Christos Lazaridis

Arima argues that ‘double effect sedation (DES)’ carries the intention to diminish consciousness, and when such reduction has disproportionally negative moral valence, DES may be rendered impermissible by the doctrine of double effect (DDE).1 I have argued elsewhere for palliative general anaesthesia in the context of withdrawal of life-sustaining treatments as the most effective and normatively justified means to safeguard against potential suffering at the end of life.2 I will not repeat that discussion, instead I focus on two points that Arima makes to show that consciousness reduction is intended rather than merely foreseen. Following Anscombe and Davidson, intentional actions are actions done for reasons or actions that can be evaluated based on the supportive or grounding reasons for acting.3 In thinking about the DDE, intention can be interrogated by examining the underlying normative and motivating reasons for action. It is useful here to distinguish these two kinds of reasons. Dancy writes: When I call a reason ‘motivating’, all that I am doing is issuing a reminder that the focus of our attention is on matters of motivation… When I call it ‘normative’, again all that I am doing is stressing that we are currently thinking about whether it is a good reason, one that favours …

Much of the debate over the definition and criteria for determining our death has focused on disagreement over the correct biological account of death, i.e., what it means for any organism to die. In this paper, we argue that this exclusive focus on the biology of death is misguided, because it ignores ethical and social factors that bear on the acceptability of criteria for determining our death. We propose that attention shift from strictly biological considerations to ethical and social considerations that bear on the determination of what we call “civil death.” We argue for acceptance of a neurological criterion for determining death on grounds that it is the most reasonable way to synthesize biological, ethical, and social considerations about our death..

In this article I examine the question of how a liberal state should go about defining death. Plausible standards for a definition of death include a somatic one based on circulatory criteria, death by neurologic criteria (DNC), and higher brain death. I will argue that Rawlsian “burdens of judgment” apply in this process: that is, reasonable disagreement should be expected on important topics, and such disagreement ought not be resolved via the coercive powers of the state. Nevertheless, the state must legislate a definition of death, and in doing so faces a “neutralist dilemma,” that is, when there are multiple reasonable ways to move forward, only one can be chosen. I will examine a possible way to exit this neutralist dilemma. Finally, I will argue for DNC as the normatively preferred default definition of death. To do this, I will employ the Rawlsian heuristic of the “original position” and offer public reasons in favor of using DNC as the preferred default definition of death.

The recently published World Brain Death Project aims in alleviating inconsistencies in clinical guidelines and practice in the determination of death by neurologic criteria. However, critics have taken issue with a number of epistemic and metaphysical assertions that critics argue are either false, ad hoc, or confused. In this commentary, I discuss the nature of a definition of death; the plausibility of neurologic criteria as a sensible social, medical, and legal policy; and within a Rawlsian liberal framework, reasons for personal choice or accommodation among neurologic and circulatory definitions. Declaration of human death cannot rest on contested metaphysics or unmeasurable standards, instead it should be regarded as a plausible and widely accepted social construct that conforms to best available and pragmatic medical science and practice. The definition(s) and criteria should be transparent, publicly justifiable, and potentially allow for the accommodation of reasonable choice. This is an approach that situates the definition of death as a political matter. The approach anticipates that no conceptualization of death can claim universal validity, since this is a question that cannot be settled solely on biologic or scientific grounds, rather it is a matter of normative preference, socially constructed and historically contingent.

This article considers recent developments in neurotechnology and their potential to either mitigate or exacerbate the uncertainty of diagnosis and prognosis of DoCs, as well as the potential impact of replacing the diagnosis of vegetative state with unresponsive wakefulness syndrome. The main reasons for abolishing the term “vegetative state” are (1) the unacceptably high misclassification rate of patients with covert awareness, (2) the undesirable prescriptive connotations of the term, and (3) the unwarranted prognostic connotations. While improving prognosis and diagnosis may help surrogates as they face decisions concerning treatment, more accurate diagnosis and prognosis will not by themselves provide decisive answers. Significant diagnostic and prognostic uncertainties are likely to persist and may in fact be ineliminable. We argue that this uncertainty has to be acknowledged, communicated, and factored together with patient values, desires, and preferences in ethically complex, value-laden decisions about the treatment of brain-injured patients.

Background There is lack of consensus in the bioethics literature regarding the use of cardiopulmonary resuscitation (CPR) for organ-preserving purposes. In this study, we assessed the perspectives of clinicians in critical care settings to better inform donor management policy and practice.Methods An online anonymous survey of members of the Society of Critical Care Medicine that presented various scenarios about CPR for organ preservation.Results The email was sent to 10,340 members. It was opened by 5,416 (52%) of members and 405 members (4%) completed the survey with few missing data. A majority of respondents (81%) answered that donation status should not influence whether CPR is performed on an imminently dying patient. There was very strong agreement (>85%) that 1) CPR should be performed on a registered donor who experiences a cardiac arrest with an unknown code status before death by neurological criteria (DNC) and 2) CPR should be performed if the patient is not a registered donor and experiences cardiac arrest but the surrogate/power of attorney (POA) has not yet been approached regarding code status and donation. When a registered donor with a DNR order experiences cardiac arrest before DNC, 98% of respondents would not perform CPR. However, after DNC, respondents were evenly divided on whether they would (49%) or would not (51%) perform CPR on a registered donor with an undocumented code status. When asked whether consent should be required for CPR for organ-preserving purposes, 39% answered “Yes” when a patient arrests before DNC and 48% answered “Yes” when a patient arrests after DNC (P = 0.2).Conclusions The majority of respondents did not consider donor status relevant to CPR decisions before DNC, and virtually all would respect a DNR order in a registered donor before DNC. Respondents were divided about the need for an affirmative consent for CPR for organ-preserving purposes both before and after DNC.