German Ethics Council considers the question: “When does life end?”

On 21 March, in its “Bioethics Forum” series of events, the German Ethics Council discussed new arguments on the question of when life ends and what consequences this has for transplantation medicine.

Under current transplantation law, the essential principle is that organs may only be removed from persons who have been conclusively pronounced dead. For some years, there have been increasing public discussions as to whether brain death should be the decisive criterion of this. The answer varies, depending on the understanding of human death on which it is based.

The American neurologist D. Alan Shewmon, the author of a large number of studies on this topic, was of the opinion that the end of human life is marked not by the cessation of brain functions, but by a loss of integrative unity of the whole organism. In many cases, this integrative unity remains even when all brain functions cease. According to Professor Shewmon, it is shown on the one hand by the fact that brain-dead patients, among other things, can regulate their body temperature, fight infections and give birth to an unborn child, and on the other hand by the fact that in some cases Shewmon examined the organism required relatively little technical support, for example long-term artificial respiration, to maintain its vital functions.

In contrast to Shewmon, Stefanie Förderreuther, a neurologist at the  Medical Center of the University of Munich, advocated the concept of brain death. She said that brain death is clearly distinct from other syndromes such as coma and locked-in syndrome. According to her, it is clinically impossible to confuse brain death and a persistent vegetative state. The diagnosis of brain death is made on the basis of strict standardized criteria, on the basis of which it is possible to diagnose with certainty the irreversible failure of all brain functions. Unlike Shewmon, she concludes: “Without a brain, a person no longer exists as a physical and mental entity.”

Ralf Stoecker, Professor of Applied Ethics at Potsdam University, in contrast, finds “no convincing argument to support the validity of the brain death concept”. He agreed with Shewmon that although brain-dead persons have irreversibly lost consciousness and their inner mental life, they are not yet dead, because the unity of the organism continues. Stoecker attempted to solve the ethical dilemma that organ donations can help people but the only suitable donors are those who are definitely dead by drawing attention to the fuzzy boundaries of concepts like life and death. He said that brain-dead persons are in an intermediate stage between life and death, and they have characteristics both of life and of death; consequently they must be treated as living persons in some respects, but in other respects it is not possible to hurt them, because they have no future which they could be robbed of, and therefore it is ethically justifiable to remove their organs.

Michael Quante, Professor of Philosophy at Münster University, referred to far-reaching philosophical differences with regard to Stoecker’s views. According to Quante, the appropriate concept of death is not an ethical question but a metaphysical one relating to existence and its termination by death. In order to answer these questions, he said, there must be a dialogue between scientists and natural philosophers about the end of human existence. There is a need for “a concept of the (human) organism which is appropriate in science and natural philosophy”.

The following panel discussion, between the evening’s speakers and also Eckhard Nagel and Eberhard Schockenhoff, members of the German Ethics Council, concentrated above all on the consequences of the various viewpoints for medical practice. For Nagel as a transplantation medicine specialist it is unthinkable to kill one human being in order to save another. In contrast to Shewmon and Stocker, however, he regards the brain-dead as unequivocally dead and therefore regards transplantation medicine practice as legitimate. Schockenhoff is also convinced that brain-dead patients must be seen as definitely dead. For unlike Shewmon, his concept of life is that a living organism is itself productive and therefore represents a self-effected unity, which cannot be restored by any comprehensive substitution of failed organ functions.

In both the panel discussion and the contributions from the public there was clear agreement that the dignity of brain-dead persons must be respected in every case and that the family members should be addressed and involved to a greater degree in the intensive care unit. If, for example, they were able to follow the progress of the diagnosis of brain death, they would be in a better position to understand the death of their relative and ultimately to accept it.

Audio recordings of the individual contributions may be accessed here.