Alan D. Shewmon, the professor of pediatric neurology at UCLA Medical School believes that "until the turn of the decade, most people thought that 'brain death' was a settled issue; it no longer is. An increasing number of experts have begun to re-examine critically and to reject various key underlying assumptions" (Shewmon 1998). Determination of death has obviously become more complex, and the questions of when death is final require answers. According to most recent definitions, if the brain is entirely and irreversibly destroyed, a person can no longer relate to the world. As with any definition however, there are exceptions, gray areas, and blurred lines. We cannot strive for one all-encompassing definition. We will always need to modify our definitions based on the changing beliefs of the community, and the changes in technology.

Until midway through the 20th century, it was believed that the functioning of the cardiac, respiratory, and brain systems were necessary for life. Before a person could be pronounced dead, all three of these had to cease functioning. It is not surprising that with no other proof, the heart was considered the organ that determined life because "it was clear that, when the respiration and heart stopped, the brain would die in a few minutes" (Ad Hoc 1968).

We now know however, that it is the brain that controls the function of these other closed systems. Without the brain, the heart and lungs can continue their normal function, and this can be the case "even when there is not the remotest possibility of an individual recovering consciousness" (Ad Hoc. 1968). Dr. Denton Cooley, who in 1968 had been in charge of more heart transplants than any other surgeon, and with more success, says, "But I look upon the heart only as a pump, a servant of the brain. Once the brain is gone, the heart becomes unemployed." When the definition of death shifted from the cessation of the heartbeat to the cessation of the brain, naturally questions arose as to whether brain death was really equivalent to the death of a person.

A severely complicating factor in defining death is that there are two ways to define brain death. Whole brain death occurs when their entire brain is irreversibly nonfunctional. The higher brain definition states that the whole brain need not be functional; only the part responsible for personhood. According to this definition, people who are in a constant vegetative state are considered dead. One case that puts this into perspective is that of Karen Ann Quinlan, a modern icon in the right to die debate.

At First, there was no dispute about whether she would ever regain consciousness or whether she would ever be able to return to a life that was in any sense normal (have a family, a home, etc). Quinlan was in a constant vegetative state and connected to a respirator. Quinlan's family wanted their comatose daughter to die with dignity, so they had the respirator removed in the expectation that she would die, however, she continued to breathe unassisted and survived for a further ten years in this state. "What this proved was that she had a functioning brain stem. What it did not demonstrate was that her continued life had any value for her, which is what her parents valued the most for her" (Fisher 1999). For those ten years, Quinlan fulfilled the higher brain criterion of death.

A key term in defining brain death is "irreversibility." An organ that no longer functions and has no possibility of functioning again is dead. In 1968 the ad hoc committee of Harvard Medical School came added irreversible coma to the definition of death. Four points were necessary to determine whether or not the coma was irreversible. These include unresponsiveness, no movement or breathing when no technology is employed, no reflexes, and a flat electroencephalogram. These things are to be recorded 24 hours apart with no change. Since this time, all states have modified their criterion to state that acceptably diagnosed brain death may be used as a sole basis for determining death, regardless of what state the rest of the body is in.

In the determination of death, despite the growing pool of definition modifications, there will always be doubts. Each community has its own definition, and religious, moral, and philosophical questions have always served to raise doubts, particularly to the higher brain definition. The question that needs to be addressed here is that of trust. Do we trust our doctors' ability to pronounce us dead based on their personal definition? This is important, because in many cases, the person dying is not the one who gets to make that choice.

Can we trust our doctors? Will they determine death too early? Earl E. Appleby argues, "a person who is dying is still alive, even a moment before death, and must be treated as such" (Appleby 2001). To him, it is clear when death takes place. There is a moment when the event occurs. According to Lazar however, the continuing public ambivalence toward the higher brain definition may be "rooted in the experience of witnessing a person declared brain dead who is sustained on life support" (Lazar 2001). Along with this concept is that of death not as an event but a process. If one sees death as a process, then it is inevitable that there will be persons who place the time of actual death at any possible point along this continuum. Again, we see the importance of definitions on the personal or community level.

