IS-OUGHT: PRESCRIBING AND A PRESENT CONTROVERSY* S INCE THE PUBLICATION of John Finnis"'s Natural Law and Natural Rights,1 a controversy concerning the position of Aquinas on the " is-ought " question has intensified. Finnis follows Germain Grisez's stance, which sharply divides the realms of "is" and "ought", as will be explained below. Grisez articulated his views in his 1965 article "The First Principle of Practical Reason: A Commentary on the Summa Theologiae, 1-2, Question 94, Article 2 ". 2 Recently Grisez reaffirmed his adherence to the position expressed in that commentary and indicated that he and Finnis agree on the issues discussed in it. 3 In the opposing camp are well-known interpreters of Aquinas such as Vernon Bourke,4 Ralph Mclnerny, 5 and Henry Veatch. 6 * I should like to express my gratitude to Canisius College, Buffalo, New York, for the faculty fellowship that made possible the research for this paper. I also wish to thank the Pontifical Institute of Mediaeval Studies in Toronto for access to its library throughout the summer of 1983. 10xford: Clarendon Press, 1980; hereafter NLNR. 2Natural Law Forum 10 (1965), pp. 168-201; hereafter FPPR. In his book Finnis acknowledges his indebtedness to Grisez on pp. vii and 53. a" The Basic Principles of Natural Law: A Reply to Ralph Mcinerny," John Finnis and Germain Grisez, American Journal of Jurisprudence 26 (1981) ; pp. 21-31; hereafter Reply to Mcinerny. In his article "Natural Law and the 'Is'-' Ought' Question: An Invitation to Professor Veatch" (Catholic Lawyer, vol. 26, no. 4, 1981) Finnis reiterates and develops points made in his book. This article will be referred to in subsequent footnotes as Response to Veatch. 4 Review of NLNR, American Journal of Jurisprudence 26 (1981), pp. 24347; hereafter Bourke's review; "Justice as Equitable Reciprocity: Aquinas Updated," American Journal of Jurisprudence 27 (1982), pp. 17-31; hereafter Bourke on justice. s "The Principles of Natural Law," American Journal of Jurisprudence 25 ( 1980), pp. 1-15; hereafter Mcinerny. 6Review of NLNR, American Journal of Jurisprudence 26 (1981), pp. 247-59; hereafter Veatch's review; "Natural Law and the 1 JANICE L. SCHULTZ All three criticize the Grisez-Finnis position for failing to ground adequately ethics in metaphysics, and for holding that Aquinas did the same. Bourke, for example, says that " Finnis' approach to ... natural law ... [reveals] his lack of interest in realistic meta.physics. Because he is too much impressed with Hume's version of the relation of 'is ' and ' ought', Finnis does not pay enough attention to the realities of the world in which man lives ... " 7 In criticizing Grisez's exposition of Aquinas's ethics, Bourke states " .... Grisez's ethics is too far divorced from Aquinas's general metaphysics and philosophy of man." 8 Similarly, Ualph Mcinerny takes issue with Grisez's "insistence that no transition from is to ought, from fact to value is going on in natural law ". 9 Most overtly distressed is Henry Veatch, who attributes to Finnis the position that, in truth as well as according to Aquinas, ethics need not be based on metaphysics, that the norms of human existence are not founded on the facts of human nature. 10 Veatch dubs this stance, which he ascribes also to Grisez, a." canker" on Finnis's otherwise excellent account, 11 which establishes a wall of separation that provides support for an ethics of mere convention. 12 Of course Bourke, Mcinerny, and Veatch take issue with Grisez and Finnis on a variety of points; in so doing, they reveal Question," Catholic Lawyer, vol. 26, no. 4 ( 1981), pp. 251-65; hereafter NLIOQ. The aoove citations are not intended to be exhaustive. Furthermore, there are other authors on both sides. Some, such as Joseph M. Boyle, explicitly adopt Grisez's position (e.g., " Aquinas and Prescriptive Ethics," Proceedings of the American Catholic Philosophical Association 49, 1975, esp. pp. 86 ff.) Obviously, depending upon how one identifies the points of disagreement, there are an enormous number of other authors who fit into one camp or the other. 7 Bourke on justice, pp. 23-24. s Bourke's review, p. 244. In both articles cited here Bourke notes Finnis's debt to Grisez. In his review Bourke also comments approvingly on Ralph Mcinerny's criticism of Grisez as an interpreter of Aquinas's ethics: p. 244. 9 Mclnerny, p. 11, his emphasis. 10Veatch's review, pp. 256 and 258; see also NLIOQ, esp. pp. 253, 254, 256, 265. In both articles Veatch, too, notes the dependence of Finnis on Grisez. 11 Veatch's review, p. 259. 12 NLIOQ, f· 265 7 IS-OUGHT: PRESCRIBING AND A PRESENT CONTROVERSY 3 their distinct approaches. Still, they are united in the conviction that metaphysics and the philosophy of man must ground ethics, that "ought" thus depends on "is", and that Grisez and Finnis, misinterpreting Aquinas on this point, offer an unacceptable alternative. In this paper, I attempt to show that the Grisez-Finnis view does not neglect nature as a basis for moral value. However, owing to their interpretation of "ought "-judgments as prescriptive rather than descriptive, Grisez and Finnis incorrectly separate the realms of " is " and " ought." After explaining these points, I offer an analysis of moral "ought "-judgments as inherently descriptive, recognizing that prescriptive uses can occur. Even in such cases, however, the descriptive component remains the ground of the directive. Nature and Value There is no question that both Grisez and Finnis sharply separate descriptive and evaluative activity. Contending that the Aristotelian-Thomistic distinction between the speculative and practical reason corresponds to the modern distinction between" is" and" ought", Finnis argues that Aquinas would allow no deduction of " ought " from " is '', nor would he sanction attempts to derive basic practical principles or practical (evaluative) judgments from facts. 13 This is in keeping with Grisez' s more specific contention that moral " ought "-utterances-which he considers to be moral judgments or " ethical evaluations "-are fundamentally different from, and irreducible to, factual claims. 14 The question that must be considered here, however, is: Does the above position entail the rejection of nature as a basi,s for moral value, or even a denial that all goodness is to be understood in terms of being? 15 Neither Finnis nor Grisez thinks that it does. In a rejoinder to Veatch, Finnis points out that 1a E.g., NLNR, pp. 36, 47, 33-35, 63, 66, 73, 81, 85, 91. 14 FPPR, pp. 194-95. u Veatch's review, p. 256. 4 JANICE L. SCHULTZ he considers basic goods to be " basic aspects of human flourishing." 16 He quotes from his book: "The basic forms [of human good] grasped by the practical understanding are what is good for human beings with the nature they have." 17 Again," The basic forms of good are opportunities of being; the more fully a man participates in them the more fully he is what he can be." 18 Following this, Finnis attempts to explain how the fundamental practical principles, dependent upon these goods, acquire moral force. 19 Grisez makes similar points in numerous places. For example, he says" ... the rightness of moral choices must be based upon the well-being or flourishing of persons, for a moral agent can identify with this and find self-fulfillment in it." 20 Holding that ' oughts ' arise from ' goods', that certain kinds of human activity are conducive to furthering all aspects of :flourishing or self-realization, which depend for their character on human nature and its potentialities, he declares the basic moral requirement to be " that one choose and act for some human goods, while at the same time one maintain one's appreciation, openness, and respect for the goods one is not now acting for." 21 Indeed, with one voice Finnis and Grisez reaffirm their commitment to a teleological understanding of all nature, including human nature, and a corresponding ethical objectivism. 22 1aResponse to Veatch, p. 269; see NLNR, pp. 23, 67, 87, 144. 11 Response to Veatch, p. 271; NLNR, p. 34. Again, Finnis is purporting to develop Aquinas's position: p. 46. Veatch does, in fact, recognize that Finnis considers human goods to be determined by human nature: Review, p. 251. is Response to Veatch, p. 270, NLNR, p. 103 (Finnis's emphasis). 19 See esp. NLNR, pp. 101 and 103. 20 Life and Dea.th with Liberty and Justice: A Oontribution to the Euthanasia Debate, co-author, Joseph M. Boyle (Notre Dame: University of Notre Dame Press, c. 1976; hereafter LDLJ), p. 362; FPPR; esp. 171, 180. 21 LDLJ, pp. 362-64; see also pp. 345, 368; cf. Oontraception and the Natural Law (Milwaukee: The Bruce Publishing Co., c. 1964; hereafter CNL), pp. 60-72; Reply to Mclnerny, p. 28. 