Friday, November 30, 2012

Brain Death Is Not The Death of the Human Being

1I wish to thank the staff of Communio for their assistance in editing the present
article. The editors’ help in giving more precise expression to some of my
philosophical ideas is especially appreciated. I am also indebted to Prof. Josef
Seifert for illuminating comments in the preparation of the manuscript.
Communio 39 (Fall 2012). © 2012 by Communio: International Catholic Review


• D. Alan Shewmon •

[My argument] has revealed the total absence of any compelling
philosophical or scientific reason to interpret brain-mediated somatic
integration as constitutive of the human organism; all the evidence is
compatible with, indeed, positively suggests, the conclusion that brainmediated
somatic integration maintains the organism’s health or promotes
its survival, but does not constitute it as a living whole in the first place. By
the same token, there is absolutely no compelling philosophical or scientific
reason to suppose that brain death, however total and irreversible, is ipso
facto the death of a human being as such . . .
[The] accusation that I am in conflict with Church teaching about death
relies . . . not only on a mischaracterization of my position, but also on a
mischaracterization of Church teaching itself. In point of fact, the
Magisterium does not formally oblige us to hold that the brain is the
master organ of somatic integration, or that its death is therefore the death
of the human being as such. Nor does the hylemorphism espoused by
Boethius, Aquinas, and the Council of Vienne entail any such claim.
You Only Die Once: A Reply to Nicholas Tonti-Filippini 423
2Nicholas Tonti-Filippini, “You Only Die Twice: Augustine, Aquinas, the
Council of Vienne, and Death by the Brain Criterion,” Communio: International
Catholic Review 38 (Summer 2011): 308–25.
3Ibid., 308.
4Ibid., 308.
5Ibid., 313.
6Ibid., 311.
7Ibid., 313.
I. Introduction
In “You Only Die Twice,”2 bioethicist Nicholas Tonti-Filippini
seeks to draw a line in the sand against the rising tide of what he
calls the “mentalist view” of death,3 which “argues in effect that
when a human being ceases to be able to function at those higher
levels of activity that we consider human or even sentient life, then
the person has died even if the body continues to function.”4 As an
alternative to mentalism, Tonti-Filippini defends a mainstream
integrationist version of brain death as the criterion for determining
when a human organism has died. Since, Tonti-Filippini argues,
bodily integration is mediated by the endocrine and nervous
systems, and since both depend on brain function, total irreversible
loss of brain function eo ipso results in loss of bodily integration and,
therefore, in the death of the human organism: The brain is
“essential for integration of the body and without it the parts of the
body cease to be an integrated whole.”5
Tonti-Filippini regards the integrationist account of brain
death as the centerpiece of an empirically airtight case against
mentalism, but he also insists on its compatibility with Church
teaching, in particular with that of “the Council of Vienne, which,
following Boethius and Aquinas, adopted the notion of the unity of
the human person with the soul as the substantial form of the
body.”6 Indeed, Tonti-Filippini even goes so far as to suggest that
in recent times the account of brain death that he favors has been
endorsed by the Church’s Magisterium in the person of Pope John
Paul II.7
For Tonti-Filippini, then, the mainstream account of brain
death is a godsend to loyal Catholic bioethicists, a weapon against
424 D. Alan Shewmon
mentalism that is at once empirically unassailable and
philosophically-theologically orthodox. By the same token, he
considers my theoretical and empirical challenge to mainstream
thinking about brain death to be unsound scientifically and out of
keeping with Church teaching, which in Tonti-Filippini’s view is
committed to the proposition that total irreversible loss of brain
function is (a sure sign of) the death of a human being.
In what follows, I will argue that Tonti-Filippini’s critique
of my position is wrong on both counts: Neither the empirical
evidence nor Church teaching requires us to hold that the brain is
“essential” for organismic somatic integration, or that the brain’s
death is automatically the death of a human being. My aim,
however, is not simply to refute Tonti-Filippini’s charges against
me, but also to show that the integrationist account of brain death
is not at all the empirically sound, theologically-philosophically
orthodox godsend that he asserts.
In the next section of the paper (II. Brain Death: Sharpening
the Question), I propose to work out a philosophical framework for
understanding somatic integration and the role the brain plays in it.
The following section (III. A Bold Assertion) will then apply this
framework to the available empirical evidence, all of which suggests
that the integration accomplished by the brain, rather than
constituting the human organism, only maintains its health or
promotes its survival. Having presented my case against the somatic
integration rationale for the brain death criterion, I will conclude
(IV. Conclusion: What Does the Church Really Teach?) by
rebutting Tonti-Filippini’s charge that my position deviates from
Catholic orthodoxy, which does not in fact declare brain death to be
death, end of story. Tonti-Filippini’s attempt to wrap himself in the
mantle of Catholic doctrine reveals more about his own flawed
hermeneutic of the Magisterium than it does about the actual
substance of the magisterial statements he invokes.
II. Brain Death: Sharpening the Question
Tonti-Filippini’s article is full of inaccuracies, small and large. One
of the largest pertains to his treatment of Augustine, whose position
about the unicity of the human soul he very seriously
You Only Die Once: A Reply to Nicholas Tonti-Filippini 425
8“You Only Die Twice,” 315.
9Ibid., 320.
10Catechism of the Catholic Church, no. 365,
ccc_css/archive/catechism/p1s2c1p6.htm, accessed 21 October 2012.
mischaracterizes. A full exposure of this and other
misrepresentations must wait for another occasion; for now, let me
briefly clarify my view of death in general and of brain death in
particular, as this clarification will help bring into focus the guiding
thread of the argument that follows.
Tonti-Filippini consistently labels me a “somaticist.” He
also ascribes to me the view that a brain-dead body is alive because
of integration merely at the level of organs and not at a holistic
level. For example, Tonti-Filippini states that he “aim[s] to defend
the Church’s adoption of the loss of integration view” not only
against the President’s Council’s “mode of being view” but also
against the somatic integrationists, such as Shewmon.
Shewmon fails to take into account the intercommunicative
meaning of the body as an integrated whole. . . . Evidence of
communication between some parts of the body is not the same
as the body retaining evidence of unity of the whole body.8
In a similar passage, we read that
Shewmon does overlook the intercommunicative meaning of
integration. What he considers to be ‘integrative’ is something
less than would seem to be meaningful in the context of
considering that death is the separation of the life principle or
soul from the body.9
The truth is that Tonti-Filippini seriously misrepresents my
view of death, portraying it as if it were opposed to the Church’s
“integrationist” view. In matter of fact, however, I hold, along with
the Council of Vienne, and with Tonti-Filippini himself, that the
soul is the substantial form of the body. I also subscribe to the
Catechism of the Catholic Church’s reaffirmation of this teaching and
its emphasis on the unity aspect.10 Finally, I endorse every word of
John Paul II’s description of the death of a human person as “a
single event, consisting in the total disintegration of that unitary and
426 D. Alan Shewmon
11John Paul II, Address to the 18th International Congress of the
Transplantation Society (Rome, 29 April 2000), 4, http://www.vatican.
_spe_20000829_transplants_en.html, accessed 21 October 2012.
12D. Alan Shewmon, “Recovery from ‘brain death’: a neurologist’s Apologia,”
Linacre Quarterly 64, no. 1 (1997): 30–96. D. Alan Shewmon, “The brain and
somatic integration: insights into the standard biological rationale for equating
‘brain death’ with death,” Journal of Medicine and Philosophy 26, no. 5 (2001):
457–78. D. Alan Shewmon, “Mental disconnect: ‘Physiological decapitation’ as a
heuristic for understanding ‘brain death,’” in Marcelo Sánchez Sorondo, ed., The
Signs of Death. The Proceedings of the Working Group 11–12 September 2006 (Vatican
City: Pontificia Academia Scientiarum, Scripta Varia 110, 2007), 292–333. D. Alan
Shewmon, “Constructing the death elephant: a synthetic paradigm shift for the
definition, criteria, and tests for death,” Journal of Medicine and Philosophy 35, no. 3
(2010): 256–98.
integrated whole that is the personal self. It results from the
separation of the life-principle (or soul) from the corporal reality of
the person.”11
It seems to me, then, that both Tonti-Filippini and I agree
that a holistic integration of the body is evidence of life. Where we
disagree is the question of whether a body with irreversible loss of
brain function instantiates death according to the integrationist
view that we both share. He says it does, I say it does not. The
reasons why I say it does not have been set forth in previous
publications.12 Nevertheless, I would like to clarify them again here.
Before doing so, however, I want to highlight two
fundamental assumptions on which Tonti-Filippini’s defense of the
brain criterion rests, namely, (i) that the brain is the master organ of
organismic somatic integration and (ii) that this assertion regarding
the brain somehow follows from the Council of Vienne’s embrace
of hylemorphism. Consider the following key statement:
We can take from the doctrine proclaimed at the Council of
Vienne that the ongoing causative effect of the soul is its
informing the body. Therefore the type of integration that is
relevant is a communication of information to all parts of the
body. Because integration implies unity, the type of integration
that is relevant is the transfer of information that keeps the body
united and hence a single whole. On these grounds I would
argue that Shewmon and others are wrong to claim that the
type of integration that may subsist in a body after loss of all
You Only Die Once: A Reply to Nicholas Tonti-Filippini 427
13“You Only Die Twice,” 318f.
brain function is relevant. The transfer of information merely
between one part of the body and another is insufficient to
establish that the soul has not separated from the body.13
Tonti-Filippini’s argument in this passage is that the
hylemorphic information of the body by the spiritual soul requires
“information” transfer over the whole bodily organism (rather than
only between one part of the body and another), that such transfer
depends essentially on a central organ, and that this central organ
must be the brain. Unfortunately, Tonti-Filippini never explains
why hylemorphism entails a single master organ of somatic
integration, or why this single master organ must be the brain.
It is hard to resist the impression that Tonti-Filippini
unconsciously assumes an unfortunate picture of the brain as a kind
of hardware by means of which a psychic software program
exercises control over a set of movable robotic parts. But if Tonti-
Filippini repudiates this dualistic and mechanistic image of
ensoulment, on what grounds does he say that hylemorphism
necessarily requires the brain as the master organ of somatic
integration, or, indeed, necessarily requires any one such master
organ at all?
Tonti-Filippini of course claims that the empirical evidence
supports, or even commands, this conclusion, but he appears to
read that evidence through the distorting lens of a fundamental
petitio principii. For even if we grant his rather quick move from the
soul’s “informing the body” to “information transfer” (or is he in
fact equivocating on the word “information”?), we still need to ask
what kind of “information transfer” is constitutive of organismic
integrity and what role the brain actually plays in it. Might there not
be a kind of “information transfer” that, materially speaking, is
sufficient for organismic somatic integration, yet doesn’t require a
functioning brain? Whatever his intention, Tonti-Filippini’s failure
to consider this possibility is a form of question-begging that
vitiates his defense of the brain death criterion. This will become
more evident as we pursue the argument through the rest of this
section (II) and the whole of the next (III).
428 D. Alan Shewmon
14Ibid., 319.
15D. Alan Shewmon, “The brain and somatic integration.”
16“You Only Die Twice,” 318.
A. A philosophy of integration
“I am inclined,” Tonti-Filippini writes, “to conclude that it is
difficult to hold that functional unity of the body can exist when a
major part, the brain, is no longer functioning. The remaining
integration can only be partial.”14 What Tonti-Filippini seems to assert
here is that the interactions among the various parts of a brain-dead
body are insufficient to unify those parts into a true organismic
whole, and that what is left of unity in a brain-dead body is not the
bearer of any sort of “integration,” but simply a set of “interactions”
at the level of organs. The issue is this: Does a brain-dead body
possess integrative unity or is it a mere collection of interacting
organs in a bag of skin?
There is no developed philosophy or science of
“integration” cited in the extensive brain death literature, so in that
respect we are in uncharted territory. Ironically, however, one of
Tonti-Filippini’s criticisms of my position actually involves a
helpful hint, which he does not develop in his article but which I
shall develop here into a preliminary framework for understanding
and categorizing “integration.” These ideas build upon what I
published on somatic integration back in 2001,15 and I must thank
Tonti-Filippini for having provoked this further development of
thought. The key word is “type” of integration. Tonti-Filippini
Therefore the type of integration that is relevant is a
communication of information to all parts of the body. Because
integration implies unity, the type of integration that is relevant
is the transfer of information that keeps the body united and
hence a single whole.16
On these grounds I would argue that Shewmon and
others are wrong to claim that the type of integration that may
subsist in the body after loss of all brain function is relevant.
The transfer of information merely between one part of the
body and another is insufficient to establish that the soul has not
separated from the body. . . . Most of the examples that
You Only Die Once: A Reply to Nicholas Tonti-Filippini 429
17Ibid., 319.
18James L. Bernat, Charles M. Culver, and Bernard Gert, “On the definition
and criterion of death,” Annals of Internal Medicine 94, no. 3 (1981): 389–94.
Shewmon has given of integration in someone who lacks all
brain functions do not involve integration in the sense of a
communication that unites the parts of the whole.17
Unfortunately, Tonti-Filippini nowhere explains what he
means by “type” of integration, or how many types he thinks there are,
or how they are to be distinguished in practice. Reading between the
lines, I suspect that “type” is actually a misnomer for “level” of
integration. What Tonti-Filippini accuses me of is asserting that
interactions at the level of organs and tissues, and not at a holistic level,
suffice to establish bodily unity and the soul’s informing presence. In
fact I have never asserted such a thing (vide supra), but rather have
maintained that a holistic level of integration does occur in at least some
brain-dead bodies—a very different proposition.
In order to make this case, I propose an account of the
distinction between “level” of integration and “type” of integration
below. In working out this distinction, however, we need to keep
in mind at all times the following fundamental principle.
The “wholeness” that integration brings about is not to be
understood in the sense of structural or functional completeness.
James L. Bernat and colleagues were quite right to emphasize, in
their seminal 1981 paper and subsequently, that what counts is not
whether there is a “whole organism” but rather whether there is an
“organism as a whole.”18 An amputee may not be structurally
complete but is no less an “organism as a whole” than a full-bodied
person. Someone blind or hemiplegic may not be functionally
complete but is just as much an “organism as a whole” as a fully
functioning person.
1. Levels of integration
We can distinguish two kinds of levels of integration corresponding
to two different ways of looking at the human body: either as a set
of increasingly encompassing structures and functions (“structural430
D. Alan Shewmon
19Trunk, limbs and head could possibly be considered an additional level,
structurally analogous to body systems, which are defined more functionally. It is
not so clear at what level of integration various kinds of bodily tissues and fluids
should be categorized; it is possible that they lack sufficient distinctness and
wholeness for the concept of “integration” to apply. A compulsive theorist might
also want to add levels below organelle, from macromolecule all the way down to
quark. Such issues need not be decided here.
20Despite the fact that systems, organs, cells, etc. are parts of an organism, the
term “integration” still applies analogically to each of them, because each has a
structural and functional distinctness from the other parts, and each possesses a
certain unity. A liver in an organism is legitimately considered a “whole” liver,
with its own subsidiary level of integrative unity, even though it is not a whole
organism. The same is true of the other parts and levels of the organism.
21For example, removal of one kidney reduces renal structure by half but does
not diminish renal function (only its margin of reserve). Conversely, a body can
be in renal failure despite possession of two whole kidneys. Although the
nonfunctioning kidneys might appear intact macroscopically, they would not be
structurally intact at the microscopic or molecular level. The same can be said
about various other organs and systems, such as the lungs or the blood, whereas
functional” levels) or as a hierarchically graded display of vital
operations rooted in the human soul (“vital-operational” levels).
a. Structural-functional level
For “higher” organisms, at least five structural-functional levels can be
distinguished: organism, body system (digestive, immune, etc.),
organ, cell, and cellular organelle.19 I call these levels “structuralfunctional,”
because they involve both structures and, mutatis
mutandis, their associated functions. The structural-functional level
is determined not only by relative size and degree of complexity, but
also by the kind of organism and its stage in the life cycle: a onecelled
human zygote is an integrated human organism, but a
fibroblast growing in a culture dish is only an integrated human
The relation between structural completeness and
functional adequacy is complex. At any given level, structure and
function are inherently linked, but in such a way that function
cannot exist in the absence of some underlying structure (how
much varies), while a structure can exist without functioning.21
You Only Die Once: A Reply to Nicholas Tonti-Filippini 431
with still other organs, such as the heart or an eye, removal of half or even just a
small part of it (depending on which part) can eliminate its entire function.
Obviously there are limits to the extent that an organism,
organ or cell can be reduced by mutilation and still remain that
organism, organ or cell. The limit will vary according to the type of
thing and the type of mutilation under consideration; no generally
applicable criterion can be given, and in many cases (if not all) the
limit will be surrounded by an epistemic “gray zone” of uncertainty.
Fortunately for our topic, it is not necessary to have to be able to
solve all possible thought experiments involving progressive
mutilation in order to be sure that brain-dead bodies are neither in
that “gray zone” nor on the other side of it.