There are some cases in which a patient who has been declared brain dead according to the higher brain definition has recovered. Chris Wilson is a child who was declared brain dead after a severe playground accident in which he fell nine feet, landing on his head. Chris's parents were told to begin planning a funeral, and to think about organ donation. Seeing that their son could breathe on his own, Chris's parents did not give up, and now Chris is a healthy teenage boy, with only some vision problems and a need for physiotherapy. It is cases like these that make us really think about how careful our doctors really can be when it comes to determining death. Ultimately, the most important factor in not prematurely determining death is the passing of information. The doctors must be willing to work with families to ensure that things are done in a way that is comfortable to everyone. For closure, it is important to let each community deal with death in its own way.

Although death of the higher brain has gained acceptance in many communities to be the death of a person, there continue to be many complicating factors. A person in a persistent vegetative state for example, will show no responsiveness to stimuli and display no self-awareness. However, "they may exhibit yawning and chewing movements and may swallow spontaneously" (Lamb 1985). According to the higher brain definition, such a person is dead, because they have lost all signs of personhood. Elaine Eposito is a woman who entered such a state after a surgery in 1941. She remained this way for 37 years, not her entire brain not ceasing to function until 1978.

Also complicating to the higher brain definition is the vague idea of identity. At what point does a person lose identity? The main argument for higher brain death as a definition is that "consciousness and the capacity to relate to other people and the wider world is a defining characteristic of human beings" (Lazar 2001). However, there is no set point for which this capacity begins or ends. Each person will place this point in a different place, and argument will not cease unless we can respect each community's decision on where to put this point.

Why are the lines so blurred? Prior to the 1950's it seemed simple. No heartbeat meant the patient in question was dead. Although technology saves many lives today that would have been lost prior to 1950, it makes things difficult today because the employment of various forms of technology enable us to keep hearts beating and lungs breathing. Transplant technology has allowed us to take beating hearts out of dead patients, only to beat again in a new person. Obviously the original patient is not alive, although their heart still beats elsewhere.

According to Ronald E. Cranford, who agrees that defining death was not so complicated during the early twentieth century, "Prior to antibiotics, respirators, resuscitators, dialysis, intensive care units, and paramedics, there was little control over the dying process" (Cranford 1996). A person could not be resuscitated time and time again, coming to the edge of death and back again.

Cranford goes on to contrast dying in the past and present. He writes about a woman in her 70's, dying of old age during the 1940's. Her family is present, and they all reminisce about the old days. The family doctor examines her with a stethoscope and explains that there is nothing to be done; she is simply dying of old age. The family stays with her until she passes away. Next, Cranford tells the tale of a woman in her 80's. The setting is a 1990's hospital, and the woman is in intensive care for the sixth time. Each time she nears death, specialists do all they can to keep her alive. Her record lists several diseases from heart disease to Alzheimer's; yet there is no mention of old age. Finally, the woman dies of cardiac arrest because the family has decided not to have her resuscitated. This contrast indicates the great complexity that technology has added to the dying process.

Can redefining death simplify things? One person who believes that it can is Dr. Keith Martin, of British Columbia, who speaks to the lack of information in the field of organ donation technology. Every year, many people "die waiting for transplants," he says. "The people who were against organ transplantation were wrong factually. They objected on a moral or religious basis. It was really quite sad to see. If they were informed, it would be different." A proponent for the more recently defined whole brain criteria, Martin says, "Unless oxygen-laden blood is still pumping through the tissues, organs cannot be used in transplants. This means that if doctors follow the 'normal' criteria for death-heart and respiratory failure-they cannot recycle organs. 'Brain death' diagnosis means that a living body can be considered dead if the brain is non-functioning" (Yu 1999). Martin clearly acknowledges the need for new definitions based on growing technology and the need for organs.

Josie Fisher, who writes for the Journal of Medical Ethics is on the other end of this spectrum. Fisher's greatest argument is with the motivation for redefining death, which claims that those who are in a constant vegetative state are dead. This would include those who fit the higher brain definitions of death. She explains that the resource implications of maintaining these patients for extended periods are significant. If it could be successfully argued that they are dead, then no medical treatment is ethically required. Put another way, redefining death is a way to remain blissfully ignorant of resource needs and ethical issues. Her ultimate argument is that "there is no need to redefine death in order to identify which treatments ought to be provided for the permanently and irreversibly unconscious." She claims that "There are already clear treatment guidelines" for patients in question, because they are not dead and should not be treated as such.