22 Reply to Mcinerny, pp. 23-24. Perhaps it should be pointed out here that Finnis's claims about the existence of definite human values or goods would be interpreted by many as :ts-OUGHT: :i>REscRIBING AND A PREsENT CONTROV:ERSY 5 Moreover, they do not deny that metaphysical truths are an essential component in the formation of "normative conclusions"; their central contention concerns the essential difference between theoretical and practical principles (judgments), reflecting the distinct activities of theoretical and practical reason.23 This theme is paramount in the works of these authors; one more quotation should help to formulate it as a position: [between Veatch and Finnis l is this: I " The [Finnis] assert that judgments [about man's natural goods, about what man should be] are primarily (though perhaps not exclusively) judgments of practical reason ... The differences between speculative and practical reason are differences between intellectual operations with differing objectives .. '. our primary grasp of human good ... is practical." 24 The Grisez-Finnis affirmative of the is-ought dichotomy, then, relates to the distinct mode of the apprehension of goods by the practical reason, and the consequent formulation of praetical principles as irreducibly prescriptive. The critics of Grisez and Finnis do take issue with them on the relation between the practical and theoretical reason. Bourke suggests that Finnis's "strict separation" of these is un-Thomistic. 25 Veatch comments on the inordinate fear of Grisez and Finnis that the distinction between these might be blurred, 26 and Mclnerny objects to excluding purely factual statements from the domain factual. At least he considers as legitimate characterizing the judgment "Knowledge is a good to be pursued" as objectively the case, correct, a correct assertion or affirmation (NLNR, p. 75) and as a "rational judgment about a general form of human well-being, about the fulfillment of a human potentiality" (NLNR, p. 72; see also p. 53). As already noted (n. 13 above) he identifies value-judgments with practical principles, but with regard to the former he uses language appropriate to descriptive utterances (more on this below). At any rate, he explicitly asserts that both he and Grisez reject ( 1) the assertion "that ethical principles can have no grounding in fact and in nature" as well as (2) the denial "that morals and ethics have any basis in nature or the facts of nature": Reply to Veatch, p. 266. 2s Reply to Mcinerny, pp. 24-25. 24 Response to Veatch, p. 272. See note 59 below. 25 Bourke on justice, p. 23. 20 Review of Veatch, p. 258. JANicE :t. SCH:ut'l'i of practical discourse. 21 Still the heart of the controversy seems untouched by such objections. Below it will be shown how the ascribing of the different roles by Grisez and Finnis to the theoretical and practical reason is fundamental to the overall controversy. It will be held that the Grisez-Finnis position is objectionable not because it separates description and prescription, but because it identifies prescriptions and "ought"judgments.28. To understand this, an explication of the operation of the practical reason according to Grisez and Finnis must be proffered. Basic Principles of Practical Reason In his commentary on the first principle of practical reason Grisez stresses the point that the practical reason is reason directed to activity, to accomplishing some work or operation. Now such activity presupposes a good, something attracting, an object of tendency, which establishes the activity's direction. Thus is explained, in summary fashion, why Aquinas says that as being first falls within the unrestricted grasp of the mind, so good first falls within the grasp of practical reason. 29 This good is not the moral good; rather, " a good " here designates simply the enUGHT: PRESCRi:BING AND A PRESENT CONTROVERSY 11 [imperans] orders the one commanded to do something, by way of intimation or declaration." Such ordering [ordinare] is an act of reason. But, he continues, reason can in general intimate or declare something in two ways: either absolutely, in which case an indicative verb is used, or in a way by which a person is, as it were, moved to act, expressed in an imperative. };.quinas gives as an example of absolute (indicative) declaration or intimation " This is what is to be done by you " ("Hoc est tibi faciendum ") . The example he gives of reason commanding is "Do this" ("Fae hoc") . 'Vhen Aquinas says reason can declare or intimate in two ways, he does not use the words " in general," as contained in the above paragraph. However it is important to include them in order to avoid a misinterpretation of Aquinas's position, namely, that he is saying that reason can order in two waysi.e., absolutely, or by moving. According to the Grisez interpretation, ordering with a kind of " motion " would be commanding or imperation, whereas ordering "absolutely" would be prescription. Yet it would indeed be odd if Aquinas first associated commanding (imperare) with ordering (ordinare) as he does in the text, and then divided ordering into two activities, one of which is not commanding (declaring or intimating by moving) . Furthermore, in ST 2-2, 47, 8 Aquinas states that the principal act of the practical reason is to command. " Praecipere " here is used for command, but in this article Aquinas not only uses imperare and praecipere interchangeably (obj. 3, unchallenged) but he also points out that praecipere implies a motion with a certain order (" praecipere importat motionem cnm qnadmn ordinatione ") , which is an act of reason (ad 3). This is the way he characterizes imperare in the previously discussed article. 47 Hence in 1-2, 17, 1 Aquinas distinguishes two modes by which reason declares or intimates something: absolutely (here ex47 ST 1-2, 17, l and ad 1 and 3; see also 1-2, 17, 2. In ST 2-2, 47, 8 ad is stressing the rational aspect of command, refuting the claim that command (praecipere) is not an act of prudence, an intellectual virtue (obj. 3). For praecipere as the principal act of the practical reason, see also ST 1-2, 57, 6. 3 Aquinas 12 J ANIC.t!J L. SCHULTZ pressed in the gerundive), and by commanding (imperare or praecipere), the domain of the practical reason. Thus there is no basis for claiming, as Grisez does, that Aquinas is distinguishing two distinct activities of the practical reasonprescription and imperation-and that the gerundive of the first practical principle is the former, but is not the latter. 48 Rather, given the analysis above, it must be concluded that reason directing is reason engaged in one type of activityimperative, i.e., prescriptive-which can be expressed either in the gerundive or the imperative form. The first principle of practical reason is an imperative (= prescription) expressed by a gerundive. This analysis may be thought to be inconsistent, in that the gerundive used in 1-2, 17, l is not here considered to be an imperation or prescription, but is rather an absolute declaration or suggestion (which I shall characterize here as a descriptive use of the gerundive: compare Aquinas's use of "indicative ") . This can be explained if one considers gerundives to be descriptive or prescriptive depending on context, as I think is the case. Space limitations make it impossible to show this in this paper. However, it might be noted that the descriptive gerundive-as well as value-judgments containing words such as " good " and " ought "-need not be prescriptive to be suggestive or action-guiding to one seeking advice about how to act. As will be shown below, value-judgments may well be descriptive but also motivating in conjunction with human natural inclinations and human commitments. Now, as Grisez points out and as will be explained, Aquinas holds that an imperative presupposes an act of the will.49 Thus the contention that the first principle of practical reason is, in a Thomistic context, an imperative must be supported by evidence showing this principle to be preceded by activity of the will. Aquinas discusses the nature of commanding (imperare) in the context of his analysis of the structure of human acts. He is basically considering the alternating movement of reason and 48 FPPR, p. 192. 49 Ibid. IS-OUGHT; PRESCRIBING AND A PRESENT CONTROVERSY 13 will from intention (will) through counsel (intellect), choice (will), command (intellect), use (will) .5-0 Command here, then, is the direction by practical reason to the other powers to make use of a. means already chosen by the will.51 That is, it is an act of reason presupposing an act of the will. Does this mean the practical reason, which commands, is not operative until this stage? This does not seem to follow. Certainly there are other acts of the will leading up to the stage of choice, and Grisez is addressing himself to this more fundamental intelleot-will interaction. However, he not only holds tha:t a condition for the operation of the practical reason is the presence of a good; he also argues that no act of will is presupposed by the first principle of practical reason. Indeed, he holds tha.t practical direction makes all acts of will possible; hence no basic practical principle can be an imperative, which presupposes the activity of the will.52 He, of course, is considering practical principles to be prescriptions rather than imperatives, a distinction argued against above. While it is true that Aquinas contends that no willing is possible without prior apprehension, he also speaks of the first act of the will, i.e., its necessary orientation toward the universal good, as due not to the direction of reason but to the nature of a higher ca.use, namely God. 53 Indeed, such an inclination is necessary in order for any further activity of the will to occur, since the very attractiveness of an object apprehended as good depends not only upon the object, but also the subject. 