Before proceeding to the next subsection, let us recall the
fundamental principle that “organism as a whole” is not
synonymous with “whole organism.” Structural or functional
incompleteness, to lesser or greater degrees, does not per se vitiate
the integral wholeness of an organism. The same concept applies at
every level: a brain following a mild stroke is still a “brain as a
whole,” and a cell minus some of its mitochondria or affected by a
not-quite-lethal toxin is still a “cell as a whole.”
b. Vital-operational level
We can also distinguish at least three main levels of vital integration,
each of which physically expresses one of the main kinds of vital
operation rooted in, though not identical with, the essence of the
soul: vegetative, sensorimotor, and intellectual-volitional.
Vegetative-level integration is the most basic, involving
nutrition, metabolism, growth, self-assembly and self-maintenance,
etc. It is intrinsic to life in general. It occurs in and among all cells
and organs of an organism, and embraces many sublevels and
degrees of complexity (down to some minimal qualitative limit,
below which there is no life). Integration at the sensorimotor level
is carried out by the nervous system in conjunction with the
sensory organs and muscles. It too features many sublevels. For
example, our unified and seamless experience of vision results from
synthesis within the brain of many integrative subprocesses such as
432 D. Alan Shewmon
22I am assuming that an embodied human being is by definition a human
organism. If a consensus definition of “organism” is reached such that the brainin-
a-vat would not qualify, then the terminology in this article would need to be
edge detection, motion detection, color perception, shape
identification, etc. The human body’s highest vital integration
involves those brain processes that participate in (and are necessary
for properly human, as opposed to angelic) spiritual activities:
concept formation, language, self-awareness, intention and
voluntary action. Here, too, there are many sublevels and degrees
of complexity (underlying types and degrees of cognitive abilities or
The subordinated structural-functional levels of integration
within an organism may stand in different relationships to the vitaloperational
levels of integration. For example, the functions of the
respiratory and circulatory systems are more crucial for the
immediate vegetative survival of the organism than that of the
nervous system, while the functions of the nervous system are more
decisive for the exercise of the hierarchically highest dimensions of
human rational life.
c. Resolving discrepancies between types of levels
Structural-functional and vital-operational levels of integration are
distinct, but they are also mutually relevant. Their joint
consideration therefore provides a basis for determining how
discrepancies between them affect the organismic status of a human
body. In particular, we need to consider what happens to the
organism when the highest structural-functional level—that of the
body as a whole—coexists with a physical impediment to the
exercise of the higher vital operations.
Consider two dissociative extremes of a disabled “organism
as a whole”: disabled human organism A with the highest vital
operation (rationally conscious life) but only an organ level
structural-functional completeness (the brain), and disabled human
organism B with structural-functional integration at the whole
body level but with vital-operational integration only at the
vegetative level.22
You Only Die Once: A Reply to Nicholas Tonti-Filippini 433
modified accordingly.
23In a previous article I referred to the brain-in-a-vat as a “conscious nonorganism”
(D. Alan Shewmon, “On conscious non-organisms, unconscious
persons, and bisected person-organisms,” American Philosophical Association
Newsletter 9, no. 1 (2009): 14–18). After the subsequent three years of reflection,
I think I prefer to call any embodied human person a human organism, even if all
that is left of his original body is only a brain, for which the vat and its contents
would of course have to serve as an artificial body. A preliminary foray into a
philosophy of organism has been made by Bonelli et al., in Raphael M. Bonelli,
Enrique H. Prat, Johannes Bonelli, “Philosophical considerations on brain death
and the concept of the organism as a whole,” Psychiatria Danubina 21, no. 1 (2009):
3–8. They propose four criteria for life in general and four additional criteria for
an organism as a whole. Although they argue that brain-dead bodies do not fulfil
the latter criteria, I would maintain that if their criteria (accepting them for the sake
of argument) are understood in such a way as to judge that a moribund, almostbut-
not-quite-brain-dead patient with multisystem failure in an intensive care unit
is still a living organism-as-a-whole, then those same criteria would also qualify a
brain-dead body as a living organism-as-a-whole. This line of reasoning will be
further developed below.
24This thought experiment rests of course on the unproven assumption that the
brain-in-a-vat would be supporting the full consciousness of the same person,
from whose previously intact body it was extracted. There is an almost sacred
mysteriousness enshrouding the question, which cannot ever be empirically
investigated in an ethical manner. Example A is mentioned here simply to
illustrate, through the starkest contrast with example B, the principle for resolving
structural-hierarchical discrepancies. More realistic but less symmetrical (and less
entertaining) comparisons could also be made. For further discussion of the
uncertainties surrounding isolated-brain and brain-transplant thought experiments,
see Josef Seifert, “On ‘brain death’ in brief: philosophical arguments against
equating it with actual death and responses to arguments in favour of such an
To illustrate example A, compare two living human organs
technologically maintained in respective vats: one a kidney and the
other a brain. The kidney is merely an organ, because its structural
wholeness is obviously at the organ level, its function is at the organ
level (production of urine), and, in vital-operational terms, its
integrative function is at the vegetative level. The envatted brain, on
the other hand, despite being structurally also an organ,
nevertheless ex hypothesi supports the rational consciousness
characteristic of a human organism.23 The absence of many lowerlevel
acts would certainly be severely disabling but it would not
entitle us to conclude that the brain-in-the-vat was not a living
human organism.24
434 D. Alan Shewmon
equation,” in Roberto de Mattei, ed., Finis Vitae: Is Brain Death still Life? Consiglio
Nazionale delle Ricerche (Soveria Mannelli: Rubettino, 2006, 2007), 189–210. For
a critique of the explanatory utility of thought experiments in general, see Kathleen
V. Wilkes, Real People: Personal Identity Without Thought Experiments (Oxford:
Clarendon Press, 1988).
25Obviously a permanently vegetative human body is not structurally complete
stricto sensu: parts of the brain are damaged; but this does not undermine the
structural integral wholeness of the organism. Also, it should be emphasized that
example B is about a true “vegetative state,” not some misdiagnosis of “super
locked-in syndrome” or another inwardly aware but externally unresponsive state.
The difficulties of establishing that distinction in practice are beside the point of
the example.
In example A, then, we find that the hypothetical exercise of
the highest vital-operational activity in the brain-in-a-vat suffices
to establish the existence of a live human organism, despite its
abnormal situation with respect to organ-level structure.
Note, however, that the vat (and its contents) would have
to provide the functional equivalent of a human body, which in the
normal case is both a necessary condition of the brain’s facilitation
of rational consciousness and the basic reference-point of that
consciousness itself (in that I am aware of myself, not of my brain).
Contrary to what we might suppose, then, the thought experiment
of the brain-in-the-vat does not in fact entail that the brain alone is
the master organ of somatic integration, but merely that it plays a
necessary role in man’s exercise of rational consciousness.
What, then, about example B? The human organism does
not lose its organismic status even when it becomes physically
incapable of manifesting sensitive or rational vital operations due to
some defect in its higher-level neural integration. Exercise of vital
operation at the structural-functional level of organism therefore
suffices to assure us that (1) we are still dealing with an organism
despite that vital operation being only at the vegetative level, and
that (2) by virtue of the unity of the human soul, the organism we
are dealing with is still rationally animate. Hence example B: If an
otherwise structurally complete human body survives while
exercising only vegetative-level integration, it is still a living human
organism, albeit one cognitively incapacitated to the extreme.25 The
soul continues to inform and give life to the human body even if
the person cannot exercise higher acts or faculties proper to human
You Only Die Once: A Reply to Nicholas Tonti-Filippini 435
beings due to incapacitation of the neural integration required for
that purpose.
The real-life example of the person in a vegetative state and
the science-fiction example of the brain-in-a-vat are not the two
incommensurable cases they at first appear to be, but two widely
divergent illustrations of the same truth. To be an “organism as a
whole” does not imply or require either structural-functional or
vital-operational wholeness. If there is a discrepancy between these
two types of levels, the higher one is determining. In other words,
something from the species homo sapiens is a human organism if it
is either at the highest structural-functional level of “organism”
(regardless what deficits in vital-operational level it may suffer due
to some impediment) or at the highest vital-operational level of
self-awareness, intellection and volition (regardless what deficits in
structural-functional integrity it may suffer due to mutilation).
2. Types of integration
We turn now from level of integration to the other axis of
categorization: type of integration. By “type” I am not referring to
Tonti-Filippini’s usage of the term (implicitly synonymous with
“level”) but to its proper meaning, i.e., a kind of integration. I
propose that there are at least two basic types of integration, each of
which applies at each structural-functional and vital-operational
level, making type and level conceptually orthogonal “axes” of
categorization. The two main types will be designated “lifeconstituting”
and “life-sustaining”; the latter will be subdivided into
“health-maintaining” and “survival-promoting.”
a. Life-constituting integration
Integration is “life-constituting” (or “constitutive”) when it makes
a body simply to be alive and to be a whole (at least materialiter, which
is the point of view I will be considering here).
As a lead-in, consider the question: On what basis do we say
that a vegetative state patient is an integrated organism, but a fresh
corpse in a morgue is not (at any level) despite possessing the same
436 D. Alan Shewmon
26Erwin Schrödinger, What is Life? The Physical Aspect of the Living Cell (New
York: The Macmillan Company, 1946).
27Gregoire Nicolis and Ilya Prigogine, Self-organization in Nonequilibrium Systems:
From Dissipative Structures to Order Through Fluctuations (New York: Wiley, 1977).
28Francisco J. Varela, Principles of Biological Autonomy (New York: North
Holland, 1979).
29Josef Seifert, What is Life? The Originality, Irreducibility, and Value of Life
(Amsterdam: Rodopi, 1997).
30If the level at issue is cellular, then the integrative biochemical exchanges
would be within and between all the parts of the cell.
full complement of body parts? The corpse may appear grossly intact,
but microstructurally (at the molecular level), and even more
clearly functionally, it is not at all intact. The only dynamism of a
corpse is the process of decay, the giving-in to the second law of
thermodynamics (the general tendency of closed physical systems
to increase in entropy). By contrast, a living organism is in a
dynamic state of endogenous active opposition to the tendency to
increasing entropy.
Looked at in terms of physically exercised vital operation, an
“organism” could be described as a “bubble of anti-entropy.” This
thermodynamic view of the essence of life has been advanced by
well-known physicists, such as Erwin Schrödinger26 and Ilya
Prigogine,27 and by biologist Francisco Varela, who coined the term
“autopoiesis” (“self-generation”).28 Of course, as philosopher Josef
Seifert emphasizes, neither life (as the being-alive of a living body),
nor its vital operations, nor even their exercise can be reduced to
purely thermodynamic considerations.29
Biological anti-entropy involves crucial biochemical
processes powered with energy generated, for the most part, by the
oxidation of basic molecular substrates in mitochondria. It is an
orderly process (it does not happen just by throwing all the same
chemicals together in a test tube) consisting in innumerable, highly
complex and mutually influencing biochemical exchanges within
and between all the cells throughout the body or organ (depending
on the structural level at issue30). Long-distance exchanges are
accomplished by blood circulation (intravascular fluid
compartment), while short-distance exchanges occur in the
extravascular compartment through diffusion, active and passive
You Only Die Once: A Reply to Nicholas Tonti-Filippini 437
31I do not mean, of course, that constitutive integration is that which is alive (on
any structural-functional level of bodily organization). Rather, constitutive
integration is a fundamental criterion of being alive. One could say that it is the
primary and fundamental manifestation of being alive, though we must keep in
mind that being alive belongs per se to the order of (non-material) formal
32At whatever structural level, integrative unity is spatially coextensive with antientropic
interactions. For example, a gangrenous toe does not participate in the
organism’s anti-entropy, and strictly speaking it is not part of the organism.
transport across cell membranes, etc.; these two compartments
intercommunicate across the capillary endothelium. The circulation
also accomplishes critical energy-maintaining exchanges between
the internal milieu and external environment, at specialized
interfaces between the “bubble of anti-entropy” and the
surrounding “sea of entropy” (e.g., at the alveoli of the lungs,
bringing in oxygen and eliminating carbon dioxide; at the intestinal
lining, absorbing molecular substrates for eventual oxidation; at the
glomeruli of the kidneys, eliminating soluble wastes, etc.).
Let me be clear: When I say, for example, that active antientropic
exchange “constitutes” the living body, I simply mean that
it is, physically speaking, the very life process itself of the living
body, insofar as the living body can be looked at (somewhat
abstractly, to be sure) as a “bubble of anti-entropy.” But if this
“bubble” is the same, physically, as the body, then it owes its
actuality to the same formal cause that the living body does: the
soul. That is, while the anti-entropic bubble constitutes the living
body materially—it is the living body described biochemically—the
soul constitutes the living body formally. The soul is the immanent
first principle accounting for the living body’s actuality, for its being
vitally integrated in the first place.31
Now, constitutive integration occurs at every functionalstructural
level. Not only does it make an organism to be a live
organism (as opposed to a decaying former organism), but also a
kidney on its way from donor to recipient to be a live kidney, and a
fibroblast in tissue culture to be a live fibroblast.32 Our question
regarding brain death thus boils down to whether the integration
materially constitutive of human life occurs at the highest
structural-functional level of organism or merely at the level of
organs, i.e., a collection of interacting organs enclosed in a bag of
438 D. Alan Shewmon
33In man, constitutive integration can be found at each of the three hierarchical
levels of life that are in turn integrated with each other in the one human person
(who, in virtue of this unity, only “dies once”); but it need not occur at all three
levels. For example, if constitutive integration at the highest vital-operational level
(i.e., self-consciousness) is present, then a human organism is unquestionably
constituted. But if it is absent at the highest level, that would not necessarily mean
that a human organism is not constituted. For indeed, anti-entropy at the
structural-functional level of organism could represent another kind of constitutive
integration that constitutes a human organism, even though it is at the lowest vitaloperational
skin. Does a brain-dead body still exercise organismic somatic
integration, albeit only on the vegetative level, thus remaining a
living human organism (and so a person) by virtue of the unity of
the human soul? I will argue for an affirmative answer to this
question in the following section (III) of the paper.33
b. Life-sustaining integration
Whereas constitutive integration makes something to be alive in the
sense just explained, life-sustaining integration merely helps it to
stay alive. At least two subtypes can be distinguished: “healthmaintaining”
and “survival-promoting,” the difference being that the
former is internally directed while the latter is externally directed.
i. Health-maintaining integration
Health-maintaining integration keeps the organism’s/organ’s/cell’s
internal milieu optimal, with a wide safety margin far from death.
The complex integration of the immune system, for example,
protects the body from attack by pathogens. If the immune system
is completely destroyed, as for example by chemotherapy and
radiation in the initial stage of a bone marrow transplant, the body
is not ipso facto dead, but it is at high risk of dying soon without
medical intervention. Similarly, the integrative functions of the
pancreas are of the “health-maintaining” type. Surgical removal of
the pancreas does not ipso facto make the body dead at the moment
of removal, but loss of its integrative functions will result in death
You Only Die Once: A Reply to Nicholas Tonti-Filippini 439
after a few days if left untreated. Upon a little consideration, it
becomes obvious that the integrative functions of every non-brain
organ and organ system at the vegetative level are of the healthmaintaining
type. Even heart and lung functions are of the healthmaintaining
type, although the latency to death if they fail is much
shorter than in the case of an organ like the pancreas—on the order
of minutes rather than days.
ii. Survival-promoting integration
Survival-promoting integration has to do with goal-directed
interactions with the environment, so it is primarily at the
sensorimotor and cognitive levels. It therefore involves the brain
and other body parts closely related to the brain, such as sensory
organs and muscle. Such integration, for example, underlies
instinctive and need-driven behaviors (such as satisfying hunger
and thirst), the anticipation and avoidance of danger, the planning
and carrying out of survival strategies for adverse weather, etc. In
higher vertebrate organisms, survival-promoting and healthmaintaining
integration are coordinated with each other through
the limbic system, the autonomic nervous system and the
hypothalamic-pituitary axis (e.g., the autonomic and hormonal
changes associated with “fight and flight reactions”). As with
health-maintaining integration, loss of survival-promoting
integration does not make an organism instantly, ipso facto, dead, but
it will lead to premature death if not compensated for. A blind or
paralyzed or demented person is not dead, but will be soon if unassisted.
c. Non-substitutability: Correlate of constitutive integration
Health-maintaining and survival-promoting integration are
replaceable, in the sense that the organism can survive without such
integration as long as its role is fulfilled by some exogenous
replacement. Referring to the previous examples, patients with
immunodeficiency can survive with the help of antibiotics
whenever they get an infection. Patients with pancreatic
insufficiency can survive by taking insulin and digestive enzymes.
440 D. Alan Shewmon
34Substitutability, in the sense intended here, does not imply equivalence;
obviously it is better to have seeing eyes than a seeing-eye dog. We are concerned
with types of integration as they relate to life versus death. Substitutability is also
a relative thing: futuristic computerized stimulation of the occipital cortex will be
a better substitute for lost natural vision than a seeing-eye dog. Pancreatic
integrative functions are more easily and more thoroughly replaceable than are
sensory integrative functions.
35Enthusiasts of “strong” artificial-intelligence would take issue with this
statement, but this paper is a response to Tonti-Filippini, not to them. I trust that
Tonti-Filippini and the readers of Communio agree with me on this point.
