Science in Christian Perspective

A Christian Definition of Death
BERNARD RAMM
American Baptist Seminary of the West 
Covina, California

From: JASA 25 (June 1973): 56-60.

This article is written in the form of a response to Robert B. Morison, "Death Process or Event?" and, Leon R. Kass, "Death as an Event: A Commentary on Robert Morison," Science, 173:694-702, August 20, 1971

One of the results of the great sophistication of modern medical technology is the creation of imponderable ethical crises. One of these crises is the definition of death. We now know it is a continuous and complex process so that we may speak of many kinds of death, (brain death, physiological death, medical death, cellular death, legal death, etc.). Furthermore the same sophisticated technology may prolong dying or shorten it. In prolonging death, machines may replace one of the major life-systems of the body (breathing, heart
beat). Heart transplantation has brought this techno-logical crisis to its most dramatic focus. In order to cope with this increasing sophistication in medical technology and its impact on the problem of death (for it is not only a medical problem but a legal one, a social one, and a psychological one) a new journal has been founded: The Journal of Thanatology (from the Greek word for death, thanatos,).

In the articles by Morison and Kass one scientist offers his opinions on the problem of defining death in the light of the new technology and the second offers a critique of the first with some observations of his own (Morison vs. Kass)

A Naturalist View

ApparentlyMorison is a thorough-going naturalist and reductionist, for to him the difference between the living and the dead is apparent, not real. There is one spectrum of chemical changes wherein we arbitrarily call one part of it "life," as if life were a thing or a substance. The passage from one set of classifiable chemical reactions (the so-called processes of living protoplasm) to another is a continuum and it is only by social custom that we specify death as an event.

Morison rejects any attempt to redefine death, as that would presume the old errors over again that "life" is some sort of essence and that death is some sort of event. As far as medical practices are concerned he thinks the difficult cases (shortening or prolonging life) should be decided upon by a team. He ends his article by making a case for euthanasia. A patient knowing of an impending terrible illness and death could talk the matter over with his doctor and settle on some sort of procedure for euthanasia. Morison has a good word for men like Eastman and Bridgman, who when informed of their incurable and painful disease, committed suicide and shortcut the whole lamentable process of a prolonged and agonizing dying.

Rebuttal by Kass

Kass's article is a point-by-point rebuttal of Manson's basic theses. What Morison and Kass have in common is the recognition of the complex decisions modern technological medicine puts on the back of the doctor. To Kass death is an event no matter how much recent bio-medicine has shown how difficult it is to define. There is a distinct difference between a living body and a dead cadaver and not a continuum of chemical processes where for society's sake we draw an artificial line of death. As Kass remarks, according to Monison's thesis, there is no such thing as murder, for murder is only a process to Morison!

Furthermore Monison's pragmatic solutions to difficult cases are not that simple. Value judgments are involved in every decision and values cannot he settled by votes nor weighed in grams. He also contests Morison's brief for an intelligently planned euthanasia between patient and doctor when the patient is in full possession of his senses. There is a difference between letting a patient die (such as stopping a heart-pacer or respirator) and actually doing something to induce death. Kass is very insistent that in no situation should the doctor ever leave his role as healer and take on that of a killer.

Christian Insights

Fortunately Christians who are knowledgeable in these matters have also written on these topics and attempt to bring theological insights to decision-making dilemmas in technologically advanced medicine. We look at three such attempts to correlate Christian ethics with the topics discussed by Morison and Kass,
1. Harmon L. Smith, Ethics and the New Medicine (New York: Abingdon Press, 1970).

Coming to terms with these problems in chapter 4 of his book Smith follows the set pattern in which he writes the entire book. The first part of the chapter reviews the complexities of the problem from a strictly medical standpoint with specific examples; then be cites the opinions of some theologians; and he con cludes with his own judgments.

One of the crises medical technology has produced is connected with organ transplants. We know that dying is a process and that there are many kinds of death (e.g., brain, cellular, etc.). Modern practices in organ transplanting seem to require a Stage I death at which time an organ may be removed from the patient and a Stage II death where the body is a cadaver and is to he buried.

