Commentary Whole-braindeath reconsidered- physiological ... · one whohas suffered whole-brain death is dead'. Is thatcorrect? Andwhatexactlydoesit mean? Thestatementis ambiguous:it

Journal ofmedical ethics, 1983, 9, 32-37

Commentary

Whole-brain death reconsidered-physiological facts and philosophy

C Pallis Reader Emeritus, Royal Postgraduate Medical School, Consultant Neurologist, Hammersmith Hospital

Author's abstractFour main areas generating confusion in discussion onbrain death are identified as a) the relation of criteria ofdeath to concepts ofdeath, b) the argument about whetherdeath is an event or a process, c) the inadequatedifferentiation of different neurological entities havingdifferent cardiac prognoses, and d) insufficientawareness of the separate issues of 'determining death'and 'allowing to die'. It is argued that ifby death we meanthe dissolution of the human 'organism as a whole', thenwhole-brain death is death. Behavioural patterns,legitimate in the presence ofa cadaver, should be legitimatefrom the time whole-brain death is diagnosed.

Discussions between philosophers and neurologists onthe subject of death require a double commitment. Asneurologists begin to differentiate their patients morecarefully, philosophers will have to ask their questionsmore precisely. And as philosophers probe deeper intowhat it really means to be alive, physicians will have toabandon some of their more traditional attitudes.Neither philosophers nor neurologists can any longeraccept death as a brute empirical fact, the recognitionof which is just a technical problem. Whether we real-ise it or not there are philosophical implications to bothour acts, and our failures to act. There is no harm inseeking to make our assumptions explicit. In factrecent developments in the fields of resuscitation andintensive care render the task imperative. And ifphilosophers wish their skills to help this endeavour,rather than hinder it, they will have to familiarisethemselves with these developments.Four main areas of confusion bedevil most discus-

sions about brain death. They concern:the kind of relation necessary between concepts ofdeath and criteria of death;what is meant by the 'biological fact' of death? Inti-mately related to this are the twin questions as towhether death is an event or a process, and whetherwhat is of clinical significance is 'death ofthe organismas a whole' or 'death of the whole organism';

the recognition ofthe important clinical, physiological,pathological and prognostic differences between thevegetative state, whole-brain death and death of thebrain stem. Unless agreed definitions are reached con-cerning these states, terminological problems soonrender meaningful communication impossible;The difference between 'identifying death' and'allowing to die'. Discussions about what have beencalled the 'uncomfortable dimensions of the care of thedying'(i) have nothing to do with identifying a deadbrain stem.

Concepts and criteria

Two boys were walking in a field, arguing fiercely. Onewas carrying a butterfly net, the other a mousetrap.Each was claiming that his was 'the better' instrument.They almost came to blows. A third boy (an obviouscandidate for a First in philosophy) came up and askedthe necessary question: 'Better for what?'.

This apocryphal tale emphasises that all talk aboutthe criteria of death - and ipso facto about 'better'criteria or 'new' criteria - must be related to someoverall concept of what death means. Dr Brownerightly stresses that important behavioural conse-quences flow from the recognition that a person isdead. But we cannot argue about whether a neuro-logical or a cardio-respiratory approach is 'better' forrecognising such a state, unless we are agreed on whatexactly it is that we are seeking to identify. When weconsider death, the tests we carry out and the decisionswe make should be logically derived from agreed con-ceptual and philosophical premises.

I find it a novel experience to have to argue with aphilosopher who asserts that 'even granting that ...important legal, moral and medical consequences flowfrom the determination of death . . . it still does notfollow that we ought to precise the definition of death'.Even more surprising is his statement that 'we canremove any uncertainty in practical affairs withoutfiddling with the definition of death'. Dr Browneseems here to be donning the garb of the pragmatic,unreflecting physician. It is not reassuring whenphilosophers, of all people, tell us that we can leave theconcept of death in. its present 'indeterminate' state,

Key wordsBrain death; whole-brain death; death; philosophy; medicalethics.

