Peter Singer: Rethinking Life and Death
PART I: DOUBTFUL ENDINGS
Chapter 1: “Birth After Death” 
An American Story 
Trisha Marshall: declared brain dead on
Darious Marshall: born
Dr. James Jackson: chairman of Maternal and Child Health
A German Story 
Marion Ploch: brain dead
The Clinic’s legal advisor, Prof. Hans-Berhard Wűrmeling: “Respect for the dead body is not an absolute ethical demand, as the right to life is.”
Julius Hackethal: “The expression ‘brain death’ is a verbal construction that avoids the heard of the matter. In fact only the cerebrum of the patient does not function, but the rest of the brain works very well. She is alive.”
Our Choice 
1. If you are dead when you’re brain dead, when do you “die” if you never had a brain (like some babies)? May the organs be taken when the baby’s heart is still beating?
2. Can you remove feeding tubes from people in “persistent vegetative states”?
3. What should happen to fertilized embryos created in fertility clinics?
Doe, born 1982 in
Pink, supple…and dead 
“Isn’t it odd that for a human being to die requires a different concept of death from that which we apply to other living things?”  (What would Feldman say to this?)
“The burden is great”: The Harvard committee on the determination of death 
Two crucial medical developments:
1. 1950s: respirator invented: can keep alive people who earlier would have died. Initially polio sufferers, but also people who looked like they would never regain consciousness.
2. 1967: first heart transplant.
The first presented the spectre of hospitals filling up with permanently comatose patients filling up hospitals and draining resources. The second suggested a use for the live hearts of those patients. (Unlike kidneys, which can be taken from a subject whose heart has stopped beating, hearts must be kept beating until very shortly before donation, otherwise they will get damaged.)
Harvard Committee met quickly and published their report in 1968:
Our primary purpose is to define irreversible coma as a new criterion for death. There are two reasons why there is a need for
(1) Improvements in resuscitative and supportive measures have led to increased efforts to save those who are desperately injured. Sometimes those efforts have only a partial success so that the result is an individual whose heart continues to beat but whose brain is irreversibly damaged. The burden is great on patients who suffer permanent loss of intellect, on their families, on the hospitals, and on those in need of hospital beds already occupied by these comatose patients.
(2) Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation. 
Two remarkable facts about this decision:
Why did the Harvard committee limit its concern to those with no brain activity at all, rather than those with no consciousness?
A revolution without opposition 
How was this new standard implemented so quickly? Why no “pro-life” opposition?
1. The Harvard committee could quote the Pope’s 1957 speech that “it remains for the doctor…to give a clear and precise definition of ‘death’ and the ‘moment of death’ of a patient who passes away in a state of unconsciousness”
2. The new standard was popular, and the pro-life lobby worried that standing up to it might cause a wave to wash over into euthanasia. (In other words they were prepared to lose a battle so as not to lose the war – a tactical retreat.)
If the hormonal function of the brain is what matters, then why pick death of the brain as death rather than death of the heart or kidneys?
Answer: it’s consciousness that matters. (In which case, again, why aren’t people in PVS dead?)
Brain death: Who believes it? 
A 17-year-old was pronounced brain dead after being accidentally shot in the head…[he is] being kept alive on life support
How can he be both? Also, what doctors say to families of brain-dead people:
At this point in time, it doesn’t look like the patient is going to survive.
The machine is basically what’s keeping him alive.
Why do people refuse to accept that brain death is really death?
An unstable compromise 
Problem: according to the Harvard committee, death occurs when all functions of the brain have irreversibly ceased. Tests have been developed to say when this has occurred. HOWEVER, there is evidence of brain function even in patients who meet this standard: for example, when brain-dead patients are cut open, their pulses quicken.
What should we do?
1. Get better tests to ensure that all brain functions have totally ceased.
2. Move to a definition of death as ceasing of higher brain functions (consciousness).
Option 1 would require expensive tests and keeping bodies on life-support for much longer as the tests are carried out, knowing all the time that nobody being tested would ever regain consciousness.