5 ' Per50 ST 1-2, 12-17. Consent, which Aquinas also discusses, is an aspect of choice: 1-2, 15, 3 ad 3. 51 A more detailed list of moments of the human act: intention (will); deliberation about means (counsel: intellect; consent: will; judgment or selection: intellect); choice of means (will); command (intellect); use (will). Counsel, consent and selection are discussed in ST 1-2, 15, 3 ad 3 and 1-2, 57, 6; I have combined Aquinas's discussions. 52 FPPR, p. 193. 53ST 1-2, 17, 5 ad 3; 1-2, 9, 4; 1-2, 9, 6 and ad 3; 1, 18, 3. On the other hand, every act of the will is preceded by an act of the mind: 1-2, 4, 4 ad 2; 1-2, 5, 8 ad 2. For necessary orientation of the will, see also 1, 82, I and 2; 1, 83, I ad 5, 1-2, 10, 2 and note 55 below. 54 ST 1-2, 9, 2. 14 JANICE L. SCHULTZ haps, then, a distinction should be made between willing as actual moving toward an already apprehended end, and the natural orientation of the will toward the ultimate end, a disposition which persists whether adverted to or not, in virtue of which the subject can be aclivated toward specific ends when apprehended. 55 Of course, as Grisez points out, the possible ends that activate, that we find attracting, are set within the domain of the objects of the natural inclinations. Grisez specifies that the practical reason views these objects to be possible ends, and prescribes according to them, when it is already operative, directed to work. However, it seems that one's disposition to be able to be attracted to some project, and hence to engage in activity or work, includes a disposition to be attracted by certain kinds of things, namely, those relating to the objects of the inclinations. It is the conjunction of an apprehended possible end (e.g., writing an article) and its initial attractiveness, dependent upon an inclination (to pursue the truth) , that gives rise to a surge from immediate tendency instantaneously to conscious orientation toward the enterprise. This orientation consists in the intellectual urging to pursue the object grasped as attracting or good-i.e., it consists in a precept or imperative. It is in this way that the practical reason seems to become operative, that the basic precept of action seems to arise-i.e., just before an intention, which is an actual settling of the will on pursuing an end. 56 Still, through inclination and orientation 55 See, e.g., ST 1-2, 16, 4; 1-2, 25, 2. Actual moving toward an end as desire or willing: ST 1-2, 1, 2; ST 1-2, 3, 4; orientation or tendency as persisting: ST' 1-2, 1, 6 ad 3; see also 1-2, 3, 2 ad 4; 1-2, 2, 4. In some places Aquinas distinguishes natural appetite (inclination, love) and rational appetite or inclination (will): ST 1, 19, 1; 1, 60, 1; 1, 80, 1; 1-2, I, 2. In other places he speaks of natural orientation or love all creatures share: I, 60, 3-5; 1-2, 26, I ad 3; 1-2, 27, 2 ad 3. In I, 80, I and replies Aquinas speaks of both natural and rational appetite in rational beings. 56 The activity of the intellect may also involve judgment about the possibility of achieving the end. Of course in any concrete context there may he competing goods. But in order for action that brings about some result to take place, some end must be actively pursued. In order, then, for practical reason as such to carry through, it must follow its precept to pursue an apprehended good. IS-OUGHT: PRESCRIBING AND A PRESENT CONTROVERSY 15 the will has been engaged from the beginning, as manifested in the human ability or disposition to be attra.cted and so moved by certain kinds of objects. And so the first precept or principle thus explained is appropriately considered an imperative to pursue an end before it. Grisez does address himself to the role of the natural inclinations. In another place he says " It is impossible to act for anything without having an interest in it and it is impossible to become attracted to anything, and so to develop an interest in it, except to the extent that it falls within the scope of some inclination already present within oneself." 57 Must not such an inclination precede the arising of a practical precept that makes further action possible? Finnis seems to affirm this, when he suggests that an inclination or desire first arouses an interest in knowledge and may persist as motivation for one's pursuit of it. 58 These authors and I, then, seem generally to hold that natural inclination somehow makes possible the operation of the practical reason, although I contend that the dynamism of such inclination counts as will-activity, and hence that, in harmony with Thomistic principles, a self-prescription to pursue an object apprehended as good or attracting counts as an imperative. According to the analysis offered above, in a. situation of, for example, pursuing the answer to a particular question, one's practical reason directs by issuing an imperative to the agent to pursue the possible end (the answer) grasped as attracting. Thus is illustrated the directive role of the first principle. However, as already indicated, this paper is concerned with dis57 ONL, pp. 63-64, but cf. p. 60. See also FPPR, p. 180: "However, when the question concerns what we shall do, the first principle of practical reason assumes control and immediately puts us in a nontheoretical frame of mind. . . . The object of a tendency becomes an objective which is to be imposed by the mind ... " Yet the wording "when the question concerns what we shall do " suggests that practical reason is already somehow op· era ting in a practical context; I am arguing that such context is estab· lished by the initial activation of some inclination. 58 NLN R, p. 72; see also pp. 60-61, 65, and note 35 above. 16 JANICE L. SCHULTZ tinguishing prescriptivity and " oughtness "; until now it has simply shown that practical reason seems first to become operative in an imperative way. In order to move to a discussion of" ought" (value) -judgments, the Grisez-Finnis position on the arising of the various (other) principles of practical reason or natural law must be examined further. First Principles as Value-Judgments Finnis gives his view succinctly in a quotation perhaps already known to readers familiar with the controversy under discuss10n: One cloes not judge that 'I have [or everybody has] an inclination to find out about things' and then infer that therefore 'knowledge is a good to be pursued'. Rather, by a simple act of non-inferential understanding one grasps that the object of the inclination which one experiences is an instance of a general form of good, for oneself (and others like one) .59 In another place Finnis explains how, when directed to finding out something, the mind naturally moves beyond the particular question to the judgment that knowledge is a good thing to have: "'It's good to find out .. .'now seems to be applicable not merely in relation to oneself and the question that currently holds one's attention, but at large-in relation to an inexhaustible range of questions and subject-matters, and for anyone." 60 Such judgment, Finnis says, is about an aspect of human flourishing," the fulfillment of a human potentiality." 61 Finnis is thus denying that the basic principles of practical reason and natural law are simple prescriptions or imperatives 59NLNR, p. 34. See also p. 52; Response to Veatch, p. 271; and note 24 above. In the context in which the passage referred to in note 24 arises, I am attempting to show that Finnis affirms as a difference between his criticll (at least Veatch) and himself the mode of operation of the practical reason and the consequent prescriptive formulation. Here I am specifically concerned about the formulation of the practical principle as a "good "-judgment or "ought "-judgment. 60 NLNR, pp. 60-61. 61 fbid., p. 72; see also p. 85 and Response to Veatch, p. 269. 1S-0UGH'l:: PRESClUBING AND A PRESENT CON'l:ROVERSY 17 to the self to pursue a particular end. 62 What he is affirming is that basic precepts arise in a particular context but are the result of the mind's traveling beyond that context, arriving at a formulation concerning a basic human good. Since, as was pointed out above, he considers the gerundive form to be expressible in" ought "-judgments and these to be equivalent to value-judgments identifying basic human goods, such latter judgments are also deemed prescriptive. 