Whole-brain death reconsidered - physiological facts and philosophy 33

and that we should get on with the job of specifying'what can appropriately be done to whom' - and'when'. Dr Browne questions the desire to solve practi-cal problems by making definitions more precise. Hecalls it a temptation (implying it should be resisted). Ibelieve a more positive approach would be to acceptOscar Wilde's suggestion that 'the only way to get ridof a temptation is to yield to it'. I cannot endorse DrBrowne's view that in discussing death 'we should firstsettle the question of what behaviour becomes appro-priate when' - and even less his conclusion that 'thiscan be settled independently of the question ofwhen aperson is dead'.Dr Browne seems to be arguing for an ad hoc patch-

work of practices, of unspecified relationship to oneanother, and certainly unrelated to any overallphilosophical concept. I don't know if any school ofphilosophy exists whose main aim is to purgephilosophical awareness from the minds of humanbeings. If it does neurologists should caution theirphilosopher colleagues against it, for the only real al-ternative to an overall philosophical concept ofdeath isa set of arbitrarily assembled rules of conduct. Whowould issue such rules? On what basis? And would notthe issuing of edicts, unrelated to a widely discussedand generally accepted concept ofdeath, constitute thevery 'medical paternalism' Dr Browne so rightlydecries? History tends to show that when prescribedobservances and practices have no roots in generallyaccepted conceptual frameworks they face one of twofates: they are either abandoned (and sooner ratherthan later) - or they are only sustained by the imposi-tion of force. Is the latter what Dr Browne means whenhe quotes proposed empirical rules that threaten thosewho transgress them with 'the most severe sanctionavailable' to particular jurisdictions?

I have elsewhere sought to argue against what I havecalled 'free floating criteria of death' and to show how,historically, different concepts of death have necessi-tated the adoption of different criteria of death (2). Inthis context I have outlined my own concept ofhumandeath (to which criteria assessing brain stem functionare central). The full argument for defining humandeath as the 'irreversible loss of the capacity for con-sciousness, combined with the irreversible loss of thecapacity to breathe' cannot be recapitulated here.Briefly, this admittedly hybrid definition seeks tocombine philosophical and physiological con-siderations, The loss of the capacity for consciousnessand of the capacity to breathe relate to functional dis-turbances at opposite ends of the brain stem, while theformer is also a meaningful alternative to 'the depar-ture of the soul'. I believe the concept to be consonantboth with modern developments in the fields of resus-citation and intensive care, and with the endeavours ofmodern Man 'to secularise his philosophical under-standing of his nature' (3). The concept itself willalmost certainly have to be amended in the light ofdeveloping experience. But it provides, I hope, amomentary locus of coherence in a rapidly evolving

situation. Dr Browne, on the other hand, does notdefine death at all. This makes it very difficult to get togrips with what he writes. He seems opposed both to a'whole-brain' definition of death (p 3I) and to the iden-tification of the vegetative state with death. He quotesthe definition of death given in Black's Law Dictionaryand states he is against the redefmiition ofdeath 'in anyother way'. Does he then endorse the traditional defini-tion? He is nowhere explicit enough for this confi-dently to be asserted. The problem with the traditionaldefinition he quotes is that it is not really a definition atall, or at least not one that encompasses some of themore macabre by-products ofmodern technology. It ismy belief that ifthe concept of death is left 'indetermi-nate' - as Dr Browne advocates- one will not even needto invoke the principle ofindeterminacy to foretell thatsome of the decisions reached will prove irrational andharmful as well as arbitrary.

Death as an event or death as a process?Dr Browne claims that 'it is not a biological fact thatone who has suffered whole-brain death is dead'. Isthat correct? And what exactly does it mean?The statement is ambiguous: it can be interpreted in

two different ways. Is the 'biological fact' of death, towhich - according to Dr Browne - brain death does notrelate, the 'death of the organism as a whole'? Or is itthe 'death of the whole organism', that is the death ofeach and every one of its cells? Both are legitimateinterpretations ofthe 'biological fact' ofdeath, but theylead to very different conclusions.