Chapter 3: “Dr. Shann’s Dilemma” 
Two Babies 
Anencephalic babies are those born with a brain stem but no cerebral cortex.
Cortically dead babies have irreparable damage to the cortex.
Neither of these count as dead by the Harvard committee’s standard, because they still have functioning brain stems.
Baby K born
anencephalic in 1992 in
Dr. Shann’s dilemma: he could have saved the life of a baby with a damaged heart by transplanting the heart of a cortically dead infant, but the law prohibited it, so both babies died.
Breathing but dead? 
I suggest that the organ that really matters in the cerebral cortex. If the cortex is dead, there is permanent loss of consciousness and there can be no person…If the cortex of the brain is dead, the person is dead. I suggest that it should be legal to use the organs from the body of the dead person for transplantation. 
Dr. Robert Truog:
Death is a process, and the moment of death cannot be discovered, but must be chosen. Truog’s choice: “death is the irreversible loss of the capacity for consciousness”.
Dr. Margaret de Campo (radiologist):
Thanks to new procedures (Three Vessel Angiography, etc.) we can tell in which sections of the brain blood is still flowing or not flowing. If blood is not flowing to the cortex then the patient is cortically dead. (This is a sufficient condition, but perhaps not necessary – it is possible that the patient could be cortically dead even if blood is flowing to her cortex)
Dr. Neil Campbell:
What we care about is the person rather than the body. And the person dies with the cortex, at which point, “there is no meaningful sense in which it can be claimed that decisions about life support or organ removal matter to him or her”
Dr. Steve Keeley:
Regarding anencephalic and cortically dead infants as dead would create “an ethical fiction” because it would suggest we should bury a child who can still breathe on its own.
The case for a higher brain definition of death 
1. Description of the situation
a. Death in intensive care is a process rather than a spontaneous event
b. The acceptance of brain death has meant a shift in the traditional concept of death
c. If we use brain death, we have to decide between whole brain and cortex-only conceptions of death
d. There is a shortage of organs that means that some savable children are lost
2. Appropriate medical care for anencephalic and cortically dead infants: attempts to sustain life are not obligatory
3. acceptablility of removing organs from anencephalic and cortically dead infants.
a. Redefine “dead” as meaning “death of the cerebral cortex” (Drs. Shann and Truog)
b. Don’t redefine death that way, and don’t remove organs (Dr. Keeley)
c. Don’t redefine death that way, but do allow removal of organs in tightly controlled situations (Singer)
Two medical reasons for position (a):
1. When the Harvard committee came up with the new standard, it was impossible to tell when the cortex died. Now it is possible (thanks to the methods outlined by de Campo)
2. We still can’t reliably tell when all brain functions cease, so if we leave the definition as it is, we may be actually killing “living” people.
Against brain death 
People hold two conflicting views:
The way to accommodate both intuitions is to deny that cortically dead patients are dead, but to allow organs to be taken. (Case of Laura Campo, who had her anencephalic baby delivered by C-Section so that the baby could donate organs, but wasn’t allowed to because of the current definition of death.)
A way forward? 
· When does a human being die?
· When is it permissible to stop trying to keep a human being alive?
· When is it permissible to remove organs from a human being for the purpose of transplantation to another human being?
Chapter 4: “Tony Bland and the Sanctity of Human Life” 
Fine Phrases 
The notion of the “sanctity” of human life, that “all lives are intrinsically valuable” so that “it is always wrong intentionally to kill an innocent human being” is clearly noble and something we would like to adhere to. However, it disguises real decisions we need to make about people like anencephalic infants and Tony Bland.
Tony Bland’s Tragedy 
Tony Bland: in 1989 his lungs were crushed, depriving his
brain of oxygen so that only the stem survived.
He was “cortically dead”. He was “kept
alive” in a persistent vegetative state (PVS) like between 10-25 thousand
Compare Tony Bland with Nancy Cruzan: in Tony Bland’s case the relevant question was deemed to be “what is in the best interests of the patient?” rather than, as with Nancy Cruzan [60-62] and Joey Fiori , “what would they have wanted?”