A second crisis produced by modern medical technology is just the reverse. When a person has passed a certain stage in his disease or injury so that reversibility of health or life is impossible, what right has the doctor to prolong the life of such a patient? Or to put it another way, at what point is a doctor no longer under the stipulations of the Hippocratic oath?

In matters of medicine and technology Smith cites Barth and Bonhooffer as being extremely conservative or reserved. To both of them Cod and God alone has the right to end life and man may do nothing to end the process or hasten it. Barth's one concession is that in relieving pain the powerful dosages may as a secondary cause (not primary!) shorten life. Smith thinks that the experiments in medicine by the Nazis may have influenced Bonboeffer's position but he believes there is an inconsistency in Bonhoeffer's support for the plot to assassinate Hitler.

Smith then discusses Fletcher and we find the pendulum swinging wildly (as can he anticipated) to the other side of its periorl. Fletcher wades in where theologians, doctors and angels fear to tread and says we ought to do without dispatch what love, common sense, and a regard for humanity (and humanness) dictate. Fletcher says a person ought to die in dignity and not at the end of a long drawn out debilitating, dehumanizing and undignified period of suffering.

Smith then turns to his own convictions. As a Christian his basic conviction is:

1) to perceive as clearly as possible God's will, as this is manifest in Jesus Christ, and to relate that will to the conduct of human affairs; and (2) to assess the coherence and congeniality between particular actions and affirmed values. (p. 152).

In the matter of dying, transplants, and the prolongation of life the focus becomes sharper:

Theologians, especially, must insist that the management of terminal illness or injury sustain, as tar as possible, the personal dignity and integrity of the patient, together will) the interpersonal values of the relationships between the patient and the larger contexts of other persons, particularly the immediate family. (p. 165, italics are his).

In context Smith is denying that any simple criterion is possible to follow, whether it be medical (e.g., we are only sure of death when nidation sets in) or motivational (whets the doctor is motivated by "innocence" where in other situations it would be considered a crime). Decision making in medically complex situations is a vectoring process which includes all factors.

Smith then becomes very specific. As Christians we may consider a person dead when be has undergone personality death (my expression, reflecting Smith's discussion and terminology). Personality death occurs whets it is medically ascertained that there is an "irreversible loss of consciousness and function" due to the extensive damage of the brain. At that point the Christian may consider the patient as a cadaver and its organs may be used for any reliable medical use-even though other organs or systems show signs of being alive or a machine is replacing a life system.

Concerning people who are hopelessly damaged or hurt, especially in the brain, the doctor is faced with three options:
(1). The doctor has the moral right to withhold or withdraw all mechanical supporting machines. Smith assents to this.
(2). The doctor has the moral right to administer pain-relieving drugs which may hasten the person's demise. Smith assents to this.
(3). The doctor has the moral right to actually induce death by drugs or other means (such as pumping air into the arteries). Smith disagrees at this point. Fle says that most theologians, lawyers and doctors would agree on points (1) and (2).
To sum up, Smith tries to go from general Christian convictions to specific points in medical ethics: (1) lie does believe that organs may be taken from patients who have suffered personality death; and (2) he does not believe that doctors should use all measures possible to prolong senselessly the inevitable ebbing away of life in catastrophic cases.

2. Hemut Thielecke, "The Doctor as Judge of Who Shall Die." Kenneth Vaux, editor, Who Shall Live:
Medicine, Technology, Ethics (Philadelphia: Fort ress Press, 1970). Pp. 146-186

Thielecke is a distinguished professor at the University of Hamburg who has written several massive volumes in a set on Christian Ethics. He was also one on the few men left after the end of World War II who proved a real point of beginning again for a dispirited German nation.

Like any other person interested in medical ethics lie has read extensively in medical literature and medical ethics. Thielecke has also been personally involved in much counseling in medical eases. Furthermore, more than any other writer in ethics (as I have read them) he attempts to be as Biblical as he can, drawing very consciously from Biblical materials.