63 Here is the true locus of the objectionable is-ought dichotomy maintained by Grisez and Finnis. That is, the distinction between imperatives-prescriptions and descriptions is not incorrect; insofar as a principle of practical reason may be viewed as an imperative, there is no difficulty with maintaining a distinction between this imperative and a theoretical or descriptive principle. What is objectionaple is a claim that in themselves value-judgments and "ought "-judgments are prescriptive and that they therefore cannot be arrived at by theoretical reasoning, based on the understanding of human nature. Let it be perfectly clear that Grisez and Finnis do contend that the first principles stated as value-judgments are normative (=prescriptive), and hence are the products of practical reason; as such, they are underivable from metaphysical claims: One of the principles of practical, thinking is that knowledge is a good to be pursued; this principle entails that knowledge ought to be pursued ... If " knowledge is a good for man " were understood theoretically, simply as a truth of metaphysical anthropology, then it would have no more normative implication than " knowledge is good for angels " has practical implication for us ... there can be no valid deduction of a normative conclusion without a normative principle, and thus ... first practical principles cannot be derived from metaphysical speculations. 64 62 This sentence should not be taken to imply that I am maintaining position Finnis is denying. 63 See notes 39-42 above. 64 Reply to Mcinerny, pp. 23-24, authors' emphases. the ts j ANICE L. SCHULTZ Finnis explicitly denies that value-judgments about basic human goods are arrived at by activity from the outside, by psychological, anthropological, or metaphysical observations. 65 Yet one may ask, what does he mean when he says in a passage already quoted, that judgments about human goods are primarily although not exclusively judgments of practical reason? 66 Is he allowing for the possibility that such judgments may be judgments of theoretical reason? This latter is an extremely important question, because if it can be answered in the affirmative, Finnis is saying one of two things: Either such value-judgments are sometimes descriptive and sometimes prescriptive, depending upon how they are arrived at, or they are always prescriptive, although sometimes arrived at by theoretical reason. Yet, as has been seen, Grisez and Finnis attribute the prescriptive status of principles to their generation by the practical reason; hence the latter could not be the case. On the other hand, is it reasona.ble to hold that value-· judgments can be sometimes descriptive, sometimes purely prescriptive? Above it was suggested that the gerundive can assume both forms, but here" good "-judgments and" ought"judgments are being discussed. Without examining in great detail the status of such valuejudgments, it can nevertheless be shown that Finnis, apparently without realizing it, recognizes them as inherently descriptive. 67 He sa.ys, for example, that the basic forms of human flourishing are (naturally) understood to be desirable and realizable and thus to-be pursued. 68 His adding that in the practical understanding of the goodness of knowledge one is already beginning to direct oneself to action does not alter the point that if something is grasped as to-be-done or pursued (taken prescriptively) becau.'!e it is understood as desirable, "desirable" must have some descriptive content that can be formulated. This content is no less descriptive because, in apprehending the ob65NLNR, pp. 33-34, 65; Response to Veatch, p. 268; cf. FPPR, pp. 19496; ONL, pp. 65-66. 66 Note 24 above; Response to Veatch, p. 272. 67 I discuss the status of such value-judgments in my doctoral thesis, chapters 4-7 (note 46 above). ss NLNR, p. 45, my emphasis. IS-OUGHT; PRESCRIBING AND A PRESENT CONTROVERSY 19 ject, one is attracted to it. Of course the content may simply be " having qualities I like "-this is descriptive, yet in the process of actual decision, this description will be a reason for acting for someone bent on possessing an object having the qualities he likes. In fact Finnis denies human goods a.re desirable in such a subjective sense. Like Aquinas, he sees human goods as objectively completing, as making one better off, as fulfilling human potentialities, as aspects of authentic human flourishing, and understood as such. 69 True, he distinguishes the way judgments of the truth of commonly acknowledged descriptive utterances and judgments concerning human goods come about. But as non-derivability need not imply lack of objectivity (as Finnis holds), neither need this different context for judgment entail lack of descriptivity .70 Grisez and }'innis seem to argue that value-judgments must be prescriptive because otherwise they would not be actionguiding, as a quotation above indicates. 71 Grisez suggests this in other places as well.12 Interestingly, Finnis points out that Aquinas holds reason to be an ' active principle ' because " one is motivated according to one's understanding of the goodness pp. 64, 72-73, 78-79; cf. ONL, p. 66. on non-derivability and objectivity: NLNR, p. 70. On the different mode or context of judging, see pp. 71-72, and Response to Veatch, pp. 270 ff. Of course objections may be raised that an utterance such as " Knowledge is a completive aspect of human nature " or "'Knowledge is fulfilling for humans as humans" is not descriptive but prescriptive, since "human ture" is covertly evaluative. Aquinas, however, considers human nature to be the same in all, having definite characteristics and properties. I have treated this matter more fully in my doctoral thesis (note 46 above). It might be pointed out here that the analysis of a statement such as "Pursuing knowledge is a humanly (morally) good act" is more complicated. Briefly, it is roughly translatable as "Pursuing knowledge is an act that is complete, or has what belongs to it (and hence is suited to a desire one might have for such an act) according to the criterion of what belongs to, or is completive of, human beings. (This is explained more fully in my thesis, chapter 7.) On the logic of value-judgments, see also note 77 below. On Grisez and Finnis on moral precepts, see note 80 below. n See note 64 above. 12 E.g., FPPR, p. 194; ONL, pp. 65-66. so [bid., 7-0 Finnis 20 JANICE L. SCHULTZ and desirability of human opportunities ... "; 73 according to the analysis just offered, this understanding is of a descriptive notion, even if, for humans, attracting. Yet this supposed prescriptive function of value-judgments is not the reason for the Grisez-Finnis cla.im; rather, as already seen, their claim emerges from their conviction that such judgments are inherently prescriptive as formulations of reason prescribing. According to my alternative interpretation, prescription is basically imperation; prescription may involve directing to apprehended goods, and the goods-as-apprehended may be attracting, but the object understood as good and so as to be pursued must be understood under some descriptive aspect. Yet it is possible that this descriptive aspect-e.g., fulfilling, completive of human na.ture--will become clear in a practical context and will be attracting to humans because they are humans; so will arise self-prescriptions based on the first practical principle. If human goods are grasped as Grisez and Finnis claim, if human goods understood as fulfilling not just for the one prescribing but also for all humans are attracting to the one prescribing, 74 then in the context of practical reason, prescriptions will be issued to pursue such human goods. Whether or not the above antecedents are true will not be discussed here. What must be stressed is that the prescription that follows the (descriptive) value-judgment emerges from the condition for human goods being attracting-i.e., the natural orientation toward them or, at later stages, the commitment to pursue what one understands to be really humanly good: not to resist, as Finnis might say. 75 Now if propositions about what human goods consist in are inherently descriptive, there is no reason why in principle they cannot be derived from theoretical reflection concerning human nature. Of course even if it is granted that those things that really perfect human beings are those to which in fact they all incline-i.e., presupposing the dynamism of the natural inclinap. 47, author's emphasis. pp. 34, 61; ONL, p. 66. 15 NLNR, p. 72. 