Giacomini M
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
Soc Sci Med. 1997 May;44(10):1465-82. doi: 10.1016/s0277-9536(96)00266-3.
In 1968, an ad hoc committee of Harvard faculty publicly redefined death as "brain death". What interests and issues compelled the redefinition of death, and formed the "spirit" of this precedent-setting policy? This paper reports on an historical study of the files of the Harvard ad hoc committee, the proceedings of an international conference on ethical issues in organ transplantation, and a review of the medical literature and media in the decades preceding the redefinition of death. This analysis of the technological and professional forces involved in the redefinition of death in 1968 questions two common theses: that technological "progress", primarily in the areas of life support and electroencephalography, literally created brain-dead bodies and dictated their defining features (respectively), and that Harvard's definition of brain death by committee constituted a net loss of autonomy for medicine. In fact, medical researchers through the 1960s disputed and negotiated many features of the brain death syndrome, and transplantation interests-perhaps more kidney than heart-played a particularly influential role in tailoring the final criteria put forth by Harvard in 1968. It is also doubtful whether Harvard's definition of brain death by multidisciplinary committee undermined medical privilege and autonomy. The Harvard Ad Hoc Committee may not have succeeded in establishing definitive, indisputable brain death criteria and ensuring their consistent application to all clinical cases of brain death. However, it did gain significant ground for transplant and other medical interests by (1) establishing brain death as a technical "fact" and the definition of brain death as an exercise for medical theorists, (2) involving non-medical ethics and humanities experts in supporting the technical redefinition of death, and, (3) successfully involving transplant surgeons in the redefinition of death and attempting (albeit unsuccessfully) not to exclude them from the actual diagnosis of death in individual cases.
1968年，一个哈佛教员特别委员会公开将死亡重新定义为“脑死亡”。是哪些利益和问题促使了对死亡的重新定义，并形成了这一开创先例政策的“精神”呢？本文报告了一项历史研究，该研究涉及哈佛特别委员会的档案、一次关于器官移植伦理问题的国际会议的议程，以及对死亡重新定义前几十年的医学文献和媒体的回顾。对1968年死亡重新定义中所涉及的技术和专业力量的这种分析，对两个常见观点提出了质疑：一是技术“进步”，主要是在生命支持和脑电图领域，实际上创造了脑死亡尸体并分别规定了其定义特征；二是哈佛委员会对脑死亡的定义对医学来说意味着自主权的净损失。事实上，整个20世纪60年代，医学研究人员对脑死亡综合征的许多特征进行了争论和协商，而移植利益——也许肾脏移植比心脏移植更甚——在制定哈佛于1968年提出的最终标准方面发挥了特别有影响力的作用。哈佛多学科委员会对脑死亡的定义是否削弱了医学特权和自主权也值得怀疑。哈佛特别委员会可能没有成功确立明确、无可争议的脑死亡标准，也没有确保这些标准在所有脑死亡临床病例中得到一致应用。然而，它确实通过以下方式为移植和其他医学利益取得了重大进展：（1）将脑死亡确立为一项技术“事实”，并将脑死亡的定义作为医学理论家的一项工作；（2）让非医学伦理和人文专家参与支持对死亡的技术重新定义；（3）成功让移植外科医生参与死亡的重新定义，并试图（尽管未成功）在个别病例的实际死亡诊断中不将他们排除在外。
