More dead than dead? Attributing mentality to vegetative state patients

In a recent paper, Gray, Knickman, and Wegner (2011) present three experiments which they take to show that people perceive patients in a persistent vegetative state (PVS) to have less mentality than the dead. Following on from Gomes and Parrott (forthcoming Gomes, A., &; Parrott, M. (forthcoming). Epicurean aspects of mental state attributions. Philosophical Psychology. [Google Scholar]), we provide evidence to show that participants' responses in the initial experiments are an artifact of the questions posed. Results from two experiments show that, once the questions have been clarified, people do not ascribe more mental capacity to the dead than to PVS patients. There is no reason to think that people perceive PVS patients as more dead than dead.     

Are there dead persons?

Schechtman’s ‘Person Life View’ (PLV) offers an account of personal identity whereby persons are the unified loci of our practical and ethical judgment. PLV also recognises infants and permanent vegetative state patients as being persons. I argue that the way PLV handles these cases yields an unexpected result: the dead also remain persons, contrary to the widely-accepted ‘Termination Thesis.’ Even more surprisingly, this actually counts in PLV’s favor: in light of our social and ethical practices which treat the dead as moral patients, PLV gives a more plausible account of the status of the dead than its rival theories.     

Is solo practice really dead?

For years, the demise of solo practice has been predicted as a consequence of the corporatization of health care, the rise of managed care programs, and the creation of preferred provider organizations (PPOs). The predictors of the demise are leaders in the health maintenance organization (HMO) and PPO movement and therefore have much to gain if solo practice dries up. A survey of a random sample of licensed psychologists in New Jersey was conducted to determine the current state of private practice. A 58% return of the anonymous questionnaire revealed that 87% were in solo practice; 90% were not members of any PPO; 92% received either no referrals or less than 5% from HMOs; and 92% indicated that their referral rates and practices have either stayed the same or increased in the past three years. Clearly the predictions as far as New Jersey goes are wrong! The findings are discussed in terms of economics, humanistic concerns, and political concerns.     

Handedness and stuttering: A dead horse?

A handedness questionnaire was administered to 446 stutterers and a control group. No significant male/female or stutterer/control effects were found, although both males and stutterers tended to be less right handed. The slight sex effect in handedness is consistent with previously reported studies and with cerebral structural and functional asymmetries.     

The dead donor rule: lessons from linguistics?

American society traditionally has assumed a univocal notion of "death," largely because we have only one word for it and, until recently, have not needed a more nuanced notion. The reality of death-processes does not preclude the reality of death events. Linguistically, "death" can be understood only as an event; there are other words for the process. Our death vocabulary should expand to reflect multiple events along the process from sickness to decomposition. Depending on context, some death-related events may constitute a more obvious discontinuity than others and more justifiably may be considered "death" within that context. There is no reason to assume a priori that there must be an overarching, unitary concept of death from which all diagnostic criteria must derive. Regarding organ transplantation, the relevant question is not "Is the patient dead?" but rather "Can organs X, Y, Z ... be removed without causing or hastening death or harming the patient?"     

The ‘living dead’ — Survivors of torture and psychosis

Regardless of all differences between patients who have suffered from psychotic breakdowns and those with the sequelae of torture, our experience have shown that some common features can be recognized. We can attempt to understand patients' experience of being ‘living dead’ in terms of regression to the ‘psychotic core’ in the personality, and in terms of actualisation and enactment of archaic relations to primary objects. The major difference between thee two categories of patients deals with a located, limited, and concrete traumatic event in the life of the torture-survivor, whilst in the schizophrenic individual the trauma also emanates from within through own destructiveness and rage. Regressive forms of relations toward distorted, aggressively cathected and persecutory primary objects are reestablished in both cases, leading to a more or less stable reorganisation of the ego. Difficulties in psychotherapy with schizophrenic patients and torture-survivors are here discussed as a consequence of the patients' persistently holding onto the distorted and regressive forms of relating to primary objects, when the projections of the patients' own destructiveness and hate is followed by a strong tendency to symbiotic merging.     

Abandon the dead donor rule or change the definition of death?

Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. One strategy would be to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law--such as authorizing procuring surgeons to end the lives of patients by means of organ procurement--and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those who would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained.     