78 NLNR, 74 Ibid., IS-OUGHT; PRESCRIBING AND A PRESEN•.r CONTROVERSY 21 tions-one might despair over the problem of induction: how do we know to what things all human beings tend? But that such problems may (or may not) exist does not militate against the appropriateness of such an attempt. Those of us who would wish to sort out our peculiar affections from those that are universal, who would like to confinn our initial intuitions with a more exhaustive search may prefer this route and still sustain an orientation toward human goods, understood as such, through our general inclination and perhaps commitment to act according to virtue. 76 What, finally, of the" is"-" ought" dichotomy? If" ought" is taken simply to imply prescriptivity, " is" and "ought " can remain separated; but since value-judgments are descriptive, there is no "is "-value dichotomy, either in fact or in linguistic (or logical) characteristics. However " ought " seems to imply something more-or other-than prescriptivity, as suggested by the problems pointed out in section two above with regard to interpreting all the basic precepts as "ought"utterances. In the absence of detailed analysis of the logic of such utterances, I venture to say that they are primarily descriptive, expressing the appropriateness of a given action based on a specific criterion. To say that a human good ought to be pursued is to say that such pursuit meets whatever criterion characterizes the "ought": if it is moral, such a statement expresses the appropriateness of pursuing the human. good to the completing of human nature. 77 Yet it seems that at times prescriptivity characterizes the moral "ought" too; after all, such "ought "-judgments do seem to be uttered as directives, as intending to motivate. Is such an utterance simply a (descriptive) value-judgment conjoined with an (implicit) imperative expressing a desire (natural or otherwise) of the one prescribing: "This is the morally good act and [let me] do it"? 1a ST 1-2, 94, 3. moral "ought" also implies that not doing the action in question would be wrong. Of course it could be true that not doing an act designated as· a morally good act could be wrong, but the use "a morally good act" 11 A of JANICE L. SCHULTZ No, moral "ought "-directives seem to encapsulate the descriptive value-judgment as a reason for acting: "This is the morally good act, so [let me] do it." 78 Now if " ought "-utterances are essentially descriptive, they too may emerge from metaphysical speculation. Yet if the practical reason at some point issues directives or imperatives as embracing and presenting the completing of human nature as their rational ground, then such directives concerning human goods may be appropriately described as full-fledged (descriptive and prescriptive) "ought "-judgments. According to the explanation proposed here, both the descriptive and prescriptive components are grounded in human nature: the former, as the criterion, the latter as having its roots in the natural inclination to act virtuously-to do the good because it is good.79 Yet such moral "ought "-judgments seem to go beyond naturally formed precepts in that the former, as described above, imply a commitment on the part of the prescriber to acting on the basis of such goodness, insofar as he is offering 8Uch goodness as the rea.8on for action (to himself or others) .80 does not entail this: this phrase seems also to cover cases where alternative acts would equally meet the moral criterion regarding the (general) kind of action in question (e.g., helping one's parents). "X is the morally good act", on the other hand, implies that to omit X would be wrong; this phrase, however, seems to be restricted to very concrete situations, where "ought" too, is used. "Ought", however, is also used of very general types of acts, the omission of which would be wrong. The logic of " ought" is treated further (if not absolutely thoroughly) in my thesis, chapter 7; note 46 above. 1s R. M. Hare, who would not agree with our analysis, nonetheless insists on the necessary relation between value-judgments and reasons: this is at the heart of his universalizability thesis (e.g., Freedom wnd Reo,son, London: Oxford University Press c. 1963, p. 21.) I cannot here engage in a comparison between Hare's theory and mine; perhaps it should simply be pointed out that he rejects the essential descriptivity of value-judgments as explained above. 79 ST 1-2, 94, 3; 1-2, 19, 6 ad 1; 1-2, 19, 7 ad 3. so It seems that at least the precepts enjoining the pursuit of human goods might be considered by Grisez and Finnis to be moral insofar as they direct to ends completive of human nature. These authors clarify their application of .the. terms " premoral" to such goods by pointing out that "both morally good and morally bad choices are directed (although in different wa:ys), IS-OUGHT: PRESCRIBING AND A PRESENT CONTROVERSY 28 In other words, it would be inconsistent for the prescriber to propose :moral goodness as the reason for acting, issuing an im· perative on this basis, and yet not accept that goodness as a reason for action. On the other hand, there is no reason why simply descriptive "ought "-judgments-including moral judgments--cannot be assented to and proclaimed but not conformed to in by the one assenting and declaring. For he may not be committed to acting on the basis of understood moral goodness. The basic objection to severing "is" from "ought" is the objection to divorcing authentic humanly enhancing principles for actions from their source in the human subject. A fully humanly directive principle-a moral "ought "-judgmentalludes to that source as its ground and its justification as prescriptive. To equate the " ought "-aspect of a principle with its prescriptivity, as the Grisez-Finnis position does, is to excise from such a principle its intrinsic relation to its foundation in human nature as its very reason for being authentically directive. This is to strip the principle of its inherent rationality. JANICEL. SCHULTZ Canisius College, Buffalo, New York toward one or more of them (or, at least, toward some partial aspects or appearances of one or more of them)": Reply to Mcinerny, p. 28. As the quotation seems to suggest, however, many morally bad choices are not directed toward even one specific human good as universal-Le., as completive of not only the agent, but of all humans (or at least as not interfering with the flourishing of others). In fact, much moral evil consists in making an exception of oneself unjustifiably. Furthermore, the authors hold that a morally bad choice can be directed to one genuine human good while running counter to others. (See notes 21 and 38 above). This does not entail that the directive to pursue that good is not of a moral nature; it simply implies that, according to Grisez and Finnis, th.e choice in question encompasses direction to an action against at least one (other) human good. As such, that choice would lack what is required for it to be, simpliciter, conducive to human flourishing. THE METAPHYSICS OF BRAIN DEATH, PERSISTENT VEGETATIVE STATE, AND DEMENTIA A. LIFE-SUPPORT TECHNOLOGY has advanced over the past half-century, a great number of thorny philosophical and moral problems have arisen regarding patients with serious neurologic damage, who in generations past would have died from their acute illness. While the concept of " brain death " as death of the person has finally gained almost universal acceptance in the medical, legal, and public sectors, there are still a number of vigorous critics. Persistent vegetative states have become a still more perplexing issue for medical ethics. This article is intended to provide a brief overview of the salient arguments in these debates, followed by the author's analysis of the issues according to the metaphysical principles of Aristotle and St. Thomas Aquinas. THE BRAIN DEATH DEBATE Up until the 1960s, the diagnosis of death was relatively straightforward. Dea.th occurred when the heart irreversibly stopped. With cessation of blood flow, the first organ to become irreversibly damaged is the brain, with the other body tissues succumbing shortly thereafter. There is, therefore, the possibility of a critical period of a few minutes during which the only irreversibly damaged organ is the brain. The heart still has the potential for being revived, since it is driven by its own intrinsic pacemaker, and not by the brain (the role of which is merely one of moditlating the heart rate) . If the lungs were ventilated mechanically, then the heartbeat and blood flow could continue, and the non-neural tissues of the body could remain a.live. 24 BRAIN DEA'.rH, VEGETATIVE STATE, AND DEMENTIA 25 With the advent of advanced cardiopulmonary resuscitation and improved mechanical respirators in the 1950s, this condition passed from a theoretical possibility to an increasingly common reality in hospital intensive care units. The initial confusion concerning the nature of this state is reflected in the various terms that have been used to describe it: "co11w depasse ",1· 2 "irreversible coma ", 3 • 4 "brain death ", 5 and" cerebral death." 