If we accept the first interpretation (namely that the'biological fact' ofdeath relates to the dissolution ofthe'organism as a whole') Dr Browne's statement (that it isnot a biological fact that brain death is death) is self-evidently untenable. The very opposite would seem tobe nearer the truth, namely that only when the brain isdead can the individual (the 'organism as a whole') beconsidered dead. Whereas the functions of lungs andheart can (for a while) be taken over by a machine, thoseof the brain cannot. In this perspective the classicalcriteria of death (arrest of the heart beat and circula-tion) are only indicative of death when they have per-sisted for long enough for the brain to die. All humandeath, according to this view, is (and always has been)brain death. That is the position I hold.Would Dr Browne agree that a decapitated indi-

vidual is dead (as an independent biological unit, ie asan 'organism as a whole') from the moment the head issevered, irrespective of the fact that the heart may goon beating for some time? And if so, why? And what ifthe circulation had been closed prior to decapitation(the carotid arteries being joined to the jugular veins)?Would the resulting preparation, after decapitation, bealive or dead? The identity of brain death with deathhas been very perceptively realised by people with littleor no knowledge of physiology: we have been hangingand decapitating for centuries. We have only to think

34 C Pallis

of 'whole-brain death' as physiological decapitation forthe relationship to become crystal clear.What is it that is so important, anyway, about the

action of the heart? Only the hopelessly romanticwould consider it an end in itself. Surely cardiac func-tion is only relevant if it results in irrigation of thebrain? Is a frog alive, whose isolated heart is keptbeating in a test tube? Is a heart donor alive (even ifcremated) provided the heart he or she has donated isbeating vigorously in its new host? Is the recipientdead, because his own damaged heart has beenremoved and discarded, to make room for the new onehe has just received?Dr Browne's assertion that 'it is not a biological fact

that one who has suffered whole-brain death is dead'can be taken in a different sense, however, and onewhich is worth exploring. It could be taken to meanthat someone who is brain-dead (according to any ofseveral possible sets of criteria of brain death) will stillhave a beating heart, kidneys that can form urine, or aliver still able to conjugate bilirubin. Formulated inthis way, Dr Browne's statement is incontrovertiblytrue.The implicit (and unformulated) concept of death

underlying such a statement would be that a person canonly be dead when such activities cease. Biologicaldeath, according to this approach, is the death of 'thewhole organism', the death of all of its componentparts, the cessation offunction in each and every one ofits cells. But even irreversible asystole is not immedi-ately followed by biological death, defined in this way.Quite apart from the question of continued growth ofthe hair and nails, there is no doubt that cells with lowoxygen requirements (in skin, arterial walls and thematrix of bone) may remain alive for variable periodsafter the heart has permanently ceased to beat. Put-refaction would be the only criterion relevant to such aconcept of biological death.

Neither doctors (too busy with practical decisions toquestion, as they should, the philosophical implica-tions ofwhat they are doing) nor philosophers (usuallytoo concerned with conceptual problems to find time toascertain what is real and unreal in their speculations)have ever demanded putrefaction as a criterion ofdeath. Rightly, both are more concerned with cessa-tion of function of the 'organism as a whole' than withcessation offunction of 'the whole organism'. And herebrain-stem death begins to assert its relevance. Whenthe human organism has irreversibly lost the crucialcapacity for consciousness and the ability to breathe(and thereby to maintain a spontaneous heart beat),and when moreover it has lost such importantresponses to its environment as the homeostatic main-tenance of temperature and blood pressure (which aremediated through or by the brain stem), in what sensecan it be said to be an independent biological unit?

Technological developments (such as cardiac trans-plantation and our capacity, for a while, to maintain aheart-lung pteparation) make a redefinition of deathimperative. And it helps no one when the issue is

evaded, on the ground that to face it would generate a'conceptual crisis'. The known facts do indeed createsuch a crisis. In my opinion the challenge should bemet.

