Paper addresses ethical issues in determining death and recommends clarification to Uniform Determination of Death Act

The American College of Physicians (ACP) has issued a new paper addressing current controversies about the standards for determining death, supporting a clarification to the Uniform Determination of Death Act (UDDA) but otherwise reaffirming the current UDDA and the ethical principles that are its foundation. The paper is published in Annals of Internal Medicine.

Highly publicized legal cases have challenged the standards used to determine brain death and clinical questions have arisen about the use of the word “irreversible” when death is declared, sparking re-examination of the UDDA. The Uniform Law Commission appointed a committee that has been debating whether to revise the 1981 UDDA, the legal standard in the United States.

Competing revisions have been proposed, including everything from eliminating brain death altogether to stipulating that brain death means only the loss of certain specified functions. Also of concern is the extent to which issues of organ transplantation and organ availability seem to be influencing efforts to modify the UDDA. While revisiting the more than 40-year-old UDDA is clearly indicated, ACP urges caution—and recommends that only a clarification revision is needed.

The paper also includes a glossary of important concepts and their definitions to further clarify these complex issues. Developed by ACP’s Ethics, Professionalism and Human Rights Committee, ACP believes physicians should advocate for policies and practices on the determination of death that are consistent with the medical profession’s fundamental commitment to individual patients and to the public and supports:

• Revising the Uniform Determination of Death Act to replace the word “irreversible” with “permanent” in clarifying the permanent cessation of circulatory and respiratory functions, but retaining the word irreversible in describing brain death (the “irreversible cessation of all functions of the entire brain…”).
• Maintaining circulatory and whole brain (neurologic) standards for determining death as separate, independent standards, consistent with current medical practice and with respect for established standards as well as for those cultures and religious traditions that accept only the circulatory determination of death.
• Retaining the whole brain standard for determining death according to neurologic criteria and opposing “higher brain” function standards.
• Aligning medical tests used for determining death with legal standards, not the other way around, asserting that medical criteria or tests should not be specified in the UDDA as they do not define death but rather, indicate whether death has occurred.
• Acknowledging that determination of death is a distinct issue from organ transplantation, and that the criteria for determining death should not be governed by the need to procure organs for transplantation.
• Calling for additional education for physicians, other clinicians, and the public about how death is determined and improving communication about the determination of death and dying process.