The latter question requires us to know the decision the patient would have made (in the case of Nancy Cruzan, friends and family suddenly “remembered” her saying she wouldn’t have liked to stay on life support, but because nobody said that for Joey Fiori, he was still being kept alive in 1994, 18 years after he entered a PVS), the latter can be made without such considerations.
Deciding on the basis of Quality of Life 
Each of the British Law Lords made it clear that “he did not value life that is human only in a biological sense” . Lord Justice Hoffman said “the stark reality is that Anthony Bland is not living a life at all”  but clearly this is playing with words. He was living a biological life, so in saying that he wasn’t living “a life” Hoffman clearly meant “a life of sufficient quality”.
Lord Mustill: withdrawing life-support was not only legally, but also ethically justified
since the continued treatment of Anthony Bland can no longer serve to maintain that combination of manifold characteristics which we call a personality. 
There can therefore be no doubt that, with the decision in the Bland case, British law abandoned the idea that life itself is a benefit to the person living it, irrespective of its quality…. The conclusion we can draw is that British law now holds that for life to be a benefit to the person living it, that person must, at a minimum, have some capacity for awareness or conscious experience. [67/8]
Lawfully Intending to End Innocent Life 
In the Tony Bland case, the intended purpose of ceasing treatment was to bring about Bland’s death. Previously, the most a doctor could do was bring about death as an unintended consequence of treatment, whose intended purpose was to alleviate pain (Mrs. Morrell, from the John Bodkin Adams trial of 1957 ). This is sometimes called the doctrine of double effect.
Discarding a Fig Leaf 
Karen Quinlan case:
Is ceasing treatment “turning on the gas chamber”  or ceasing “extraordinary” treatment?
Reasons why the “extraordinary/ordinary” distinction is a “fig leaf” covering the fact that real quality of life decisions are being made:
1. A respirator is only described as “extraordinary treatment” if a quality of life decision has already been made about the patient. If the patient will recover fine after being on the respirator then everyone would regard the treatment as “ordinary”.
2. The distinction is also intended to disguise the fact that Quinlan’s parents wanted her to die: it’s meant to look as if their intention is to “alleviate suffering” and so if death results, it’s because of the doctrine of double effect. But Quinlan could not suffer, because she was cortically dead.
Beyond the Sanctity of Human Life 
The principle of the sanctity of life states:
It is absolutely prohibited either intentionally to kill a patient or intentionally to let a patient die, and to base decisions relating to the prolongation or shortening of human life on considerations of its quality or kind.
Clearly this is not intended to be outweighed by other factors, but that’s what happened in the Tony Bland case. This means that, in effect, the Law Lords were discarding it as stated.
Acts and Omissions 
Were the Law Lords in effect sanctioning euthanasia in the Tony Bland case by allowing a doctor to intentionally end his life? They didn’t think so: they relied on a distinction between acting to end someone’s life and allowing someone’s life to end. In terminating treatment to Bland, the doctor was allowing him to die by “natural causes” – the doctor was not administering a lethal dose. But none of the Law Lords denied that this distinction between action and omission was anything but a stopgap compromise.
How can it be lawful to allow a patient to die slowly, though painlessly, over a period of weeks from lack of food but unlawful to produce his immediate death by lethal injection, thereby saving his family from yet another ordeal to add to the tragedy that has already struck them? 
The acute unease which I feel about adopting this way through the legal and ethical maze [i.e., allowing passive euthanasia but not active] is I believe due in an important part to the sensation that however much the terminologies may differ the ethical status of the two courses of action is for all relevant purposes indistinguishable. 
This suggests that we need a new legal framework to avoid being forced to make such bogus distinctions. That is, although the decision in the Tony Bland made a revolutionary step in allowing quality of life decisions, it still didn’t go far enough, as it should have carried through and allowed active euthanasia in certain cases.