The vegetative state, whole-brain death, anddeath of the brain stem

Dr Browne is rightly concerned about what is ap-propriate behaviour in different clinical circum-stances. But several ofhis proposals and concerns are, Ithink, based on faulty physiological premises. Theseundermine the temporal aspects of much of his argu-ment. As a result the argument itself - at least for onefamiliar with the handling of such patients - has an airof unreality about it. He erects straw men - albeitperplexed straw men, constantly tormenting them-selves with impossible questions.

It is important, at this stage, to be careful about theterms we use. Take the words 'irreversible coma' forinstance. They have a venerable genealogy, but havecome to denote quite different states. They were firstused in the title ofthe classical American description ofwhole-brain death (the 1%8 report of the HarvardCommittee) (4). The Boston workers had spokenof 'irreversible coma' in an attempt to conveysomething of the flavour of 'coma d6passe' (literally astate beyond coma) which is how the French had origi-nally described whole-brain death in I959 (5). Thestate described by these various groups was not onlytotal death of the brain, but total death of the wholenervous system (in that areflexia of spinal origin wasalso demanded). Patients in 'coma depasse' had not onlylost all capacity to respond to external stimuli, theycould not even cope with their internal milieu: theywere poikilothermic, had diabetes insipidus, and couldnot sustain their own blood pressure. The cardiacprognosis of the condition was at most a few days, butsometimes as little as a few hours.

Unfortunately, the words 'irreversible coma' werelater used (quite inappropriately) to describe some-thing very different, namely the vegetative state (and itis as a synonym for this condition that Dr Browne usesthe words). The vegetative state was clearly describedby Jennett and Plum in I972 (6). For many years it hadbeen 'a syndrome in search of a name'. (The conditionis also known as 'neocortical death', the 'apallic state',or 'cerebral death'.) The vegetative state has a potentialprognosis of months or years. It usually results fromeither cerebral anoxia (which may devastate the corticalmantle of the brain while sparing the brain stem) orfrom impact injury to the head (which may massivelyshear the subcortical white matter, disconnecting thecortex from underlying structures). Other pathologicalprocesses may, on occasion, be responsible. Chroniccare units all over the world are full of such patients.Affected individuals open their eyes, and show al-ternating sleep-wake sequences. By definition theycannot be described as comatose, for coma is a state of

Whole-brain death reconsidered - physiological facts and philosophy 35

sleep-like unresponsiveness, from which the patientcannot be roused. (Empirical evidence is now over-whelming that coma, so defined, never lasts more thanabout three weeks. Comatose patients either developasystole during this period, or they open their eyes andpass into a vegetative state).

Although intermittently awake, patients in a vegeta-tive state exhibit no behavioural evidence ofawareness.Conjugate roving movements of the eyes are common,orienting movements rare. The patients do not speakor initiate purposeful movement of their limbs. Ab-normal motor responses to stimulation may often beproduced. The patients grimace, swallow and breathespontaneously, and their pupillary and corneal reflexesare usually preserved. They clearly have a workingbrain stem, but no evidence of function above the levelofthe tentorium. The words 'irreversible coma' shouldclearly be dropped when what is meant is the vegetativestate. Although the condition is usually irreversible,the patients are not comatose.No culture has ever considered patients in the veg-

etative state as dead, or suitable subjects for organdonation. No physician would be authorised, any-where in the world, to use the bodies of such patientsfor what Dr Browne calls 'certain experimental orinstructional purposes'. No doctor would be preparedto perform an autopsy on such a case, or to 'initiateburial procedures', or to do any of the other thingswhich Dr Browne lists as appropriate death-behaviour.Against whom then is he arguing when he repeatedlyraises the issue of such patients? For instance when hestates that according to the 'cerebral-death definitionof death [by which he means the vegetative state] aperson is dead as soon as he is in irreversible coma'?'Whose cerebral-death definition of death?' one may ask.That of philosophers? Idiosyncratic viewpoints aside,no authoritative medical or legal body has, tomy know-ledge, ever defined the vegetative state as death. In thereal world, there is no socially significant acceptance ofa 'cerebral-death definition of death'. Has Dr Browne,at times, confused whole-brain death with the vegeta-tive state? I suspect he may have. For instance to whatcondition precisely is he referring when he talks (p 30)about patients who are 'irreversibly comatose [ie inthe vegetative state] but have artificially supportedrespiration and heart beat'. Patients in the vegetativestate breathe spontaneously, so that it cannot be aboutthem that he is thinking. And patients who are'whole-brain' dead - and who require artificial respira-tion - are not in 'irreversible coma' . . . at least not inthe sense in which Dr Browne repeatedly uses theterm. In his whole discussion of the vegetative state heseems to be tilting at windmills with very blurrededges.There is, admittedly, a substantial body of medical

