Abstract
Professors Truog and Miller1 are correct in their assessment that the British definition of death is focused on the loss of two discrete functions, both anatomically located to the brainstem; the capacity to breathe and the capacity for consciousness. This does, as is asserted, offer advantages over a whole brain definition of death, requiring loss of all functions of the brain.
Unfortunately the examples given by Truog and Miller, to rebut the British criteria, prove insufficient. The ‘locked in’ may have ‘loss of virtually all other brainstem functions’ but ‘virtually’, is not all, and therefore the patient is not dead. Certainly no patient who blinks or has reactive pupils, as occurs in the locked in syndrome, would ever be considered as deceased.
Nor are quadriplegic apnoeic patients who suffer an event rendering them in a persistent vegetative state (PVS), deceased under British criteria. PVS patients continue to have clear evidence of brainstem function, and the diagnosis of PVS has a 40% misdiagnosis rate,2 hardly suitable criteria to use for diagnosing death using any criteria. Furthermore, consciousness is best understood as a state of being awake and aware of self and environment.3,4 PVS patients demonstrate arousal (wakefulness), and therefore they too, even if irreversibly apnoeic, will not satisfy British criteria for loss of consciousness.
It was with quiet satisfaction that we in the UK read the President's Council's white paper on Controversies in the Determination of Death, ‘If there are no signs of consciousness and if spontaneous breathing is absent… a once-living patient has now died’.5 Thanks to the forward thinking of men like Christopher Pallis, the British definition of death has been saying this for many decades.