PART II: CRUMBLING AT THE EDGES
Peggy Stinson’s Puzzle 
Peggy Stinson wanted an abortion because the life of her and the baby was threatened. However, she went into labor unexpectedly and gave birth prematurely. The baby was very likely to be handicapped and brain-damaged and the Stinsons asked that “no heroic measures” be taken to save his life, but the doctors threatened to take them to court and put the baby on a respirator. Peggy wrote:
A woman can terminate a perfectly healthy pregnancy by abortion at 24 ½ weeks and that is legal. Nature can terminate a problem pregnancy by miscarriage at 24 ½ weeks and the baby must be saved at all costs; anything less is illegal and immoral.
Why should birth make all the difference? Shouldn’t we treat fetuses of the same age the same whether inside the womb or out?
The unavoidable issue 
It is misleading to call the pro-abortion-rights movement “pro-choice” because you cannot get around the issue of whether or not the fetus has a right to life simply by focusing on the right of the mother to choose abortion.
Similarly, it is misleading to call the anti-legal-abortion movement “pro-life” because they’re not typically vegetarians and they’re often (unless Catholic) pro-capital punishment.
Anti-abortion comparatively new for religions:
Judaism has never taught that abortion is equivalent to murder.
Jesus never mentioned abortion ( and if it is so bad, you would think he would’ve).
Aquinas held that abortion was okay until “the quickening” which happened at 40 days after conception for males, 80 for females (according to him).
Why did Catholics switch to opposing abortion from conception? Because advances in biology suggested that the embryo was not “inert” for 40 days, but alive from day 1. (That is, they accepted Aquinas’s claim that abortion was wrong after “quickening” but thought that that happened at conception.)
In the 19th century in
1. “real” doctors supported the change in the Hippocratic Oath to distinguish them from “irregular” purveyors of medicine (like Midwives)
2. scientifically trained doctors took the quickening to occur at conception
3. The AMA crusaded to outlaw abortion
This change took hold until in the 1950s it was pretty much set in stone. All abortions were illegal.
The era of legal abortion 
a pain-killer given to pregnant women in most commonwealth countries (although
2. The number of women injured or killed in illegal abortions
By the time of Roe v. Wade, 18 states (including CA and NY), home to (or within 100 miles of) 2/3 of the population of the US had allowed some abortions to be legal.
Now (i.e., 1994, when the book was published) about 1.5 million legal abortions are carried out a year, the majority on women in their 20s and 30s.
Abortion on the grounds of defects evident thanks to
ultrasounds are legal in countries as diverse as
Between 1972 and 1987 this question was asked of a national sample 13 times:
Please tell me whether or not you think it should be possible for a pregnant woman to obtain a legal abortion if there is a strong chance of a serious defect in the baby.
The answer has always been between 75-78% “yes”. This shows a majority prepared to make quality of life decisions.
New reproductive technology and the abortion debate 
Is the early embryo, before implantation, a human individual?
Catholic Theologian, Father Norman Ford, Master of Melbourne’s Catholic Theological College was troubled by identical twinning, which is where the early embryo splits and two separate individuals develop.
Two puzzles for the claim that human life begins at conception:
call the fertilized egg
In case (a), which one gets to be
In case (b), should we have a funeral for
2. SYNGAMY: conception does not occur allatonce. Once a sperm enters the egg, the outer layer of the egg “locks up” so no other sperm can enter. BUT the genetic material of the egg and sperm are separate and do not merge until about 22 hours later (syngamy). So does conception occur when the sperm enters the egg or 22 hours later?
Wood and Trounson’s experiments: the law of the Australian state they were in forbade the creation of embryos for research UNLESS those embryos were later brought to term. Wood and Trounson didn’t want to implant their embryos because of possibilities of birth defects, so their suggested compromise was to observe embryos up to but not including syngamy. Is an egg in the process of fertilization an embryo? 
Objections to regarding the potential of the fetus as sufficient reason for preserving its life:
1. Population concerns: we don’t believe that contraception or abstinence is bad, even though both of these prevent potential people. In fact, we think them almost required.
2. Sperm and egg have potential too, perhaps comparable with an early embryo, because:
a. modern technology teaches us that spontaneous miscarriage of embryos occurs more often than we (including Noonan) thought, and before the embryo implants in the uterus, the probability of it surviving to birth is about 30%. Immediately following implantation, it is still less than 60%. It reaches 80% about 6 weeks after conception.
b. modern technology (microinjection) raises the chance of single sperm, combined with an egg, surviving up almost parallel with the embryo. (In fact, fertilizing eggs is the easy part of IVF.)
