CHAPTER FO UR| 63
As a vital sign, the spontaneous action of breathing can and must be dis-
tinguished from the technologically supported, passive condition of
being ventilated (i.e., of having one’s “breathing” replaced by a me-
chanical ventilator). The natural work of breathing, even apart from
consciousness or self-awareness, is itself a sure sign that the organ-
ism as a whole is doing the work that constitutes— and preserves—
it as a whole. In contrast, artificial, non-spontaneous breathing pro-
duced by a machine is not such a sign. It does not signify an activity
of the organism as a whole. It is not driven by felt need, and the ex-
change of gases that it effects is neither an achievement of the
organism nor a sign of its genuine vitality. For this reason, it makes
sense to say that the operation of the ventilator can obscure our
view of the arrival of human death— that is, the death of the human
organism as a working whole. A ventilator causes the patient’s chest
speaking refers to the exchange of oxygen and carbon dioxide, then its
locus is twofold: (1) across the alveolar lining of the lungs, and (2) at
the biochemical level of the electron transport chain in the mitochon-
dria of every cell in the body. (Shewmon, “Brain and Somatic
Integration,” 464.)
In his eagerness to debunk what he considers the myth of lost somatic integra-
tion, Shewmon fails to convey the essential character of breathing. We might
summarize his account of breathing as follows:
Breathing = Inflation and deflation of a bellows + D iffusion at the al-
veoli + Cellular respiration
But Shewmon misses the critical element: the drive exhibited by the whole organ-
ism to bring in air, a drive that is fundamental to the constant, vital working of
the whole organism. By ignoring the essentially appetitive nature of animal breath-
ing, Shewmon’s account misses the relevance of breathing as incontrovertible
evidence that “the organism as a whole” continues to be open to and at work upon
the world, achieving its own preservation. The breathing that keeps an organism
alive is not merely the operation of a “bellows” for which a mechanical ventilator
might substitute. Bringing air into the body is an integral part of an organism’s
mode of being as a needy thing. More air will be brought in if metabolic need de-
mands it and the body feels that need, as for example during exercise or in a state
of panic or injury. The “respiration” taking place at the cellular level can be un-
derstood adequately only in the context of the work of the whole organism— the
work of breathing.
64| CO NTRO VERSIES IN THE D ETERMINATIO N O F D EATH
to heave and the lungs to fill and thereby mimics the authentic work
of the organism. In fact, it mimics the work so well that it enables
some systems of the body to keep functioning— but it does no
more than that. The simulated “breathing” that the ventilator makes
possible is not, therefore, a vital sign: It is not a sign that the organ-
ism is accomplishing its vital work and thus remains a living whole.*
We have examined the phenomenon of breathing in order to un-
derstand and explain a living organism’s “needful openness” to the
world— a needful openness lacking in patients with total brain fail-
ure. Having done this, however, we must also emphasize that an
animal cannot be considered dead simply because it has lost the
ability to breathe spontaneously. Even if the animal has lost that
capacity, other vital capacities might still be present. For example,
patients with spinal cord injuries may be permanently apneic or un-
able to breathe without ventilatory support and yet retain full or
partial possession of their conscious faculties. Just as much as striv-
ing to breathe, signs of consciousness are incontrovertible evidence
that a living organism, a patient, is alive.
If there are no signs of consciousness and if spontaneous breathing
is absent and if the best clinical judgment is that these neurophysi-
ological facts cannot be reversed, Position Two would lead us to
conclude that a once-living patient has now died. Thus, on this ac-
count, total brain failure can continue to serve as a criterion for
declaring death— not because it necessarily indicates complete loss
of integrated somatic functioning, but because it is a sign that this
* If the view presented here is correct, that is, if the presence of spontaneous
breathing truly reveals a persistent drive of the organism as a whole to live, we
can better understand the force of a rhetorical question sometimes posed to
those who view the loss of “higher” mental and psychological capacities as a suf-
ficient criterion for declaring death. “Would you,” they may be asked, “bury a
patient who continues to breathe spontaneously?” Q uite naturally, we recoil from
such a thought, and we do so for reasons that the account given above makes
clear. The striving of an animal to live, a striving that we can discern even in its
least voluntary form (i.e., breathing), indicates that we still have among us a living
being— and not a candidate for burial.
CHAPTER FO UR| 65
organism can no longer engage in the essential work that defines
living things.
B. Comparison with the UK Standard
Although the terms may be different, the concepts presented here
to defend the use of total brain failure as a reasonable standard for
death are not wholly new. A similar approach to judging the vital
status of a patient diagnosed as “brain dead,” emphasizing the cru-
cial importance of both spontaneous breathing and the capacity for
consciousness, was advocated by the late British neurologist Chris-
topher Pallis.8 His conceptual justification for this argument was
influential in gaining acceptance for a neurological standard in the
United K ingdom.*
Like this report’s Position Two, Pallis attempted to strike a balance
between the need to be “functionalist” and the need to remain
rooted in the biological facts of total brain failure. He stated in very
direct terms that the relevant functions that were irreversibly absent
from the patient with a destroyed brainstem were the ability to breathe
and the capacity for consciousness. When challenged as to why these two
functions should be singled out, Pallis pointed to what he called
“the sociological context” for basic concepts of life and death. In
the West, he maintained, this context is the Judeo-Christian tradi-
tion in which “breath” and “consciousness” are two definitive
features of the human soul:
The single matrix in which my definition is embedded is a
sociological one, namely Judeo-Christian culture… The
“loss of the capacity for consciousness” is much the same
as the “departure of the conscious soul from the body,”
* O ther countries have adopted this conceptual framework as well. The Canadian
Forum that issued its recommendations in 2006 followed the UK approach in
adopting “irreversible loss of the capacity for consciousness combined with the
irreversible loss of all brain stem functions, including the capacity to breathe” as
the definition of neurologically determined death. Shemie, et al., “Neurological
D etermination of D eath: Canadian Forum,” S1-13.