(and lay) opinion which holds that patients in a persis-tent vegetative state should be allowed to di,:. But evento envisage that the persistent vegetative state could beequated with death is both to confuse the issues of'allowing to die' and 'determining death' - and to

ignore some further fundamental differences betweenwhole-brain death and the vegetative state. The latter iseasier to describe than to define physiologically. In factit is doubtful whether it will ever be possible to define itwith the physiological rigour needed if practical steps(and behavioural patterns) are to flow from the defini-tion. The loss of cognition and affect (in the vegetativestate) cannot be quantitated in the way absent brain-stem reflexes can (in whole-brain death). The loss ofawareness (including self awareness) in the vegetativestate cannot be recognised as readily as a respiratorycentre incapable of responding to an arterial carbondioxide tension of 6.65 kPa. A second year medicalstudent could diagnose whole-brain death - but evenan experienced neurologist has difficulties in assessingthe various deficits in the vegative state. In a nutshell itis easier to test pupils than to be certain about senti-ence.Death behaviour is eschewed by relatives confronted

with the more severe forms of the vegetative statebecause open eyes, grimacing, swallowing and spon-taneous breathing are, rightly or wrongly, associated intheir mind with the capacity for awareness. Deathbehaviour is eschewed by doctors, in similar circum-stances, because it is widely felt that such behaviourwould be the first step along a very slippery slope. Ifthe 'irreversible loss ofhigher functions' (or the 'loss ofpersonal identity') were equated with death, thenwhich higher functions? Damage to one hemisphere orto both? If to one hemisphere, to the 'verbalising'dominant one, or to the 'attentive' non-dominant one?To the frontal lobes or to the parietal lobes? In next tono time leading politicians all over the world would bedeclared brain-dead.

I described the vegetative state in some detail so thatit should not be confused withwhole-brain death, whichis something very different. Brain-dead individualsexhibit no signs of neural function above the level ofthe foramen magnum. Brain-stem death is the physio-logical kernel of brain death, the anatomical sub-stratum ofthe physical signs encountered in the condi-tion (apnoeic coma with absent brain-stem reflexes)and the main determinant of its invariable cardiacprognosis: asystole within hours or days.Dr Browne conjures up visions of whole-brain dead

individuals, maintained on ventilators, being used as 'aself-replenishing blood or skin bank, a reservoir oftransplantable organs in the freshest possible condi-tion, a plant for manufacturing biomedical compoundsand so on'. In this he seems to be under a misappre-hension as to how long the heart may continue to beatwhen the brain stem is dead. I have summarised else-where (7) the published evidence concerning whathappens when brain-dead patients are maintained onventilators. Asystole invariably develops. Forinstance, ofthe 63 patients diagnosed as brain-dead in alarge Danish series (8) (and maintained on the ven-tilator) 29 developed asystole within 12 hours, io be-tween 12 and 24 hours, i6 in 24-72 hours, and theremaining 8 in 72-21I hours. Experience in Great

36 C Pallis

Britain (g) and elsewhere is in line with these observa-tions. The reasons why the heart stops within a shortwhile when the brain-stem-mediated baroceptorreflexes are disrupted, and when the vasomotor centreis destroyed, are complex but the empirical fact isestablished beyond all doubt.The twin pillars of Dr Browne's whole argument

have now been shown to be shaky. The categorisationof what is or is not appropriate death-behaviour isirrelevant in the context of patients in the vegetativestate (whom no one would consider dead). It is unreal,in practical terms, in the context of whole-brain death(because as soon as this state is diagnosed doctorsusually withdraw ventilatory support and the heartstops). Even if physicians did not act in this way, therepertoire of potential behaviour patterns possiblebetween the two events (the irreversible cessation ofbrain function and the irreversible cessation of heartfunction) would be strictly limited, for reasons oftime.And what if the heart could be permanently replacedby some mechanical device? It is impossible to predicthow prevailing attitudes would, by then, have evolved.But it will certainly be a meaningless question to ask,for those who still accept the framework of Black'sLaw Dictionary.