This means that, if potential is the reason not to destroy a fertilized egg, then it should also make destruction of sperm just as immoral.
Unlocking the abortion deadlock 
The argument against abortion:
Attacks on this argument usually target premise 2. Roe v. Wade decided that viability was the cut-off point at which abortion was impermissible (i.e. the start of human life)
1. as medical technology improves, viability moves earlier and earlier, and when artificial wombs (allowing ectogenesis) are perfected, it will move back to conception
2. viability is a function of where you are: if you’re near a good hospital the fetus is viable much earlier than if you’re stuck in the middle of nowhere
Alternative suggestion: the brain life criterion (Hans-Martin Sass )
This brings back all the issues of brain death: do we mean life of the cortex (starts after 10 weeks) or the brain stem (activity has been observed from 54 days)?
Also: are we really saying that the fetus “becomes alive” when the brain starts working? If so, this is the same “convenient fiction” as claiming a body is dead when the brain stops working. It’s clearly not true. Singer thinks the better way to take this proposal is that we are allowed to terminate human life before the brain starts working (just as he thinks we should be allowed to remove organs from living humans with dead cortexes). Understood this way, the brain-life criterion is an attack on premise 1: it is okay to take some innocent human life – that is, the life of those who do not have active cortexes.
How the Reagan administration chose a quality of life ethic 
“Baby Doe” was a Downs Syndrome baby, born in 1982 with an intestinal blockage. The Parents supported Dr. Walter Owens (the obstetrician who had delivered the baby) in his suggestion that the blockage not be removed and the baby be given drugs to ensure that he be free from pain.
2 weeks later, Reagan ordered that all providers of health care receiving federal funds should be notified that they must not discriminate against the handicapped. 6800 hospitals received new guidelines, including that posters must be put up saying that “DISCRIMINATORY FAILURE TO FEED AND CARE FOR HANDICAPPED INFANTS IN THIS FACILITY IS PROHIBITED BY FEDERAL LAW.” If such failure was spotted, a hotline should be called and “Baby Doe” squads would roll into action to investigate.
Most health-care professionals affected were opposed to the new “Baby Doe Guidelines”. Several organizations including the American Academy of Pediatrics sued to have the regulations struck down. The academy argued that some conditions were “simply not treatable” including anencephaly, a brain haemorrhage leading to cortical death, and absence of a major part of the digestive tract.
At the trial, the Reagan administration was represented by C. Everett Koop, who was supposedly in favor of a “sanctity of life” ethic agreed that children without intestines should not be kept alive on drips. In effect, the difference between him and Owens was not that one had a quality of life ethic and the other didn’t, but rather what quality mattered. Koop had a quality of life ethic, but thought Downs syndrome children of sufficient quality, but (e.g.) anencephalic children not.
The Baby Doe guidelines were struck down, and the size of the poster reduced. This statement was released:
the law does not require the imposition of futile therapies which merely temporarily prolong the process of dying of an infant born terminally ill, such as a child born with anencephaly or intra-cranial bleeding. 
The terms in bold reveal a quality of life ethic. Why is an anencephalic terminally ill, while a child with diabetes, who also needs constant care, not? Because of their differing “qualities of life”.
The Linares case : in 1989, the only way that Rudy Linares could get doctors to take his brain-dead child Samuel off a respirator was at gunpoint. The grand jury refused to indict him for homicide, and even his misdemeanor charge of unlawful use of a weapon was given a suspended sentence.
Treating to die 
Spina Bifida cases [115-119]
Surveys on attitudes of obstetricians and pediatricians 
The trial of Dr. Leonard Arthur (John Pearson, Downs child, born 1980) [121-4]
Babies B, C, J and M [124-128]
Selective non-treatment and infanticide 
These cases illustrate the practice of “treating unwanted babies to die” by giving them drugs that will make them sleepy and uninterested in food is not only fairly common, but fairly well accepted by a large proportion of the general public. The jury’s verdict in the case of Dr. Leonard Arthur  “suggests that the protection we give to the lives of older human beings does not apply to an unwanted baby” .
