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Emil J.N. Busch: Restoring the organism as a whole: Does NRP resurrect the dead?

18 comments:

1. John Lizza March 27, 2024 at 8:38 PM

In an early paper on why brain death is death, James Bernat, Charles Culver, and Bernard Gert (1981) argue that the irreversible loss of circulation and respiration serves as a criterion for determining death because it leads to the destruction of brain function necessary for the integration of the human organism as a whole. Busch correctly follows this view in his paper. However, his conclusion, "...it seems that we can claim with some confidence that death determination is not reversed or violated in cDCDD-NRP when circulation to the brain is effectively cut off" does not really follow from the article by Bernat et al (2023) that he cites. In that article, Berrnat et al ai raises serious issues about whether we can be sure that brain flow is cut off from the brain in cDCDD-NRP. There is also an article, "Neither Ethical, Nor Prudent: Why Not to Choose Normothermic Regional Perfusion" by Omelianchuk, Bernat, et al forthcoming in HCR in which this same concern about blood flow to the brain is raised.

2. David H March 29, 2024 at 12:32 PM

Does NRP c-DDCD with its circulatory cessation permanence kill the patient? Imagine that an MD decides not to resuscitate grandma and so takes her organs believing her cessation of circulation to be permanent. Another MD, perhaps on a court order, would have restored circulation but doesn’t given that grandma’s organs are taken – either he couldn’t restore without the organs or it is pointless. So the organ taking makes the cessation permanent, thus killing grandma. The action of organ taking, rather than omission of not restoring circulation, is responsible for cessation being permanent.

3. David H April 1, 2024 at 4:05 PM

Steve argued at the working dinner that clamping the blood flow to the brain was killing the patient. I agree, interrupting blood flow that would resuscitate the living person is making his death permanent, just as taking the organs in my above example. An intervention is making death permanent, not an omission to intervene. I am assuming the person is still alive just not breathing and circulating blood when the NRP starts. but I will try to be charitable. It may be that Busch thinks the person is dead as three necessary conditions for being dead from the President's commission discussion of the organism a whole. So the local perfusion would be not preventing the living from continuing to live or helping them live longer, but failure to being them back to life. That makes sense of the article title about resurrecting the dead. Busch thinks that the patient is dead, and only his organs are resurrected, so to speak. the clamp prevents life from being restored. there are two senses of permanence - the first is making the loss of respiration permanent which leads to the loss of integration of the whole and thus death. the second is permanently keeping the loss of integration from being reversed. I think Busch thinks the clamping is doing the second. I suspect that the clamping is doing the first, so it is killing.

4. Kurt B. April 2, 2024 at 12:56 PM

Hi David (and Steve), I liked the thought experiment about the court order and the “premature procurement” case, though I had a clarifying question. Are you thinking of it as the woman in the premature procurement case has already passed the five-minute rule that Busch talks about? If so, then grandma would be dead (according to Busch) and the procurement would be morally permissible. It might also raise a question about why another doctor would get the court order and disregard the five-minute test. Or, if she hasn’t undergone the five-minute test, then she still is “alive” and the procurement would be impermissible. But I guess this takes me to a larger concern about the five-minute test with respect to restored circulation.

Relating to your (and Steve’s) point about killing the patient, Busch says that “when blood flow to the brain is excluded, it is hard to argue that the circulation that is present is circulation that supports the functioning of the organism as a whole and enables the organism to perform its fundamental vital work” (p. 13). But, to maybe build on your concerns, I wasn’t sure what clamping the blood to the brain did for the view.

If what matters is not just replicating local function (as per the circulation cases excluding the heart and lungs) but restoring it so that the other organs auto-resuscitate and resume their unified function in the body as a living organism, then, either the brain will auto-resuscitate as an organ (and thereby the rest of the organism?) or it won’t by having blood go back to it.

While it’s not clear what happens in these cases empirically (Busch cautions against immediately taking the porcine results too readily), suppose that after a five-minute test, there are no signs of auto-resuscitation. Then, why not let the blood go back to the brain? One concern might be that by letting the blood go back to the brain, it would restore organic unity and genuine functioning to the organism. But I’m not sure that would be a bad thing because it would show that the patient isn’t really dead and, perhaps more importantly, that the five-minute rule is an unreliable way to determine death. Or, if it doesn’t result in auto-resuscitation (because the artificial blood-flow is causing the functioning, not the brain’s contribution), then there isn’t an issue with procuring the remaining organs.

Perhaps I’m missing something here though and maybe Busch wants to defend the idea that preventing circulation isn’t killing the patient, but is simply keeping them dead. This might be a causal distinction that doesn’t matter from a moral point of view (cp. Rachels on killing/letting die).

5. David H March 29, 2024 at 12:41 PM

NRP c-DDCD account of death might mean that there is no fact of the matter if someone is dead. At least this might be true if there are no facts about future (presentism or expanding block accounts of time). The patient is neither dead nor alive because there is no fact about whether permanent as the future doesn't exist yet.