6 • 7 In the first two terms, the word " coma" implies that the person is still alive, although unaware of self and environment, as in a very deep and permanent sleep. "Brain death " is the most commonly employed term today, although its meaning still varies from one author to the next, often without explicit definition. 8 It has been used in any of three basic ways. The first implies that, within an otherwise alive body, one organ (the brajn) has died. This usage is equivalent to speaking of a "dead piece of skin " or a " dead finger " due to gangrene, in no way implying that the person himself is dead. The second usage implies a more radical concept: namely that brain death is actually a type of personal death, in addition to the standard cardiopulmonary death. This interpretation is especially prevalent in the legal sector, and is explicitly formulated in the brain death statutes of a number 1.Mollaret, P., Goulon, M: Le coma depasse. Rev. Neurol. (Paris) 101:3-15, 1959. 2 Mollaret, P., Bertrand, I., Mollaret, H.: Coma depasse et necroses nerveuses centrales massives. Rev. Neurol. (Paris) 101: 116-139, 1959. a Beecher, H. K., et al: A Definition of Irreversible Coma; report of the ad hoc committee of the Harvard Medical School to examine the definition of brain death. JAMA 205 :337-340, 1968. 4 Walker, A. E. Diamond, E. L., Moseley, J.: The neuropathological findings in irreversible coma. A critique of the "respirator brain." J. Neuropathol. Exp. Neurol. 34:295-323, 1975. Medical and Social Issues. 5 Korein, J. (ed.) : Brain Death: Interrelated Ann. N.Y. Acad. Sci., Vol. 315, 1978. s Walker, A., et al: An appraisal of the criteria of cerebral death; a summary statement. JAMA 237 :982-986, 1977. Baltimore-Munich, Urban & Schwarzen1 Walker, A. E.: Cerebral Death. berg, 2nd ed., 1981. s Black, P. McL.: Brain Death. N. Engl. J. Med. 299 ( 7) : 338-344 (Part I] and 299 (8) :393-401 [Part II], 1978. 26 D. ALAN SHEWMON, M.D. of states (e.g., Kansas, Maryland, New Mexico, Virginia, Oregon, and Colorado) .0 • 1° Finally, the most radical sense of the term implies that there are not two " types " of death, but only one death, which occurs when the essential organ, the brain, dies,11 According to this view, the only reason that traditional cardiopulmonary death is death at all, is precisely because it necessarily includes brain death, not vice versa. "Cerebral death" is an unfortunate choice of words as applied to death of the entire brain, since, literally, the cerebrum is only a part of the brain; this usage is therefore easily confused with the concept of death of the cerebral hemispheres alone (also known as " neocortical death " or " persistent vegetative state " -see below) . The proponents of the radical interpretation of " brain death " argue that, since the brain is the organ which mediates all that is specifically human-thought, desire, emotion, etc.-then the death of this essential organ should suffice to result in the death of the per8on. They also point out that modern technology makes it possible to take a fresh cadaver (already pronounced" dead" using cardiopulmonary criteria), warm it, force air into the lungs, and cause the blood to circulate again. Even though this body looks alive to a superficial observer, it was and still is a cadaver. Such "life support" would be both a misnomer and a grotesque game. l\foreover, the modern phenomena of heart transplantation and artificial hearts render the traditional cardiac criterion of death rather meaningless. It is no longer necessary that the natural heart function in order to be alive. This fact was recently brought o Capron, A. M.: The Development of Law on Human Death. In Korein [5], pp. 45-61. 10 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Defining Death; Medical, Legal, and Ethical Issues in the Determination of Death. U.S. Government Printing Office, Washington D.C. 20402, 1981, pp. 62-67, & Appendix C, pp. 109134. 11 Korein, J.: The Problem of Brain Death: Development and History. In Korein [Q], pp. 19-!lS. BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 27 home to the public quite strikingly in the case of Barney Clark, the first artificial heart recipient, who lived for 112 days on the device. 12 Critics of this position 13 -18 maintain that, while the brain is certainly essential for thought, thought is not the same as life itself. Furthermore, those who accept the existence of a spiritual soul insist that we cannot know precisely when the soul leaves the body. For this reason it is traditional that priests, for example, give conditional anointing even up to an hour or so after cardiopulmonary death has been medically declared.19 This being the case for the traditional criteria of death, it would seem imprudent and presumptuous for medical science to declare a person dead merely because he has irretrievably lost only cognitive function. Critics of the notion of brain death also fear that such a concept represents the first step in the direction of legalized euthanasia. " Brain death " is seen as a mere construct designed to deceive society into accepting medical practices which otherwise would never be tolerated on living patients. The most important of such practices is the harvesting of vital organs for transplantation. There is also the concern of possible misdiagnosis of a salvageable patient as brain dead. A lesser fear is that lives may be termi12 Los Angeles Times. March 24, 1983, part I, p. 1. Harrison, C. P.: Re: Cerebral Death. Linacre Quarterly 4(9) :291-293, 1982 (letter) . H Byrne, P. A., O'Reilly, S., Quay, P. M.: Brain Death-An Opposing Viewpoint. JAMA 242: 1985-1990, 1979. s1 Byrne, P. A.: Response. In McCarthy, D. G., Moraczewski, A. S. (eds.) : Moral Responsibility in Prolonging Life Decisions, St. Louis, Pope John Center, 1981, Chap. 3, pp. 53-57. 1a Fost, N.: Research on the brain dead. J. Pediatr 96: 54-56, 1980. 11 Jonas, H.: Against the Stream: Comments on the Definition and Redefinition of Death. In Jonas, H. (ed.) : Philosophical Essays: From Ancient Creed to Technological Man. Englewood Cliffs, Prentice Hall, 1974, pp. 132-140. is Currie, B. S.: The redefinition of death. In Spicker, S. F. (ed.): Organism, Medicine, and Metaphysics. Boston, Reidel, 1978, pp. 177-197. 19 Moraczewski, A. S., Showalter, J. S.: Determination of Death. Theological, Medical, Ethical, and Legal Issues. St. Louis, Catholic Health Assoe. of United States, 1982, P· 11, 13 28 D. ALAN SHEWMON, M.D. nated simply for the economic consideration of the cost of extended intensive hospitalization. By simply redefining death in order to call such patients " dead," transplantation and cost consciousness could be made to appear more acceptable to the public. The facts that brain death statutes in some states define it as an alternative " type " of death, and that many employ terminology such as: "for legal purposes" a brain-dead patient " may be considered dead " (as though tacitly aclmowledging that in reality he is not dead) -only serve to reinforce these fears. THE NEOCORTICAL DEATH DEBATE In spite of such concerns, most doctors, legislators, and lawyers, as well as the lay public, have come around to accepting the notion of brain death as true death of the person, rather than as verbal trickery. Not so with the concept of neoco1·tical death, 20 also known as "cerebral death ", 21 • 22 "persistent vegetative state ", 23 • 24 "apallic syndrome '', 25 • 26 and "coma vigile." This state differs from brain death in that only part of the brain is destroyed (the neocortex, or cerebral hemispheres) . Although some daring persons have advocated that total brain death is too restrictive a concept, and that neocortica.l death 20 Brierly, J. B., Adams, J. H., Graham, D. I., Simpson, J. A.: Neocortical death after cardiac arrest. Lancet 2: 560-565, 1971. 21 Korein, [5], pp. 95-96. 22 Kricheff, II, Braunstein, P., Korein, J., George, A. E., Kumar, A. J.: Isotopic and angiographic determination of cerebral blood flow. A correlation in patients with cerebral death. Acta Radiol. [Suppl.] (Stockh.) 347: 119-129, 1971. 2a Cranford, R. E., Smith, H. L.: Some critical distinctions between brain death and the persistent vegetative state. Ethics Sci. Med. 6: 199-209, 1979. 24 Jennett, B., Plum, F.: Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet, 1 :734-737, 1972. 25 Ingvar, D. H., Brun, A., Johansson, L., Samuelsson, S. M.: Survival after severe cerebral anoxia with destruction of the cerebral cortex: The appallic syndrome. In Korein [5], pp. 184-214. 26 Ingvar, D. H.: Cerebral blood flow and metabolism in complete apallic syndromes, in states of severe dementia, and in a.kinetic mutism. Acta Neurol. Scand. 