Death by the Brain Criterion: A Response to Shewmon

Nicholas Tonti-Filippini

2. Defining Integration

In his critique, Alan Shewmon, asserts that I have not provided a definition of what integration means in this context.7  In the original article, I had written,

We can take from the doctrine proclaimed at the Council of Vienne that the ongoing causative effect of the soul is its informing the body. Therefore the type of integration which is relevant is a communication of information to all parts of the body that keeps the body united and functioning as a single whole.8

This would seem to be consistent with John Paul II's teaching that death is the separation of the soul from the body; that it consists in the total disintegration of the unitary and integrated whole that is the personal self; and that therefore what we are looking for is evidence or “clinical markers” that indicate the loss of the integrated and coordinated life of the person as a single living organism in which the soul forms and informs the matter to maintain the unity of the body. The relationship between soul and body is thus dynamic.

In defending John Paul II’s acceptance of determining death by the brain criterion, I proposed only that the loss of all brain function is a state of loss of dynamic unity of the body, not that the brain is the master organ, as Shewmon expresses it. As indicated above, the same claim can be made about loss of circulation. When the heart stops beating there is also a loss of integration, largely because vital organs such as the brain permanently cease to function soon after and the parts of the body have no means of communication if there is no circulation. The heart and the lungs perform an essential function in keeping the organs of the body alive, though the latter die at different rates when the heart stops beating.

The problem a faithful physician has in medically determining that death has occurred is that the soul is not observable. The doctrine, however, implies that the effects of the soul may be observable. When we observe the integrated functioning of the organic unity that is the human body, as a matter of faith we are confident that that body is formed by a human soul, and therefore that the human soul must be present. Though there is no event that marks the separation of the soul at death, what the physician observes is the disintegration of the body that results from that separation. Loss of a communicative relationship between the parts of the dynamic unity that is the body would indicate loss of the dynamic role of the soul.

Pope John Paul II, expressed this in the following way:

It is helpful to recall that the death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person. The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly.
Yet human experience shows that once death occurs certain biological signs inevitably follow, which medicine has learnt to recognize with increasing precision. In this sense, the "criteria" for ascertaining death used by medicine today should not be understood as the technical-scientific determination of the exact moment of a person's death, but as a scientifically secure means of identifying the biological signs that a person has indeed died.9

John Paul II does not proclaim doctrinally the diagnosis of death by the brain criterion. His words are more cautious. He gives permission for health practitioners to adopt the neurological criterion:

the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology. Therefore a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgement which moral teaching describes as "moral certainty". This moral certainty is considered the necessary and sufficient basis for an ethically correct course of action.10

It is, however, open to a faithful Catholic to challenge the medical empirical grounds on which the Pope based his judgement.

Nevertheless, one would reasonably expect that challenge to be based on accepting that the separation of the soul at death results in loss of integration and that the latter means a loss of dynamic unity in which not all the remaining parts of the body are unified through being interrelated to one another in a communicative sense (forming and informing). My concern with Shewmon’s position is not that he rejects Pope John Paul II’s permission for health professionals to use the brain criterion to determine death - it is open to him to challenge the empirical grounds for that permission - but that he does not accept the notion of integration that the Pope engaged which implies dynamic unity of the organism that is the life of the person. Shewmon’s notion of integration does not require that unity.

Shewmon’s key point is that his notion of integration is more in line with reality. However his distinction between life-constituting and life-sustaining types of integration is problematic.

