There are archaeological findings that lead us to firmly believe that already ancient civilizations had already practised, often in relation to mystical-religious conceptions, a sort of cardio-pulmonary resuscitation, albeit in a naive way and without any real scientific knowledge of the real functioning of the cardio-respiratory system.  Today these techniques have been widely explored, studied and refined even though they always have, if not the same methodologies and theories, the same aim: to rescue the mortal man from ‘thanos’ – death.

     In our days there are basically two criteria by which death can be declared: cardiorespiratory and cerebral or neurological; the first is mainly used to establish in a definite and unequivocal way the death of the patient (for example if the lesions are such as to make resuscitation impossible), while the second one concerns the cases of patients in a state of irreversible coma – with the almost complete zeroing of neural functions. 

At first glance, the subject can be extremely complex and for this reason – in the name of simplicity and clarity – it should be allowed to begin by mentioning a recent article published last August in JAMA (an exquisitely medical journal that enjoys a great reputation on an international level) in which eminent experts in this field have expressed their polemical opinions on the lack of certain knowledge and the unresolved doubts that remain around the theoretical foundations of these medical practices.  The authors of the article express the pressing need to formulate a generally shared scientific document that includes all the statements relating to the determination of brain death, reviewing all databases and including articles from 1992 to the present day, clearly identifying the most useful and relevant.

     Of particular theoretical and human importance is a case that occurred some years ago and became famous in the media and will now serve as a concrete example to shed light on the complexity and contradictions embedded in these medical practices. The story of Alfie Evans begins in December 2016; little Alfie, just seven months after birth, is admitted to intensive care due to a degenerative neurological pathology not yet known and, a year later, the medical team decrees the suspension of artificial ventilation that keeps him alive because there is no scientific possibility of recovery. Alfie’s parents do not give up and ask for a relocation to the Bambino Gesù Children’s Hospital in Rome to try new experimental treatments, but the judge of the High Court of Justice of England, as well as the Supreme Court of the UK, express their opposition, endorsing the medical decision to interrupt all the child’s vital support. Although the Italian government decides to give the child citizenship hoping that he will be granted a relocation, this does not happen. In April 2018, Alfie’s respiratory support is switched off and the doctors are forced to hydrate him again since, against all expectations, natural respiratory functions do not stop. On the same day, the European Court of Human Rights also rejected the appeal against the relocation injunction and the European Commission’s spokesman stated that there is no law that can be invoked to bring Alfie to Italy; on the 28th April Alfie Evans’ death is recorded.

     This affair also had other legal implications, reporting media attention on alleged transplant organ removal practices from children declared dead in the years 1988 to 1995 at Alder Hey Hospital in Liverpool, where Alfie Evans was hospitalised.  It would be superficial not to read in the latter case the possible link between the medical practice of the declaration of brain death, organ transplantation, and the possible subjugation of such medical action to unethical ends, and to dubious interests. In this sense the conceptual tension that is highlighted is profound, and is based on multiple theoretical assumptions in the social, ethical, scientific and legal fields – assumptions that should be carefully reviewed and discussed.

Historically, the scientific article that determines the definition of ‘death’ linked to the cerebro-centric paradigm is the one drawn up by the Harvard Commission, established in 1968 (let us bear in mind that the great expansion of the practice of organ transplantation arose at the same time and, since these two concepts converge and intertwine, the impact of the former on the latter cannot be underestimated at all) and that it included mainly doctors but also a jurist, a historian and a theologian.  The article was entitled “A Definition of Irreversible Coma” and had the pretension of fixing with scientific certainty a new and reliable criterion of death, defining it as “the total and irreversible loss of the organism’s ability to maintain autonomously its functional unity”. Subsequently, in 1981, also in the United States, the “Uniform Determination of Death Act” (UDDA) was published, which aimed to standardise the definition of ‘death’ and to provide adequate responses from a medical-biological point of view. Later, in 1981, still in the United States, the “Uniform Determination of Death Act” (UDDA) was published, which was intended to standardise the definition of ‘death’ and to provide adequate medical-biological responses. Nonetheless, even though it was published in 1981,  they did nothing more than reiterate the idea that brain death is to be identified with the death of the entire brain – considered as the critical organ of bodily integration – and that it is manifested in the non-responsiveness and non-receptivity psychologically understood (unconsciousness) towards an external environment. The irreversible end of all brain functions determines the irreversible loss of the integration of the various components of the organism and, therefore, the death of the individual.