Fisher farther explains, "What medical science has made possible is continued non-conscious life. "Life without conscious experience may be meaningless, possibly futile, but it does not amount to death." For her, the definition of death seems very clear cut and there is no need to redefine it. Fisher does not however, acknowledge that persons in other communities also have a clear-cut definition of death that is very different from her belief. Some communities place great value on the quality of life, and do not want to accept a person in a constant vegetative state as having a quality life. Perhaps the patient has expressed a belief that death occurs when the personality is gone, and did not want to live on in a vegetative state. Fisher's opinion represents only one side of the story.

Robert S. Morison's argument is with the reasons for which we have had to redefine death. He claims technology and transplantation as reasons for having to redefine death, but also adds in the factor of loved ones having to expend time and energy caring for a person in a constant vegetative state. Morison explains "the great practical merit of these proposals is that they place the moment of death somewhat earlier in the continuum of life than the earlier definition did" (Morison 1971). By doing this, the physician may discontinue therapy, though signs of life may still be present, in order to spare "relatives, friends, and professional attendants the anguish and the effort" of caring for a person who has lost all traces of personality.

Morison's argument shows clearly how changes in our technology and society have pushed us to redefine death. Furthermore, he is clearly against having to change our definitions, saying "there is clearly something arbitrary in tying the sanctity of life to our ability to detect the electrical potential charges that managed to traverse the impedance of the skull" (Morison 1971). The fact still remains however, that technology will continue to advance, and communities will continue to disagree. Therefore, by not changing our definitions, we make the dying process even harder for those involved.

Perhaps the biggest issue complicating the definition of death is that of organ donation. George P. Smith explains in his book "The New Biology" that the foremost concern of transplantation is to replace a non-functioning body part with a new "naturally or artificially designed one." The question this raises for the defining of death comes into play because "the effect of such efforts, then, can be seen as either prolonging life or the death process and, furthermore, as augmenting or attenuating the very quality of living or dying" (Smith 1989).

Earl E. Appleby tells us "anyone unwise enough to have signed an organ donor card also has legitimate cause for concern. Would you trust a doctor who regards your body 'not as an organism in need of healing but as a container of biological useful materials?' That's exactly what organ donors do" (Appleby 2001). Fortunately, it is very likely that most doctors do not see patients merely as a "container of biological useful materials." Nonetheless, Appleby's strong opinion raises the very important question of what it really means to be an organ donor.

We must also consider that organs are in great demand. Smith tells us that as various forms of transplantation become accepted therapy for a variety of threatening conditions, and the ability to perform such surgical procedures becomes more accurate, the "shortage of organs will directly cause a greater number of potentially avertable deaths" (Smith 1989). Again, the issue of separate communities comes into play. If we cannot modify our definitions of what is acceptable on a case-by-case basis we will eliminate problems. Smith agrees, saying "the actual 'harvesting' of cadaver organs should be done so as to minimize any traumatic effect of the practice upon grieving relatives and with respect for donors' religious beliefs."

The focus so far has been on communities in the USA. Other countries continue to have different approaches as well. Many of these are based on religion and tradition.

Japanese ethics, deeply rooted in religion and tradition, have affected their outlook on life and death. They do not as easily recognize the concept of "Brain death." Many Japanese are Sinto followers, and because they believe that to declare death while the heart is still beating is premature, as well as unnatural; again, nature is paramount in their beliefs. This has been the greatest obstacle in their acceptance of brain death, which is absolutely necessary for the transplantation of vital organs such as the heart and liver.

In the Chinese religion, Confucius taught that mankind possessed a general goodness and encouraged the suppression of individual desires in order to benefit humanity. Through the virtue of kindness, the idea of organ transplantation is supported (McConnell 1999).

An important thing to remember is that there will always be beliefs on the far ends of every spectrum and the defining of death is no exception. This is not as much of a problem in one specific community, where most beliefs on death are fairly similar. When the worldwide community is taken into consideration however, some practices considered perfectly civil in some communities may seem cruel in others. This is where we must lean to work together to understand the beliefs of others rather than accusing them of committing wrongdoing.

The fact that there exists such a big debate shows that we will likely continue to redefine many definitions in the near future. We cannot ignore the effects of technology and the growing need for organs. We would like to save as many lives as possible, but with so many exceptions, blurred lines, and gray areas, we may have to accept that our definitions will never be perfect, and perhaps it is better that they not be. Somehow we must find a way to work towards saving as many lives through education and taking as much care as possible despite that fact. Taking the time to be careful and conscientious of each patient is a step in this direction.

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