A difficulty that I have with Alan Shewmon’s treatment of integration is that he seems to considerate it sufficient that some parts of the body remain related to other parts of the body for the body to be considered integrated. This is not unity of the body in the sense implied by the doctrine proclaimed at Vienne, a unity that is a result of the soul forming and informing the matter. He also criticizes me for thinking in terms of levels of integration. That may have been a misunderstanding in that I conceded that what he refers to as “integration” was an acceptable meaning of the word and that could be taken to imply different levels of integration. But for the purposes of understanding what integration must mean in the context of understanding the concept as a necessary element of being a living human person, his meaning will not do at all, because the concept must at least imply a dynamic intercommunicative unity between the parts. We take it that that dynamic unity, taking its form from the immortal soul, persists from the formation of the zygote until the soul separates from the body at death, even though in both Donum Vitae and Dignitas Personae the Congregation of the Faith is a little more circumspect about declaring that the zygote has a soul. It instead poses a question:

Certainly no experimental datum can be in itself sufficient to bring us to the recognition of a spiritual soul; nevertheless, the conclusions of science regarding the human embryo provide a valuable indication for discerning by the use of reason a personal presence at the moment of this first appearance of a human life: how could a human individual not be a human person?11

Shewmon devotes a great deal of space to his own theoretical analysis of integration, contrasting life-constituting and life-sustaining “types” as he expresses it and envisioning integration as being on two different axes. The analysis is novel and interesting but ungrounded. There is no anthropological starting point and no apparent basis in existing philosophical or theological perspectives within the Tradition.

To try find an answer to this question of death that is consistent with our Tradition or, at least, a development of the Tradition, we do need to work from the point of view of trying to understand theologically what happens at death and what it is to understand what an individual life is from the single cell zygote until death: we need to develop an anthropology that makes sense of what it is to have an immortal rational soul that forms and informs the matter so as to be the unity that is a human person, as we understand the latter to be from the doctrine proclaimed at the Council of Vienne, and renewed many times since. At Vienne the doctrine was not presented as a philosophical thesis but instead offered a theological starting point by being based upon John’s Gospel:

When Jesus had received the vinegar, he said, "It is finished"; and he bowed his head and gave up his spirit. 31 Since it was the day of Preparation, in order to prevent the bodies from remaining on the cross on the sabbath (for that sabbath was a high day), the Jews asked Pilate that their legs might be broken, and that they might be taken away. 32 So the soldiers came and broke the legs of the first, and of the other who had been crucified with him; 33 but when they came to Jesus and saw that he was already dead, they did not break his legs. 34 But one of the soldiers pierced his side with a spear, and at once there came out blood and water. 35 He who saw it has borne witness--his testimony is true, and he knows that he tells the truth--that you also may believe.12

Linked to this Gospel account in our Tradition is the teaching that

Jesus "descended into the lower parts of the earth. He who descended is he who also ascended far above all the heavens." The Apostles' Creed confesses in the same article Christ's descent into hell and his Resurrection from the dead on the third day, because in his Passover it was precisely out of the depths of death that he made life spring forth.13

In summary, the Catechism expresses the teaching in the following words:

In his human soul united to his divine person, the dead Christ went down to the realm of the dead. He opened heaven's gates for the just who had gone before him.14

Also in developing this anthropological understanding, we must include the imago dei15 and the significance of being a person in the image of the Persons of the Blessed Trinity, again from the time we are a zygote until death, and then in the continuity of being a body after resurrection.

Shewmon makes no apparent attempt to link his theories of integration to doctrine and Tradition or to any accepted philosophy.

His account leads to an oddity in his discussion of the notion that a person might consist of a “brain in a vat”. If this view is linked to his idea that the body could be considered to continue as a living person after the brain has died, then a person could be at the same time two persons – the isolated brain in a vat and the body left behind. There is something distinctly odd about a notion of integration that would allow for such a division which would contradict the essential unity of the human body. The possibility highlights the fact that Shewmon does not understand integration as implying the role of the soul in forming and informing the dynamic unity that is a human being.

I recall standing in an IVF clinic, a result of serving in a government role, and wondering about the precious content held within the tanks of liquid nitrogen. In the tanks there were literally hundreds of straws held in racks, each containing a human embryo, dried and frozen and held in a state of suspended animation. By the latter I mean that there was no growth and no biological activity of any kind. But as a matter of faith, I believed that each embryo instantiated a human soul and, because of that, each was the form and the reality of the adult he or she would become, if given the right environment in which he or she would be rehydrated and thawed and then transferred to a woman’s uterus. Each of those straws contained such an extraordinary reality. Each was just a cluster of cells, but at the same time so much more than just cells, because those clusters of cells were human lives. They already contained the form of that person. As a cluster of cells they were linked together as a single entity already pre-programmed to develop in a predictable fashion, given the right conditions.