Should we be shocked by this?
Infanticide is actually fairly common across cultures across history:
Thousands of years of lip-service to the Christian ethic have not succeeded in suppressing entirely the earlier ethical attitude that newborn-infants, especially if unwanted, are not yet full members of the moral community. 
Now there is less talk of ordinary vs. extraordinary treatment and
More open acknowledgement of what Lord Justice Taylor called the correct approach: ‘to judge the quality of life the child would have to endure if given the treatment’. 
Chapter 9: “In Place of the Old Ethic” 
The Structure of Ethical Revolutions 
Comparison between current crisis in Ethics and crisis in Ptolemaic astronomy: just as epicycles on epicycles had to be added to orbits of the planets to make their motion “fit” with a cosmology that had the earth at the centre of the universe, so the “Sanctity of life” ethic (that has humans at the centre of the ethical universe) has to make the following “patches”:
a. Death redefined so that breathing humans are “dead”
b. Distinction between “ordinary” and “extraordinary” treatment invented
c. Euthanasia permitted if the intention is to relieve pain (doctrine of double effect)
d. “Non-treatment” permitted for disabled infants
e. Denying that humans exist before birth/viability
f. Taboo made on comparisons between disabled humans and non-humans of any kind
Rewriting the Commandments 
In none of these cases is defining death the important issue.
Some Answers 
1. Brain death, anencephaly, cortical death and
the persistent vegetative state 
The new commandments settle Dr. Shann’s dilemma and the cases of Babies Theresa and Valentina (cortically dead, whom their parents wanted to be organ donors, but the courts intervened – chapter 3, 53-4). They aren’t as clear cut in cases where the parents aren’t yet ready to part from their children: they allow that the parents have the right not to donate organs, which is right.
2. Abortion and the brain-dead pregnant woman
What the commandments say: commandment 1 allows that some or possibly all fetuses don’t have the right to life. Commandment 5 demands that whatever rights we ascribe to fetuses, we must also do so for non-humans with comparable cognitive capacities. When the fetus can feel pain (possibly from ten weeks) abortions that are painless are more likely to be permissible. In these cases causing death to the fetus will not be as bad as causing it pain, because the fetus doesn’t have plans for its future, but it does have desires not to feel pain.
What about the cases of Tricia Marshall and Marion Ploch (chapter 1)? Here we are not morally required to keep their bodies alive to bring the fetuses to term, although this is certainly permissible, particularly if the father really wants this.
3. Infants 
If we allow late abortions, does that mean we must also allow infanticide, given that the capacities are the same (particularly for premature infants)? Birth is the only difference – that might be relevant in two ways:
Whether or not the child continues
to live should be up to the parents (not
a judge), as they are charged with its care, and its continued life will affect
them (and their prospective future children) the most.
Singer argues that the desires of a parent for the kind of life involving “normal” child are enormously important. They have the right not to choose the life of someone who has to care for a handicapped child. ALSO this may effect future children – Peggy Stinson noted that delay on decision on her premature and handicapped child might take away the possibility of another child. In Should the Baby Live? Singer and Helga Kuhse suggest that after 28 days the baby should be granted the same rights as an adult.
4. People 
Commandment 3 says that every person has the right to life. Persons should (mostly) therefore be beings who can fear their own death because otherwise they do not have much need for the right. (This applies even to those who can fear but don’t – we don’t want to say it’s not murder to kill Epicureans.) BUT: one can choose to waive one’s rights, so someone who really wants to die should have that right.
The Basis of the New Approach to life and death 
The two central assumptions of the old ethic that Singer rejects (because they are untenable, he claims, in the light of the various examples discussed):
1. we are responsible for what we intentionally do in a way that we are not for what we deliberately fail to prevent (distinction between acts and omissions)
2. the lives of all and only members of our species are more worthy of protecting than any other being.