation Ethics, 2^nd ed., Washington D.C.: Georgetown University Press, 2015
• _____, Donating hearts after cardiac death—reversing the irreversible, New England Journal of Medicine 2008; 359(7): 672-3
• _____, Defining Death, the Case for Choice; Washington, DC, Georgetown University Press, 2016
• Yannaras, Christos, from Elements of Faith: An Introduction to Orthodox Theology, Edinburgh, T&T Clark, 1991
• Zizioulas, Being as Communion, Crestwood, NY, St. Vladimir’s Seminary Press, 1985; Chapter 1, “Personhood and Being”

Internet sources:

• https://www.unos.org
• http://www.ncbcenter.org/page.aspx?pid=1285  http://lacopts.org/articles/brain-death

Endnotes

1. According to the United Network for Organ Sharing (UNOS) website around 8,000 patients die annually while waiting for an organ. https://www.unos.org accessed 1/14/16
2. P. Moreland, The Soul, Moody Publishers, Chicago, 2014, p 140-141
3. Henry Beecher et al, A definition of irreversible coma: Report of the ad hoc committee of the Harvard Medical School to examine the definition of brain death, JAMA, 1968, 205(6) 85-88
4. Presidents’ Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death: Medical, Legal, and Ethical Issues in the Determination of Death, Washington, DC, 1981, pp 37-38. WBD was established to be the ‘irreversible’ loss of higher-brain function (for example, conscious awareness) as well as the deepest level of brain function which controls respiratory drive.
5. James Bernat, “Life or death for the dead-donor rule?” New England Journal of Medicine 2013; 369(14) 1289-91
6. The President’s Council on Bioethics (PCB): White Paper Report on Controversies Surrounding the Determination of Death; 2009, Washington DC, Chapter 4, II, A; To this day, however, “whole-brain death” remains the common clinical parlance.
7. Ibid.
8. Ibid.
9. Robert Truog and Franklin Miller, The dead donor rule and organ transplantation, NEJM 2008; 359(7): 674-5
10. Alan Shewmon, “Controversies Surrounding Brain Death” in Steven Jensen, ed., The Ethics of Organ Transplantation, Catholic University of America Press, 2011, p 27-28
11. Ibid., 27, 40-41
12. Robert Veatch and Lainie Ross, Transplantation Ethics, 2^nd ed., Georgetown University Press, Washington DC 2015; p 89
13. Ibid.
14. Shewmon, 27
15. Veatch, 89-91
16. Ibid., 90
17. Ibid., 93
18. Ibid., 45
19. Robert Veatch, “Donating hearts after cardiac death—reversing the irreversible,” NEJM 2008; 359(7):672-3
20. Veatch & Ross, 2015, 110-111
21. Robert Veatch and Lainie Ross: Defining Death, the Case for Choice; Georgetown University Press, 2016
22. Jeff McMahan, An alternative to brain death, in Symposium: Defining the Beginning and the End of Human Life, Journal of Law, Medicine, and Ethics, Spring 2006, p 47
23. Ibid., 47
24. Ibid., 47-48
25. President’s Commission 1981, 39
26. John Lizza, Persons and death: what’s metaphysically wrong with our current statutory definition of death? The Journal of Medicine and Philosophy, 1993; 18:351-374
27. Ibid.
28. Lizza, 363
29. John Lizza, Persons, Humanity, and the Definition of Death, Johns Hopkins University Press, Baltimore, Md., 2006, p 4
30. Joseph Torchia, Exploring Personhood: An Introduction to the Philosophy of Human Nature, Rowman & Littlefield Publishers, Boulder, 2008, 221 (italics are mine)
31. Ibid., 17
32. Ibid., 44
33. Ibid., 43
34. Ibid., 36
35. Ibid., 40
36. Ibid., 49
37. Ibid., 49
38. Jeffrey Bishop, The Anticipatory Corpse: Medicine, Power, and the Care of the Dying, 2011; University of Notre Dame Press, p 193
39. PCB 2009, Personal Statement of Edmund D. Pellegrino, M.D.
40. Truog, 2007, 278
41. Bernat, 2006, 38
42. Ibid., 38
43. Adrian Owen, et al, “Detecting awareness in the vegetative state,” Science, 2006; 313, 1402
44. David DeGrazia, Persons, organisms, and death: a philosophical critique of the higher brain death approach, The Southern Journal of Philosophy, 1999: 37:419-440
45. Ibid., 424 (emphasis is DeGrazia’s)
46. Ibid., 430 (emphasis is DeGrazia’s)
47. Seema Shah, et al, A narrative review of the empirical evidence on public attitudes on brain death and vital organ transplantation: the need for better data to inform policy, Journal of Medical Ethics 20165; 41:291-6; and Laura Siminoff et al, Families’ understanding of brain death, Progress in Transplantation 2003; 13(3):218-224