His first point is that the Hippocratic oath calls upon doctors to preserve human life, not biological life, That 'which makes man human is his huoianom or image of God (imago Dei). When the humanism is no longer there, the moral obligation of the doctor to follow the Hippocratic oath no longer exists. This he reasons from Genesis 1. Animals and plants are created. But man is specially created and called by name and addressed as a thou, a person. This leads him to a modern definition of man with "the consciousness of self" as "the critical sign of human existence" (p. 161). The corollary is that "a man devoid of any trace of selfconsciousness, 'would be, as it were, merely a biological culture" (p. 162).

If a man is no longer addressable as a person or a thou, if he no longer possesses the homanum or the imago, lie is, from the standpoint of Christian theology, dead as a person. Scientists may then use the body for transplants or for whatever else medical science may use a body for. Technological difficulties in determining when a person has lost his humanism and become a culture should not deter us from operating with such a distinction. With the increase of medical knowledge the point of transition will become less ambiguous.
In this exposition there is a treatment of a theological theme that should not go unnoticed. According to Tluelecke (as a theologian) man lives in the halflight of creation and sin. This is God's world and man is God's creation. This is clear. But sin has entered the world and man is a sinner. The light of creation is not extinguished but yet burns. This Thielecke calls the halflight of the existence of a sinner. In a half-light many moral decisions are ambiguous because we cannot sec clearly. All man's existence is in half-light and therefore shot through-andthrough with ambiguities.

Medical ethics does not escape these ambiguities. Medical ethic's will always be fraught with problems because decisions in medicine are made in half-light, as are all other moral choices, and therefore will suffer from ambiguities. To expect simple, direct, easy answers in medical ethics is to misunderstand the essential ambiguity of human existence. Although he makes no reference to Fletcher, this is a devastating attack upon Fletcher's bold pronouncements in medical ethics, where lie seems to speak as if he stood in the clarity of daylight and not in the half-light of human sinfulness with its inescapable ambiguities.

Thielecke does not believe a flickering life ought to be prolonged by heroic medical measures. It should be mentioned parenthetically that Thielecke has been a wheel-chair case himself and is not talking pure theory. He admits that be has a hard time finding moral arguments for not prolonging a flickering life for he feels that his answer is more intuitive than reasoned. Yet he does some reasoning. Hebrews 9:27 says that it is given to man once to die. What is the logic then of dragging out the flickering period of man if man does have such an inevitable appointment? Or, in prolonging a flickering life do we really prolong agony and not life?

We know that dying is a process and that there are many kinds of death.

Thieleeke then, thinking deeply as a theologian, raises the question of suffering. Maybe we ought to let life keep flickering. We kill an injured animal because suffering is not an ethical issue to an animal. It is a burden and man mercifully shoots a horse with a broken leg. But suffering is an ethical problem to man and we don't shoot a man if he breaks his leg. When then does a doctor frustrate suffering by refusing to prolong life; and when does he expect a patient to endure suffering as part of his lot as a moral creature? Thielecke admits that there is no rule of thumb to differentiate cases, so that in some instances we end suffering and in others we permit the patient to endure suffering as an ethical challenge. In the language of the English, Thielecke says that in such eases we can only "muddle through."

When it comes to organ transplants Thieleeke suddenly flips on us. He deserts his Biblical exposition, his theological resources, and his ethical analyses. He simply announces that when a person is in an irreversible coma due to extensive brain damage he has become a cadaver and a doctor may use the cadaver as he wishes as a medical researcher. It is not a religious or a moral question (p. 176).

But has he not forgotten himself? Did he not previously state that when the humanism is gone the person has become a biological culture? This he bases on Biblical texts and their theological implications. To be consistent he should have said it is, morally right to use a biological culture for transplants and not that it is a morally or theologically indifferent matter.

3. Paul Ramsey, The Patient as Person: Explorations in Medical Ethics, New Haven: Yale University Press,
1970. The Lyman Beecher Lectures at Yale University.

Of the three Christian moralists we have read in connection with the issues raised by the Morison-Kass article Ramsey is both the best and the poorest. 

He is the best in that he has written an entire book on this subject and related subjects with extensive medical, ethical and theological documentation. Our discussion of Ramsey cannot begin to do justice to the enormous amount of materials he has amassed and the mastery of them manifested in the way in which he handles them. He is no research grubber who can dig out a mass of data but is helpless to assess it and interpret it.

It is the poorest book however, because the theological elements are so far in the background. If he had not tipped us off (very rarely) of his Christian Protestant stance we would assume he was writing merely as a philosophical ethicist. We know from his other ethical writings that he is very well acquainted with the Christian ethical heritage and is the most articulate critic of the "shoot and ask questions later" ethics of Joseph Fletcher. Frequently when he states "from the standpoint of ethics" he really means "from the standpoint of Christian ethics." So what I mean by saying that his is the poorest of the three books, is that he does not make his connections between his theology, his ethics, and his medical ethics as obvious as Smith and Thielecke do.
My impression from reading Ramsey is that his decisions about medical ethics, and especially the extreme kinds of cases we are dealing with in this article, are based on two premises:

(1) Medical technology is in such a rapid state of progress and transition that Christian ethicists ought to move very slowly and not plunge into the situation with premature rules or principles. Here he parts company with Fletcher who wants to cut loose radically from the binding cords of the past and retool medical ethics according to the latest theory or practices. Ramsey has much appreciation for Hans Jonas and his extreme regard for the patient and life no matter how low the candle flickers and for Barth's extreme regard for God as the Creator, Lord, and Determiner of our lives (even though he does think Barth is too extreme in the way he uses this principle in medical ethics).

(2). The ultimate value in medical ethics is the person, or the patient as a person. To be specific, the need for organs for transplants might make social needs the basic value in medical ethics; or from our knowledge of genetics we might make consideration of future generations (as Thieleeke sometimes does) the basic value. Ramsey resists this and makes the patient as a person the primary value in medical ethics.

This second principle comes out clearly when he discusses the necessity of updating death. He is aware of all the technicalities of the problem. But he seems far more informed of the complications of updating death than Smith or Thieleeke. What doctors call brain death Smith calls personality death and Thieleekc calls it loss of the humanum. But brain death is not an adequate criterion. Ramsey chooses the definition of the Harvard Medical School report of 1968 which lists four criteria (which I shall condense): (1) the patient does not respond to the most painful stimulus; (2) the patient shows no signs of resuming breathing after being taken off the respirator for more than three minutes; (3) the patient does not respond to any of the standard neurological tests for reflexes; and (4) the eleetrocncephelogram is flat.

The Hippocratic oath calls upon doctors to preserve human life, not biological life.

After establishing a more vigorous criterion for death than Smith or Thieleeke he then makes his main point. We must keep separate our concern for updating death with a view to organ transplanting and our concern for a medically accurate definition of death. Ramsey's fear is that in our anxiety to transplant organs we will have a short-cut definition of death in order to get the organ. This does not do justice to the patient as a person, ignores other values in the situation besides the values of a transplant, and could lead to the actual killing of a patient because we are working with a definition of death aimed at transplanting but not for the ultimate concern of the patient.

With reference to the patient who is catastrophically sick or injured, Ramsey is again reserved in order to preserve his thesis of the ultimate value of the patient as a person. He goes into great detail of medical complications about such cases. The problem hinges around the meaning of the terms ordinary and extraordinary. There is general agreement that the doctor is morally obliged to use ordinary methods for treating a desperately sick person and that it is cruel and financially unjustifiable (care of "human vegetables" can cost .825,000 to $30,000 a year) to use extraordinary measures. Then Ramsey shows in a number of cases that an ordinary measure is really an extraordinary measure, and that in other cases an extraordinary measure would be considered ordinary. So there is no simple definition of ordinary and extraordinary.

But Ramsey does not leave us hanging in the air because the terms ordinary methods and extraordinary
methods are not capable of simple definition or identification. Ramsey's guides in this matter are: (1) It is morally proper to give pain-relieving drugs with the knowledge that as a secondary effect they will shorten life. (2) We must be very careful in defining what we mean by a doctor doing something by omission (as if that were morally right) and what he does by commission (as if that were morally wrong [as in euthanasia]). Medical procedures of omission and commission must he determined by the value of the patient as a person and not by clever definitions of terms. (3) As a refinement of point (2) Ramsey says that the real point of any medical procedure of omission or commission is that the doctor be humanely present with the dying and not treat him as a "ease." (4) A doctor' should never abandon a patient or hasten the death of a terminally ill patient except when medical treatment is "entirely indifferent to the patient" (p. 161, italics are his).

According to Ramsey one of the most distressing aspects of dying is not physical or medical, but psychological. One should not die in solitude. But this is so often the ease. The terminal patient is in a private room and allowed visits for only short periods of time. He eventually dies alone or in the presence of unknown hospital personnel. Ramsey thinks that it is not wrong for a patient to die at home. In the company of his loved ones he makes his transition from life to death surrounded by their love and comfort. Further, children, whom we so efficiently isolate from the terminally dl and the dying, learn that death is part of the cycle of human existence and not a sudden and foreign catastrophe that happens to people in hospitals.
Ramsey is not too anxious about heart transplants. The terrible psychological agony that the patients and the nursing staff go through has been documented for us in an article in Life (Thomas Thompson, "A New and Disquieting Look at Transplants," 71:56-71, September 17, 1971). Ramsey supplies us with a chart of disappointing results of transplants to the time of his writing (p. 232) which may be updated by referring to the article in Life.

To expect simple, direct, easy answers in medical ethics is to misunderstand the essential ambiguity of human existence.

Transplants throw an enormous responsibility on the doctor. Who shall receive the kidney or the dialysis machine or the new heart? The usual method of taking the decision and its awful burden from one doctor is to place it on the shoulders of a team within the hospital (doctors, nurses, social workers). The Swedish Hospital in Seattle has gone a further step (known in the literature as the Seattle Experiment). A committee within society' has been set up of knowledgeable laymen. They are given the documents on the patients with pertinent medical advice and they are left to make the decisions. Their identity is kept anonymous for obvious reasons.

On paper such a committee seems like an excellent idea, as now medical ethics is the concern of society and not medical experts whose range of concern must be too professionally limited. But the practice ran into a snag. To prefer one patient over another is to express a value judgment as to the worth of individuals. But there is no common value system under which Americans live. Is one life more valuable because of its meaning to the immediate family? Or, is the value of a life to be judged by its social worth? But what value among social values is the higher value? Is an ardent church member whose activities help an entire community more valuable than the pharmacist who is the important link between doctor and patient, yet who may never lift a finger for social reform?

The issues as I see them (in a summary way) are:

(1). Technological medicine is moving faster than our ability to assess ethically the decisions it summons us to make.
(2). Medical technology is becoming so complex that it is more and more difficult for laymen and perIsaps even well-read theologians to comprehend the factors involved and their complex inter-rclatediscss. For example, what does a doctor do when a patient is suffering from two or more catastrophic diseases at once where the treatment for one will cause death by the other, etc.?
(3). Team decisions, seem the easiest way out for "playing God" (an expression we should perhaps eliminate from future discussions because to turn one shovel of dirt and plant a potato is "playing God" in that it is not letting nature run its course!) in these catastrophic cases and perhaps in time we will "muddle through" to a common ethical ground.
(4). Christian theologians have wrestled with these problems and have supplied theological criteria. However this should not he sporadic but programmatic (as it now is in the Houston medical complex under the leadership of Kenneth Vaux). Furthermore, I believe that it should not only include medical experts and theologians but knowledgeable Christian laymen.
(5). Of the three men discussed Thielecke has given us the best model (which we could not adequately reproduce for reasons of space) for a theologian working ss itls Biblical materials and drawing guide-lines from them for medical ethics.

One of the most distressing aspects of dying is not physical or medical, but psychological.