This document aroused a great deal of criticism both from the medical field and from jurists, bioethicists and philosophers. In this regard, it is now time to bring the discourse to a more strictly philosophical level, attempting to provide food for thought on the ethical and normative dimension of this issue, by placing under a magnifying glass the actual theoretical correctness of these medical practices.

     First of all, can we say that there is a coincidence between the almost complete cessation of brain functions diagnosed and the ‘death’ of the individual as such? Obviously doctors, due to the essentially practical nature of their work, are forced to make decisions that will have real and often even definitive consequences in relation to the life – or death – of their patient. However, the question remains: is it legitimate to assume the so-called ‘brain death’ as ‘death’ tout court even though the heart still beats, hair and nails grow, tissues regenerate, and the patient’s life is not yet over?

Is there any sign, even if minimal, of metabolic activity? In other words, it is necessary to reconcile the fact that the individual is to be considered dead even though his organism continues to live in some way.

     In Italy, the National Committee for Bioethics, even though it has received and analysed the criticisms made, considers only the criterion of ‘total brain death’ to be valid – “understood as organic, irreparable, acutely developed brain damage, which has caused an irreversible state of coma” – on the grounds that, although we can see a residual electrical and metabolic activity still in progress, what counts is the absence of integration and in this case the characterization of the individual as an overall system is lacking.  But, ethically speaking, are we following the best possible path?

A case that happened at the beginning of 2019 has caused a scandal and is certainly moving because of its tragic peculiarity: a woman gave birth to a child after being in a coma for fourteen years in a protected hospital, during which she was raped by a nurse.  Beyond this deplorable gesture, one wonders whether the unconsciousness in which the woman had been living for more than a decade could be considered sufficient to decree the end of a human existence that manifests such a complex and general integration that it is capable of generating a new life. Even assuming the brain as the ‘supreme integrating organ’, in these cases we must ask ourselves whether the concept of ‘integration’ that we adopt today is so fitting when we shift our attention to the human individual as a single, unique and unrepeatable being.  The clarification of semantic and conceptual plans and levels must be clarified if we do not want to go against theoretical inconsistencies. Even neuroscience itself suggests that motor reflexes cannot establish the presence or absence of higher integrative neurological functions and that the potential for recovery of conscious awareness through neurogenesis and neuroplasticity cannot be excluded in full. Given these ‘insights’, it seems fair to say that the behavioural assessment related to the sensory non-response of the individual in a coma does not necessarily amount to an absence of awareness. What remains to be underlined is that from the reviews carried out on hundreds of cases of death, it has not yet been possible to ascertain that all the functions of the brainstem were completely and definitively absent without any awareness, but, nevertheless, in all these cases ‘brain death’ has been declared, endorsing the practice of expropriation of organs as determined by current practice.

     Aristotle affirms that it is precisely the well-educated man who does not insist on the search for greater precision in knowledge than the subject of the investigation itself does not admit. The reality of certain types of concepts – to which ‘life’ and ‘death’ perhaps belong – may be imprecise in itself, or at least the knowledge derived from them could be.  

However, uncritically assuming as true and correct a state of affairs that is recognised at the same time as ‘imprecise’ risks being dangerous, especially when it is the basis of concrete practices – such as medical practices – that have direct and unchangeable consequences on the very life or death of human beings.

Although the criteria adopted to date may be considered the best possible explanation, the reader will find a certain paradoxicality in relation to the objective concepts used in the biological field (‘life’ and ‘death’ above all).  

Today we are faced with the decomposition of the concept of ‘death’ into at least four different determinations – cardiac death, overall brain death, brainstem death and ontological death – which lead to an ambiguous polysemanticity that will need to be addressed and, if possible, resolved.