Death . . . and appropriate 'death-behaviour'

We are told that 'it has not been characteristic foradvocates [of a whole-brain concept of death] to ac-knowledge, let alone defend' its implications, and that'some weighty moral arguments' are needed beforethose who accept such a concept can justify 'death-behaviour' such as the harvesting of organs.

I do not see the need for special pleading whenconfronted with what I have called a 'beating heartcadaver', that is a dead patient in whom only a machine(maintaining ventilation) ensures a transient continua-tion of the heart beat. If one is convinced, sincere andlogical about one's conviction that whole-brain deathequals death, what one considers to be permissibleflows simply and without fuss. A death certificate may,for instance, be issued. And with proper respect for thesusceptibilities and wishes of the relatives all classicalcadaver-related behaviour becomes acceptable (dissec-tion, the removal of organs, the teaching of' anatomy,etc). No intellectual contortions are needed. The wholematter centres on the acceptability of the conceptualpremise, and on confidence that the clinical assessmenthas been meticulously carried out.Dr Browne and I would agree, I suspect, that what is

considered acceptable is culturally determined. We arenow in a state of transition in these matters. In manycountries brain death has achieved legal status and issynonymous with death (io). In some parts of theworld the concept of a 'beating heart cadaver' is widelyestablished, and not only among doctors. In California,for instance, a surgeon who transplanted the anoxicand discoloured kidneys of a brain-dead donor whose

heart had been allowed to stop would probably beguilty of malpractice. In other parts of the world, suchas Poland and Sweden, brain death is recognised anddisconnection from ventilators is permissible, al-though surgeons have to wait some 20 minutes until theheart has stopped before they can remove organs. Thisstate of conceptual schizophrenia cannot be expectedto last. It is striking how readily the relatives of brain-dead patients already accept the diagnosis. I recentlyinformed the nephews of a brain-dead patient that Ihad just diagnosed their uncle as brain-dead. 'That'sstrange', one of them said, 'I thought he died lastTuesday'.Those who think that 'weighty moral arguments' are

necessary seem to doubt that whole-brain-dead indi-viduals, maintained on ventilators, are 'really dead'.They imply (although seldom say so explicitly) thatsuch individuals are not really dead, and that whateveris done to them is somehow being done to 'persons'.The very use ofsuch terms as 'maintaining life-supportsystems' and 'the administration of health care' (whenapplied to the brain-dead) are examples of termino-logical sleight of hand. Playing on atavistic anxietiesgenerated by the presence of a still beating heart, thosewho reject the whole-brain concept of death seek tolure their opponents into terminological quagmires.The trap is easy to avoid if recognised. The best way toavoid it is to ask those who refuse a whole-brain defmi-tion of death to come out in the open, and give us theirown concept of death. To seek refuge behind legalisticdictionary 'definitions' that predate the developmentofmodern intensive care facilities - and which often arenot definitions at all - is just not good enough.There is finally something offensive - and not a little

paranoid - in the suggestion that those who want toredefine death (some would say, who want to define itadequately for the first time) are seeking a 'death jus-tification' to legitimise their practices. It is implied thatphysicians are seeking to change the definition ofdeathso that they may continue to do what they want, with-out being accused of practising euthanasia. There is nofoundation for this view. Brain death has a soundphysiological basis, in its own right. It had been identi-fied before renal transplantation got under way. And ifbetter methods were discovered for treating end-stagerenal failure, well run intensive care units would still beproducing whole-brain-dead patients, in increasingnumbers all over the world.Modern technology, in its desperate attempts to save