49:233-244, 1973. BRAIN DEATH, VEGE'I'ATIVE STATE, AND DEMENTIA %!9 should suffice to constitute the death of a person, 21 - 30 most people regard this position with great suspicion. The idea was rejected by the President's Commission which studied brain death and related issues.31 All the criticisms and fears mentioned above with regard to brain death are even more justified with regard to neocortical death. The most important concern is that withholding fluids and nutrition from a patient in this condition might constitute euthanasia. Viewed in historical perspective, however, the level of acceptance today of the concept of neocortical death is rather similar to that of brain death two decades ago. It would hardly be surprising, given the direction in which society has been moving, if in another decade or so the laws will have been revised to reflect a general acceptance of neocortical death as death of the person. Up to now this evolution has reflected merely the chaotic tossing of the waves of emotional opinion and the biases of the mass media, without any basis in clear or uniform principles. The purpose of this article is to summarize the medical facts and to provide a philosophical framework by which to interpret them, humbly proposing it as a reasonable foundation for the development of public policy regarding these issues. PATHOGENESIS OF BRAIN DEATH The brain is one of the most metabolically active organs of the body. Although it constitutes only 23 of body weight in an adult, it utilizes 15-203 of the output of blood from the 21 Veatch, R. M.: Death, Dying and the Biological Revolution. New Haven, Yale Univ. Press, 1976, pp. 71-76. 2s Veatch, R. M.: The whole-brain-oriented concept of death: An outmoded philosophical formulation. J. Thanatol. 3 ( 1) : 13-30, 1975. 29 Pearson, J.: Korein, J., Braunstein, P.: Morphology of defectively perfused brains in patients with persistent extracranial circulation. In Korein [5], pp. 265-271. so Beresford, H. R.: The Quinlan decision: Problems and legislative alternatives. Ann. Neurol. 2:74-81, 1977. s1 President's Commission [10], p. 40. 30 D. ALAN SHEWMON, M.D. heart. 82· 83 As a consequence, brain cells are more vulnerable to lack of blood or oxygen than most other cells of the body. At normal body temperature after only four minutes of loss of blood flow (ischemia), nerve cells in the cerebral cortex begill to die, 84· 85 while after IO minutes the entire brain is destroyed.36· 37 What happens at the cellular level is the following.38· 39 Cells require a constant source of energy in order to maintajn the integrity of their membranes. Normally this energy is derived from sugar and oxygen from the blood stream. Under ischemic conditions, a cell must begin to break down its own proteins for energy, resulting in its membranes becoming leaky. Not only is the cell then unable to function normally, but digestive enzymes, which are normally packaged safely within intracellular membranes called lysosomes, leak out into the cytoplasm and begin to digest the cell itself. In addition to directly damaging the cells, this causes water to be drawn into them by osmosis from the blood stream. The cells lining the capillaries of the brain also swell, thereby obstructing the blood flow through them. As the brain swells, the pressure within the head rises, so that even if the heart were restarted, it would not be able to pump sufficient blood to the brain against the pressure. The decreased blood flow to an 32Folkow, B., Neil, E.: Circulation. New York, Oxford University Press, 1971, p. 434. 38 Keele, C. A., Neil, E. (eds.): Samson Wright's Applied Physiology. London, Oxford Univ. Press, 1971, p. 143. 34 Plum, F., Posner, J. B.: The Diagnosis of Stupor and Coma. Philadelphia, Davis, 3rd ed., 1980, p. 209. 35 Levy, D. E., Brierley, J. B., Silverman, D. G., Plum, F.: Brief hypoxia-schemia initially damages cerebral neurons. Arch. Neurol. 32: 450-456, 1975. 36 Weinberger, L. M., Gibbon, M. H., Gibbon, J. H., Jr.: Temporary arrest of the circulationto the central nervous system: I. Physiologic effects. Arch. Neurol. Psychiatry43: 615-634, 1940. 37 Myers, R. E., Yamaguchi, M.: Effects of serum glucose concentration on brain response to circulatoryarrest. J. Neuropathol.Exp. Neurol. 35:301, 1976. 88 Fein, J.M.: Brain Energetics and Cerebral Death. In Korein [5], pp. 97-104. 39 Plum & Posner [34], p. 196, 202-206. '.BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 3l already sick brain causes still more brain damage and swelling, so that a vicious cycle is established. When cerebral blood flow drops below 203 of normal (at normal body temperature), a critical point is reached when the cells can no longer survive, 40 - 42 ending in total cessation of blood flow to the brain (the "no-reflow" phenomenon), even in the face of normally restored blood flow to the rest of the body. 48 - 46 This takes place as soon as the intracranial pressure exceeds the mean arterial blood pressure. As brain swelling continues, the cerebral hemispheres are squeezed out through an opening in the tough membrane called the tentorium, into the posterior fossa (where the brainstem is located) . The brainstem is then squeezed out through the opening at the bottom of the skull where it connects with the spinal cord. Such herniation of the softened brain through these small openings is very similar to the way that toothpaste is squeezed out through a tube. Often at autopsy brokenoff pieces of necrotic brain are found floating in the spinal fluid up and down the spinal canal. The spinal cord itself, how4o Korein, J., Braunstein, P., George, A., \Vichter, M., Kricheff, I., Lieberman, A., Pearson, J.: Brain Death: I. Angiographic correlation with the radioiosotopic bolus technique for evaluation of critical deficit of cerebral blood flow. Ann. Neurol. 2(3) :195-205, 1977. 41 Hoyer, S., Wawersik: Untersuchungen der Hirndurchblutung und des Hirnstoffwechsels beim Decerebrationssyndrom. (Studies of cerebral blood flow and cerebral metabolism in the decerebration syndrome.) Langenbecks Arch. Klin. Chir. 322: 602-605, 1968. 42 Brierley, J. B., Brown, A. W., Meldrum, B. S.: The nature and time course of the neuronal alterations resulting from oligaemia and hypoglycemia in the brain of Macaca mulatta. Brain Res. 25 :483-449, 1971. 43 Ames, A., Wright, R. L., Kowada, M., Thurston, J. M., Majno, G.: Cerebral Ischemia. II. The no-reflow phenomenon. Am. J. Pathol. 52: 437453, 1968. 44 Braunstein, P., Korein, J., Kricheff, I., Lieberman, A.: Evaluation of the critical deficit of cerebral circulation using radioactive tracers (bolus technique). In Korein [5], pp. 143-167. 45 Kricheff, II, Pinto, R. S., George, A. E., Braunstein, P., Korein, J.: Angiographic findings in brain death. In Korein [5] pp. 168-183. 46 Rosenklint, A., Jorgensen, P. B.: Evaluation of angiographic methods in the diagnosis of brain death. Correlation with local and systemic arterial pressure and intracranial pressure. Neuroradiology 7 :215-219, 1974. D. ALAN SHEWMON, M.D .. ever, may remain relatively intact, or may have been directly damaged from the initial cardiac arrest. Such a condition of the brain at autopsy (the technical term is" respirator brain") is the rule in cases of brain death, with the occasional discrepancies between clinical signs and autopsy findings being largely attributable to variations in timing of the autopsy. 47 • 49 The same end-stage may also result from causes other than cardiac arrest. Any condition that causes severe brain sw;elling (e.g., head trauma, infection, etc.) may set up the same vicious cycle leading to brain death. Over time, if the rest of the body is supported with mechanical ventilation, nasogastric feedings, and intensive nursing care, the intracranial pressure drops back down, and blood flow to the dead brain resumes. 50 - 52 This subsequent blood flow may even be greater than normal (so-called "global luxury perfusion"), but it does no good, since the brain cells are already dead, and the brain remains without any electrical activity. 53 During the course of many weeks, the body's scavenger cells, called macrophages, remove the dead brain tissue, eventually leaving nothing but water in the skull. This natural process thus has the same effect as though some macabre neurosurgeon had opened up the skull, A. E.: Pathology of Brain Death. In Korein [5], pp. 272-280. J. I., Molinari, G. F., Walker, A .. E.: Respirator brain. Report of a survey and review of current concepts. Arch. Pathol. Lab. Med. 100: 61-64, 1976. 49 Pearson, J., Korein, J., Harris, J. H., Wichter, M., Braunstein, P.: Brain death: II. Neuropathological correlation with the radioisotopic bolus technique for evaluation of critical deficit of cerebral blood flow. Ann. Neurol. 2 :206-210, 1977. 5o Radberg, C., Soederlundh, S.: Computer tomography in cerebral death. Acta Radiol. [Suppl.] (Stockh.) 346:119-129, 1975. 51 Hekmatpanah, J.: Cerebral circulation and perfusion in experimental increased intracranial pressure. J. Neurosurg. 32:21-29, 1970. 