Smrt a filosofické myšlení Criteria for death

Marek Vácha 2011 Smrt a filosofické myšleníCriteria for death

Smrt • Konec života, ale i úleva od vezdejších strastí

Once a central ritual of social and religious life, death has been privatized, desacralized, hidden behind institutional walls, and implicitly made taboo. • (Singer, P.A., Viens, A.M., (eds.) (2008) The Cambridge Textbook of Bioethics. Cambridge University Press, p.67)

„Ještě před sto lety byla smrt něco „barokního“, něco drtivě přítomného. Mrtvý zůstával po svém „odchodu“ jistý čas ve svém rodném domě, byl navštěvován, byl provázen modlitbami, byl vnímán.“ • (Martin, E.P., Umění neotrávit se protijedy. in Žijeme v civilizaci smrti, nebo přechodu? Revue Prostor 86, str. 12)

Vytěsnění smrti • smrt se stala léčitelnou chorobou, abnormalitou

Velká světová náboženství jsou v zásadě přípravou na smrt (C.G.Jung)

Smrt • Téměř všechny společnosti na světě povolují zabití za určitých okolností: • ochrana manželky, dětí, sebe, (sebeobrana) • Národa (obranné či útočné války) • V některých společnostech existuje trest smrti, v některých lidské oběti (Mayové, Aztékové), v některých se praktikuje eutanázie • Řada společností toleruje sebevraždu

někdy se zdá, že člověk nějak ví, že zemře • jako by v něm zároveň běžely dva televizní kanály • ve vědomém se ubezpečuje a je ubezpečován že vše ve zdraví přežije a plánuje dovolenou na příští rok • v nevědomém ví, že to tak nebude • pacienti občas říkají protichůdné věci • lékaři často pracují jen s prvním kanálem, vědomým

Pitvy – situace v Thajsku • král Bhumibol oficiálně povolil pitvy • donor těla dostává titul ajarn yai – velký učitel

Pitvy

„Dobrý člověk na smrtelné posteli“kol. 1470dřevořez, tištěno v Ulmu „Obr. představuje stránku z jedná rané blokové knihy používané církví jako obrázkové kázání. Mělo věřícím připomínat hodinu smrti a naučit je – jak to říká jeho název – „umění dobře zemřít“. Dřevořez ukazuje pobožného muže na smrtelné posteli a vedle něj stojícího mnicha, který mu podává hořící svíčku.

„Dobrý člověk na smrtelné posteli“kol. 1470dřevořez, tištěno v Ulmu Anděl přijímá mužovu duši, která mu vyletěla z úst v podobě modlící se postavičky. V pozadí vidíme Krista a jeho světce, na které se má umírající v duchu obrátit. V popředí vidíme spoustu ďáblů nejošklivějších a nejfantastičtějších podob a nápisy, které jim vychází z úst, nám oznamují, co říkají: „Zuřím“, „Upadli jsme v nemilost“, „Jsem ohromen“, „Toto není žádná útěcha“, „Ztratili jsme jeho duši“. Jejich groteskní průpovídky jsou však marné. Člověk, jemuž je dáno dobře zemřít se nemusí pekelných mocností obávat.“ (E.H. Gombrich: Příběh umění)

Nedherlands, around 1460

Kdy je nejvhodnější začít s nemocným mluvit o smrti • „Neotevírejte před nemocným tento problém sami od sebe. Vyčkejte, až sám nastolí téma smrti a umírání. Bude-li hovořit o bolesti, hovořte o jeho bolesti. Jestliže vyjádří strach ze smrti, usedněte, vyslechněte ho a zeptejte se ho, z čeho konkrétně má obavy. Pokud si chce vyřídit nějaké záležitosti kolem pohřbu nebo sepsat poslední vůli ještě dlouho před tím, než se přiblíží smrti, nezkoušejte ho od toho zrazovat, ale sežeňte mu právníka a pomozte mu uspořádat jeho záležitosti.“ • (ElisabethKubler-Ross)

The Definition of death

Until the invention of the stethoscope and the acquisition of knowledge about human anatomy in the early nineteenth century, physicians were unable to diagnose death with precision. • the ability to do so provided them with great credibility from a public that had, until then been concerned about premature burial

PrematureBurial • Count Karnice-Karnicki, chamberlain to the Tsar of Russia, patented and marketed a device to prevent premature burial in 1896 (see panel). The apparatus allowed the buried to signal that he or she was still alive by activating a flag and ringing a bell.

PrematureBurial • It could be rented for a small amount of money and, after a length of time, when there was no chance of revival, the tube could be pulled up and used in another coffin. There is no record of what the success rate of these devices might have been.

