- Maurizio Salvi, Ph.D.
Research Fellow of European Union (Biotechnology Programme) in the Science and Technology and Modern Culture WTMC Institute, Limburg University, Department of Philosophy, Postbus 616, 6200 MD, Maastricht, Netherlands.
Email: m.salvi@philosophy.rulimburg.nl

The subject of brain death has been a topic of cross-cultural comparisons in earlier issues of EJAIB (Morioka 1995). In this paper I look at the relationship between brain death criteria and self identity. Acceptance of the whole brain death (WBD) definition depends on recognition of the fundamental element of human existence in the brain function. Philosophical analysis of the self identity problem is a clarifying key for the acceptance of the WBD criteria and is an important instrument for the debate on the definition of death, either Cortical Death (CD) or WBD.

2. Death in Medicine

In 1968 the Harvard ad hoc committee defined death as the irreversible loss of the cerebral functions. WBD results from massive damage to either of the hemispheres or the encephalic trunk. This means that the subject in WBD cannot carry out their own organic functions. Without a respirator cardiovascular death will follow shortly.

In CD the encephalic damage is partial. The interaction among trunk, thalamus and cortex is interrupted. The scientific literature on this topic is enormous (see references). CD is not WBD because the functions of the encephalic trunk persist. The fundamental problem in medical acceptance of CD as a definition of death is that we cannot be 100% certain of CD by diagnostic tests. We could summarize this to say that if WBD corresponds to homeostatic control, CD refers to continuity of awareness. Which criteria should be accepted?

3. Death of the identity

We can link biological problems to philosophical ones. If we consider the philosophical literature on self identity there are several different positions and theories. I will not analyze all , rather focus on non-reductionist theories and try to identify the most important problems to be resolved in the definition of death.

Let us consider a person X. By what reason can we say that X is an identity? Also by negation of hat principle can we say that X does not exist any more? How do we define the life of a human being? We don't have to consider X in abstract terms (as a subject referring to himself as "I"), but as a living organism. In this view we have to underline (1) what makes X living; and (2) Does this property of X have an exhaustive value or not?

The first intuitive answer to this question is that X is that person because he possess is body, corporal identity (CI). This criterion was defended by Williams (1973), namely an equational dynamic that X=X. We cannot utilize this criteria in our case for two reasons: (1) the biological peculiarity of an organism is the continual substitution of the cell elements (X=X is a bijective property when an organism X continues in time with a progressive substitution of his sub-elements, cells); (2) CI does not draw us in to focus on one criteria to explain the definition of death. When X dies he continues to "possess" his body. We are looking for the explanatory relationship through which we can identify an individual causal principle making X a human being. If we think that we have to accept the criteria of death as the end of physiological functionalities made by the brain, we have two possibilities: (1) the brain is the fundamental element of self-identity; (2) the fundamental mechanisms of X identity must be referred to as the brain.

The first position was adopted by Nagel (1973), the second by Parfit (1984). Nagel focused on the possession of the fundamental condition of self-identity, X is that person because he has the x-brain. The X identity implies his physical and physiological continuity. Still the criterion of the brain's continued existence doesn't solve the problems of brain functionality. If X has some brain damage and if the brain is the fundamental element of x-identity, how can this damage harm the subject's self identity? If my brain has 51% damage should I be dead? Whereas if the damage extends to 49% of my brain, should I survive? Can the border between life and death be a numerical problem?

The problem is that we cannot limit identity as unique and to stationary requirements. The brain is not the X identity. We have to add to the brain the ensemble of mental conditions, relationships, acts, memories, experiences, etc. We can attribute to the brain a primal value in biological terms, but in this case we would not have solved the X identity problems, simply we have attributed to the brain a primal value (which has to be defined) in the biological meaning of X. What is the nature of this value? How can this value be related to brain damage mechanisms? If we attribute a fundamental value to the brain (because it possesses the memories, the awareness, the rational and sensible activity), the criteria to diagnose death should be CD. If we accept this awareness (I utilize this term senso lato, because it implies a deep analysis which I do not make in these pages) is the causal requirement of the existence of X, we could accept the CD criteria because the phenomenon of self-awareness is located in the cortex.

But we have not to forget the fundamental problem of the definition of death, identifying one criteria to diagnose death (the consequence of this criterion is large, for example organ transplants). We are interested in the causal relationship through which X is a human being, and not the definition of a peculiar element of the condition of X. Awareness in these terms is a secondary element. His end does not imply the end of the organism's life. Since if we accept the CD criteria (Engelhardt 1986, p. 245-8), we must use awareness as the fundamental requirement of human beings. But I believe that the problem is not the definition of the moral meaning of an organism dying, but the definition of the causal principle of his life. The capacity to be moral agents is a following step, which does not solve the problem of what makes X to be living.

I believe that this element lies in the primal biological process allowing the homeostatic regulation of X. Death is the negation of a principle (or set of principles) regulating casually X as an organism. The regulation concept implies the definition of a dynamic structure which while changing remains similar to herself. If we forget this we follow William's mistake (thinking of the identity as a bijective dynamic). At the same time this concept implies a relationship among many physiological elements, regulated by one or more unifying elements.

Let's think now of our individual X. If we think of X in terms of a biological organism, it follows that the problem of his self-awareness is not interesting for us (though important for him!), but we are interested in the causal relationship unifying X as "I". Self-awareness is a necessary but insufficient condition to indicate living.

Parfit (1984) thinks that the fundamental criterion of self identity must be completely changed - the identity is not limited to detrimental elements. Talking about the self in these terms does not mean to indicate only one of the requirements which constitute the Self. Identity is a dynamic relationship which changes its requirements over time. The fundamental element of the self identity does not lie in the self's requirements. Our choice is hypothetical research of the requirement definition that cannot justify what really is important regarding the self identity problems. Because Parfit thinks that self identity is not the fundamental element of Self. This element must be searched in the relationship R, the psychological identity. In psychological terms we are all different and unique, but in biological terms we have the same physiological regulation. The causal dynamic which can be applied to all human beings is biological regulation, not self-awareness of psychological identity.

4. Conclusion

Therefore I conclude that the universal criterion for diagnosis of death must be searched for in this direction. In the official document of the Italian National Committee for Bioethics (NCB) of 15 February 1991 on "Definizione di Morte nell'uomo" it is written that death is the end of an organism as a whole (l'organismo cessa di essere un tutto). This means that the unifying relationship of an organism in terms of physiological regulation, has fundamental importance. This conclusion is in line with our analysis of identity as a unifying process, regulated by causal principles following a structural hierarchy order (cells, tissues, organs, systems, etc.). The NCB concept, following most other national decisions (e.g. President's Commission) is tied to Hume's theory of identity, the "I" as an "individual nation". As the concept of a nation implies the territory, the peoples, the history, the political peculiarities and the social differences, and is not limited to only one of these elements; in the same way the organism is a differentiated whole. In the biological sense the fundamental element regulating the organism X is his primal causal element; homeostatic regulation. This element makes the organism a unified whole. When homeostatic regulation ends the organism ceases to be a whole and dies. Because this activity is regulated by the encephalic trunk, we have to accept the CD criterion. When a subject dies we don't think of the death of self-awareness, but we think of the end of a life. The CD criteria has in the philosophical analysis more reasons for acceptance.

5. References

Comitato Nazionale di Bioetica (15.02.1991) Definizione ed accertamento di Morte nell'uomo

Defanti C. "Stato Vegetativo Persistente e Morte Corticale" Le Scienze n. 88, Mars 1996

Engelhardt H.T. The Foundations of Bioethics Oxford University Press, 1986

Glover J. I: The Philosophy and Psychology of Personal Identity Penguin Book London 1989

Glover J. The Philosophy of Mind Oxford Un. Press Oxford 1976

Green M.B. Wilker D. "Brain Death and Personal Identity" in Medicine and Moral Philosophy ed. Cohen M. Nagel T. Princeton Un. Press, Princeton 1981 pp.49-77.

Harris, J. The Value Of Life, Routledge, London 1985.

Kennedy, I. The Unmasking of Medicine, Paladin, London 1985.

Lamb, D. "Diagnosing death", Phil. & Pub. Affairs 7 (1978),No.2.

Lecaldano E. L'etica l'identita' personale: tra prudenza e azione morale in "Archivio di Filosofia" LV 1987 pp.231-60

Morioka, M. Bioethics and Japanese culture: Brain death, patient's rights, and cultural factors. EJAIB 5 (1995), 87-91.

Nagel T. Mortal questions Cambridge Un. Press 1973 pp.208,

Nozick R. Spiegazioni filosofiche Milano Saggiatore 1987 pp.804,

Oksenberg Rorty The Identities of Person Un. of California Press Oxford 1976.

Pallis, C. ABC of Brain Stem Death, British Medical Ass., 1983.

Parfit D. On the importance of self-identity in "The Journal of philosophy" LXVIII n¡. 20,

Parfit D. Personal identity in Philosophical review" LXXX n¡.1,

Parfit D. Reasons and persons Oxford Un. Press. 1984 pp.680.

Veatch, R. Theory of Medical Ethics, Basic Books, NY. 1981.

Williams B. Bodily continuity and personal identity in "Analysis" XX n¡.5

Williams B. Problems of the self Camb. Un. Press 1973 pp.332.