6. David H March 29, 2024 at 12:42 PM

NRP c-DDCD is a bizarre modal/non-modal hybrid: there is the modal feature of auto-reversibility being impossible, but circulation need not be irreversible but just to have permanently ceased. I think that it should be modal or non-modal conditions throughout. So, the person is dead if he, in fact, won’t auto-reverse even if the point of impossible auto-irreversibility hasn’t been reached. Or the person is not dead if cessation isn’t irreversible but merely permanent.

7. David H March 29, 2024 at 12:43 PM

Strange mix of brain death criterion and circulation criterion: Typically, circulation is opposed to brain death. Shewmon thinks the brain is not the central integrator but merely modifies an existing life, its activity is not constitutive of life. Busch is suggesting that the person is dead undergoing NRP c-DDCD because circulation has not reached the brain.

8. David H March 29, 2024 at 12:47 PM

Death determinations should not treat intrinsic duplicates differently: NRP c-DDCD does. There could be two intrinsic duplicates, one is revived, and the other isn’t. So, one is dead, and the other isn’t.

9. Stephen Kershnar April 1, 2024 at 6:19 PM

SOME QUESTIONS FOR THE PRESIDENT’S COUNCIL OF BIOETHICS

Here is The President’s Council of Bioethics theory of death.

1. A person has died if and only if the organism as a whole has been defeated.
2. Whether an living organism has been defeated if the following capacities are lost.
(a) Openness to the world, that is, receptivity to stimuli and signals from the surrounding environment
(b) The ability to act upon the world to obtain selectively what it needs
(c) The basic felt need that drives the organism to act as it must, to obtain what it needs, and what its openness reveals to be available

Openness to the world is described as being manifested by consciousness or felt awareness.

However, it is unclear if the three capacities are necessary. Busch says, “three fundamental capacities that are required for this vital work of the organism.” Fundamental capacities and vital work sound like essential conditions.

Concern #1: Individually Necessary. It is unclear if the conditions are individually necessary.

Concern #2: Coma. I am not sure whether a person in a coma has consciousness or felt awareness. Perhaps all that is needed is a capacity. But note that (c) is not written as a capacity.

Concern #3: Animalism. I do not see any reason to see why this collection of conditions is better than animalism.

10. David H April 8, 2024 at 10:39 AM

President’s commission necessary conditions for death are too psychological: lack of conscious reaction to the world seems irrelevant but true. Sure, the dead aren’t thinking. But it isn’t important. On PAPI one could die but still be thinking if one becomes inorganic or cerebrum-size. So it is not a sufficient condition for still being alive. Maybe on animalism there could be a flicker of thought when freshly dead just as isolate cells and organs might still do something without integrated organism. Of course, a thinking corpse is something we may very much want to avoid. But a flicker of thought in a freshly dead corpse may not be so embarrassing.

11. Stephen Kershnar April 1, 2024 at 6:21 PM

ANIMAL TSURIS #1 – LIFE IS AN ACTIVE-AND-PARTICULAR OBJECT-MAKER (WITH A SNEAK ATTACK ON RELIGION)

Consider this problem for animalism.

(1) Animal. A person is an animal (a living organism).
(2) Life. An animal is a flow of material unified by a dynamic process (specifically, life).
(3) Imposing Form. Life is a complex, self-sustaining physical-chemical event that imposes constant form on ever-changing particles.

Consider a case in which an individual is frozen down to absolute zero and later unfrozen. Here are the possibilities.

A Replica The unfrozen individual is a replica. The life-process is essential to an individual.
B Persistence The individual persists the whole time. The capacity for life is essential to an individual.
C Gappy The individual exists, then goes out of existence, and then comes back into existence. A life-process, but not a particular life-process, is essential to an individual’s existence.

Account B is false. If a process – life – is necessary to make something (e.g., particles) into an individual, then when the process ceases to occur, the individual ceases to exist. In addition, a capacity is a disposition to make (or do) something and not itself a maker (or doer).

Account C is false. The particular process is the individual-maker. Replacing it with a similar process will not bring about the same object.

By analogy, an act is an event. If a person mid-act were frozen down to absolute zero and a year later unfrozen, he would complete a different act rather than continue the original act. Here I assume that a (basic) act is a basic event and a basic event is a change in a property in a thing.

Account A is true.

Note #1: Religion. This is bad news for Jews and Christians if they were to believe that an individual’s life process were to temporarily stop at Earthly death, which it does. The result would be that our replicas might enjoy heaven, but we won't.

Note #2: Irreversible. This might explain why death is irreversible.

12. Kurt B. April 2, 2024 at 1:37 PM

Hey Steve,
Very interesting points and objections. I wanted to ask more about this at dinner, but the topic changed. I was wondering a bit more about your replica example, specifically in cases of hibernation. In most cases of hibernation, the animal’s organs just slow down to a glacial pace. But some frogs, for example, freeze from the outside in. They don’t die because they produce a kind of antifreeze that keeps their cells from freezing, but, from what these articles tell me, their major organs and organ systems do freeze. So, for these cases, do you see them as replicas because they freeze and thaw with the seasons or do you see them still as continuous beings because they still remain somewhat unfrozen on a cellular level? I know it’s somewhat beside the point you made about absolute zero conditions, so I apologize if it’s off topic, but it did seem like an important borderline case.

https://new.nsf.gov/news/frozen-frogs-dont-croak#:~:text=The%20frog's%20heart%20stops%20beating,Fahrenheit%20(0%20degrees%20Celsius).

https://www.scientificamerican.com/article/how-do-frogs-survive-wint/

13. Stephen Kershnar April 1, 2024 at 6:22 PM

ANIMAL TSURIS #2 – GOD, GUNK, AND SILICON PARTS

Question for David Hershenov: Do brains exist?