The scientific status of unconscious processes: is Freud really dead?

At regular intervals for over half a century, critiques of Freud and psychoanalysis have emerged in the popular media and in intellectual circles, usually declaring that Freud has died some new and agonizing death, and that the enterprise he created should be buried along with him like the artifacts in the tomb of an Egyptian king. Although the critiques take many forms, a central claim has long been that unconscious processes, like other psychoanalytic constructs, lack any basis in scientific research. In recent years, however, a large body of experimental research has emerged in a number of independent literatures. This work documents the most fundamental tenet of psychoanalysis--that much of mental life is unconscious, including cognitive, affective, and motivational processes. This body of research suggests some important revisions in the psychoanalytic understanding of unconscious processes, but it also points to the conclusion that, based on controlled scientific investigations alone (that is, without even considering clinical data), the repeated broadside attacks on psychoanalysis are no longer tenable.     

When are you dead enough to be a donor? Can any feasible protocol for the determination of death on circulatory criteria respect the dead donor rule?

The basic question concerning the compatibility of donation after circulatory death (DCD) protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term “death” nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death can be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of “irreversibility” need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty.

     

J. J. Katz' logic of questions: New departure or dead end?

Philosophical Studies -     

The dead donor rule: should we stretch it, bend it, or abandon it?

The dead donor rule--that persons must be dead before their organs are taken--is a central part of the moral framework underlying organ procurement. Efforts to increase the pool of transplantable organs have been forced either to redefine death (e.g., anencephaly) or take advantage of ambiguities in the current definition of death (e.g., the Pittsburgh protocol). Society's growing acceptance of circumstances in which health care professionals can hasten a patient's death also may weaken the symbolic importance of the dead donor rule. We consider the implications of these efforts to continually revise the line between life and death and ask whether it would be preferable to abandon the dead donor rule and rely entirely on informed consent as a safeguard against abuse.     

The dead donor rule: how much does the public care...and how much should we care?

In this brief commentary, we reflect on the recent study by Siminoff, Burant, and Youngner of public attitudes toward "brain death" and organ donation, focusing on the implications of their findings for the rules governing from whom organs can be obtained. Although the data suggest that many seem to view "brain death" as "as good as death" rather than "dead" (calling the dead donor rule into question), we find that the study most clearly demonstrates that understanding an individual's definition of death is neither a straightforward task nor a good predictor of views about donation. Reflecting on the implications for ongoing debates over the dead donor rule, we suggest that perhaps it is not a change in policy that is warranted, but rather a change in the priorities that have garnered such intense focus on this issue within the field of bioethics.     

‘Martyrs as really as St Stephen was a martyr’? Commemorating the British dead of the First World War

Taking its cue from a phrase in a wartime sermon by the Bishop of London, Arthur Winnington-Ingram, this article examines the tensions between Christian and more secular approaches to the commemoration of the military casualties of the First World War. An initial overview of perceptions of sacrifice, martyrdom and Christian militarism in the early twentieth century is followed by discussion, in turn, of local war memorials, of the early policies of the Imperial (now Commonwealth) War Graves Commission, and of the arrangements for the dedication of the Cenotaph and the interment of the ‘Unknown Warrior’ in Westminster Abbey on Armistice Day 1920. At the local and institutional level a wide spectrum of approaches between the overtly Christian and the robustly secular were adopted, but national memorialisation required compromise and consensus. Hence it was agreed that the war cemeteries should include both a Cross of Sacrifice and Stone of Remembrance, and that there should be uniform headstones engraved with a cross or other religious symbol. Similarly the primarily (but not exclusively) secular ceremonial at the Cenotaph was seamlessly linked to the Christian funeral service for the Unknown in the Abbey. At the same time non-Christian faiths were accorded significant recognition. While other belligerent powers faced similar issues, and in some respects adopted similar solutions, in Britain there was nevertheless a distinctive and particularly pronounced blending of the Christian and the national which has had an abiding legacy.     

The last low whispers of our dead: when is it ethically justifiable to render a patient unconscious until death?

A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: (1) double-effect sedation, (2) parsimonious direct sedation, and (3) sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient’s consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected.