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Commentary on "Brain Dead Person" Chapter 1

Robert D. Truog, MD (Harvard University)

>>Brain Dead Person, Chapter 1


Dear Professor Morioka,

I enjoyed reading the translation of the first chapter of your book. Clearly, the experience of life, death, and relationship is different in Japan than it is in the West. Yet I think your attempt to differentiate three "states of being" -- living person, brain-dead person, and cardiac-dead person -- is an insight that is just as helpful in Western culture as I am sure it is in Eastern culture.

To say that both brain-dead persons and cardiac-dead persons are all "dead" in the same way is simply untenable. Below is a table that I use in my lectures on brain death. It shows that brain-dead persons and living persons share most of the characteristics that we usually associate with being alive. As the table shows, brain-dead persons are like living persons in every way except for one -- they have lost the capacity for consciousness.

Features of Living Persons Living Persons Brain-Dead Heart-Dead
Heart-beating, warm, well-perfused Yes Yes No
Breathing Yes Yes
(with vent, see note below)
Functioning vital organs (liver, kidneys, etc.) Yes Yes No
Capable of reproducing Yes Yes No
Capacity for consciousness Yes No No

If I understand you correctly, each of your three categories, or "fields," is associated with a set of rules or traditions that define the way these persons interact with others. Obviously, these traditions are very complex and well-developed for the categories of living persons and cardiac-dead persons. Your description of some of these traditions is very useful. Unlike these first two categories, however, we are only beginning to define (as societies) the traditions and rules that should govern the way we interact with brain-dead persons. These rules must determine whether these persons may be organ donors, and whether their families can demand that they continue to be treated in intensive care units.

The American view has been that the rules should be the same for brain-dead persons and cardiac-dead persons. It seems to me that this is a terrible mistake, since these two categories differ in so many ways --medically, philosophically, and socially. While I agree that it may be ethical to remove organs from persons who are brain-dead and from persons who are cardiac-dead, I do not agree that this is ethical because these groups are equivalent. The justifications for why it may be acceptable to remove organs from these two categories must be different, since each of these two categories is so different.

I think your way of presenting these three categories and explaining the differences between them in terms of the relationships between people is a wonderful and very useful insight. Thank you for sharing it with English-speaking readers.

Note: Some might say that breathing with a ventilator should not "count" as breathing, since it is artificial. But we do not consider people with cervical quadriplegia as only "half alive" because they require a machine to breathe, just as we do not consider patients with chronic renal failure as only "half alive" because they have lost the natural function of a vital organ (i.e., the kidneys). In other words, as long as a function is present, even if it is being maintained artificially, it should be considered a property of the person.


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