People without heart or lung function can survive with the help of
extracorporeal membrane oxygenation (ECMO) or an artificial
heart. Blind people compensate by walking sticks, seeing-eye dogs
and a society that accommodates their disability. Paralyzed people
get around with the help of wheelchairs and assistants. Demented
people survive through the ministrations of caregivers.34
By contrast, constitutive integration is intrinsically and
absolutely not substitutable. By its very nature, if it does not exist
at a given hierarchical level, neither does the corresponding
organism, organ or cell exist. Nor is it even partially substitutable.
Unlike the therapeutic replacement of a health-maintaining
integrative function, which can replace the natural function well or
poorly, constitutive integration is all or none, just as “unity” is all or
none. Some or many cells might cease to participate in an
organism’s anti-entropic constitutive integration, for example, but
if the remaining ones suffice to maintain the organism’s antientropy,
the constitutive integration remains undiminished; indeed
it is undiminishable, only present or absent. No futuristic intensivecare
technology can prevent the increase in entropy (i.e., biological
decay) if it is not endogenously opposed from the very lifeprocesses
themselves of the living organism.
What about the extraordinarily complex electrochemical
information exchange within the brain that facilitates specifically
human consciousness? Clearly, it is another type of constitutive
integration, as its absolute non-substitutability attests: No
computer, no matter how futuristically advanced, can take the place
of someone’s brain in supporting that person’s self-awareness and
intellectual-volitional acts.35 It does not follow, however, that the
You Only Die Once: A Reply to Nicholas Tonti-Filippini 441
36Or in Bernat’s scheme and terminology, any residual “critical” brain function.
Cf. James L. Bernat, “How much of the brain must die in brain death?” Journal of
Clinical Ethics 3, no. 1 (1992): 21–26; discussion 27–28. James L. Bernat, “The
biophysical basis of whole-brain death,” Social Philosophy & Policy 19, no. 2 (2002):
failure of conscious activity, or even of the electro-chemical
exchange underlying it, is ipso facto the death of a person.
In any case, this latter consideration is irrelevant, since the
only integration at issue in the brain death discussion is somatic
integration. The crux of the debate can therefore be reframed in
terms of the following question: Is brain-based somatic integration
indispensable to the constitutive integration of a human organism,
or is it only health-maintaining and survival-promoting? In the
following section, I propose to demonstrate the latter.
III. A Bold Assertion
Tonti-Filippini’s defense of the somatic-integration rationale for
brain death implicitly presupposes that brain-based integration is
not only necessary for organism-level constitutive integration (i.e.,
without it, the organism ceases to be a living “organism as a
whole”), but that it is actually sufficient for it (i.e., if there is any
residual brain function at all,36 the person is neither brain dead nor
dead). Two respective corollaries are that the absence of the soul is
always deducible from the irreversible absence of all brain function
and that the presence of the soul is deducible from the presence of
any brain function.
My task now is to show that these assumptions have no
sound basis in the available empirical evidence. I will thus assert
something that I have never previously formulated quite so clearly
or in such terms—something bold, which warrants placing in bold:
The empirical evidence suggests that all brain-mediated
somatic integration is either of the health-maintaining or of
the survival-promoting type. Or, expressed the other way
around: The constitutive integration minimally needed for
442 D. Alan Shewmon
37“You Only Die Twice,” 318.
the existence of a rationally ensouled human organism is
entirely non-brain-mediated.
In the remainder of the present section I will prove this
assertion and refute the main empirical components of Tonti-
Filippini’s central theses (both explicit and implicit). In subsection
A, I will refute the claim that the somatically integrative activity of
the nervous system derives wholly from the brain (A, 1) and that
the integrative activity of the endocrine system is entirely directed
by the brain (A, 2). In the following subsection B, I will highlight
Tonti-Filippini’s mistake in downplaying the importance of the
circulatory system, which he seems to believe has no integrative
role other than serving as a vehicle for endocrine-mediated
integration. Finally, in subsection C, I will refute the assumption,
which Tonti-Filippini shares with many advocates of the brain
death criterion, that the integration observed in cases of chronic
brain death is only at the structural-functional level of organs, not
at that of the organism as a whole. This discussion will also give me
the opportunity to rebut one other charge: that my claim that at
least some brain-dead bodies manifest integrative functions at the
organism-level has been based on a misattribution to the holistic
level of the supposedly “local phenomenon” of wound healing.
A. Two major bodily systems and their types of integration
1. The nervous system
The assertion that “the brain . . . mediates . . . the neural . . .
system”37 is a non-starter. The brain is part of the nervous system.
The human brain is considered by many to be the crown jewel of
God’s physical creation, the most marvelous and complex structure
in the entire universe. This does not imply, however, that the rest
of the nervous system counts for nothing, or that in pathological
states where brain functions are lost the rest of the nervous system
carries out no autonomous integrative functions.
You Only Die Once: A Reply to Nicholas Tonti-Filippini 443
38R. D. Fitzgerald, I. Dechtyar, E. Templ, P. Fridrich, and F. X. Lackner,
“Cardiovascular and catecholamine response to surgery in brain-dead organ
donors,” Anaesthesia 50, no. 5 (1995): 388–92. Hans-Joachim Gramm, Jürgen
Zimmermann, Harald Meinhold, Rüdiger Dennhardt, and Karlheinz Voigt,
“Hemodynamic responses to noxious stimuli in brain-dead organ donors,”
Intensive Care Medicine 18, no. 8 (1992): 493–95. S. H. Pennefather, J. H. Dark, and
R. E. Bullock, “Haemodynamic responses to surgery in brain-dead organ donors,”
Anaesthesia 48, no. 12 (1993): 1034–8. Randall C. Wetzel, Nancy Setzer, Judith L.
Stiff, and Mark C. Rogers, “Hemodynamic responses in brain dead organ donor
patients,” Anesthesia & Analgesia 64, no. 2 (1985): 125–28.
a. Spinal cord-mediated integration
When the spinal cord suddenly loses rostral influences from the
brain (e.g., in high cervical cord transection), the structurally intact
cord below the lesion goes into a state of temporary shut-down,
called spinal shock; then after a few days or weeks it regains
autonomous functioning. During spinal shock, blood pressure
regulation and other autonomic functions (apart from vagus nerve
functions) cease, requiring pressor medications and complex ICU
support. As the spinal shock resolves, autonomous thoracolumbar
sympathetic and sacral parasympathetic functions return, roughly
in parallel with return of tendon reflexes; blood pressure supporting
medications can be tapered off, and overall medical management
becomes easier. Of course autonomic regulation mediated by the
cord is much less robust than that mediated by a fully functioning
nervous system, but it is also a lot better for the body than no
central nervous system regulation at all. It is cord-mediated
integration that no doubt underlies, for example, the cardiovascular
and hormonal stress responses that can occur during
unanesthetized organ harvesting from brain-dead donors.38
From the perspective of the spinal cord, transection at the
base of the brain and destruction of the brain have the same effect:
it makes no difference to the cord whether the brain above the
transection is intact or not. In either case there is sudden, complete
loss of brain control over the cord, and consequent spinal shock. In
a detailed clinical and physiological comparison between high spinal
cord injury and brain death, I showed that the respective somatic
dysfunctions, apart from the endocrine disturbances in brain death
and the preserved glossopharyngeal and vagus nerve functions in
444 D. Alan Shewmon
39D. Alan Shewmon, “Spinal shock and ‘brain death’: somatic
pathophysiological equivalence and implications for the integrative-unity
rationale,” Spinal Cord 37, no. 5 (1999): 313–24. D. Alan Shewmon, “The ‘critical
organ’ for the organism as a whole: Lessons from the lowly spinal cord” in Brain
Death and Disorders of Consciousness, Advances in Experimental Medicine and
Biology 550, Calixto Machado and D. Alan Shewmon, eds. (New York: Kluwer
Academic/Plenum Publishers, 2004), 23–41.
40In the context of suppressed vagus nerve function, the very limited afferent
function of the glossopharyngeal nerve would have no somatic effect.
41Michael D. Gershon, “The enteric nervous system: a second brain,” Hospital
Practice (Minneapolis) 34, no. 7 (July 1999): 31–32, 35–38, 41–42 passim. Michael
D. Gershon, The Second Brain (New York: Harper Collins, 1998). Pankaj Jay
Pasricha, “Stanford Hospital’s Pankaj Pasricha discusses the Enteric Nervous
System, or brain in your gut,”
UXx4WTVU34Y, accessed 21 October 2012.
spinal cord injury, are virtually identical, in terms of both clinical
manifestations and evolution over time.39 If we consider that some
cases of brain death do not have clinically significant endocrine
disturbances (vide infra) and that in some cases of spinal cord
transection atropine is administered to suppress unopposed
parasympathetic functions of the vagus nerve, the somatic
physiologic comparison can be made exact.40 This gives strong
empirical support to the theoretical predictions that (1) the acute
non-endocrinologic somatic disturbances of brain death are due
more to spinal shock than to loss of brain-mediated integration, and
(2) the relative somatic stability of the rare cases of chronic brain
death (rare because the motivation to support such patients more
than a few days is rare) is due in large part to recovery of cordmediated
somatic integration following spinal shock.
b. Enteric and cardiac nervous systems
Not only does the spinal cord carry out autonomous integrative
functions, but the body even has two other nervous systems that
have still less to do with the brain. The gastrointestinal system has
its own enteric nervous system, which autonomously carries out
such complex integrative functions related to digestion as to
warrant being called a “second brain.”41 Although often classified as
You Only Die Once: A Reply to Nicholas Tonti-Filippini 445
42Julius Korein, “The problem of brain death: development and history,” in
Brain Death: Interrelated Medical and Social Issues, Annals of the New York Academy
of Sciences 315, Julius Korein, ed. (1978): 19–38. Julius Korein, “Ontogenesis of
the brain in the human organism: definitions of life and death of the human being
and person,” Advances in Bioethics 2 (1997): 1–74.
a subdivision of the autonomic nervous system, it differs radically
from the sympathetic and parasympathetic subdivisions, insofar as
it is anatomically self-contained (not part of the central or
peripheral nervous systems) and it can and does function
independently from the brain and spinal cord. Likewise, the heart
has its own intrinsic nervous system, including a pacemaker and a
network of neurons that synchronize and optimize the heart’s
function. The autonomous integrative role of the intrinsic cardiac
nervous system with respect to cardiac function is most evident in
the continued, coordinated beating of a freshly explanted heart.
c. Brain-mediated integration is of the non-constitutive type
The foregoing reveals that, as a matter of fact, it is simply not true
that all neural-based integration is mediated by the brain. The next
question is: What types of integration are accomplished by the brain,
the spinal cord, and the enteric and cardiac nervous systems?
Neurologist Julius Korein claimed that in higher vertebrates
what opposes the otherwise relentless increase in entropy is the
organism’s “critical system,” which he identified with the brain, and
this is precisely why brain death is death.42 Paraphrased in the
terminology introduced above, he maintained that brain-based
somatic integration was of the constitutive type. His evidence for
this was that brain-dead bodies demonstrate multisystem
dysfunction and invariably undergo imminent (within a few days)
cardiac arrest despite all resuscitative measures. This “evidence” was
in fact nothing of the kind: some brain-dead bodies—those with
primary brain pathology and no direct damage to other organs—do
not demonstrate multisystem dysfunction, and some can be
maintained chronically with relatively little technological support.
In any case, Korein’s claimed “evidence” was also irrelevant.
Even in those cases that do spiral downhill to cardiovascular
446 D. Alan Shewmon
43James L. Bernat, “The biophilosophical basis of whole-brain death,” Social
Philosophy & Policy 19, no. 2 (2002): 324–42.
collapse despite all therapeutic measures, all that is proved is that
the lost integration could just as well have been of the healthmaintaining
type. Korein suggested no definition or means of
measuring entropy in a living system, and a fortiori no means of
measuring the strength of active opposition to entropy. By the same
token, he suggested no empirical evidence whatsoever that an
organism’s endogenous, active opposition to entropy requires or
even involves brain function. His claim that the brain is the body’s
thermodynamically “critical system” was merely a bald assertion
that supported itself essentially by its own bootstraps.
Citing Korein, Bernat, a preeminent proponent of the
somatic integration rationale, endorses the idea that an organism’s
“most important control system is the ‘critical system,’”43 as though
it were a foregone conclusion that any organism necessarily has to
have a single critical control system; this assumption is neither selfevident
nor backed up by Bernat (nor even true—e.g., embryos).
Significantly, in light of the distinction of types of integration
introduced above, Bernat pulls the rug out from under himself by
The critical system is the irreplaceable, indispensable, complex,
structural-functional control system that maintains the health and
life of the organism, without which the organism no longer can
function as a whole. The vital importance of this system for the
continued health of the organism. . . . No organism can survive the
loss of its critical system (emphasis added).
In essence, he is stating that the critical system, which later
in the article he identifies with the brain, performs healthmaintaining
and survival-promoting integration. This line of
thought then makes an enormous logical leap to thermodynamics,
without explaining in any way how or why the loss of those two
types of life-sustaining integration would result in loss of
constitutive integration:
With the loss of the critical system, the organism loses its lifecharacterizing
processes, especially its anti-entropic capacity, and
You Only Die Once: A Reply to Nicholas Tonti-Filippini 447
44James L. Bernat, “The definition, criterion, and statute of death,” Seminars in
Neurology 4, no. 1 (1984): 45–51, at 48.
entropy (disorder) inevitably increases. The inexorable increase
in entropy is conceptually tied to the irreversibility of the
In the context of his whole article, Bernat seems to be
endorsing the idea, following Korein, that brain-dead bodies lack
anti-entropic capacity and that their entropy is in fact inexorably
increasing. But, like Korein, he suggests no method for measuring
entropy in a biological organism, and a fortiori presents no evidence
to back up the claim that entropy increases in brain-dead bodies but
remains opposed in still living, moribund, non-brain-dead bodies
in ICUs. To my knowledge, no other defender of the somatic
integration rationale of brain death has taken up this ball and run
with it.
The empirical evidence actually points to quite the contrary
conclusion. In terms of sheer volume, the bulk of the human brain
is in the cerebral hemispheres, the integrative functions of which
are sensorimotor and cognitive in nature. Therefore, it is fair to say
that the great preponderance of brain-based integration is of the
survival-promoting type. In the words of Bernat, the brain is the
body’s critical organ, because
it is primarily the brain that is responsible for the functioning of
the organism as a whole: the integration of organ and tissue
subsystems by neural and neuroendocrine control of
temperature, fluids and electrolytes, nutrition, breathing,
circulation, appropriate responses to danger, among others.44
Of the functions explicitly cited by Bernat, one is obviously of the
survival-promoting type, while the rest are clearly of the healthmaintaining
The parts of the brain that regulate the body’s internal
milieu are the relatively small brain stem and hypothalamus. The
role of the hypothalamus will be considered below under the
heading of the endocrine system; here we shall focus on the
integrative role of the brain stem through its neuronal connections
with the rest of the body. The key question is whether brainstem
448 D. Alan Shewmon
45Eelco F. M. Wijdicks, Brain Death (Oxford: Oxford University Press, 2011),
32–41. Eelco F. M. Wijdicks, “Determining brain death in adults,” Neurology 45,
no. 5 (1995): 1003–11. American Academy of Neurology—Quality Standards
Subcommittee, “Practice parameters for determining brain death in adults
(Summary statement),” Neurology 45, no. 5 (1995): 1012–4. Eelco F. M. Wijdicks,
Panayiotis N. Varelas, Gary S. Gronseth, David M. Greer, “Evidence-based
guideline update: determining brain death in adults: report of the Quality
Standards Subcommittee of the American Academy of Neurology,” Neurology 74,
no. 23 (2010): 1911–8.
46Arguably, the classification of some brainstem reflexes is ambiguously survivalpromoting
or health-maintaining, such as the corneal reflex, which directly
maintains the health of the eye and therefore indirectly promotes survival.
47Someone might object that the above set of clinically testable, non-constitutive
brainstem integrative functions is merely a reliable surrogate for constitutively
integrative brainstem functions that are clinically untestable; i.e., their collective
absence, in the proper clinical context, guarantees associated absence of all other
brainstem functions, including untestable constitutively integrative ones.
Nevertheless, the only potential candidates for somatically unifying brainstem
functions are the autonomic ones: the visceral parasympathetic components of the
vagus nerve and the entire sympathetic system, which originates in the
hypothalamus and is highly modulated by various brainstem centers along its way
to the spinal cord and from there to its visceral, vascular and other targets.
integrative functions, whether individually or collectively, are of the
constitutive type. A quick survey of all the brainstem reflexes that
are tested in clinical brain death determinations45 reveals that every
single one is of the survival-promoting or possibly healthmaintaining
type (pupillary light reflex, corneal reflex,
oculocephalic and oculovestibular reflexes, grimacing to noxious
stimuli, gag and cough reflexes).46 Respiratory drive, assessed by the
apnea test, is clearly a health-maintaining integrative function. The
bellows function of the diaphragm, driven by medullary centers and
modulated by more rostral brainstem and even cortical influences,
is easily substitutable by a mechanical ventilator, and the huge
majority of patients without respiratory drive supported in ICUs
across the world are not brain dead and are obviously living
organisms as a whole.47
i. The heuristic value of brain disconnection examples
The brain destruction vs. brain disconnection comparison was the
You Only Die Once: A Reply to Nicholas Tonti-Filippini 449
48Sánchez Sorondo, The Signs of Death.