At another time I chaired a government committee16 to develop ethical guidelines for the care of people in a post coma unresponsive state, (sometimes unfortunately referred to as a persistent vegetative state). It was brought home to me, by those caring for the patients I visited, that the unresponsiveness was just what we observed. What was happening within those individuals remained so much a mystery to us despite our brain scanning technologies. They had brain activity, but it was not connected to any observable expression of that activity. I also met some rare individuals who had survived several years in that state before recovering to a point that they could speak of their experiences.

I asked one young such man, (he had been over two years without showing any responsiveness), who came to the launch of the ethical guidelines, what he remembered of his experience. He said he recalled conversations being held about whether to continue nutrition and hydration delivered through a PEG (percutaneous endoscopic gastrostomy). He said that he was also aware of the love of his parents (his father, a general medical practitioner, and his mother, a nurse), and had confidence that they would protect him, as indeed that did.

There is, however, such a contrast between post-coma unresponsiveness which includes sleep-wake cycles, on the one hand, and, on the other, a person whose brain has completely died and the harsh reality of seeing the images of that patient’s contrast angiogram showing no blood supply to the brain. In the latter case one knows that on autopsy the brain would be found to be a liquid without structure or life, and that it is only technology that sustains a semblance of the dynamic unity possessed by both the frozen-dried embryo and the person in an unresponsive state. In fact, no such unity exists once there is complete absence of brain function because the systems that communicate between organs, the neural and endocrine systems, are missing a vital element. Circulation can be maintained, with assistance, but circulation without a brain is like a postal system, without mail. Circulation is the means of communication, it is not in itself communication. The dynamic unity that is a personal life has been lost. Shewmon’s insistence on circulation being a form of integration really misses the point that integration implies a dynamic intercommunicative unity. To be a unity in a meaningful sense the parts must be in actual communication with each other, not just be collocated with a system that could carry communications. The fact of the matter is that without the functions of the brain, the neural and endocrine systems have been profoundly interrupted. Circulation may be maintained, for a time, and thus the system for carrying communications, but the means of generating those communications is no longer present. There is thus no empirical evidence of the forming and informing that the doctrine refers to as the functions of the the unity that is the life of the person.

7. Shewmon, Op. Cit. p. 429.

8. “You Only Die Twice: St. Augustine, St. Aquinas, and the Concept of Death by the Brain Criterion,” Communio 38 (Fall 2011).

9. John Paul II, Op. Cit., n. 4.

10. Op. Cit., n. 5.

11. Congregation for the Doctrine of the Faith, Donum Vitae (1987) 5, I , 1.

12. John 19:30-35.

13. Catechism of the Catholic Church, n. 631. The doctrine from the Apostle’s Creed on the descent into Hell, as a doctrine based in Scripture, is complex. The Scriptural basis for the doctrine includes: Acts 3:15; Rom 8:11; 1 Cor 15:20; Heb 13:20; 1 Pet 3:18-19; Phil 2:10; Acts 2:24; Rev 1:18; Eph 4:9; Pss 6:6; 88:11-13; 481 Cf. Ps 89:49; 1 Sam 28:19; Ezek 32:17-32; Lk 16:22-26; Mt 27:52-53; 1 Pet 4:6; Jn 5:25; cf. Mt 12:40; Rom 10:7; Eph 4:9. Heb 2:14-15; Acts 3:15; and Rev 1:18. I am not a Scripture scholar and take what is in the Apostle’s Creed as a matter of faith.

14. CCC, n. 637.

15. Genesis 1.

16. Australian National Health and Medical Research Council, Working Committee to Develop Ethical Guidelines for the Care of People in a Post Coma Unresponsive State or Minimally Responsive State, 2007–2009.