Amanda Hine

The determination of death by neurologic criteria (brain death) has increasingly become a topic of controversy. Here we address a question that provokes clinical ethics consultations and scholarly debate: “how should objections to the declaration of neurologic death be handled?” While much of the discourse on this question has focused on the legitimacy of the criteria for brain death determinations or the motivations of individuals' objections to declarations of death, our analysis addresses a deeper issue inherent in the conflicts in clinical settings. We argue that some objections to brain death cannot be explained away as grief, misunderstanding, or different religious beliefs. Rather, tensions between worldviews—fundamental standpoints or lenses through which humans experience and conceptualize the world around them—may drive conflicts around brain death. In what follows, we introduce the concept of worldview silencing as a means of recognizing the injustice that can occur when brain death objections grounded in alternative ontologies of death are unfairly dismissed or disrespected. Ultimately, we contend that the concept of worldview silencing offers moral guidance for just recognition of objections to brain death in practice, education, and policy.

Alasdair MacIntyre described the late modern West as driven by two moral values: efficiency and effectiveness. Regardless of whether you accept MacIntyre's overarching story, it seems clear that efficiency and effectiveness have achieved a zenith in institutional health care structures, such that these two aspects of care become the final arbiters of what counts as “good” care. At the very least, they are dominant in many clinical contexts and act as the interpretative lens for the judgments of successful health care managers. The drive of efficiency can also be seen in “lean” management methods (originally imported from the automotive manufacturing industry) increasingly deployed in the intensive care unit. This drive gives us pause. The high stress of the ICU is exacerbated by the enormous complexity of technological interventions designed to maintain physiological functioning as the body heals, as well as the ever‐present concerns related to cost, effectiveness, and efficiency. The ICU, therefore, provides an illustrative view of the challenges facing clinicians, as well as resource managers, in terms of delivering care. In short, the goal of technocratic efficiency often ends up at odds with humane purposes. To better understand these contemporary health care dynamics, we conducted a limited series of focus group discussions and interviews with residents experienced in the challenges of delivering care in the ICU environment. In what follows, we highlight some narrative observations drawn from these focus groups. We found a recurrent and disconcerting refrain among our informants that has not been adequately described or addressed in the literature: technocratic management techniques have crept into and bifurcated clinical care strategies in the ICU. Specifically, we highlight the influence of concerns around efficiency and effectiveness and the ways in which these foci have contributed to a bifurcation in care in the ICU along two trajectories: either compassionate care or curative care.