• Background Information and Definitions. The diagnosis of brain death is a clinical diagnosis that is sometimes made with the help of cerebral per.
• Recent years have seen the emergence of a certain opposition to the neurological criteria used to determine death, generally known as cerebral death.

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At its inception, “brain death” was proposed not as a coherent concept but as a useful one. The 1968 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death gave no reason that “irreversible coma” should be death itself, but simply asserted that the time had come for it to be declared so. Subsequent writings by chairman Henry Beecher made clear that, to him at least, death was essentially a social construct, and society could define it however it pleased. The first widely endorsed attempt at a philosophical justification appeared thirteen years later, with a report from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research and a seminal paper by James Bernat, Charles Culver, and Bernard Gert, which introduced the insightful tripartite scheme of concept, criterion, and tests for death.

The most common pattern is manifested by an elevation of ICP to a point beyond the mean arterial pressure (MAP), and hence cerebral.

Their paper proposed that the correct concept of death is the “permanent cessation of functioning of the organism as a whole,” which tenuously remains the mainstream concept to this day. In this essay, I focus on this mainstream concept, arguing that equating brain death with death involves several levels of incoherence: between concept and criterion, between criterion and tests, between tests and concept, and between all of these and actual brain death praxis. Is brain death a coherent and justified concept for determining death?At its inception, “brain death” was proposed not as a coherent concept but as a useful one. The 1968 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death gave no reason that “irreversible coma” should be death itself, but simply asserted that the time had come for it to be declared so. Subsequent writings by chairman Henry Beecher made clear that, to him at least, death was essentially a social construct, and society could define it however it pleased.The first widely endorsed attempt at a philosophical justification appeared thirteen years later, with a report from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research and a seminal paper by James Bernat, Charles Culver, and Bernard Gert, which introduced the insightful tripartite scheme of concept, criterion, and tests for death. Their paper proposed that the correct concept of death is the “permanent cessation of functioning of the organism as a whole,” which tenuously remains the mainstream concept to this day.Its major challenger is the “mentalist” concept: that the essence of human death is irreversible loss of consciousness, which erases the person, understood as essentially a mind. I join many in rejecting this approach because it does not correspond to the perennial understanding of the word “death,” which in ordinary parlance has a biological connotation.

The views of my colleague James Bernat have evolved over the years, and it is not clear to me whether his most recent proposal of consciousness as the sine qua non critical function of the human “organism as a whole” differs substantially from the mentalist rationale rejected in his previous writings or merely dresses it in the formulational garb of mereology and emergent functions.The idea that irreversible unconsciousness per se is death essentially implies that “irreversible coma” is an oxymoron. (Coma is not attributable to dead individuals.) Suppose that a patient with end‐stage cancer and multiorgan failure slips into coma but is not brain‐dead. There is inexorable deterioration, precluding emergence from coma and ending in cardiac arrest a week later. According to mentalism, the death certificate should be dated at the onset of the irreversible coma rather than when everyone intuitively would say the patient died.

Everyone considers comatose patients alive, and that is so even if the coma lasts indefinitely until cardiac arrest.My critique of the novel rationale for brain death proposed by the 2008 President's Council on Bioethics has already been published in this journal and is beyond the scope of this brief paper. I shall therefore focus on the mainstream, “organism as a whole” concept of death.Equating brain death with death involves several levels of incoherence: between concept and criterion, between criterion and tests, between tests and concept, and between all of these and actual brain death praxis.

Incoherence between Concept and CriterionThe mainstream view considers the concept of death to be instantiated by the criterion of “irreversible cessation of all functions of the entire brain,” on the ground that the brain is the body's master coordinator: without its unifying influence, the body dis‐integrates. As evidence, the President's Commission cited the then commonly held dogma that, absent all brain functions, “even with extraordinary medical care, vital functions cannot be sustained indefinitely—typically, no longer than several days.” But future experience with brain‐dead patients would prove this to be false.We now know that the cardiovascular instability commonly seen in patients who suffer acute brain death is due to a variety of factors other than the mere absence of brain function. These factors include direct damage to vital organs by the initial etiology, secondary damage to those organs from sympathetic storm during brain herniation, a widespread inflammatory reaction to tissue damage, and autonomic dysfunction from spinal shock.

Thyroid and adrenal insufficiency may exacerbate these factors. If the patient survives the first week or so, then hormone replacement is typically given, and the other disorders self‐resolve.

Such stabilization is not usually encountered clinically, because brain‐dead patients either become organ donors or have care withdrawn. But in rare cases with a motivation to provide support indefinitely, brain‐dead patients have even been discharged home on a ventilator and survived in that state for years.The bodies of such patients manifest many holistic properties, such as homeostasis, proportional growth, and overcoming intercurrent illnesses. If a visiting biologist from another galaxy were asked to examine such a body and opine whether it was a life form, the answer would obviously be “yes.” And if asked whether it was a single life form or a colony, the answer would obviously be “single life form.” The irony is that, in intensive care units, many patients with terminal multisystem failure require even more complex interventions than the typical brain‐dead patient, yet they are considered alive (even if comatose and ventilator dependent). But the chronic brain‐dead patient—at home with no more support than a ventilator, tube feedings, a few medications, and good nursing care—is considered dead. This makes no sense.

Incoherence between Tests and ConceptThe standard diagnostic tests for brain death consist of demonstrating coma, absence of a handful of brain‐stem reflexes, and apnea. None of these has any bearing on the integrative unity of the organism. Even if the clinical tests are understood as a proxy for postulated nontestable integrative brain‐stem functions, that assumes, first, that there is a set of unstated brain‐stem functions that determine the difference between a living and a dead organism, and second, that the triad of coma, absence of several brain‐stem reflexes, and apnea necessarily implies absence of those hypothesized functions. Neither of those assumptions has ever been established nor is plausible.I know a case of a teenage girl with end‐stage glioblastoma multiforme that had invaded the brain stem. At one point, she fulfilled all criteria for brain death (including an apnea test with final pCO2 89 mm Hg) except for a right corneal reflex and a weak cough to tracheal suctioning. Forty‐eight days later, she fulfilled all criteria and was declared brain‐dead. Is it coherent that, in the context of perfect functioning of all nonbrain organs, a right corneal reflex and a weak cough should determine the boundary between life and death?

What if the tumor infiltration had eliminated the cough but not the corneal reflex? Would it have made any sense that a right corneal reflex should be the sole discriminator between life and death? Brain Death Isn’t Death—So What Is?One reason debates about death have remained so intractable is that unnecessarily irresolvable disagreements arise when different concepts are denoted by the same word. The English language accommodates just one alive‐dead distinction, so we tend to assume that “death” signifies a single phenomenon.

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By contrast, some languages make more vital‐status distinctions than does our “alive‐dead” dichotomy, while others, amazingly, have no equivalent for the English word “death,” so it is possible that cognitive channeling imposed by the very language we think in could contribute to the impasse.I have come to agree with Robert Veatch and Lainie Ross that there are two equally legitimate death‐related concepts, normative and ontological, that entail different sets of “death behaviors.” This dichotomy is actually the traditional understanding. In the classical death‐bed scene, the surrounding family rightfully begins to grieve as soon as the person stops breathing and having a pulse. In a hospital setting with a do‐not‐resuscitate order in place, the doctor lists as the time of death the point at which the patient became apneic and pulseless. This is death in the normative sense.