human life, has produced the entity we call braindeath. The conceptual problems this creates will not goaway, just because we choose to ignore them. Theredefmiing of death has become one ofthe more impor-tant challenges of modern medicine. In accepting thechallenge physicians need the creative help ofphilosophers, not proclamations of conceptualagnosticism.Dr Browne's arguments have been directed against

both a specific target of 'whole-brain death', and

Whole-brain death reconsidered - physiological facts and philosophy 37

against the more general target of any definition ofdeath in terms of brain function. I have attempted toshow why his arguments fail against each of thesetargets. I have suggested elsewhere, however, that justas brain death is the necessary and sufficient com-ponent of human death so is brain-stem death thenecessary and sufficient component of brain death(i i). Brain stem death can moreover readily be iden-tified clinically. But that is another issue.

References(i) Beresford H R. Cognitive death: differential problems

and legal overtones. Annals ofthe New York Academy ofScience I978; 315: 339-348.

(2) Pallis C. An ABC of brain stem death. British medicaljournal I982; 285: 1409-1412.

(3) Veatch R M. The definition of death: ethical

philosophical and policy confusion. Annals of the NewYork Academy ofScience I978; 315: 307-321.

(4) Ad Hoc Committee of the Harvard Medical School. Adefinition of irreversible coma. Journal of the AmericanMedicalAssociation 1964; 205: 85-88.

(5) Mollaret P, Goulon M. Le coma depasse (memoire pre-liminaire). Revue neurologique I959; 101: 3-15.(6) Jennett B, Plum F. Persistent vegetative state afterbrain damage: a syndrome in search of a name. Lancet1972; I: 734-737.

(7) Pallis C. An ABC of brain stem death. British medicaljournal i983; 286: 123-124.

(8) J0rgensen E 0. Spinal man after brain death. Actaneurochirurgica 1973; 28-: 259-273.

(g) Jennett B, Gleave J, Wilson P. Brain death in threeneurosurgical units. British medical journal I98I; 282:533-539.

(io) Pallis C. An ABC of brain stem death. British medicaljournal I983; 286: 209-2IO.

(iI) Pallis C. An ABC of brain stem death. London:British medical journal, I983.

Contributors to this issueAlan G Johnson is Professor of Surgery at the Univer-sity of Sheffield.

David Belgum is Professor ofreligion in the Universityof Iowa's School of Religion and Head of PastoralServices at University of Iowa Hospitals and Clinics.

Diana Brahams is a barrister practising in Lincoln'sInn London.

Malcolm Brahams is a solicitor practising in London.

Peter Ferguson is an undergraduate in his final year ofHonours in Scots Law at the University of Edinburgh.

John Havard is the Secretary of the British MedicalAssociation.

The Right Revd John Habgood is the Bishop ofDurham and has for nine years been Chairman of aworking group which has published a series of studieson various problems in medical ethics.

Kenneth M Boyd is Scottish Director of the Societyfor the Study of Medical Ethics.

Alister Browne is an Instructor in Philosophy at theUniversity of British Columbia, Capilano College andDouglas College. He has published in the areas ofphilosophy of mind, social philosophy and medicalethics (his current research interest).

C Pallis is Reader Emeritus at the Royal PostgraduateMedical School and Consultant Neurologist at Ham-mersmith Hospital, London.

Mark S Komrad is a senior medical student at DukeUniversity School of Medicine, Durham, NorthCarolina.

Brendan Caliaghan, sJ, (Society of Jesus), is a ClinicalPsychologist and Lecturer in Pastoral Theology atHeythrop College.

Gregory Stone is a barrister.

Luke Zander is a General Practitioner and Senior Lec-turer in the Department of General Practice, StThomas's Hospital, London.

Alastair Campbell is Senior Lecturer, Department ofChristian Ethics and Practical Theology, University ofEdinburgh.

Case conference editorRoger Higgs, 8i Brixton Water Lane, London SW2iPH.

American correspondentBernard Towers, Department ofPediatrics, University ofCalifornia at Los Angeles.