Treatment decision, death and the value of life

The ontological status of patients—i.e. whether they are alive or dead—doesn’t usually influence treatment decisions. That most patients are alive is self-evident and irrelevant, and treatment decisions are no longer required for the clearly deceased. But the appropriate treatment of a minority of troubling patients turns on their ontological status. For example, that a brain dead patient artificially maintained on life-support is legally dead permits the retrieval of transplant organs. Treatment should be based on ontological status only if two questions can be compellingly answered: first, is the patient alive or dead; and second, if the patient is alive, what is the value of their life? But both questions are notoriously controversial. The first requires a definition of death whilst the latter requires ascertaining what makes life valuable. This review article clarifies why the prospects of answering each question remain poor. It is well established that the definition of death—and the criteria and tests to determine whether death, thus defined, has occurred—is controversial (Youngner et al. 1999).1 Less obvious is the root cause of the problem, which is that our ordinary concept of death is too complex to be reduced to one simple definition. This will be illustrated by considering patients in the Permanent Vegetative State (PermVS). There are two main approaches to defining death. On the first, death is a biological phenomenon which is the same for all (and only) organisms.2,3 Organisms are alive when they function in a holistic fashion, their components integrating to form a coherent organic whole; they die when they undergo irreversible breakdown in the functioning of the organism as a whole. There are two main candidates for determining when a human has undergone organismic breakdown. One is cardio-centric: death has occurred when the cardiorespiratory system is defunct. The other is …