In the modern ICU, physicians are able to break down the dying process, teasingapart each of its component parts and supporting some functions while providingtechnologicalreplacement for others. • the cascade of events that previously led to death is no longerinevitable. Before, if one vital function ceased, the othersquicklyfollowed • oncethought to be in the hands of God or fate, the time of death is now most often a matter of deliberate human decision

The Criteria for Death • seriouscontroversies over formallydefining death began with the invention of the positive pressuremechanicalventilator in the 1950s. • prior to the development of mechanicalventilators, brain injuries severe enough to induceapneaquicklyprogressed to cardiacarrest from hypoxemia. • before the 1950s, the loss of spontaneousbreathingondheartbeat ("vital function") were perfectpredictors of death because the functioning of the brain and of all other organsceasedrapidly and nearlysimultaneouslythereafter, producing a unitary death phenomenon. • it all happened at once

The Criteria for Death • with the advent of mechanical support of ventilation, the previousunitarydetermination of death becameambiguous • now patients were encountered in whom some vital organ functions (brain) had ceasedtotally and irreversibly, while other vital organ functions (such as ventilation and circulation) could be maintained, albeitmechanically.

The Criteria for Death • these patients resembleddead patients in that they could not move or breathe, were utterlyunresponsive to any stimuli, and had lost brain stem reflex activity. • but they also resembledliving patients in that they had maintainedheartbeat, circulation and intactvisceral organ functioning. • Were these unfortunate patients in factalive or dead? • Bernat, J.L., The Whole-Brain Concept of Death Remains Optimum Public Policy. Journal of Law, Medicine and Ethics 34, no. I (2006):35-43.

Death • a higher vertebrateorganism can reside in only one of two states, alive or dead: • no organism can be in bothstates or in neither • simply because we currentlylack the technical ability to alwaysaccuratelyidentify an organism´s state does not necessitatepostulating an in-between state. • death must be an event and not a process. • if there are only two exclusiveunderlyingstates of an organism, the transition from one state to the other, at least in theory, must be sudden and instantaneous, because of the absence of an intervening state.

Death as a process too early too late + organs are in good physiological condition + donor is certainly dead taking organs ethically impossible taking organs medically impossible

Without the pressing need for organs, the definition of death would remained on the back shelf, the conversation of a few interested philosophers or theologians

Mr. Smith is walking down the street and hs a massiveheartattack resulting in cardiopulmonaryarrest and loss of consciousness at time T1. Fourminutes later, at T2, he is discoveredlying on the sidewalk, is not breathing, and has no pulse. CPR is begun and a 911 call is placed. The EMS squadarrives and continues the resuscitationefforts as they transport the patient to the emergencyroom, where it is continued for a total of forty-fiveminutesfollowing T2 when the patient was found on the street. After forty-fiveminutes of resuscitation, there is no resumption of spontaneousheartbeat so the emergencyroomphysicians stop and declare the patient dead at T4. Since there is no good data on how long resusscitativeefforts must continuebeforedeclaring them a failure, it is likely that the situation becamehopelesssometimeearlier, between T2 and T4. Let us call this time T3. • Steinbock, B., (2009) The Oxford Handbook of Bioethics. Oxford University Press, Oxford. p. 295)

T1 ...lying on the sidewalk • T2 ...found on the street • T3 ....Mr. Smith is dead • T4 ...the physicians declare patient dead

The Definition of Death • definition • what functions are so essential that its irreversible loss signifies the death of human being? • criterion • determining that the definition has been fulfilled

Death • death is irreversible • by its nature, if the event of death were reversible it would not be death but rather part of the process of dying that was interrupted and reversed

The Definition of Death • by "death" it is not required the cesation of functioning of every cell in the body, • because some integument cells that require little oxygen or blood flow continue to function temporarily after death is customarily declared • "death" is not the cessation of heartbeat and respiration

The Definition of Death • RoberVeatch: • "the irreversible loss of that which is considered to be essentiallysignificant to the nature of man" • his projectattempted not to reject brain death, but to refine the intuitive thinking underlying the brain death concept by emphasizing that it was the cerebralcortex that acounted in a brain death concept and not the more primitive integrating brain structures • BUT that a higher-brain formulation of death would count PVS patients as dead... • ...despite their profound and tragicdisability. all societies, cultures, and lawsconsider PVS patients as alive

The Criterion of Death • the whole-brain formulation • USA and most parts of the world • cessation of all brain clinicalfunctionsincludingthose of the cerebralhemispheres, diencephalon (thalamus and hypothalamus) and brain stem • it does not require the loss og all neuronalactibities. Some neurons may strvive and contribute to recordable brain activities by an electroencephalogram, f.e. but not to clinicalfunctions • the higher-brain formulation, • popular in the academy but accepted in no jursdictionsanywhere • the brain stem formulation • accepted in the UnitedKingdom • the cardiacoption • some religious communities

The Criterion of Death • the brain has two major function: • the integrative functions of the brain stem • brain stem • capacity for consciousness and cognition • cerebral hemispheres

Another Approach • loss of vital fluid flow • circulation of blood and oxygen throughout the body • loss of functioning of the organism as a whole • irreversible loss of all brain function, including that of brain stem