(1) Option #1: Yes. If yes, the brain does the thinking in the body or animal similar to how a horn makes the sound in a car. And no amount of upstream causation or downstream effects will make this less plausible.

(2) Option #2: No. If no, then there likely is very restricted composition. Only simples and animals exist.

Objection #1: Gunk. Because space is infinitely subdivisible and, hence, objects are infinitely subdivisible, there are no simples. So, only organisms exist. How bizarre. The notion that we can subdivide something into distinct regions without the regions being proper parts is implausible.

Objection #2: God. God is neither simple nor an organism. Hence, he does not exist. Some animalists might secretly welcome this result.

Objection #3: Replacement. At one point, Eric Olson seemed to suggest that a person’s neurons – or other parts – can be replaced with silicon or metal parts. I do not see how this is possible if the person persists.

Objection #4: Continuum. Life both within a cell and between many cells is a matter of degree (that is, a smooth continuum) with no natural threshold. As a result, there is no significant difference between life and death. But there must be if death ends the existence of an object that can constitute the individual.

14. David H April 7, 2024 at 7:25 PM

Steve
I think it is better if we we stick to the article.

But if you insist, I will take the bait. the classical conception of God is that he is simple, not a material simple in space and time.

Gunk is a hypothesis with no scientific basis, no laws, no empirical support, no explanatory power, nothing but armchair hypotheses and a use of parts that is, at best, analogous to other uses. 1) Spatial parts are suspect as you can destroy all of the parts of the left side without destroying the left side. 2) You can also move all the parts of the left side, keeping them intact and in the same position relative to each other, and the left side doesn't go with the parts. the left side just moves to the right in both cases. 3) You can destroy all the parts of the right side and that will make the left side half of the size it was before. So the left side loses half of its parts without being causally impacted. I doubt things can be destroyed by destroying things outside their boundaries that don't causally impact anything within their boundaries.I find these three phenomena reason to doubt there is a left side. there is no causal connections between the parts of the left side making them into the left side. the left side is not a genuine part. so I don't think the move from spatial parts to gunk is satisfactory.

I suspect parts have causal powers. there is no z shaped object in your chest as it has no causal powers qua Z shaped part. I think the same is true for spatial parts.

I suspect the argument for induction is not very good. atoms have protons and electrons or quarks. not a great deal of inductive success in finding things composed of smaller things to suspect it continues forever.

There is a lot of literature on gunk and neither of us are very familiar with it or can recall it

15. David H April 8, 2024 at 10:13 AM

Steve
You like the embodied mind thesis. that is a capacities thesis. the person still exists when he is not thinking but is capable of thinking. What is essential and crucial for existence is a ready-to-hand capacity for thought. The capacity suffices.

The animalist can say the same thing - the animal exists when it is not alive but capable of life. It has the power (disposition) to think, it is just suspended. it is not lost so it is not a different life process when thawed. Everything is where it is in virtue of earlier life processes. In the case of the cryptobiotic organism (frozen or dehydrated tartigrades), all that is needed is heat or water and it springs back to life. so there is immanent causation between present and previous states.

I find it hard to believe that the frozen doesn't survive thawing nor is the same thing that was earlier not frozen. These are dispositions it possesses, and not dispositions that bring about its destruction as the entities don't blow up like the dispositions of a bomb or collapse and disintegrate as the disposition to die. I take it you don't think ponds cease to exist when they freeze.

By the way, there is no absolute zero so there is no possibility of there being no motion.

16. David H April 8, 2024 at 10:14 AM

Again, I recommend we stick to the article in this blog.

17. Catherine Nolan April 18, 2024 at 3:29 PM

Sorry I'm so late on this. I think the debate surrounding NRP-cDCDD sheds light on deeper problems with the circulatory criterion for death in the UDDA.

The whole reason that people (with common sense) want the word "irreversible" in a criterion for death is because they want to know that their organs won't be taken when they could still live.

Current practice in DCDD organ retrieval means taking vital organs when circulation has permanently stopped, *not* irreversibly stopped (or at least, that its cessation is not irreversible in the way that most people believe death is irreversible, and hence is not a sufficient criterion for death). This is already a problem for informed consent.

NRP cDCDD shows that in fact we can restore circulation and even the heartbeat of the donor, and that we have reason to worry about the oxygenation of the patient's brain.

I think Parent et. al. had an interesting insight in that "if irreversibility were interpreted as 'circulation has stopped and cannot be restarted,' then almost no one would be dead*, including donors involved in standard DCD."

*Obviously false - we've got thousands of years' worth of skeletons that can't have circulation restarted.