Donation after brain death is organ procurement classified clinically and legally as postmortem, following a determined irreversible loss of brain function. The designation as “postmortem” donation presupposes the identification of irreversible loss of brain function with certain death — an identification that the ontology defended here explicitly rejects: certain death and irreversible loss of brain function are posited as two distinct, mutually exclusive states of affairs. The following account therefore uses the term “postmortem” in the clinical-legal sense in which it is posited (Harvard 1968, UDDA 1980, in Germany TPG §3), without endorsing the ontological claim.
Donation after brain death thus stands on equal footing with donation after circulatory death as a clinically and legally recognized form of postmortem donation. The two forms differ in which criterion of death is drawn upon to determine death:
| Form | Criterion of death | Practiced in |
|---|---|---|
| Donation after brain death | Irreversible loss of brain function | standard worldwide; in Germany the only permitted form |
| Donation after circulatory death | Permanence of circulatory arrest | 18+ countries; excluded in Germany |
Substance-ontological assessment
The personal ontology defended here regards both forms of postmortem donation as standing under the tension of the Dead Donor Rule, but in a differently situated way:
In donation after circulatory death (permanence stipulation): the violation lies in the question of whether permanence suffices for certain death — substance-ontologically it does not (cf. Permanence and Irreversibility).
In donation after brain death (brain-death stipulation): the violation lies in the question of whether the irreversible loss of brain function may be identified with certain death. The ontology defended here denies this identification: the irreversible loss of brain function concerns only the deutera energeia, not the prote energeia; the person is thus not definitively dead upon irreversible loss of brain function, but severely restricted in its actualization (cf. irreversible loss of brain function).
In the ontology defended here, certain death and irreversible loss of brain function are two different states of affairs; clinical practice may not, without further ado, set them as one.
Arguments against equating irreversible loss of brain function with death
Several arguments support the position defended here:
D. Alan Shewmon (2001) — The brain and somatic integration: after irreversible loss of brain function, numerous integrative functions persist (homeostasis, thermoregulation, wound healing, the hormonal stress response, the successful continuation of a pregnancy). The brain therefore cannot be the sole somatic integrator.
Hans Jonas (1974) — Against the Stream: Comments on the Definition and Redefinition of Death: the redefinition of death for the purpose of transplantation fragments the living personhood into brain and body — a dualism that does not do justice to organismic wholeness.
German Medical Association (Bundesärztekammer) (2015, 2022) — terminological refinement: the shift from “brain death” to “irreversible loss of brain function.” The correction linguistically concedes that this is a loss of function, not necessarily the death of the person.
UDDA revision, USA (2021—2023): the attempt to amend the Uniform Determination of Death Act foundered on the finding that in up to 50 percent of patients clinically diagnosed as brain-dead, hypothalamic osmoregulation persists — a brain function that the wording of the UDDA requires.
Magisterial position
Benedict XVI (2008, Address to the International Congress on Organ Donation) formulates the precautionary principle: “Where certainty has not been reached, the principle of precaution must prevail.” In the context of donation after brain death this means: as long as the identification of irreversible loss of brain function with death is substance-ontologically controversial, the stricter condition holds — the assumption that the donor is still alive.
Practical asymmetry with donation after circulatory death
Even though donation after brain death and donation after circulatory death both stand under the DDR tension, the practical situation differs:
- Donation after brain death has been established for 50 years; social consensus carries the practice.
- Donation after circulatory death is a more recent practice (UDDA 1980 permitted it; broadly established since the Pittsburgh protocol of 1992).
- In donation after brain death, mechanical life support (ventilation) during organ procurement is the standard case — the body visibly “lives” on.
- In donation after circulatory death, the circulation is stopped; the visible dying is shorter.
Ontological classification
Superordinate concept: postmortem donation (clinical-legal classification; sibling class of donation after circulatory death)
Ontological relations:
- presupposes: determination of irreversible loss of brain function
- problematic under: precautionary principle
- potentially violates: Dead Donor Rule (substance-ontological gap between irreversible loss of brain function and certain death)
- sibling class of: donation after circulatory death
Chapter assignment: Chapter 4: What Is Human Personhood? (German), Chapter 5: Oblivion of the Person (German)
Sources
Clinical-legal foundations
- Ad Hoc Committee of the Harvard Medical School (1968): A Definition of Irreversible Coma. JAMA 205(6): 337—340. — First systematic definition of brain death.
- President’s Commission for the Study of Ethical Problems in Medicine (1981): Defining Death: A Report on the Medical, Legal, and Ethical Issues in the Determination of Death. — Basis of the Uniform Determination of Death Act (UDDA, 1980).
- Bundesärztekammer (2022): Richtlinie zur Feststellung des irreversiblen Hirnfunktionsausfalls (Fifth update) (German).
- Transplantation Act (Germany), §3.
Substance-ontological critique
- Shewmon, D. Alan (2001): The brain and somatic integration: insights into the standard biological rationale for equating “brain death” with death. Journal of Medicine and Philosophy 26(5): 457—478.
- Jonas, Hans (1974): Against the Stream: Comments on the Definition and Redefinition of Death. In: Philosophical Essays: From Ancient Creed to Technological Man. Englewood Cliffs: Prentice-Hall.
- Veatch, Robert M.; Ross, Lainie F. (2016): Defining Death: The Case for Choice. Washington: Georgetown University Press.
- Truog, Robert D.; Robinson, Walter M. (2003): Role of brain death and the dead-donor rule in the ethics of organ transplantation. Critical Care Medicine 31(9): 2391—2396.
Magisterial support
- John Paul II (2000): Address to the 18th International Congress of the Transplantation Society. — Differentiated reception of the neurological criterion.
- Benedict XVI (2008): Address to the International Congress on Organ Donation. — The precautionary principle.
See also
- Donation after Circulatory Death
- Irreversible Loss of Brain Function
- Dead Donor Rule
- Precautionary Principle
- Mechanical Life Support
- Certain Death
- Benedict XVI
- John Paul II
Generated by querying the Personhood ontology.