Brain Death • Brain-dead patients´ • heartscontinue to beat spontaneously • they breath with the aid of a ventilator • the kidneysproduce urine • their pancreasproduce insulin • their liversmetabolizewasteproducts in the blood • In the earlystages of pregnancy. such "dead" patients can gestatefetuses for months until they are capable of livingex utero • Althoughinitiallyconsidered very unstable, better technology, persistence, and demands of familymembers have kept some brain-dead patients "alive" for up to ten years • Steinbock, B., (2009) The Oxford Handbook of Bioethics. Oxford University Press, Oxford. p. 288)

Brain Death • Brain-dead patients will never wake up and they will never breathe on their own. • Steinbock, B., (2009) The Oxford Handbook of Bioethics. Oxford University Press, Oxford. p. 290)

The Criteria for Brain Death • ...given by the Harvard Medical School Ad Hoc Committee, 1968: "total and irreversible loss of functioning of the whole brain" • unreceptivity and unresponsiveness • no movements or breathing • no reflexes • flat E.E.G of confirmatory value

The Criteria for Brain Death • Demonstration of coma • Evidence for the cause of coma • Absence of confounding factors, including hypothermia, drugs, and electrolyte and endocrine disturbances

Irreversibility • a lost function cannot be restored by anyoneunder any circumstances at any time now or in the future • loss of function cannot be reversed by thosepresent • this construal would preclude taking organs in DCD (Donation after CardiacDeath) protocols after two to fiveminutes because electricshock could restoreheartbeat • a function is reversiblylost if a morally defensible decision has been made not to try to reverse lost

The Criteria for Brain Death • Brain death cases are often very problematic to families, as the patient appears to have natural warmth and color, the EKG may be in sinus rhythm, and the chestrises and falls with each cycle of the ventilator. • Familiesviews these as signs of life and need time to be brought to an understanding of the truecondition. • Edge, R.S., Groves, J.R., (2006) Ethics of Health care. Thomson DelmarReading, New York. p. 203

Diagnostic criteria for brain death (American Academy of Neurology guidelines, 1995) • Demonstration of coma • Evidence for the cause of coma • Absence of confounding factors (hypothermia, drugs, electrolyte, and endocrine disturbances) • Absence of brainstem reflexes • Absent motor responses • Apnea • A repeat evaluation in 6h • Confirmatory laboratory (when specific components of the clinical testing cannot be reliably evaluated)

Coma • = a state of unarousable unresponsiveness in which the patient lies with the eye closed and has no awareness of self and surroundings (Posner et al., 2007). • These patients will never open their eyes even when intensively stimulated. • coma must persist for at least one hour. • In general, comatose patients who survive begin to awaken and recover within 2 to 4 weeks. • This recovery may sometimes go no further than the vegetative state or the minimally conscious state.

DiagnosticCriteria for Coma • Absence of eye opening even with intense stimulation • No evidence of awareness of self and their environment • Duration: at least one hour

Differences in brain metabolism measured in brain death and the vegetative state, compared with healthy subjects. Patients in brain death show an ‘empty-skull sign’, clearly different from what is seen in vegetative patients, in whom brain metabolism is massively and globally decreased (to 40-50% of normal values) but not absent.

The Test of Death • Brain death tests must be used to determine death only in the unusual case in which a patient´s ventilation is being supported • traditionalexaminations for death, in addition to testing for heartbeat and breathing, alwaysincludedtests for responsiveness and pupillaryreflexes that directlymeasure brain function • Bernat, J.L., The Whole-Brain Concept of Death Remains Optimum Public Policy. Journal of Law, Medicine and Ethics 34, no. I (2006):35-43.

how can we measure that the brain has been irreversiblydestroyed (that it has "died")? • ought we as a society or as individuals to treat an individual with a dead brain as a dead person? • this question is clearly not something about which the neurologicalcommunity can claim expertise • this is a religious, philosophical, ethical or public policyquestion, not one of neurological science

Donation after Cardiac Death • "In the currentpractice of organ donation after cardiac death (formerlyknown as non -heart-beating organ donation), I and othersraised the question of whether the organ donor patients were trulydead after only fiveminutes of asystole. The five-minute rule was accepted by the Instutue of Medicine as the point at which death could be declared and the organsprocured. Ours was a biologicallyvalidcriticism because, at least in theory, some such patients could be resusucitated after fiveminutes of asystole and stillretainmeasurable brain function. If that was true, they were not yetdead at that point so their death declaraltion was premature.

But thereafter I changed my position to support programs of organ donation after cardiac death. I decided that it was justified to accept a compromise on this biological point when I realized that donor patients, if not alreadydead at fiveminutes of asystole, were incipiently and irreversiblydying because they could not auto-resuscitate and no one would attempt their resuscitation. Because their loss of circulatory and respiratoryfunctions was permanent if not yetirreversible, there would be no differencewhatsoever in their outcomes if their death were declared after fiveminutes of asystole or after 60 minutes of asystole." • Bernat, J.L., The Whole-Brain Concept of Death Remains Optimum Public Policy. Journal of Law, Medicine and Ethics 34, no. I (2006):35-43.

After Death... • ...in real sense the family become the patients with whom the health practitioners are involved. • often the devices are turned down slowly so that cardiac failure takes place to simulate death

Smrt a filosofické myšlení Criteria for death