Shewmon D Alan
University of California Los Angeles, Los Angeles, California, USA.
J Med Philos. 2021 May 14. doi: 10.1093/jmp/jhab014.
Discrepancies between the Uniform Determination of Death Act (UDDA) and the adult and pediatric diagnostic guidelines for brain death (BD) (the "Guidelines") have motivated proposals to revise the UDDA. A revision proposed by Lewis, Bonnie and Pope (the RUDDA), has received particular attention, the three novelties of which would be: (1) to specify the Guidelines as the legally recognized "medical standard," (2) to exclude hypothalamic function from the category of "brain function," and (3) to authorize physicians to conduct an apnea test without consent and even over a proxy's objection. One hundred seven experts in medicine, bioethics, philosophy, and law, spanning a wide variety of perspectives, have come together in agreement that while the UDDA needs revision, the RUDDA is not the way to do it. Specifically, (1) the Guidelines have a non-negligible risk of false-positive error, (2) hypothalamic function is more relevant to the organism as a whole than any brainstem reflex, and (3) the apnea test carries a risk of precipitating BD in a non-BD patient, provides no benefit to the patient, does not reliably accomplish its intended purpose, and is not even absolutely necessary for diagnosing BD according to the internal logic of the Guidelines; it should at the very least require informed consent, as do many procedures that are much more beneficial and less risky. Finally, objections to a neurologic criterion of death are not based only on religious belief or ignorance. People have a right to not have a concept of death that experts vigorously debate imposed upon them against their judgment and conscience; any revision of the UDDA should therefore contain an opt-out clause for those who accept only a circulatory-respiratory criterion.
《统一死亡判定法案》（UDDA）与成人及儿童脑死亡（BD）诊断指南（“指南”）之间的差异促使人们提出修订UDDA的建议。刘易斯、邦妮和波普提出的一项修订案（RUDDA）受到了特别关注，其有三个新特点：（1）将指南指定为法律认可的“医学标准”；（2）将下丘脑功能排除在“脑功能”类别之外；（3）授权医生在未经同意甚至在代理人反对的情况下进行呼吸暂停测试。来自医学、生物伦理学、哲学和法律等广泛领域、视角各异的107位专家一致认为，虽然UDDA需要修订，但RUDDA并非正确的修订方式。具体而言，（1）指南存在不可忽视的假阳性错误风险；（2）下丘脑功能对整个机体的相关性比任何脑干反射都更强；（3）呼吸暂停测试有在非脑死亡患者中引发脑死亡的风险，对患者没有任何益处，不能可靠地实现其预期目的，甚至根据指南的内在逻辑，对诊断脑死亡也并非绝对必要；它至少应该像许多更有益且风险更小的程序一样，需要获得知情同意。最后，对死亡神经学标准的反对并非仅基于宗教信仰或无知。人们有权不接受专家们激烈争论的死亡概念违背他们的判断和良知而强加于他们；因此，UDDA的任何修订都应包含一个退出条款，供那些只接受循环呼吸标准的人使用。
