The neurological determination of death: what does it really mean?

The recent Canadian forum's recommendations regarding "neurological determination of death" claim to have determined a "Canadian definition, criteria, and minimum testing requirements for neurological determination of death." In this review the problems with this statement are discussed. The criterion of neurological determination of death does not fulfill the definition of death, because there is continued integration of the organism as a whole. The tests for neurological determination of death do not fulfill the criterion of neurological determination of death because they do not show the irreversible loss of all critical brain functions. The forum has provided no coherent argument for why neurological determination of death should be considered death. I suggest that one cannot invoke expert opinion to clarify a criterion of death, and tests for this criterion of death, without a clear concept of what death is. The forum has clarified tests for what they call "neurological determination of death," but this is not death itself; rather, it is a neurologically devastating state. Whether this state of "neurological determination of death" is enough to justify the morality of harvesting organs prior to death is the real question. A potential solution to this question is discussed.     

Metastatic cancer of the urinary bladder: can it be a nonnatural death?

Deaths from metastatic carcinoma are almost exclusively viewed as wholly natural deaths. However, if it can be shown that a cancer has arisen as a result of a prior traumatic injury and the body's healing response to the injury, or treatment thereof, then in select cases, the manner of death shall reflect that of the precipitating injury. This case report is that of a woman who was rendered quadriplegic from spinal cord injury sustained in a motor vehicle crash when she was 22 years old. She died at the age of 49 years from widely metastatic squamous cell carcinoma of the urinary bladder. Her bladder cancer most likely arose from decades-long chronic irritation of the bladder epithelium by physical contact with an indwelling Foley catheter and urinary infections. Over the years, the chronic bladder irritation likely precipitated metaplastic, dysplastic, and finally neoplastic changes of the bladder epithelium, providing a link between her spinal cord injury, the indwelling Foley catheter, and her bladder cancer, engendering an accidental manner of death. The manner of death reflected the circumstances of her injury that predisposed her to the cancer that eventually caused her death.     

"Natural death" of a patient with a deactivated implantable-cardioverter-defibrillator (ICD)?

A 66-year-old patient with terminal heart insufficiency (NYHA IV) received maximum medical therapy, but was also in need of an implantable-cardioverter-defibrillator (ICD). The ICD functioned flawlessly for the whole duration of implantation. It reverted several ventricular tachycardias with anti-tachycardial pacing alone, whereas some needed cardioversion as well. The patient died on the fourth day of hospitalization for a routine check of his ICD. The post-mortem examination revealed, that the ICD was deactivated and that the data had been erased after the patient's death. By reading off the raw data still stored within the ICD, the erased information could be restored. The stored EGMs showed traces of old ICD interventions as well as a permanent deactivation provoked by exposition to a magnetic field just hours before the patient's death. The problem of archiving and documenting the volatile electronic data inside the ICD is discussed. The need of a full autopsy after telemetric reading of the ICD data, including the explantation of the ICD aggregate and electrodes, as a means of quality assurance and under forensic aspects is emphasized.     

Sudden unexpected death in epilepsy: is death by seizures a cardiac disease?

RESULTS: Sudden unexpected death in epilepsy (SUDEP) gains more and more acknowledgment across the various interdisciplinary fields. Accordingly, we performed in a prospective setting a case-control study of all SUDEP cases in a well-defined part of Denmark (Northern Jutland), between January 1998 and September 2000. We attempted to look into the cardiopathologic mechanism behind this phenomenon by assessing the degree of myocardial fibrosis in SUDEP patients versus controls. The histologic evaluation was possible in 65% of the cases (15/23) whose death was attributed to SUDEP and in 71% (15/21) of controls. Forty percent of the SUDEP cases (6/15) presented several foci of fibrotic changes in the deep and subendocardial myocardium in contrast to 1 control (6.6%, P = 0.03). None of the subjects from the SUDEP group showed fibrotic changes in their conduction system as compared with 1 control (6.6%). The quantitative evaluation of fibrosis demonstrated a trend toward more fibrosis in the deep and subendocardial myocardium of the SUDEP cases. Forty percent of cases in the SUDEP group were men (6/15), characteristically young at time of death (mean age 38 years) and with a late epilepsy onset (mean age 21 years). Antemortem, 73% of the SUDEP patients (11/15) had experienced infrequent seizures (self-reported). We conclude that the SUDEP cases displayed significant fibrosis of the myocardium when this was assessed by qualitative means. This fibrosis may be the consequence of myocardial ischemia as a direct result of repetitive epileptic seizures, which, associated with the ictal sympathetic storm, may lead to lethal arrhythmias.     