48. The United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Healthcare Services, 2009, p 30.
49. Christian Medical & Dental Associations Ethics Statement on Persistent Vegetative State, 1998, III:1
50. Basil Andruchow, Medical Bioethics: An Orthodox Christian Perspective for Orthodox Christians, Vol. III:8, 2010, available at https://oca.org/parish-ministry/familylife/medical-bioethics-an-orthodox-christianperspective-for-orthodox-christians
51. John and Lyn Breck, Stages on Life’s Way: Orthodox Thinking on Bioethics, Crestwood, NY, St. Vladimir’s Seminary Press, 2005, Chapter 7: “Care in the Final Stage of Life,” p 231-2. Breck is incorrect in his assertion that PVS is considered to be brain death, as no jurisdiction recognizes patients in PVS to be brain dead.
52. Stanley S. Harakas, “The Orthodox Christian Tradition: Religious Beliefs and Healthcare Decisions,” as Part of the Religious Traditions and Healthcare Decisions handbook series published by The Park Ridge Center for the Study of Health, Faith, and Ethics, 1999, p 10
53. Gilbert Meilaender, Tera es animata: on having a life, Hastings Center Report, July-August 1993, 25-32; 26
54. Ibid., 26
55. Ibid., 32
56. Ibid., 27
57. Joseph Torchia, Exploring Personhood: An Introduction to the Philosophy of Human Nature, Rowman & Littlefield Publishers, Boulder, 2008, p 100
58. Ibid., 110
59. Augustine, De Moribus I, 4(6), cited in Torchia, ibid., 109
60. Ibid., 110
61. Saint Augustine, City of God, XIX. 3, Penguin Classics, 2003, p 850
62. Thomas Aquinas, Summa Theologica, Ia.75,a.4, accessed on 5/11/17 at http://spot.colorado.edu/~pasnau/ westview/st1a75-76.htm#_ftn1
63. Torchia, 131
64. Torchia, 139 (emphasis is Torchia’s)
65. See Gaudium et Spes, 14,1, The Dignity of the Human Person, accessed 5/11/17 at: http://www.vatican.va/ archive/hist_councils/ii_vatican_council/index.htm
66. John J. Coughlin, “Pope John Paul II and the Dignity of the Human Being,” Harvard Journal of Law and Public Policy, 2003; 27(1):65-80
67. See John Calvin, Institutes of the Christian Religion, 1.15
68. Herman Bavinck, Reformed Dogmatics: God and Creation, Vol. 2, (tr. John Vriend), 2004, Baker Academic, Grand Rapids, p 555
69. Ibid., 559
70. Ibid., 559
71. Thiago Silva, “Herman Bavinck’s Anthropology and the Recent Body-Soul Debate,” Puritan Reformed Journal 9(2), 2017: 226-240
72. Bavinck, 559, cited and quoted in Silva, 233
73. Tristram Engelhardt, “Orthodox Christian Bioethics: Some Foundational Differences from Western Christian Bioethics,” Studies in Christian Ethics 24(4), 2011:487-499.
74. See Christopher A. Hall, Reading Scripture with the Church Fathers, Downers Grove, Illinois, Intervarsity Press, 1998 for an analysis of and apologetic for reading Patristic theology.
75. Vladimir Lossky, In the Image and Likeness of God, Crestwood , New York, St. Vladimir’s Seminary Press, 1974; Chapter 6: “The Theological Notion of the Human Person,” p 111.
76. John Zizioulas, Being as Communion, Crestwood, NY, St. Vladimirs Seminary Press, 1985; Chapter 1, “Personhood and Being,” 27-65.
77. Christos Yannaras, from Elements of Faith: An Introduction to Orthodox Theology, T&T Clark, Edinburgh, 1991, p 63.
78. Daniel Varghese “Personhood and Bioethics: An Eastern Perspective,” International Journal of Orthodox Theology 6:4 (2015): 110-111
79. John W. Cooper, Body, Soul, and Life Everlasting: Biblical Anthropology and the Monism-Dualism Debate, Eerdmans, Grand Rapids, 1989, p 204
80. Michael Oliver, et al, Organ donation, transplantation, and religion, Nephrology Dialysis Transplantation, 2010, 1-10, Editorial Review
81. http://www.ncbcenter.org/page.aspx?pid=1285 accessed 7/16/15
82. Franklin Payne, Biblical/Medical Ethics: The Christian and the Practice of Medicine, Mott Media, Inc., Milford, Michigan, 1985, 198-9
83. Protodeacon Basil Andruchow, Medical Bioethics: An Orthodox Christian Perspective for Orthodox Christians, The Orthodox Church in America, III, 2010
84. http://lacopts.org/articles/brain-death accessed 7/16/15
85. Bishop, 181
86. Ibid., 109
87. This is a broad summary of Bishop’s argument.
88. Edmund Pellegrino, “Euthanasia and Assisted Suicide,” in John Kilner, Arlene Miller, and Edmund Pellegrino, Dignity and Dying: A Christian Appraisal, Eerdmans, Grand Rapids, 1996; p 109

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