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Is brain death a good criterion for determining death? In a new Opinion Article on F1000Research, Alberto Molina Pérez makes a case for taking a philosophy of science approach to debates around determining death. In analyzing two core concepts of death criteria— “irreversibility” and “functions”— he shows that each concept bears different and possibly conflicting meanings.

Alberto, what inspired you to write an Opinion Article on the academic debate surrounding brain death criteria?

On the one hand, I trained in the philosophy of science, with a doctoral thesis on biological functions. On the other, I have been interested in the debate on brain death from a bioethical point of view for some time. I wanted to reconcile these two lines of research by analyzing the concept of function as it is used in the criteria for determining death. I realized that nothing had been written on this issue and that, in general, the criteria of death had not been studied from the perspective of the philosophy of science. I wrote this Opinion Article to make this knowledge gap public.

Why do you believe it important to shift from a purely bioethical approach to examining brain death to a philosophy of science?

Almost all authors involved in this debate focus on whether the neurological criteria of death are good or bad. Can the criteria be used as they are, or should they be modified or abandoned?

Some of the controversies seem to stem from the fact that not all authors understand each other, as they come from different backgrounds: medicine, philosophy, bioethics, law, etc. I believe that adopting a philosophy of science perspective would help to avoid some of this misunderstanding by clarifying concepts. It is a way of stepping back to analyze the criteria without making judgments.

What core concepts do we need to interrogate to take a philosophy of science approach?

All the concepts used by the brain death criteria can be questioned, starting with the notion of “criteria” itself. What does the notion of criteria mean in this context? The more I ask myself this question, the less clear the answer seems to me. Similarly, I wonder about the meaning of the concepts of “function” and “cessation” of functions in medicine and of the “irreversibility” (or “permanence”) of this cessation.

How can this approach lead to broader implications, including policy recommendations and ethical considerations?

In a forthcoming article I co-authored with Anne Dalle Ave and James L. Bernat, we show that the Uniform Death Determination Act, which is the model law in the United States, is conceptually inconsistent. It employs the concept of function differently in the circulatory-respiratory criterion than in the neurological one. The various ways of resolving this conceptual inconsistency have legal and ethical implications. One option is to keep the law while admitting that the death criteria are a legal fiction. This option would mean that their definition is not only a medical matter but also a social matter, thus opening the door to pluralism, as in New Jersey and Japan. Another option is to change the law to recognize only one criterion, which would affect medical practice and make it more difficult to obtain organs for transplantation.

Why might it be valuable to distinguish between “brain functions” and “brain functionality” in determining death?

In determining brain death, the problem is to observe clinically or measure by technical means whether neurological mechanisms or processes and mental features are still present in the individual. This is what is referred to as “brain function.” However, these neural processes and mental features serve behavioral purposes. Therefore, it may be relevant to measure these processes and features in an absolute manner and whether, when present, they can serve their intended behavioral purpose. Neuroscientists such as Georg Northoff and Shankar Tumati refer to this as “functionality.”

Death is often characterized as the irreversible cessation of specific functions. How could future advancements in medicine and technology impact this definition?

Today, many brain functions that are essential for the proper functioning of the body can be replaced or maintained by artificial means such as ventilators. As a result, some brain-dead individuals can be in intensive care for weeks, months, or even years. However, medicine considers them dead because the performance of vital functions by artificial means does not count.

In the future, it may also be possible to replace or maintain cognitive functions, such as consciousness, by artificial means. Would we say that these individuals are dead? Probably not, even though the realization of their cognitive functions is only possible by artificial means. I believe that the distinction between natural and artificial functions will become less and less relevant. forcing us to rethink the definition of death.

What considerations or challenges do religious or cultural oppositions to brain death pose?

Unlike bacteria, plants, and other animals, human death is not only a biological phenomenon. It also has other dimensions, such as legal, social, economic, spiritual, etc. Although medicine has epistemic authority to determine death as a mere biological phenomenon, defining human death in a broad sense is everybody’s business. It is a political issue in its own sense, which means that all voices should be heard, whether we agree with them or not.

What’s next for your research?

I have realized that doctors do not use the concept of function as biologists do, but I still don’t understand how they use it. That is my first challenge.

Why did you publish your research openly, and how did you find the open peer review process?

I am convinced that science, philosophy, and art must be open and accessible to everyone, especially when they are carried out with public funding. Regarding the open review process, I was initially surprised that the authors and reviewers could know each other’s identities because I was used to the double-blind system. Now I think that makes a lot of sense. Each system has advantages and disadvantages; I am not sure which is better.

Read the full Opinion Article and explore the open peer review reports on F1000Research.