"Reasonable accommodation" under the Americans with Disabilities Act--what does it mean?

The Americans with Disabilities Act (ADA) imposes on employers the duty to afford qualified disabled applicants and employees "reasonable accommodation," but provides minimal guidance as to the range of actions necessary to fulfill this duty. Under the statutory scheme, required accommodations will vary from employer to employer, from worksite to worksite for the same employer, and perhaps even from employee to employee at the same worksite. Personnel managers will be required to make very fact-specific decisions in each case as to whether to offer particular accommodations, with any decision declining to provide the accommodation subject to attack in litigation. Based on an analysis of how similar reasonable accommodation requirements have been interpreted under other statutes, this article analyzes the likely parameters of the duty to afford reasonable accommodation under the ADA and offers specific suggestions for employers to minimize their risk of liability.     

Does the death penalty save lives?

Research Summary Economists have recently reexamined the “capital punishment deters homicide” thesis using modern econometric methods, with most studies reporting robust deterrent effects. The current study revisits this controversial question using annual state panel data from 1977 to 2006. Employing well‐known econometric procedures for panel data analysis, our results provide no empirical support for the argument that the existence or application of the death penalty deters prospective offenders from committing homicide. Policy Implications Although policymakers and the public can continue to base support for use of the death penalty on retribution, religion, or other justifications, defending its use based solely on its deterrent effect is contrary to the evidence presented here. At a minimum, policymakers should refrain from justifying its use by claiming that it is a deterrent to homicide and should consider less costly, more effective ways of addressing crime.     

Constitutional pluralism: Chronicle of a death foretold?

What remains of the idea of constitutional pluralism in the wake of the Euro‐crisis? According to the new anti‐pluralists, the recent OMT saga signals its demise, calling to an end the tense stalemate between the ECJ and the German Constitutional Court on the question of ultimate authority. With the ECJ's checkmate, OMT represents a new stage in the constitutionalisation of the European Union, towards a fully monist order. Since constitutional pluralism was an inherently unstable and undesirable compromise, that is both inevitable and to be welcomed. It is argued here that this is misguided in attending to the formal at the expense of the material dimension of constitutional development. The material perspective reveals a deeply dysfunctional constitutional dynamic, of which the judicial battle in OMT is merely a surface reflection. This dynamic now reaches a critical conjuncture, encapsulated in the debate over ‘Grexit’, and the material conflict between solidarity and austerity. Constitutional pluralism, in conclusion, may be an idea worth defending, but as a normative plea for the co‐existence of a horizontal plurality of constitutional orders. This requires radical constitutional re‐imagination of the European project.     

Is organ procurement causing the death of patients?

This article offers a philosophical foundation for the Uniform Determination of Death Act as it first examines death per se, and then examines brain death and the non-heart beating donor criteria for determining death. The author suggests that many of the debates over death can be bypassed by changing the terms of the debate: what matters is not whether death is a process or an event, but death as a state. Understanding death as a state allows us to determine death in a functional manner that is compatible with the needs of law and medicine. The second part examines objections that arise from ignoring or rejecting the distinction between killing and letting die and the principle of double effect. By clarifying the lines between life and death, on the one hand, and between intentionally killing and unintentionally hastening death, on the other, the author hopes to restore a sense that the proposals to drop the dead donor rule are radical recommendations to cross lines we have never crossed before.