49D. Alan Shewmon, “The ‘Critical Organ’ for the ‘Organism as a Whole’:
Lessons from the Lowly Spinal Cord” (Keynote address at the 3rd International
Symposium on Coma and Death, Havana, Cuba, 22–25 February 2000).
50Cf. Sánchez Sorondo, The Signs of Death, 297.
51N. Bakshi, R. A. Maselli, S. M. Gospe, Jr., W. G. Ellis, C. McDonald, R. N.
Mandler, “Fulminant demyelinating neuropathy mimicking cerebral death,”
Muscle & Nerve 20, no. 12 (1997): 1595–7. Taj Hassan, Colin Mumford, “Guillain-
Barré syndrome mistaken for brain stem death,” Postgraduate Medical Journal 67
(1991): 280–81. F. G. Langendorf, J. E. Mallin, J. C. Masdeu, S. L. Moshe, R. B.
Lipton, “Fulminant Guillain-Barré syndrome simulating brain death: clinical and
electrophysiological findings (Abstract),” Electroencephalography and Clinical
Neurophysiology 64 (1986): 74. J. F. Marti-Masso, J. Suarez, A. Lopez de Munain,
N. Carrera, “Clinical signs of brain death simulated by Guillain-Barré syndrome,”
Journal of the Neurological Sciences 120, no. 1 (1993): 115–17. F. Vargas, G. Hilbert,
epiphany that directly occasioned in 1992 my radical change of
opinion about the nature of brain death, and its explanatory power
has not diminished over the intervening 20 years. Experts on brain
death have either ignored it (as did, in effect, the majority of
participants in the Pontifical Academy of Sciences’ 2006 working
group on brain death48) or accepted it as definitive (as did many
participants in the 3rd International Symposium on Coma and
Death in 2000 following my keynote lecture,49 most notably the
famous neurologist Fred Plum, who exclaimed in essence during
the question and answer session, “OK, I’ll grant you that the braindead
body is a living human organism, but is it a human person?”—
thereby shifting the arena of debate from the biology of “organisms
as a whole” to the philosophy of “personhood”50).
Ever since I first proposed the brain-disconnection
comparison, defenders of the somatic integration rationale of brain
death have been scrambling and grasping at straws to escape its
implications. For it is in fact easy to show that the entire set of
brainstem functions, including the clinically untestable ones, is not
constitutively integrative for the living body. Their virtually
complete absence, as in high spinal cord transection or fulminant
Guillain-Barré Syndrome (an autoimmune inflammation of the
nerves and nerve roots, which in rare cases can be so severe as to
functionally disconnect the body from all non-pituitary-related
central nervous system control, mimicking brain death51), results in
450 D. Alan Shewmon
D. Gruson, R. Valentino, G. Gbikpi-Benissan, J. P. Cardinaud, “Fulminant
Guillain-Barré syndrome mimicking cerebral death: case report and literature
review,” Intensive Care Medicine 26, no. 5 (2000): 623–27.
52Sánchez Sorondo, The Signs of Death, XL (Wijdicks, Daroff, Bernat, Bousser),
XLI (Tandon). See also Eelco F. M. Wijdicks, Brain Death, 155.
53Sánchez Sorondo, The Signs of Death, XLI (Posner).
a very sick patient requiring intensive support, not an ipso facto
decomposing corpse. Moreover, the number of brainstem functions
that need to be technologically substituted in order to sustain life is
very small compared to the total number of brainstem integrative
functions, implying that all the unsubstituted functions (many
known, probably most as yet unknown) are even less critically
health-maintaining than the substituted ones.
Some of the participants in the Pontifical Academy of
Science’s 2006 working group dismissed the heuristic value of such
comparisons on the grounds that patients with disconnected, intact
brains are conscious, and these cases are clinically very distinct from
brain death.52 (In the case of cervical cord transection this is
obvious; with fulminant Guillain-Barré, greater clinical expertise is
required.) But such dismissal misses the whole philosophical point:
the claim is not that these conditions are clinically indistinguishable
from brain death, but that they prove that the vitality and unity of
the body remains even absent brain-based integration.
Another participant dismissed the comparison on the
grounds that it ignores the non-neuronal control pathway of several
hormonal substances “that help the organism survive when the
spinal cord is transected, but are required for survival when the
brain is destroyed.”53 His very own words place that type of
integration in the survival-maintaining rather than constitutive
category. Moreover, the only such substance mentioned specifically
was vasopressin, which is not even absent in about one-third of
brain death cases (vide infra), and is easily substituted
pharmacologically in the other two-thirds. He asserted, without
citing any evidence, that the brain “may make several other
cytokines, hormones and substances,” which together with
vasopressin “may help achieve homeostasis even when neural
communication between the brain and the rest of the body is
You Only Die Once: A Reply to Nicholas Tonti-Filippini 451
54Ibid. Emphasis added.
55Sánchez Sorondo, The Signs of Death, XLI (Masdeu).
56D. Alan Shewmon, “Spinal shock and ‘brain death,’” 313–24. D. Alan
Shewmon, “The ‘critical organ’ for the organism as a whole,” 23–41.
destroyed.”54 Cases of chronic brain death (vide infra) readily disprove
that the brain releases any substance into the circulation that is
necessary for any form of homeostasis aside from water balance.
Yet another participant dismissed the cervical cord
transection comparison on the grounds that “the neurobiology . . .
is incorrect”: in that condition, unlike in brain death, the ninth and
tenth cranial nerves bypass the disconnection, preserving medullary
control “over most of the other organs.”55 He expressed puzzlement
by the comparison, as though the difference of these two cranial
nerves was an aspect that I, a fellow neurologist, had inexplicably
and inexcusably overlooked. This difference had been carefully
considered and accounted for:56 vagal (tenth nerve) parasympathetic
control over the thoracic and abdominal viscera is necessary for
their proper functioning, but not for life itself: surgical or
pharmacological ablation of the vagus (e.g., by atropine) results in
cardiovascular, gastrointestinal and genitourinary side effects, not
organismal decomposition. The only somatically integrative
function of the glossopharyngeal (ninth cranial) nerve is the
medullary reception of visceral sensory input from the carotid
bodies and carotid sinus, which are involved in the regulation of
respiration and blood pressure, respectively. In the context of apnea
the former is irrelevant, and in the context of absent sympathetic
vasomotor control the latter is irrelevant (the unopposed vagal
parasympathetic influence on the heart being a source of potential
cardiovascular dysfunction rather than control, which is why the
vagus nerve sometimes has to be therapeutically suppressed in high
cervical cord injury victims).
ii. The requirement of irreversibility—Trojan horse for brain death theory
As with brain-body disconnection, examples of suppression of brain
function without structural damage also provide insight into the
452 D. Alan Shewmon
57Barbiturate overdose, for example, can mimic brain death and produce a flat
electroencephalogram, although typically not all brainstem functions are
suppressed. Suppose, for the sake of our hypothetical, that the patient were given
an anesthetic (or combination of anesthetics) at whatever dose might be required
to eliminate not only all cortical activity but all hypothalamic and brainstem
function as well. We further assume that an anesthetic is chosen that has
insignificant direct toxicity to other organs at brain-suppressing levels. An
alternative method for selectively suppressing brain function in this hypothetical
scenario might be extreme head cooling, similar to the treatment modality used
for asphyxiated newborns but even cooler. The point of the hypothetical is not
how selective brain suppression might be in principle accomplished, but to
illustrate the logical incompatibility between the irreversibility requirement and
the theoretical basis for the integrative unity rationale of brain death.
58Wijdicks, Brain Death, 33–34, 155–7.
necessity, or lack thereof, of brain-based integration for somatic
unity. Neurological criteria for death everywhere in the world
require that the loss of all brain functions be irreversible, no doubt
because death itself is necessarily irreversible (apart from miracles).
Ironically, this requirement actually undermines the integrative
unity rationale. If that rationale were correct, the body should begin
to dis-integrate immediately upon loss of all (or at least “critical”)
brain-based integration, whether that loss be irreversible or
reversible, permanent or temporary. Suppose a general anesthetic
were administered at such a high dose as to suppress essentially all
brain function.57 Such a patient would require expert anesthesiology
and ICU management, but no one would diagnose the patient as
brain dead, because the anesthetic would be a major clinical
confounder, and all diagnostic protocols require that reversible
causes be excluded.58 Nevertheless, the body is not receiving any
integrative influences from the brain for as long as the anesthetic is
maintained at that high level.
This scenario puts integrative-unity apologists in a bind,
because they can analyze it in only three possible ways, all of which
are incompatible with their hypothesis. (1) They could say that,
since integrative brain function is absent, the body must be already
dis-integrating (i.e., the anesthesiologist killed the patient),
regardless of the fact that the patient will make a full recovery after
the lifting of the anesthesia (a true “Lazarus phenomenon”!). (2)
They could say that there is a latency between the loss of brain
function and the beginning of somatic dis-integration, and
You Only Die Once: A Reply to Nicholas Tonti-Filippini 453
59For patients who “meet all criteria,” Wijdicks pinpoints the time of death to
“when the arterial pCO2 reached the target value. In patients with an aborted
apnea test, the time of death is when the ancillary test has been officially
interpreted” (Wijdicks, Brain Death, 56). The patient in our hypothetical does not
meet all criteria, because the loss of brain function is reversible. Nevertheless, as
far as the body’s need for brain-based integration goes, what difference does
reversibility or irreversibility make, if somatic dis-integration begins upon loss of
all brain functions as soon as the arterial pCO2 reaches the target value or an
electroencephalogram has been officialpy interpreted as isoelectric?
therefore a short period of time without brain function would not
constitute a loss of integrative unity and death. But how long would
it take for the loss of brain functions to produce the deadly effect?
Korein, Wijdicks and many others emphasize how so many braindead
patients succumb to asystole within as little as 24 to 48 hours.
Suppose the anesthesiologist maintained the anesthesia for that
long. Then they are right back to dilemma #1. More importantly,
this form of explanation would amount to an admission that the
death consisted in something other than the loss of brain-based
integration, something that brain-based integration would normally
have prevented, i.e., that brain-based integration is of the healthmaintaining
type.59 (3) Or they could simply concede that somatic
integrative unity is not lost upon cessation of all brain functions
after all.
The fact that reversible, sustained loss of all brain function is
recognized by all as not death implies that brain-based somatic
integration is entirely of the health-maintaining, not constitutive type.
iii. Acute instabilities and early asystole in brain death
Before leaving this subsection on the nervous system, it should be
noted that patients in acute brain death tend to be physiologically
very unstable, and many defenders of the integration unity rationale
have taken this as evidence that the brain is indeed the body’s
critical integrating organ. An extreme, and factually grossly
incorrect, example of this stance is the statement by one of the
Pontifical Academy of Science’s 2006 consultants, Conrado Estol:
454 D. Alan Shewmon
60Cf. Sánchez Sorondo, The Signs of Death, XL.
61Wijdicks, Brain Death, 111.
62Wijdicks, Brain Death, 117, citing T. P. Hung, S. T. Chen, “Prognosis of
deeply comatose patients on ventilators,” Journal of Neurology, Neurosurgery &
Psychiatry 58, no. 1 (1995): 75–80. Emphasis added.
63Wijdicks, Brain Death, 117, citing J. Freitas, J. Puig, A. P. Rocha, P. Lago, J.
Teixeira, M. J. Carvalho, O. Costa, A. F. de Freitas, “Heart rate variability in brain
death,” Clinical Autonomic Research 6, no. 3 (1996): 141–46.
64Sánchez Sorondo, The Signs of Death, 246, 276 (Ropper); 258, 270 (Wijdicks).
“Brain death is associated with immediate loss of all bodily
functions.”60 In a less hyperbolic vein, Wijdicks states:
Brain death affects nearly every organ system. Complications of
brain death that may impact the organ donation process include
hypotension, diabetes insipidus, hypothermia, electrolyte
abnormalities, coagulopathy, anemia, hypoxia, cardiac
arrhythmia, and cardiac arrest.61
He draws attention to the fact that many brain-dead
potential organ donors undergo cardiovascular collapse and cardiac
arrest before organs can be harvested, despite aggressive
resuscitative efforts. Citing a recent study from Taiwan, in which
“despite full cardiovascular support, 97% of 73 patients who met the
criteria for brain death developed asystole within one week,” he
concludes that “[t]he heart and the conduction system need
continuous autonomic nervous system input.”62 Although ostensibly
further supporting this assertion but actually not, he also cites a study
of heart rate variability, which in no way substantiates such a “need”
but merely asserts that the measurement of heart rate variability could
be a useful adjunct in the rapid diagnosis of brain death.63
At the Academy’s 2006 conference Drs. Ropper and
Wijdicks complained that chronic brain death cases, such as those
I reported, simply do not correspond to their extensive clinical
experience as neuro-intensivists, and therefore the cases are highly
suspect for being misdiagnoses.64 I never claimed that they were
typical, only that they occurred. The same Taiwan study cited by
Wijdicks can also be interpreted the other way around: 3% of 73
patients survived at least one week. Such cases do occur. There is
You Only Die Once: A Reply to Nicholas Tonti-Filippini 455
65Wijdicks, Brain Death, 111–24.
66Wijdicks, Brain Death, 113.
67H. Ormstad, H. C. Aass, N. Lund-Sørensen, K. F. Amthor, L. Sandvik,
“Serum levels of cytokines and C-reactive protein in acute ischemic stroke
patients, and their relationship to stroke lateralization, type, and infarct volume,”
Journal of Neurology 258, no. 4 (2011): 677–85; erratum 259, no. 2 (2012): 400. S.
G. Rhind, N. T. Crnko, A. J. Baker, L. J. Morrison, P. N. Shek, S. Scarpelini, S.
B. Rizoli, “Prehospital resuscitation with hypertonic saline-dextran modulates
inflammatory, coagulation and endothelial activation marker profiles in severe
traumatic brain injured patients,” Journal of Neuroinflammation 7 (2010): 5. J.
Rhodes, J. Sharkey, P. Andrews, “Serum IL-8 and MCP-1 concentration do not
identify patients with enlarging contusions after traumatic brain injury,” The Journal
of Trauma 66, no. 6 (2009): 1591–7; discussion 1598.
very little clinical experience in the U.S. in attempting to maintain
brain-dead patients longer than two days, because there is no
motivation to do so.
Spinal shock has already been mentioned as one factor
contributing to the acute instabilities. But there are others. The
complexities of medical management of brain-dead organ donors
are reviewed in the course of 14 pages of Wijdicks’ recent book on
brain death, which ironically contain the seeds of the answer to his
own objection.65 The subsection heading “Pathophysiologic
Changes Due to Brain Death” (emphasis added) is a misnomer,
given what he proceeds to explain in the subsequent text. A more
appropriate subheading would have been “Pathophysiologic
Changes Associated with Brain Death.” Some of the changes he cites
are actually “due to” direct multisystem damage from whatever
etiology happened to cause the brain injury (typically severe trauma
or cardiorespiratory arrest). Other types of systemic dysfunction are
“due to” hypoxic damage from apnea or from autonomic outpouring
(“sympathetic storm”) caused by the process of progressive brain
destruction prior to reaching its endpoint of brain death. Another kind
of physiologic disturbance that occurs in acute brain death is a
generalized systemic inflammatory response.66 This is not specific to
brain death, however, as it occurs in serious brain injuries short of
brain death and, like inflammatory responses in general, it is transient
in patients who survive longer than a few days.67
Clearly many, if not most, of the physiologic instabilities
that challenge the clinical management of brain-dead organ donors
456 D. Alan Shewmon
68D. Alan Shewmon, “Chronic ‘brain death’: meta-analysis and conceptual
consequences,” Neurology 51, no. 6 (1998): 1538–45.
70D. Alan Shewmon, “Mental disconnect,” 292–333.
result not from loss of brain-mediated integration but from direct
or indirect damage to multiple vital organs. Even the generalized
inflammatory response from exposure of damaged brain tissue to
the immune system is due to reasons other than loss of brain-based
integrative control over the immune system. These acute
instabilities therefore cannot be cited as evidence that the mere lack
of integrative brain functions per se is what makes some of these
bodies literally dis-integrate. Moreover, the acute instabilities do not
last forever in patients who are supported for prolonged periods of
time. Many patients certainly do succumb early; but in those who
survive more than a few days, the most serious systemic
dysfunctions gradually self-resolve (medications to support blood
pressure can be weaned off, gastrointestinal motility returns, etc.),
again indicating that the dysfunctions were due to something other
than the mere absence of brain-control.68
A meta-analysis of reported cases of brain death that
survived one week or longer revealed that the potential for longterm
survival correlated with two factors: age (longer survivals
among younger patients, shorter among older patients) and etiology
of the brain death (longer in primary brain pathology, shorter in
multisystem damage)69—again indicating that the determinant of
survival duration in the context of clinical brain death is the degree
of integrity of the vital organs, not the mere loss of brain-based
control over them. I have always maintained that there probably are
cases of brain death in which integrative unity has been lost, and
this is precisely why they deteriorate relentlessly to asystole
regardless of the most aggressive therapeutic interventions. But
such a clinical course is not because their brains are dead, but rather
because their original injury caused supracritical multisystem
damage (including to the brain).70 In Wijdicks’ own words:
The main objectives [in the medical support of brain-dead
organ donors] remain the maintenance of oxygenation and
circulation, control of polyuria, and control of hyperglycemia.
You Only Die Once: A Reply to Nicholas Tonti-Filippini 457
71Wijdicks, Brain Death, 120.
. . . The overriding principle is maintenance of normal or nearnormal
physiology. Therefore, several acute processes (i.e.,
pulmonary edema, hypovolemia) can and should be reversed.71
The fact that “normal or near-normal physiology” can be
maintained by means of technological replacement of so few
integrative functions indicates clearly that the missing integration
is of the health-maintaining type, not constitutive of the organism’s
vitality and unity.
2. The endocrine system
Regarding the endocrine system, Tonti-Filippini’s portrayal of it as
entirely brain-mediated is woefully inaccurate. What is generally
called for convenience “the endocrine system” is actually not a
single system but a set of relatively independent hormonal systems,
only one of which is master-regulated by the brain’s hypothalamus.
What follows is a brief overview of these systems.
a. The hypothalamic-pituitary axis
The pituitary gland lies directly beneath the hypothalamus, to
which it is connected by both a capillary vascular network and a
thin stalk. The gland is composed of two main parts, distinct in
both structure and embryologic origin. The hypothalamus governs
the anterior part (including a rudimentary intermediate lobe) by
secreting releasing and inhibiting hormones into the local capillary
network; when these intermediary hormones reach the anterior
pituitary, they act upon the glandular cells, which secrete their
respective hormones into the systemic circulation. The posterior
pituitary and connecting stalk are actually an extension of the
hypothalamus itself; the axon terminals release their hormones
directly into capillaries of the systemic circulation.
458 D. Alan Shewmon
72K. Arita, T. Uozumi, S. Oki, M. Ohtani, T. Mikami, “The function of the
hypothalamo-pituitary axis in brain dead patients,” Acta Neurochirurgica (Wien) 123,
nos. 1–2 (1993): 64–75. Hans-Joachim Gramm, Harald Meinhold, Ulrich Bickel,
Jürgen Zimmermann, Birgit von Hammerstein, Frieder Keller, Rüdiger
Dennhardt, and Karlheinz Voigt, “Acute endocrine failure after brain death?,”
Transplantation 54, no. 5 (1992): 851–57. G. M. Hall, K. Mashiter, Jean Lumley, J.
G. Robson, “Hypothalamic-pituitary function in the ‘brain-dead’ patient (letter),”
Lancet 2, no. 8206 (1980): 1259. Trevor A. Howlett, Anne M. Keogh, Les Perry,
Richard Touzel, Lesley H. Rees, “Anterior and posterior pituitary function in
brain-stem-dead donors. A possible role for hormonal replacement therapy,”
Transplantation 47, no. 5 (1989): 828–34. David J. Powner, Ann Hendrich, Regis
G. Lagler, Ronald H. Ng, Robert L. Madden, “Hormonal changes in brain dead
patients,” Critical Care Medicine 18, no. 7 (1990): 702–8. H. Schrader, K. Krogness,
A. Aakvaag, O. Sortland, K. Purvis, “Changes of pituitary hormones in brain
death,” Acta Neurochirurgica (Wien) 52, nos. 3–4 (1980): 239–48. T. Sugimoto, T.
Sakano, Y. Kinoshita, M. Masui, T. Yoshioka, “Morphological and functional
alterations of the hypothalamic-pituitary system in brain death with long-term
bodily living,” Acta Neurochirurgica (Wien) 115, nos. 1–2 (1992): 31–36. M. Szostek,
Z. Gaciong, R. Danielelewicz, B. Lagiewska, M. Pacholczyk, A. Chmura, I.
Laskowski, J. Walaszewski, W. Rowinski, “Influence of thyroid function in brain
The hormones released by the anterior pituitary under
hypothalamic control are:
N Thyroid-stimulating hormone (TSH, thyrotropin)
N Adrenocorticotropic hormone (ACTH, corticotropin)
N Growth hormone (GH, somatotropin)
N Gonadotropins (leuteinizing hormone and folliclestimulating
N Prolactin
N Melanocyte-stimulating hormone
N Beta-endorphin
Those released by the posterior pituitary are:
N Antidiuretic hormone (ADH, vasopressin)
N Oxytocin
Studies of pituitary function in acute brain death have found
that the anterior pituitary hormones and their target-gland
hormones tend to be either normal or subnormal, but not totally
deficient.72 In fact, complete panhypopituitarism virtually never
You Only Die Once: A Reply to Nicholas Tonti-Filippini 459
stem death donors on kidney allograft function,” Transplantation Proceedings 29, no.
8 (1997): 3354–6.
73Gramm et al., “Acute endocrine failure after brain death?”; Howlett et al.,
“Anterior and posterior pituitary function in brain-stem-dead donors”; Powner et
al., “Hormonal changes in brain dead patients”; K. M. Robertson, I. M. Hramiak,
and A. W. Gelb, “Endocrine changes and haemodynamic stability after brain
death,” Transplantation Proceedings 21, no. 1, pt. 2 (1989): 1197–8.
74K. C. Loh, and P. C. T. Eng, “Prevalence and prognostic relevance of sick
euthyroid syndrome in a medical intensive care unit,” Annals, Academy of Medicine,
Singapore 24, no. 6 (1995): 802–6. Andrea L. Cheville and Steven C. Kirshblum,
“Thyroid hormone changes in chronic spinal cord injury,” Journal of Spinal Cord
Medicine 18, no. 4 (1995): 227–32. Inder J. Chopra, “Clinical review 86: Euthyroid
sick syndrome: Is it a misnomer?,” Journal of Clinical Endocrinology and Metabolism
82, no. 2 (1997): 329–34.
75Debra H. Fiser, Jorge F. Jimenez, Vicki Wrape, and Robert Woody, “Diabetes
insipidus in children with brain death,” Critical Care Medicine 15, no. 6 (1987):
76Dusit Staworn, Laura Lewison, James Marks, Gary Turner, and Daniel Levin,
“Brain death in pediatric intensive care unit patients: incidence, primary diagnosis,
and the clinical occurrence of Turner’s triad,” Critical Care Medicine 22, no. 8
(1994): 1301–5.
77Kristan M. Outwater and Mark A. Rockoff, “Diabetes insipidus
accompanying brain death in children,” Neurology 34, no. 9 (1984): 1243–6.
occurs in brain death. The type of thyroid dysfunction in acute
brain death tends to be due not to TSH insufficiency but to the
“sick euthyroid syndrome,”73 which has nothing to do with
hypothalamic regulation and occurs in a wide variety of severe
systemic illnesses and even spinal cord injury.74
Posterior pituitary function is more often and more
seriously affected in brain death. Antidiuretic hormone, as its name
implies, acts on the kidneys to prevent diuresis (production of
copious, dilute urine—a condition called diabetes insipidus); it also
has a blood pressure raising effect (hence its alternate name,
vasopressin). Untreated diabetes insipidus causes rapid dehydration
and electrolyte disturbances. Studies of brain-dead patients report
incidences of diabetes insipidus ranging from as low as 38%75 or
41%76 to as high as 88%77, with most reporting around two-thirds
460 D. Alan Shewmon
78Gramm et al., “Acute endocrine failure after brain death;”; Howlett et al.,
“Anterior and posterior pituitary function in brain-stem-dead donors”; Eelco F.M.
Wijdicks, Alejandro A. Rabinstein, Edward M. Manno, John D. Atkinson,
“Pronouncing brain death: Contemporary practice and safety of the apnea test,”
Neurology 71, no. 16 (2008): 1240–4.
79Arita et al., “The function of the hypothalamo-pituitary axis in brain dead
patients”; Sugimoto et al., “Morphological and functional alterations of the
hypothalamic-pituitary system in brain death with long-term bodily living”;
William F. McCormick, and Nicholas S. Halmi, “The hypophysis in patients with
coma dépassé (‘respirator brain’),” American Journal of Clinical Pathology 54
(September 1970): 374–83. Eelco F.M. Wijdicks, Brain Death 2nd ed. (Oxford:
Oxford University Press, 2011), 113–15.
80Tonti-Filippini’s insistence that loss of integrative unity “requires evidence of
loss of all brain function” (“You Only Die Twice,” 322) is illogical to begin with,
given that most brain functions have nothing to do with somatic integration in the
first place.
to three-fourths.78 Diabetes insipidus is treated by administering
vasopressin or a pharmacologic equivalent.
The basis for partially preserved hypothalamic-pituitary
function in the context of brain death is believed to be the gland’s dual
arterial blood supply, from both intra- and extra-dural arteries. Even in
the absence of intracranial blood flow, as revealed by standard
radiographic techniques, there can be just sufficient flow from
extradural sources to keep portions of the gland, and in some cases even
small portions of the hypothalamus, viable and functioning.79
Tonti-Filippini maintains that the one-third to one-fourth
of clinically diagnosed brain death cases without diabetes insipidus
are not true brain death, because they retain a brain function: the
secretion of ADH. But if Tonti-Filippini wants to be consistent
with his insistence on absence of all brain functions for true brain
death, he should insist on absence of all hypothalamic functions,
manifested not only by diabetes insipidus but also by (1) cessation
of all anterior pituitary hormones dependent upon hypothalamic
releasing factors, (2) decreased though not absent levels of the
anterior pituitary hormone dependent on both releasing and
inhibiting factors (growth hormone), and (3) an increase in the one
anterior pituitary hormone regulated primarily by a hypothalamic
inhibiting factor (prolactin). Given what is known about endocrine
functions in brain death, such a strict diagnostic requirement would
eliminate virtually all brain death diagnoses.80
You Only Die Once: A Reply to Nicholas Tonti-Filippini 461
82Ibid., 324.
83Wijdicks, Brain Death, 47–52, 168–70.
84Arita et al., 1993; Gramm et al., 1992; Powner et al., 1990; Schrader et al.,
1980; Sugimoto et al., 1992.
He criticizes as lax those diagnostic protocols that do not
require demonstration of absent intracranial blood flow,81 and
proposes that “Catholic hospitals could insist that ancillary tests
including brain perfusion tests be done standardly as part of
diagnosing death by the brain criterion to establish greater certainty
that loss of all function of the brain has indeed occurred.”82 But the
standard radiographic tests have never been validated as possessing
sufficient sensitivity to distinguish, in every part of the brain, no
flow from low flow that is barely adequate for tissue viability.83 This
lack of validation is particularly problematic around the
hypothalamus, where there is good reason to believe that the tests
do in fact lack sufficient sensitivity. Many of the reported cases with
preserved pituitary function had the brain death diagnosis
confirmed by blood flow tests showing intracranial circulatory
arrest.84 So even Tonti-Filippini’s proposal that blood-flow
confirmation be required in all brain death diagnostic protocols will
not guarantee that every part of the brain (or even every somatically
relevant part) is dead.
The philosophically important question, however, is not
whether the presence of some hypothalamic-pituitary function ought
to exclude a diagnosis of death, but whether the absence of all
hypothalamic-pituitary functions (even if that hypothetically
occurred in clinical brain death) ought to establish a diagnosis of
death in the context of no other brain functions. Just how
important are those endocrine functions for somatic integrative
unity? An examination of the above list of anterior and posterior
pituitary hormones reveals that several are related to reproduction
and lactation; one is related to growth. Only three are necessary for
survival, in the sense that their end-organ function is necessary for
462 D. Alan Shewmon
85“You Only Die Twice,” 319.
N Thyroid-stimulating hormone (TSH, thyrotropin)
N Adrenocorticotropic hormone (ACTH, corticotropin)
N Antidiuretic hormone (ADH, vasopressin)
The natural secretion of these hormones, however, is not strictly
necessary for survival, because their function (or target-gland
function) can be substituted pharmacologically (and commonly is
in clinical practice). Patients with pituitary failure secondary to
hypothalamic lesions are typically treated with some form of
thyroxine, cortisol, and vasopressin, and they do just fine. The
substitutability indicates that these three integrative neuroendocrine
functions are of the health-maintaining, not constitutive type.
A more obvious reason to conclude this is the fact that it
takes days to weeks to die from untreated lack of those hormones:
the patient does not instantly begin to “dis-integrate.” For obvious
ethical reasons, we have no systematic data regarding the latency to
death following sudden elimination of any of those three
hormones. Cumulative clinical experience, however, allows us to
speculate reasonably that death from cessation of ADH would likely
occur in a matter of days due to dehydration and electrolyte
imbalance, death from cessation of ACTH would likely occur in a
matter of weeks from adrenal insufficiency, and death from
cessation of TSH would likely occur in a matter of weeks to
months from thyroid insufficiency.
In a word: The brain-mediated endocrine integrative
functions are of the health-maintaining, not constitutive type.
b. Non-hypothalamic-pituitary endocrine systems
Tonti-Filippini asserts that a person without brain function lacks “a
unified endocrine system,”85 one implication being that persons
with brain function possess “a unified endocrine system.” This is not
true, because in reality there is no “unified endocrine system,” but
rather multiple systems of mutually interacting hormones, these
systems being relatively independent of one another. Consequently
Tonti-Filippini’s assertion that “the brain . . . mediates . . . the
You Only Die Once: A Reply to Nicholas Tonti-Filippini 463
86Ibid., 318.
87G. D. Wenger, M. S. O’Dorisio, E. J. Goetzl, “Vasoactive intestinal peptide:
messenger in a neuroimmune axis,” Annals of the New York Academy of Sciences 594
(1990): 104–19.
endocrine system”86 is doubly false, both because there is no such
thing as “the endocrine system” and because only one of the
multiple endocrine systems is brain-mediated. I shall now give
some important examples of integrative endocrine functions that
have no direct relationship to the hypothalamic-pituitary axis.
Probably the most widely known is based in the digestive
system. Insulin, produced by the exocrine pancreas, has an
important role in glucose uptake by cells throughout the body and
in the balance between carbohydrate and lipid sources of
biochemical energy. Other digestive-system-produced hormones
that play a role in the assimilation of nutrients throughout the body
and in metabolism include somatostatin, secretin, cholecystokinin,
insulin-like growth factor, glucagon, pancreatic polypeptide,
ghrelin, and vasoactive intestinal peptide. The latter has been
described as the messenger in a “neuroimmune axis.”87
A hormonal feedback loop important for blood pressure and
blood volume regulation is the renin-angiotensin-aldosterone axis,
involving kidneys, liver, lungs and adrenal glands. A hormone with
the opposite effect on blood pressure and volume is atrial natriuretic
peptide, which is produced by cells in the atria of the heart and acts on
the kidneys, blood vessel walls, and on the rest of the heart; it also
increases the release of free fatty acids from adipose tissue.
The adrenal medulla secretes the “stress hormones”
adrenaline (epinephrine) and noradrenaline (norepinephrine) in
response to signals from preganglionic sympathetic fibers
originating in the spinal cord. In fact, this core of the adrenal gland
is actually a ganglion of the sympathetic nervous system itself,
releasing its neurotransmitters directly into the bloodstream rather
than into a synapse with another neuron. Many types of
physiological stresses activate the release of these hormones, which
produce essentially the same effects on target cells as direct
sympathetic nervous stimulation, such as increased heart rate and
blood pressure, vascular constriction in the skin and gastrointestinal
tract, dilation of bronchioles, and increased metabolism. It is likely
464 D. Alan Shewmon
88Fitzgerald et al.; Gramm et al.; Pennefather et al.; Wetzel et al.; op. cit.
89Andrei Krassioukov, Darren E. Warburtone, Robert Teasell, Janice J. Eng,
Spinal Cord Injury Rehabilitation Evidence Research Team, “A systematic review
of the management of autonomic dysreflexia after spinal cord injury,” Archives of
Physical Medicine and Rehabilitation 90, no. 4 (2009): 682–95. Kyung Y. Yoo, Cheol
W. Jeong, Seok J. Kim, Seong T. Jeong, Woong M. Kim, Hyung K. Lee, Kyung
J. Oh, Jong Un Lee, Min H. Shin, Sung S. Chung, “Remifentanil decreases
sevoflurane requirements to block autonomic hyperreflexia during transurethral
litholapaxy in patients with high complete spinal cord injury,” Anesthesia and
Analgesia 112, no. 1 (2011): 191–97. Subramanian Vaidyanathan, Bakul Soni, Fahed
Selmi, Gurpreet Singh, Cristian Esanu, Peter Hughes, Tun Oo, Kamesh Pulya,
“Are urological procedures in tetraplegic patients safely performed without
anesthesia? A report of three cases,” Patient Safety in Surgery 6, no. 1 (2012): 3.
that the hormonal and vascular stress responses to unanesthetized
organ retrieval in brain-dead donors are mediated by the spinal
cord, spinal sympathetics, and adrenal medulla,88 just as occurs in
surgical operations on high spinal cord injury victims despite their lack
of subjective perception of pain below the level of the spinal lesion.89
The liver and kidneys produce thrombopoietin, which
regulates the production of platelets by the bone marrow. The
kidneys also produce erythropoietin, which stimulates the
formation of red blood cells in the marrow. Calcium homeostasis
is maintained by interactions between the parathyroid glands
(parathyroid hormone), the thyroid (calcitonin), skin
(cholecalciferol), bone, liver and kidneys. Adipose tissue secretes
leptin, adiponectin and resistin, which affect energy metabolism.
The above list of non-brain-regulated integrative hormones
is already several times larger than the brain-regulated list, and it is
far from complete. There are also the cytokines, small proteins
secreted by numerous kinds of cells and used extensively in
intercellular communication. Beyond thei r loc a l
immunomodulating actions, they exert systemic effects. As more is
learned about them, the definitional boundary between cytokines
and hormones is becoming increasingly blurred.
It is clear that all endocrine-mediated integration, whether
by the hypothalamic-pituitary axis or non-brain-related hormonal
subsystems, is of the health-maintaining type. Every hormone is
either pharmacologically substitutable or simply unnecessary for
life, even if it may be necessary for optimal health. (After all, the
You Only Die Once: A Reply to Nicholas Tonti-Filippini 465
90If we accept that an irreversibly comatose human is a living human being so
long as the body is a living organism, the question arises: how much of that body
can be replaced by artificial organs, limbs, etc. before it ceases to be an organism
(since we cannot rely on consciousness to constitute organism status, as with the
brain-in-a-vat, or brain-in-a-cyborg)? I do not pretend to know the answer, and
I doubt that a philosophy of “organism” has been sufficiently developed to provide
a framework for a reasoned answer. Fortunately, we need not know the answer in
order to validly address our main question: whether a body without brain
function, but otherwise intact, is an organism.
91“You Only Die Twice,” 315.
heart, lungs, gut, and kidneys are themselves all substitutable and
not strictly necessary for life, so a fortiori neither are their related
hormones.90) Need any more be said about the necessity of brain
function for “a unified endocrine system” and the constitutive
necessity of the latter for a unified living organism?
B. The true sine qua non for somatic integration is circulation,
not the brain
Tonti-Filippini chides me for failing “to take into account the
intercommunicative meaning of the body as an integrated whole,”
because I have allegedly discounted the two systems which he
claims “unify the body by communicating with and between all
parts of the body.”91 But the nervous system actually does not reach
all parts of the body (e.g., bone marrow and blood), and the
hypothalamic-pituitary axis certainly does not communicate “with
and between all parts of the body.” But if the brain is not the sine
qua non for somatic integration, what is?
Inexplicably, Tonti-Filippini dismisses circulation from his
scheme of bodily integration, apart from being a vehicle to
distribute brain-regulated hormones. In reality, however,
circulation, unlike the influence of the brain, does reach essentially
everywhere, and the few structures without capillaries
communicate with the nearest capillaries by diffusion. This is not
merely the transference of information “between some parts of the
466 D. Alan Shewmon
92Ibid., 315.
93Ibid., 319.
94Ibid., 315.
body”92 or “merely between one part of the body and another,”93 but
it precisely fulfills Tonti-Filippini’s own litmus test of
communication “with and between all parts of the body.”94
Circulation, in fact, provides the means of the intercellular
communication involved in homeostasis, an organism’s tendency to
maintain a stable internal equilibrium in the face of external
changes. The term “homeostasis” can refer to the maintenance of
a particular component within a physiologic range or to the stability
of an organism’s internal environment as a whole. The antientropic
processes at the basis of life depend on the homeostasis of
literally thousands, perhaps tens of thousands, of interacting
biochemical components, ranging in complexity from simple ions
to enzymes and even more complex molecules like large
glycoproteins. Circulation connects all the parts of the body in a
way that allows them to cooperate in this immensely complex
dynamic. It distributes oxygen and nutrients everywhere for energy
production (necessary for opposition to entropy) and removes
carbon dioxide and other cellular wastes resulting from that energy
production and the orderly turnover of cellular components. It
allows myriad interacting biochemical feedback systems to maintain
countless organic compounds within their respective physiological
ranges. The importance of the relatively few hormones for bodily
integration pales drastically in comparison. Moreover, in contrast
to neural and hormonal integration, the anti-entropic homeostasis
mediated by circulating blood is of the constitutive type: it is
absolutely non-substitutable.
C. Structural-functional level of integration in brain death
It bears stressing that circulation is not mere heart function (which
is eminently substitutable), but is a much more fundamental system
for mediating anti-entropic homeostasis. But is circulation
therefore anything more than a necessary condition of organismYou
Only Die Once: A Reply to Nicholas Tonti-Filippini 467
95For organisms that normally possess circulation—obviously circulationless
organisms like zygotes or plants are not under discussion.
96Ibid., 310.
97Bernat, “The definition, criterion, and statute of death,” 48.
98Sánchez Sorondo, The Signs of Death, LXXII, 275.
99Ibid., LXXIII, 275.
level integration?95 What structural-functional level of life is
constituted by the anti-entropic interactions via the circulation, in
the absence of all brain function?
In effect, defenders of the somatic integration rationale
make the following claim about brain death. Loss of a particular
form of health-maintaining or survival-promoting integration (i.e.,
brain-mediated), they claim, causes a drop in the structuralfunctional
level on which constitutive integration occurs: a drop
from the organism-level to the organ-level. What looks like a whole
human body holding itself together as an organism through the
medium of the circulatory system is actually just a man-shaped bag
of interacting organs lacking any real organismic status at all.
Consider Tonti-Filippini’s assertion that “what remains
possesses only the non-integrated life of the individual organs,
rather than the life of the body as an integrated whole.”96 Bernat has
asserted that “[t]he cardiac arrest patient with whole brain
destruction is simply a preparation of unintegrated individual
subsystems, since the organism as a whole has ceased
functioning.”97 Some participants in the 2006 conference of the
Pontifical Academy of Sciences expressed the same idea with great
rhetorical flair. Robert Daroff, for example, described a brain-dead
body as nothing more than “a ventilator [keeping] a heart beating
in a corpse.”98 Bernat, after citing the examples of a human cell kept
alive in a culture medium and an artificially perfused kidney or
liver, agreed with Daroff, stating that “having a heart perfusing
blood to a series of organs mechanically supported is really not
materially different than either of those examples and does not
necessarily prove that that preparation in question is a living human
being.”99 Wijdicks and Bernat described a brain-dead body as “a
468 D. Alan Shewmon
100Ibid., LXXIII, 276.
101Ibid., 146.
102For the sake of simplicity I have described the continuum as one-dimensional
with a dividing “line” somewhere along it (mathematically, it would actually be a
dividing point). The reality is surely much more complex, with degrees of
integration being fully representable only in a multidimensional space, in which
case our concern would be to determine on which side of the multidimensional
boundary separating “organism as a whole” from “non-organism” X lies.
103D. Alan Shewmon, “The brain and somatic integration,” 457–78.
magnificent cell culture.”100 Joseph Masdeu even likened it to an
amputated finger perfused in a flask.101
The confidence of such assertions about the structuralfunctional
level of integration is unwarranted given that we lack any
operational definition or methodology for measuring or otherwise
assessing it. An empirically sensitive approach to the question must
be indirect, because no measurement scale or methodology exists.
1. Criteria for determining the structural-functional
level of integration
Accept for the sake of argument that integration occurs along a
continuum of degrees, even if we don’t know how to measure it; let
us represent that continuum by a horizontal line segment. The left
extreme represents what everyone accepts as a healthy organism-asa-
whole, and the right extreme represents what everyone accepts as
a decaying corpse. Starting at the left extreme, the further to the
right we go, the less healthy the organism is, until we cross a
dividing line between moribund organism and non-organism.102 It
is a sharp dividing line, even if we don’t know where to place it,
because the concepts “unity” and “organism as a whole” are
necessarily all-or-none. Because this cannot be measured by a
quantitative methodology, we cannot say where that dividing line
is or exactly where entity X lies along the continuum. It suffices,
however, to know merely what side of the dividing line X is on.
In 2001 I proposed two criteria for determining just that.103
So far no one has seriously challenged them, and I believe they are
just as valid now as 11 years ago. They are:
You Only Die Once: A Reply to Nicholas Tonti-Filippini 469
104The term “emergent property” is chosen for its familiarity within the
scientific community, prescinding however from possible reductionistic
philosophical overtones (for example, one would have to explain carefully what is
meant by “derives” in my definition of emergence). Let us accept, for the sake of
argument, the ontological premise that “wholes” larger than quarks do exist and
that living organisms are in fact “wholes.”
105“You Only Die Twice,” 319.
Criterion 1. “Integrative unity” is possessed by a putative
organism (i.e., it really is an organism) if it possesses at least
one emergent, holistic-level property. A property of a composite
is defined as “emergent” if it derives from the mutual
interaction of the parts,104 and as “holistic” if it is not
predicable of any part or subset of parts but only of the
entire composite.
Criterion 2. Any body requiring less technological
assistance to maintain its vital functions than some other
similar body that is nevertheless a living whole must
possess at least as much integration and hence also be a
living whole. Thus, if A has more integration than
reference entity B, and B is on the “whole” side of the
dividing line, then A is necessarily also on the “whole”
side of the dividing line.
Tonti-Filippini does not seem to take issue with either of
these criteria, but with my application of them to the facts about
brain-dead bodies.
2. Application of the criteria to brain-dead bodies
Regarding Criterion 1, in that same 2001 article I compared litanies
of brain-mediated and non-brain-mediated somatically integrative
functions. Tonti-Filippini objects to my inclusion of teleological
wound healing in the non-brain-mediated list on the grounds that
it is a local rather than holistic phenomenon, involving “only parts
rather than the whole.”105 Others have also made the same kind of
470 D. Alan Shewmon
106Sánchez Sorondo, The Signs of Death, XXXV (Estol), XXXVI (Bernat),
XXXVII (Masdeu), XXXIX (Tandon, Rossini, agreeing with Estol).
107President’s Council on Bioethics, 56.
objection to healing as an example of a holistic property.106 My
position does not depend on defending wound healing as a holistic
property; it was just one of many examples of what seemed to me in
2001 to be holistic properties that are not brain-mediated and that
occur in brain-dead bodies that survive longer than a few days.
Tonti-Filippini omits mention of any of the others, apart from
The complete 2001 litany of holistic properties, however,
sufficiently impressed the President’s Council on Bioethics that
they quoted it essentially verbatim in their white paper as “Table 2:
Physiological Evidence of ‘Somatic Integration,’”107 and it is worth
quoting again here for the readers of Communio:
N Homeostasis of a countless variety of mutually
interacting chemicals, macromolecules and
physiological parameters, through the functions
especially of liver, kidneys, cardiovascular and
endocrine systems, but also of other organs and tissues
(e.g., intestines, bone and skin in calcium metabolism;
cardiac atrial natriuretic factor affecting the renal
secretion of renin, which regulates blood pressure by
acting on vascular smooth muscle; etc.);
N Elimination, detoxification and recycling of cellular
wastes throughout the body;
N Energy balance, involving interactions among liver,
endocrine systems, muscle and fat;
N Maintenance of body temperature (albeit at a lower
than normal level and with the help of blankets);
N Wound healing, capacity for which is diffuse
throughout the body and which involves organismlevel,
teleological interaction among blood cells,
You Only Die Once: A Reply to Nicholas Tonti-Filippini 471
108President’s Council on Bioethics, 57.
capillary endothelium, soft tissues, bone marrow,
vasoactive peptides, clotting and clot lysing factors
(maintained by the liver, vascular endothelium and
circulating leucocytes in a delicate balance of synthesis
and degradation), etc.;
N Fighting of infections and foreign bodies through
interactions among the immune system, lymphatics,
bone marrow, and microvasculature;
N Development of a febrile response to infection;
N Cardiovascular and hormonal stress responses to
unanesthetized incision for organ retrieval;
N Successful gestation of a fetus in a [brain-dead]
pregnant woman;
N Sexual maturation of a [brain-dead] child;
N Proportional growth of a [brain-dead] child.
The Council then comments:
If being alive as a biological organism requires being a whole
that is more than the mere sum of its parts, then it would be
difficult to deny that the body of a patient with total brain failure
can still be alive, at least in some cases.108
Not quoted by the Council but in my 2001 paper are the
following additional examples of holistic functioning in those rare
cases of chronic brain death where there was some motivation to
maintain them for long periods of time:
N resuscitability and stabilizability following cardiac
arrest, and ability to bounce back from episodes of
472 D. Alan Shewmon
hypotension, aspiration, sepsis and other serious
systemic setbacks;
N spontaneous improvement in general health . . . , i.e.,
the gradual stabilizing of cardiovascular status so that
initially required pressor drugs can be successfully
withdrawn, the gradual return of gastrointestinal
motility so that initially required parenteral fluids and
nutrition can be successfully switched to the enteral
route via gastrostomy, etc.;
N the ability to maintain fluid and electrolyte balance in
the absence of diabetes insipidus, or even in its
presence but with no or rare monitoring of serum
electrolytes and no or rare adjustments in
administered fluids and hormonal replacement
N the overall ability to survive with little medical
intervention (although with much basic nursing care)
in a nursing facility or even at home, after discharge
from an intensive care unit.
Someone might take issue with one or more of these
examples, as Tonti-Filippini did with wound healing. I am by no
means wedded to every single one of them and am quite ready to
relinquish any that can be proved to be not truly holistic after all.
But the Council is surely correct to state that “it would be difficult
to deny” that this list contains at least one legitimate example of a
holistic property, especially homeostasis—and Criterion 1 requires
only one such property, because if there is even just one holistic
property, there must be a whole of which it is the property.
Moreover, the last four examples emphasize how some
brain-dead bodies are actually more physiologically stable and
integrated than many moribund, comatose, ventilator-dependent
non-brain-dead ICU patients with multisystem failure and an
inexorable downhill course, whom everyone considers still alive
despite their inability to maintain their tenuous integrated
wholeness for much longer, thereby fulfilling Criterion 2.
You Only Die Once: A Reply to Nicholas Tonti-Filippini 473
109“You Only Die Twice,” 319.
Tonti-Filippini admits being “troubled” by the example of
homeostasis,109 and rightly so, because in his own words,
“[h]omeostasis would seem to involve the transfer of information
in a way that keeps what is left of the body functioning as a single
dynamic unit. Thus one might conclude that it is evidence that the
body is being maintained as a single functioning being with the
parts in a functioning relationship to one another.”110 But he
resolves that concern by begging the question. Rather than
recognizing that homeostasis constitutes “evidence that the body is
being maintained as a single functioning being with the parts in a
functioning relationship to one another,”111 he gives unquestioning
logical priority to his assumption that the brain simply has to be the
master integrator of the body, and concludes that therefore in the
absence of brain-based integration “the remaining integration can
only be partial.”112
IV. Conclusion: What does the Church really teach?
The foregoing discussion has revealed the total absence of any
compelling philosophical or scientific reason to interpret brainmediated
somatic integration as constitutive of the human
organism; to the contrary, all the evidence positively points to the
conclusion that brain-mediated somatic integration maintains the
organism’s health or promotes its survival, but does not constitute
it as a living whole in the first place. By the same token, there is
absolutely no compelling philosophical or scientific reason to
suppose that brain death, however total and irreversible, is ipso facto
the death of a human being as such.
Of course, even if Tonti-Filippini accepted these findings,
he might still claim that Catholics are bound to embrace the
somatic integration rationale for brain death on religious grounds. In
fact, he repeatedly makes statements to the effect that “the Church
474 D. Alan Shewmon
113Ibid., 324.
114Ibid., 312.
115James L. Bernat, Charles M. Culver, Bernard Gert, “On the definition and
criterion of death,” Annals of Internal Medicine 94, no. 3 (1981): 389–94.
holds that death can be diagnosed on the basis of evidence that
shows a complete loss of brain function, but may not be diagnosed
if there is still some function,”113 and “the determination that a
person has died when they suffer complete loss of brain function
was readily accepted by the Catholic Church in the 1980s.”114 But
is Tonti-Filippini right about the Church’s “acceptance” of the
somatic integration version of the brain death criterion?
A. Concept, criteria, and tests for death
Brain death is a complex topic spanning several hierarchical levels
of discussion. To hold a position at one level does not necessarily
entail or imply holding a position at every other level. The tripartite
scheme introduced by Bernat and colleagues in 1981 is still helpful
for maintaining clear thinking about the diagnosis of death: namely,
the distinction between concept, criterion, and tests for death.115
The concept or definition of death (in general or specifically
of humans) is a philosophical matter; examples of candidate deathconcepts
include departure of the soul, loss of integrative unity of
the organism, loss of personhood, and arbitrary stipulation by
society. The criterion of death is the physiological event(s) taken to
be a sign of death as defined at the concept-level. The tests for death
(sometimes called diagnostic “criteria,” resulting in semantic
confusion with “criteria” in the above sense) establish whether a
criterion for death has been fulfilled in an actual individual case.
Every criterion of death presupposes, then, a concept of
death. From this point of view, it falls directly under the
competence of the Church’s Magisterium. But every criterion of
death also presupposes particular judgments about the physical
tokens indicating that death, as so defined, has in fact occurred.
This aspect of the criterion does not fall under the competence of
the Magisterium, as Pope Pius XII himself said in his address to
anesthesiologists on 24 November 1957: “Where the verification of
You Only Die Once: A Reply to Nicholas Tonti-Filippini 475
116Pius XII, “Answers to Question 3” in the Address to an International
Congress of Anesthesiologists” (Rome, 24 November 1957), http://www.lifeiss, accessed 21 October 2012.
117Catechism of the Catholic Church, no. 365.
the fact [of death] in particular cases is concerned, the answer
cannot be deduced from any religious and moral principle, and,
under this aspect, does not fall within the competence of the
According to Pius XII, then, the Church tells us what death
is, but does not pre-empt our judgment that it has occurred in a
given case (except insofar as our factual judgment is compromised
by a false concept of death that is incompatible with Catholic
teaching). Tonti-Filippini’s failure to grasp this crucial distinction
underlies his charge that, in challenging the reigning brain death
orthodoxy, I also challenge the Magisterium. In reality, however, it
is Tonti-Filippini, not I, who misunderstands what the Church
really obliges us to believe about brain death, as I will now show.
1. The Church’s view on the concept of death
Does the Church have a view on the concept of death? A
cornerstone of that view, as Tonti-Filippini rightly points out, is the
1312 Council of Vienne’s declaration that “the rational or
intellectual soul is . . . of itself and essentially the form of the
human body.” This doctrine remains official Catholic teaching, as
articulated in the second edition of the Catechism of the Catholic
Church, no. 365:
The unity of soul and body is so profound that one has to
consider the soul to be the “form” of the body [citing here the
Council of Vienne]: i.e., it is because of its spiritual soul that the
body made of matter becomes a living, human body; spirit and
matter, in man, are not two natures united, but rather their
union forms a single nature.117
In his address to the Transplantation Society on 29 August
2000, John Paul II applied that understanding of soul to the basic
concept of death:
476 D. Alan Shewmon
118John Paul II, Address to the 18th International Congress of the
Transplantation Society, 4.
[T]he death of the person is a single event, consisting in the
total disintegration of that unitary and integrated whole that is
the personal self. It results from the separation of the lifeprinciple
(or soul) from the corporal reality of the person.118
2. The Church’s view on the criterion of death
Does the Church have a view on the criterion of death? Yes and no.
Yes, as far as the conceptual aspect is concerned; no, in that the
conceptual aspect informs, but does not pre-empt, judgments as to
which particular physiological phenomena are sufficient indicators
of death as defined on the concept-level. Let me explain by way of
a comparison of two classically competing versions of the
neurological criterion: the so-called “higher brain” versus the
“whole brain” criterion.
a. The concept behind the criterion
“Higher brain” advocates, whom Tonti-Filippini labels
“mentalists,” defend the neurological criterion for death on the dual
conceptual-physiological grounds that (1) the concept of
personhood entails at least a natural potential for mental activity, if
not actual mental activity, and (2) human mental activity requires
brain function; therefore, destruction or irreversible nonfunction
of the brain results in cessation of the person whose brain it was
(i.e., death of that person). A consequence of this so-called “higher
brain death” criterion is that only those parts of the brain involved
in consciousness need be irreversibly nonfunctional for the deathconcept
to be fulfilled.
Although to my knowledge the Church has not explicitly
addressed this criterion, its implicit opinion logically follows from
its understanding of the nature of the human soul and the soul’s
relationship to the body. If the Church were to say anything at all
about this criterion, it would have to say that the criterion’s core
You Only Die Once: A Reply to Nicholas Tonti-Filippini 477
119John Paul II, Address to the Participants in the International Congress on
“Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical
Dilemmas” (Rome, 20 March 2004),
en.html, accessed 21 October 2012.
concept of human personhood (expressed in #1 of the preceding
paragraph) is inadequate, insofar as (a) human personhood derives
from the spiritual dimension of the human soul, transcending
actual or potential mental activity, and (b) if some pathology of the
organ(s) of the internal senses were to impede all intellectual and
volitional functions of the human soul, even permanently, the soul
would still be present as the substantial form of the body so long as
the body remained an integrated, unified organism.
This is clear from the words of John Paul II on 20 March
2004, to the participants of an international congress on the
vegetative state:
The person in a vegetative state, in fact, shows no evident sign
of self-awareness or of awareness of the environment, and
seems unable to interact with others or to react to specific
stimuli. . . . Faced with patients in similar clinical conditions,
there are some who cast doubt on the persistence of the
“human quality” itself. . . . In opposition to such trends of
thought, I feel the duty to reaffirm strongly that the intrinsic
value and personal dignity of every human being do not change,
no matter what the concrete circumstances of his or her life. A
man, even if seriously ill or disabled in the exercise of his highest functions,
is and always will be a man, and he will never become a
“vegetable” or an “animal.” Even our brothers and sisters who
find themselves in the clinical condition of a “vegetative state”
retain their human dignity in all its fullness.119
Thus the Church would have every right to repudiate the
higher-brain-death criterion as incompatible with its concept of
human life and death. Could the Church have anything directly to
say about the anatomical-physiological aspects of the higher-brain-death
criterion (#2 above)? In other words, would it be within the
Church’s competence to declare that the organ underlying mental
functioning is this or that part of the brain, or the entire brain, or
the fluid in the cerebral ventricles (as believed by Augustine on the
478 D. Alan Shewmon
120John Paul II, “Address to the 18th International Congress of the
Transplantation Society,” 5.
testimony of the physicians of his time), or perhaps the heart (as
many also believed in antiquity)? Clearly not. That remains within
the sphere of biologists and medical experts to determine through
empirical investigation, though of course they always in fact sight
and sift the evidence through the filter of some philosophy that does
fall more directly under the Church’s competence.
We now apply this line of reasoning to the orthodox “whole
brain” criterion, which is based on the dual conceptualphysiological
grounds that (1) death is the cessation of integrative
unity of an organism, and (2) for humans and higher animals, the
brain is the master organ that integrates all the parts of the body.
Accordingly, without brain function the body literally “disintegrates”
into a collection of organs and tissues; it is no longer a
living organism.
John Paul II, in his address to the Transplantation Society,
after reiterating the Church’s concept of death (already quoted
above), explicitly stated that the concept of death at the core of this
criterion (#1 above) is indeed compatible with the Church’s
understanding of the human soul as the substantial form of the body:
[T]he criterion adopted in more recent times for ascertaining
the fact of death, namely the complete and irreversible cessation
of all brain activity, if rigorously applied, does not seem to
conflict with the essential elements of a sound anthropology.120
Had the conceptual component of the criterion been anything
other than the integrative unity of the human organism, it would
surely have “seemed” to him to conflict with a sound anthropology.
Clearly, what John Paul II cared most about here, and had
the competence to say something about, is whether the deathconcept
underlying this version of the neurological criterion
conflicts or not “with the essential elements of a sound
anthropology.” Note, however, that the Pope refrained from fully
mobilizing this competence. He was not making a definitive
magisterial pronouncement that the whole-brain criterion is
compatible with a “sound anthropology,” but only advancing a
You Only Die Once: A Reply to Nicholas Tonti-Filippini 479
more tentative claim that such a compatibility “seems” to exist. I will
return to this point below.
b. The empirical aspects of the criterion
What about the anatomical-physiological evidence cited in favor of the
whole-brain criterion? In his address to the Transplantation
Society, John Paul II appeared to place acceptance (or rejection) of
it in the same category as particular judgments regarding the factual
verification of death, judgments that Church teaching informs, but
does not pre-empt:
It is a well-known fact that for some time certain scientific
approaches to ascertaining death have shifted the emphasis from
the traditional cardio-respiratory signs to the so-called
“neurological” criterion. Specifically, this consists in establishing,
according to clearly determined parameters commonly held by
the international scientific community, the complete and
irreversible cessation of all brain activity (in the cerebrum,
cerebellum and brain stem). This is then considered the sign
that the individual organism has lost its integrative capacity.
With regard to the parameters used today for ascertaining
death—whether the “encephalic” signs or the more traditional
cardio-respiratory signs— the Church does not make technical
decisions. She limits herself to the Gospel duty of comparing
the data offered by medical science with the Christian
understanding of the unity of the person, bringing out the
similarities and the possible conflicts capable of endangering
respect for human dignity.121 (emphasis in original)
Note that John Paul II was speaking of what he called
“scientific” approaches to death, and that the “clearly determined
parameters” he referred to are those “commonly held by the
international scientific community,” not those dictated by
magisterial pronouncements. The Pope, then, was merely
registering the fact that the “international scientific community”
considers the neurological criterion to be “the sign that the
individual organism has lost its integrative capacity.” What attitude,
480 D. Alan Shewmon
122Pius XII, Address to an International Congress of Anesthesiologists.
then, did the Pope expect the believer to adopt with respect to the
scientific consensus he describes?
First of all, echoing his predecessor Pius XII to the effect
that “the verification of the fact [of death] in particular cases . . .
does not fall within the competence of the Church,”122 John Paul
II explicitly reiterated that “the Church does not make technical
decisions” regarding the physiological “parameters” for ascertaining
death. And, as if the Church’s role in this matter were not already
clear enough, he explained that the Church “limits herself to the
Gospel duty of comparing the data offered by medical science with the
Christian understanding of the unity of the person, bringing out
the similarities and the possible conflicts capable of endangering
respect for human dignity” (emphasis added).
Thus, while John Paul II implicitly claimed in this text
direct magisterial competence over the question of whether the
neurological criterion is conceptually compatible “with the essential
elements of a sound anthropology,” he did not claim direct
magisterial competence over assessment of the technical empirical
arguments for (or against) the claim that the brain is the
coordinating agent of somatic integration, or that its death is
therefore the death of the human person. Why not? Clearly,
because he was willing to give the scientific consensus on brain
death a certain credit: just enough to allow further discussion of the
subject, but without either declaring the whole-brain criterion to
be a necessary implication of the Church’s “sound anthropology,”
or even that the whole-brain criterion is conceptually sound, but
only that it seems to be at the present time.
Clearly, John Paul II did not officially declare that a
scientist, even a believing one, must be convinced by the
physiological evidence adduced in favor of the somatic integration
rationale for brain death. But then my scientific critique of that
evidence, though certainly a challenge to the consensus of the
“international scientific community,” is not at all a challenge to
magisterially defined Catholic orthodoxy. A defense of brain death
based, say, on mind-personhood and mind-brain reductionism
clearly contradicts the “view of the Church,” but my rejection of the
somatic integration rationale for brain death just as clearly does not.
You Only Die Once: A Reply to Nicholas Tonti-Filippini 481
123C. Chagas, ed., Working Group on the Artificial Prolongation of Life and the
Determination of the Exact Moment of Death. October 19-21 1985 (Vatican City:
Pontifical Academy of Sciences, 1986). R. J. White, H. Angstwurm, I. Carrasco de
Paula, eds., Working Group on the Determination of Brain Death and its Relationship to
Human Death. 10-14 December 1989 (Vatican City: Pontifical Academy of Sciences,
124Stuart J. Youngner, C. Seth Landefeld, Claudia J. Coulton, Barbara W.
Juknialis, Mark Leary, “‘Brain death’ and organ retrieval. A cross-sectional survey
of knowledge and concepts among health professionals,” Journal of the American
Medical Association 261, no. 15 (1989): 2205–10. Ari R. Joffe, N. Anton, “Brain
death: understanding of the conceptual basis by pediatric intensivists in Canada,”
Archives of Pediatric and Adolescent Medicine 160, no. 7 (2006): 747–52. Ari R. Joffe,
N. Anton, V. Mehta, “A survey to determine the understanding of the conceptual
basis and diagnostic tests used for brain death by neurosurgeons in Canada,”
Neurosurgery 61, no. 5 (2007): 1039–45, discussion 1046–7. Ari R. Joffe, N. R.
Anton, J. P. Duff, A. Decaen, “A survey of American neurologists about brain
death: understanding the conceptual basis and diagnostic tests for brain death,”
Annals of Intensive Care 2, no. 1 (2012): 4.
125Stuart J. Youngner, “Defining death. A superficial and fragile consensus,”
Archives of Neurology 49, no. 5 (1992): 570–72.
B. An evolving position
1. The Pontifical Academy of Sciences 2005 conference
In his address to the Transplantation Society, John Paul II’s
understanding of what the “international scientific community”
holds was no doubt based in large part on the conclusions of the
two sessions of the Pontifical Academy of Sciences devoted to the
topic of brain death in 1985 and 1989123 and the 1997–98 Task
Force on Brain Death of the Pontifical Academy for Life, the
unpublished papers from which were forwarded to the
Congregation for the Doctrine of the Faith. Indeed, we have to
wonder whether the information made available to the Holy Father
on this subject included the published surveys of healthcare
professionals regarding their understanding of brain death.
Although the great majority of medical professionals accept that
irreversible nonfunction of the entire brain is death, one third to
one half of them think so for reasons quite opposed to what the
Holy Father considered “sound anthropology.”124 The consensus of
the scientific community is “superficial and fragile” indeed.125
482 D. Alan Shewmon
126Sánchez Sorondo, The Signs of Death, XIX.
Nevertheless, the Pope clearly understood the dynamic,
evolving nature of scientific inquiry, and he by no means intended
his address to the Transplantation Society as a veto on all further
philosophical debate or scientific investigation regarding the
physiological basis of somatic integration. In fact, it was he himself
who, five years later in response to the increasing critiques of
mainstream brain death theory, requested the Pontifical Academy
of Sciences to sponsor yet a third conference on this topic, with the
express purpose of hearing the other side of the scientific debate.126
This interdisciplinary conference, entitled “The Signs of Death,”
took place on 3–4 February 2005, with the preponderance of
participants arguing that the irreversible loss of brain function per
se does not entail loss of bodily integrative unity and hence death.
Being too ill to grant a personal audience, the Holy Father sent a
letter to the participants dated 1 February 2005, which was read in
his absence. In it he expressed gratitude and encouragement for
their ongoing study of this important scientific question. He once
again reiterated the perspective of “Christian anthropology,” that
“the moment of death for each person consists in the definitive loss
of the constitutive unity of body and spirit.” He went on to state:
4. . . . From the clinical point of view, however, the only correct
way—and also the only possible way—to address the problem of
ascertaining the death of a human being is by devoting attention
and research to the individuation of adequate “signs of death,”
known through their physical manifestation in the individual subject.
This is evidently a topic of fundamental importance, for which
the well-considered and rigorous position of science must therefore be
listened to in the first instance, as Pius XII taught when he declared
that “it is for the doctor to give a clear and precise definition of
‘death’ and of the ‘moment of death’ of a patient who lapses into
a state of unconsciousness.” [citing Pius XII’s 1957 address to
5. Building upon the data supplied by science, anthropological
considerations and ethical reflection have the duty to put
forward an equally rigorous analysis, listening attentively to the
Church’s Magisterium.
You Only Die Once: A Reply to Nicholas Tonti-Filippini 483
127John Paul II, Letter to the Pontifical Academy of Sciences (1 February 2005),
ents/hf_jp-ii_spe_20050201_p-acad-sciences_en.html, accessed 21 October 2012.
Emphasis added.
128Mercedes Arzu Wilson, “Save The ‘Brain Dead’ Victims,”, accessed 21 October 2012.
I wish to assure you that your efforts are laudable and will certainly be of
assistance to the competent Dicasteries of the Apostolic See—especially the
Congregation for the Doctrine of the Faith—which will not fail to ponder
the results of your reflection. . . .
In exhorting you to persevere in this joint commitment to pursue
the genuine good of man, I invoke the Lord’s copious gifts of light
upon you and your research, as a pledge of which I affectionately
impart my Blessing to you all.127
These are hardly the words of a pontiff who considered his 2000
address to represent a definitive Magisterial validation of the
scientific assumptions underlying the neurological criterion, such
that any Catholic who would dare to challenge the physiological
notion that the brain is the master integrator-organ of the body
would make himself ipso facto a heretic!
2. The Pontifical Academy of Sciences 2006 conference
Without mentioning this 2005 conference at all, Tonti-Filippini
speaks of the Pontifical Academy of Sciences’ subsequent
conference on brain death almost in the same breath as the
perspective of “the Church.” This fourth conference, under the
same title “The Signs of Death,” took place 11–12 September 2006.
What transpired between the two conferences and afterwards will
supply abundant material for Church historians researching the
kinds of intrigues and politicking that can take place within the
walls of the Vatican. This is not the place to enter into such details;
interested readers can get the gist from a web-based article by
Mercedes Arzu Wilson, who co-organized the 2005 conference
with the Pontifical Academy.128 For the purpose here of correcting
484 D. Alan Shewmon
Tonti-Filippini’s view of “the Church’s view” on brain death, it
suffices to mention the following:
N The Academy’s promise to publish the proceedings of
the 2005 conference—as with the 1985, 1989, and
soon-to-be 2006 conferences—was rescinded.
N Almost as soon as the 2005 conference had ended, the
Academy began plans for another conference the
following year on the same topic, with the same name.
Such further exploration of the scientific
developments related to determining the moment of
death was encouraged by Pope Benedict XVI.
N The selected participants of the fourth conference
were mostly world-famous neurologists or
neuroscientists, chosen for their prestige in their
respective areas of research, even though in some
cases the area of expertise and list of publications had
nothing to do with the topic of brain death. There was
no requirement that participants share the “Christian
anthropology” which John Paul II declared to be the
philosophical basis for any valid criterion of death.
N The only participants known to be critical of the
neurological criterion, namely myself and philosopher
Robert Spaemann, were invited at the last minute at
the express request of the secretary to Benedict XVI.
Unable to physically attend, I was graciously allowed
to submit a paper and to comment on the transcript of
the discussion.
N The proceedings of the conference were published in
March 2007 in a large (552-page) monograph of the
same title, “The Signs of Death” (Scripta Varia, 110).
Eventually this publication became freely available
You Only Die Once: A Reply to Nicholas Tonti-Filippini 485
varia/signsofdeath.html, accessed 21 October 2012.
130A. Battro, J.L. Bernat, M.-G. Bousser, et al., “Why the Concept of Brain
Death Is Valid as a Definition of Death. Statement by Neurologists and Others”;
A. Battro, J.L. Bernat, M.-G. Bousser, et al., “Response to the Statement and
Comments of Prof. Spaemann and Dr. Shewmon,” http://www.casinapioiv.
va/content/accademia/en/publications/extraseries/braindeath.html, accessed 21
October 2012.
over the Academy’s web site.129 Although the
introductory chapter, “The Purpose of the Meeting,”
mentions the 2005 conference (p. XIX), many of the
chapters surprisingly have nothing to do with the
debate whether and why brain death is death, and
many of the challenges to brain death orthodoxy
raised at the 2005 conference went virtually
unaddressed in the transcribed discussions.
N Receiving pride of place at the beginning of the
publication is a “Statement by Neurologists and
Others,” entitled “Why the Concept of Brain Death is
Valid as a Definition of Death” (pp. XXI–XXIX).
Remarkably, in the course of its nine pages, the 28
signatories repeatedly assert in various ways that brain
death is death, but contrary to the title utterly fail to
explain “why” it should be death itself as opposed to an
irreversible, deep coma in a moribund patient.
N Soon after the conference the Academy’s web site
featured a separate document consisting of the
statement “Why the Concept of Brain Death is Valid
as a Definition of Death” plus a “Response to the
Statement and Comments of Prof. Spaemann and Dr.
Shewmon,” without inclusion, for the benefit of the
reader, of our statement and comments being
responded to. The document included translations
into German, Italian, Spanish, and French.130
(Sometime after 1 February 2012, the Academy
changed its web site’s URL and did a major makeover
486 D. Alan Shewmon
gnsofdeath.html, accessed 21 October 2012.
uments/pasactivities.html, accessed 1 February 2012.
html, accessed 21 October 2012.
136, accessed 21
October 2012.
of its contents. On the new web site, translations of
the document include only Italian and Spanish.131)
N Up until sometime in 2012, on the Academy’s web
site, under “Publications,” the link to “The Signs of
Death” monograph did not simply read, “The Signs of
Death [PDF]. Working Group 11–12 September 2006.
. . . ” The link text continues, “Including the
Statement on Why the Concept of Brain Death is Valid as
a Definition of Death [PDF].”132 (On its new web site
the link to that Statement is still present but formatted
quite differently.133)
N On the Academy’s previous web site, under
“Activities,” the 2006 conference on “The Signs of
Death” is listed, but the 2005 conference is nowhere
to be found, although the conference listings give an
impression of completeness all the way back to
1998.134 (On its current web site the 2005 conference
is mentioned, but only toward the end of a long text
about the 2006 conference.135 That text is a
reproduction of the monograph’s introductory
chapter, “The Purpose of the Meeting” (pp. XVI-XX).
In it the 2005 conference is described as a
“preliminary meeting” (p. XIX). The chronology of
the Academy’s “Events” still does not include the 2005
You Only Die Once: A Reply to Nicholas Tonti-Filippini 487
137Roberto de Mattei, ed., Finis Vitae. Is Brain Death Still Life? (Rome: Edizioni
Consiglio Nazionale delle Ricerche, Rubbettino Editore, 2006). Translated into
Italian as Finis Vitae: La Morte Cerebrale È Ancora Vita? (Roma: Edizioni Consiglio
Nazionale delle Ricerche, Rubbettino Editore, 2007).
138Roberto de Mattei and Paul A. Byrne, eds., Finis Vitae. “Brain Death” Is NOT
True Death (Oregon, OH: The Life Guardian Foundation, 2009).
139“You Only Die Twice,” 315–17.
140The Academy’s current web page about the monograph also contains the
statement, “The reader should note that the views expressed in the papers, the
statement, and elsewhere, are those of the respective signatories and not
necessarily those of the Pontifical Academy of Sciences.” http://www.casinapio, accessed
21 October 2012.
N Out of frustration with the suppression of the 2005
conference, many of its participants departed from
protocol and published their presentations
independently in a book entitled Finis Vitae, edited by
Roberto de Mattei, vice-president of the National
Research Council of Italy and member of the Italian
National Committee on Bio-Ethics. The book came
out in early 2007 in both English and Italian.137 A
revised edition was published in 2009 by the Life
Guardian Foundation.138
The Pontifical Academy of Sciences seems to have gone out
of its way to create the impression of an official Vatican position
that “Brain Death is Valid as a Definition of Death.” And Tonti-
Filippini seems to have bought into it, citing the Academy’s 2006
conference along with American and Australian Bishops
Conferences in support of his version of “the view of the
Church.”139 Nevertheless, the very first words of the Academy’s
monograph “The Signs of Death,” on the copyright page, are:
The opinions expressed with absolute freedom during the
presentation of the papers of this meeting, although published
by the Academy, represent only the points of view of the
participants and not those of the Academy.140
And, one might add, a fortiori, “not those of the” Church.
488 D. Alan Shewmon
141Hilary White, “Vatican in ‘firestorm’ over brain death criteria for organ
accessed 21 October 2012. Sandro Magister, “Transplants and brain death.
‘L’Osservatore Romano’ has broken the taboo,” 21 October 2012,
3. The Pontifical Academy for Life 2008 conference
In November 2008 the Pontifical Academy for Life co-sponsored
a conference on organ transplantation, at which Benedict XVI
addressed the participants. There was much expectancy regarding
what he would have to say about the death of organ donors
diagnosed by the neurological criterion, in light of his predecessor’s
2000 address and the tensions surrounding the 2005 and 2006
conferences of the Pontifical Academy of Sciences. Sandro
Magister, a leading Italian journalist and expert on the Vatican,
went so far as to write that “pressure was applied” to Benedict XVI
to attempt to force him to confirm brain death as a valid criterion.141
In that context, the complete silence of the Holy Father regarding
the neurological criterion, all the while reasserting the Church’s
perennial insistence that donors of vital organs be dead, spoke
volumes regarding “the Church’s view” on brain death:
It is helpful to remember, however, that the individual vital
organs cannot be extracted except ex cadavere, which, moreover,
possesses its own dignity that must be respected. In these years
science has accomplished further progress in certifying the death
of the patient. It is good, therefore, that the results attained
receive the consent of the entire scientific community in order
to further research for solutions that give certainty to all. In an
area such as this, in fact, there cannot be the slightest suspicion
of [arbitrariness] and where certainty has not been attained the
principle of precaution must prevail. This is why it is useful to
promote research and interdisciplinary reflection to place public
opinion before the most transparent truth on the
anthropological, social, ethical and juridical implications of the
practice of transplantation.
However, in these cases the principal [criterion] of respect for
the life of the [donor] must always prevail so that the extraction
You Only Die Once: A Reply to Nicholas Tonti-Filippini 489
142Benedict XVI, Address to Participants at an International Congress
Organized by the Pontifical Academy for Life (Rome, 7 November 2008),
ments/hf_ben-xvi_spe_20081107_acdlife_en.html, accessed 21 October 2012. The
English translation on the official Vatican web site has the following words in place
of those between brackets: “arbitration,” “criteria,” and “donator.”
143John Paul II, Address to the 18th International Congress of the
Transplantation Society, 4.
of organs be performed only in the case of his/her true death (cf.
Compendium of the Catechism of the Catholic Church, no. 476).142
Thus, when John Paul II stated that the neurological
criterion “does not seem to conflict with the essential elements of a
sound anthropology” (emphasis added), he meant exactly what he
said, leaving open the possibility that new evidence from medical
science or new lines of reasoning might then make the neurological
criterion in fact “conflict with the essential elements of a sound
anthropology.” Benedict XVI takes a similar line. He obviously
intends to take no stand on the empirical aspects of the deathcriterion
and to wait patiently for the international medical
community to continue its investigations and debates until reaching
a true consensus on how to establish in clinical practice that “the
total disintegration of that unitary and integrated whole that is the
personal self”143 has taken place.
C. What the Church really teaches
Contrary to the statements of Tonti-Filippini regarding the
Church’s view on the criterion of death, quoted at the beginning of
this section, the Church’s actual view can be summarized as: (1)
“The death of the person is a single event, consisting in the total
disintegration of that unitary and integrated whole that is the
personal self. It results from the separation of the life-principle (or
soul) from the corporal reality of the person.”144 And (2) the means
to determine clinically that this has taken place is a matter for
490 D. Alan Shewmon
145Pius XII, Address to an International Congress of Anesthesiologists.
146John Paul II, Evangelium Vitae, 15,
accessed 21 October 2012.
147Henry K. Beecher, Raymond D. Adams, Clifford Barger, William J. Curran,
Derek Denny-Brown, Dana L. Farnsworth, Jordi Folch-Pi, Everett I.
Mendelsohn, John P. Merrill, Joseph Murray, Ralph Potter, Robert Schwab,
William Sweet, “A definition of irreversible coma. Report of the Ad Hoc
Committee of the Harvard Medical School to Examine the Definition of Brain
medical experts to discover and refine and “does not fall within the
competence of the Church.”145
But this is not all. In his encyclical Evangelium Vitae, John
Paul II warns:
Nor can we remain silent in the face of other more furtive, but
no less serious and real, forms of euthanasia. These could occur
for example when, in order to increase the availability of organs
for transplants, organs are removed without respecting objective
and adequate criteria which verify the death of the donor.146
John Paul’s admonition alludes first and foremost to
physicians who cut diagnostic corners in ascertaining death. But no
less importantly it applies to advocates of transplantation who cut
intellectual corners in promoting a criterion of death: philosophers,
theologians, bioethicists, neurologists and intensive care physicians
who believe so strongly in the good of transplantation that their
desire for brain death to be death takes precedence (whether
consciously or subconsciously) over philosophical and scientific
rigor. Many statutory laws and diagnostic protocols require that the
physician(s) declaring brain death not be part of the transplant
team, to avoid a conflict of interest. Brain death apologists often
assert an analogous separation between the theoretical
underpinnings of brain death and the motivation to facilitate
transplantation, as though the collective efforts over the years to
justify the neurological criterion and to reconcile it with Catholic
anthropology would have been just as intense if transplantation
never existed. Perhaps in the days of the 1968 Harvard Committee,
legitimizing the withdrawal of life support was one of the
motivations behind redefining death neurologically.147 But that is
You Only Die Once: A Reply to Nicholas Tonti-Filippini 491
Death,” Journal of the American Medical Association 205, no. 6 (1968): 337–40.
148D. Lustbader, D. O’Hara, E. F. M. Wijdicks, L. MacLean, W. Tajik, A. Ying,
E. Berg, M. Goldstein, “Second brain death examination may negatively affect
organ donation,” Neurology 76, no. 2 (2011): 119–24. J. J. Egea-Guerrero, J.
Revuelto-Rey, N. Latronico, F. A. Rasulo, E. F. Wijdicks, “The case against
confirmatory tests for determining brain death in adults,” Neurology 76, no. 5
(2011): 489; author reply 489–90.
149Wijdicks, Brain Death, 97–148.
150Ibid, 27.
151I do not mean to imply that all defenders of brain death subordinate
philosophical and scientific rigor to political expediency, but I have personally
encountered all these aberrations in the course of my involvement in the brain
death debate over the years, particularly within Catholic circles.
no longer the case, and it is fair to say that for the last two or three
decades the only raison d’être for a neurological criterion of death is
to justify transplantation of vital organs.
One need not be a transplant surgeon to be a transplant
enthusiast. An increase in organ and tissue transplants is the explicit
motivation behind proposed protocol modifications to speed up the
diagnosis of brain death (e.g., eliminating the requirement of a
second examination and of ancillary tests).148 In Wijdicks’ recent
book Brain Death, an entire chapter is devoted to organ
procurement.149 Although he states that “[t]he main purpose of
establishing the clinical diagnosis of brain death is to bring closure,”
he proceeds immediately to add, “The next step is to activate the
process of asking consent of the next of kin to donate organs and
tissue.”150—as though the diagnosis of brain death and the obtaining
of organs and tissue were intrinsically linked “steps” in a single
clinical process.
Catholic institutions and health care professionals involved
in transplantation have a very highly vested interest in brain death
being death. Ethical self-justification provides a strong temptation
to grasp at every argument and pseudo-argument in favor of brain
death being death within the Catholic anthropological framework,
and to downplay, side-step, misrepresent, ignore, or “not
understand” the arguments of brain death critics.151 Benedict XVI
has reemphasized the importance of certainty in this area, but notably
without any reference to the neurological criterion as possessing the morally
492 D. Alan Shewmon
152The tentativeness of John Paul II’s own judgment in this matter should be
kept in mind in considering his assertion that “the criterion adopted in more
recent times for ascertaining the fact of death, namely the complete and
irreversible cessation of all brain activity, if rigorously applied, does not seem to
conflict with the essential elements of a sound anthropology. Therefore a healthworker
professionally responsible for ascertaining death can use these criteria in
each individual case as the basis for arriving at that degree of assurance in ethical
judgment which moral teaching describes as ‘moral certainty.’ This moral certainty
is considered the necessary and sufficient basis for an ethically correct course of
action. Only where such certainty exists, and where informed consent has already
been given by the donor or the donor’s legitimate representatives, is it morally
right to initiate the technical procedures required for the removal of organs for
transplant (Address to the Transplantation Society, 5).” Would he have still said
that today, after having read all the intervening critical literature, including this
article? Even before his death, the fact that he encouraged the Pontifical Academy
of Sciences to revisit the topic in 2005 to hear the “other side” of the debate
indicated his openness to the possibility of new data impacting the assessment of
moral certainty.
153Benedict XVI, Address to Participants at an International Congress
Organized by the Pontifical Academy for Life (Rome, 7 November 2008).
requisite certainty, which may be read as a silent correction of the tentative
openness shown in his predecessor’s address to the Transplantation Society.152
It is worth quoting the relevant passage again:
It is helpful to remember, however, that the individual vital
organs cannot be extracted except ex cadavere. . . . In an area such
as this, in fact, there cannot be the slightest suspicion of
[arbitrariness] and where certainty has not been attained the
principle of precaution must prevail. . . . However, in these cases
the principal [criterion] of respect for the life of the [donor]
must always prevail so that the extraction of organs be
performed only in the case of his/her true death.153
Given the current status of the brain death debate within
expert circles, it is at least fair to say that “certainty” of the validity
of the neurologic criterion “has not been attained.” Therefore, “the
principle of precaution must prevail,” i.e., when in doubt, always
err on the side of assuming life. The burden of proof continues to
lie squarely with those who claim that brain function is necessary
for bodily integration.
You Only Die Once: A Reply to Nicholas Tonti-Filippini 493
154If anything, Aristotelian-Thomist hylemorphism actually invites us to adopt
a healthy skepticism in this matter, lest we allow the sweeping claims about the
brain currently fashionable in the “international scientific community” to betray
us into unconsciously imagining it as the organ of ensoulment, or even as a
material stand-in for the soul itself. If, in fact, the brain were a Doppelgänger
isomorphically mimicking or doubling the soul (but without its formal causality),
why would we need a soul in the first place, since the brain would suffice to do all
its work? Even more disturbingly: Why would we need a body—except, perhaps,
as the (dispensable) organic support of the brain’s otherwise self-contained
D. A new mentalism?
Tonti-Filippini’s accusation that I am in conflict with Church
teaching about death relies, then, not only on a mischaracterization
of my position, but also on a mischaracterization of Church
teaching itself. In point of fact, the Magisterium does not formally
oblige us to hold that the brain is the master organ of somatic
integration, or that its death is therefore the death of the human
being as such. Nor does the hylemorphism espoused by Boethius,
Aquinas, and the Council of Vienne entail any such claim.154
This is not all. If total brain death is not the death of the
human organism tout court, then Tonti-Filippini’s defense of the
whole brain criterion actually leaves him open to the very “twodeaths”
theory he wishes to refute. Ironically, the title he has
chosen for his article turns out to be as much an expression of the
unconscious implications of his own position—“you only die
twice”—as it is of the explicit claims of the “mentalist” theory he
wishes to rebut.
Rather than defeating “mentalism,” then, Tonti-Filippini
merely replaces it with a “cerebrism” that repeats its fatal flaw in
another, less obvious form. Could it be that Tonti-Filippini fails to
notice his ironic embrace of a “new mentalism” because his
impeccably orthodox profession of hylemorphism conceals a less-thanorthodox,
because less-than-impeccable, understanding of
hylemorphism? Isn’t Tonti-Filippini’s defense of brain death in fact
governed by the very picture of the brain I described earlier, i.e., as a
kind of computer electro-chemically transmitting the instructions of
the psychic “software” to the rest of the body? But then which of us,
Tonti-Filippini or myself, needs to justify his position before the bar
494 D. Alan Shewmon
of Aquinas and the Council of Vienne? I think the answer is clear:
The onus probandi lies squarely on the shoulders of my critic. Q
D. ALAN SHEWMON, MD is Professor of Neurology and Pediatrics at the David
Geffen School of Medicine at UCLA, Los Angeles, CA, and Chief of the Department
of Neurology at Olive View-UCLA Medical Center, Sylmar, CA.