52 Greitz, T., Gordon, E., Kolmodin, G., Widen, L.: Aortocranial and carotid angiography in determination of brain death. Neuroradiology 5: 1319, 1973. ss Gordon, E., Greitz, T., Widen, L.: Global luxury perfusion in deeply comatose patients: Report of 3 cases. In Russell R. W.R. (ed.).: Brain and Blood Flow. Proceedings of the 4th International Symposium on the Regulation of Cerebral Blood Flow. London, Pitman, 1971, p. 285-288. 47 Walker, 48 Moseley, BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 33 removed the entire brain, and deposited it down the garbage disposal. Of course, long before this process is complete, the heart spontaneously stops, or these patients are disconnected from the respirator, so that at autopsy the brain may be found in various stages of liquefaction, rather than completely absent. A patient in this condition lies motionless, although there may be some automatic reflex movements upon stimulation, such as tendon reflexes or spinal-mediated leg withdrawal (if the spinal cord was not damaged by the primary insult) . The patient has no awareness of his own body or the environment. The possibility that he might be aware but simply cannot communicate is simply not tenable, because patients with lesions of the brain's sensory areas specifically report numbness, blindness, etc., and these lesions are certainly included in destruction of the entire brain. Whether some sort of pure seH-awareness is or is not preserved neither is clinically ascertainable nor distinguishes per .'fe whether someone has passed from this life to the next. It therefore has no bearing on questions related to the moment of bodily death. Although purely vegetative functions such as nutrition, blood pressure, wound healing, etc., are not directly dependent upon brain functioning, eventually even these fail: the blood pressure drops and the heart stops despite resuscitative efforts. Therefore, brain dead patients cannot really be kept vegetatively "alive" indefinitely; with good nursing care, however, they can be maintained up to several months. 54 • 55 PATHOGENESIS OF PERSISTENT VEGETATIVE STATE If the original brain damage was not severe enough to cause death of the entire brain, a persistent vegetative state may result. As mentioned above, the cerebral hemispheres, and 54 Walker A. E., Molinari G.: Criteria of cerebral death. Trans. Am. Neurol. .Assoc. 100 :29-35, 1975. 55 Parisi J. E., Kim, R. C., Colins, G. H., Hilfinger, M. F.: Brain death with prolonged somatic suryival. N. Engl. J. Med. 306: 14-16, 1982, 34 D. ALAN SHEWMON, M.D. especially their mantle of gray matter (the neocortex), are more susceptible to lack of blood flow than the brainstem. An intermediate degTee of brain pathology may therefore be seen, in which only the cerebral hemispheres are damaged by the ischemia. The capillary and hemispheric swelling impede blood flow to the hemispheres as in whole brain death, but the severity is not quite sufficient to cause herniation through the tentorial notch into the posterior fossa and destroy the brainstem.56, 57 Initially following cardiac arrest, the brainstem is usually rendered temporarily dysfunctional, so that mechanical respiratory support must be provided. However, after a few days the brainstem often recovers sufficiently for the patient to breathe on his own. As in total brain death, the cerebral hemispheres eventually liquefy and the debris is gradually removed through the blood stream. All that is left is a more less functioning brainstem. This allows such patients to breathe spontaneously, open their eyes, and go through what appear to be sleep/wake cycles. In spite of their apparent wakefulness, there is no real awareness of their body or the environment. Even though their eyes are open and may even track a slowly moving object, 58 they show no evidence of effort at communication through eye movements, as patients 'vith the "locked-in syndrome " do. 59 • 60 Their limbs are typically fixed in a spastic posture with legs 56 Korein, J., Braunstein, P., Kricheff, I., Lieberman, A., Chase, N.: Radioisotopic bolus technique as a test to detect circulatory deficit associated with cerebral death. 142 studies on 80 patients demonstrating the bedside use of an innocuous IV procedure as an adjunct in the diagnosis of cerebral death. Circulation 51 :924-939, 1975. 57 Heiskanen, 0.: Cerebral circulatory arrest caused by acute increase of intracranial pressure. A clinical and Roentgenological study of 25 cases. Acta. Neurol. Scand. 40: Suppl. 7, 1964. 58 Levy, D. E., Knill-Jones, R. P., Plum, F.: 'l'he vegetative state and its prognosis following nontraumatic coma. In Korein [5], pp. 293-306. 59 Hawkes, C. H.: "Locked-in" syndrome: report of seven cases. Br. Med. J. 4:379-382, 1974. so Nordgren, R. E., Markesbery, W. R., Fukuda, K., Reeves, A. G.: Seven cases of cerebral medullary disconnexiou: the "locked-in syndrom\;." Nirnr· (:Minneap.J 21:1H0-114,8, 1971; BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 35 extended and arms flexed. There may be reflex withdrawal from noxious stimuli, as well as reflex grimacing or purposeless uncoordinated chewing movements. They cannot eat, however, and attempts to feed them result inevitably in aspiration of food into their lungs. Thus, they must be fed through a nasogastric or gastrostomy tube. Persistent vegetative state is thus an apt name for such a condition. An X-ray CT (computed tomography) scan of such a patient's head will show the supratentorial space full of fluid, surrounded perhaps by a thin shell of scar tissue. As might be expected, the electroencephalogram reveals no electrical activity from the surface of the scalp. Such patients may be kept alive in this state indefinitely, if nursing care is good enough to prevent bedsores and aspiration pneumonia, and nutrition is maintained through proper tube feedings. The longest survival on record for such a patient is 37 years. 61 Less severe forms of this state also occur commonly in clinical practice, perhaps even more frequently than those resulting in complete liquefaction of the cerebal hemispheres. It often happens that only the nerve cells themselves are lost, leaving a residual shnmken hemisphere composed of non-neural elements and scar tissue, totally lacking any functional potential. 62 In some cases, much but not all of the cerebral hemisphere is destroyed. The areas of "no-reflow" may be patchy, depending upon the degree of ischemia, and any relatively preserved areas of rain may manifest some abnormal but present electrical activity on EEG. Interestingly, with the passage of time, blood flow returns to the areas of "no reflow," resulting paradoxically in patchy " luxury perfusion " of areas without electrical activity, and less circulation to areas with electrical activity. For the sake of clarity, further discussion of vegetative states will be restricted to those cases in which the nerve . a1Cranford & Smith [23], p. 89 (quoted from Guinness Book of World Records). 62 Dougherty, J. H., Jr., Rawlinson, D. G., Levy D. E., Plum F.: Hypoxia-ischemic brain injury and the vegetative state: Clinical and neuropath· ologic correlation. Neurology (NY) 31:991-997,1981. 36 D. ALAN SHEWMON, M.D. cells 0£ both cerebral hemispheres have been totally destroyed. i.e., true " cerebral death," without necessarily requiring that ull the dead tissue have been removed yet. It should also be clear that the following will be a theoretical analysis of the nature 0£ these states in general; we are not here concerned with the practical issues related to determining whether a given patient is in such a state or not. The former is a philosophical issue, while the latter is a medical one. Both are extremely important, as is the distinction between them, which is often blurred by critics of the brain death concept. The reality and nature of these states in individual patients should not be considered vague, simply because of the difficulties in making an early diagnosis of their irreversibility. To think in this way would be the same as to imagine that the reality of an early cancer were somehow reduced simply by our inability to detect it. One should endeavor to have a clear understanding of the metaphysical nature of these states, so that when they are diagnosed in a given patient, one will know how to apply the norms of morality governing life and death. J£ the diagnosis is uncertain, then one must employ other moral norms which govern situations of factual uncertainty. It would be a great mistake to confuse the two issues, however. GENEHAL PHILOSOPHICAL PRINCIPLES At the outset, let it be explicitly stated that this analysis is based upon the metaphysical principles of Aristotle and St. Thomas Aquinas. Justification of these principles in the light of modern science is beyond the scope of this article, but interested readers may refer to a number of contemporary works. 63 "70 It will be seen, however, that the neuroanatomical considera68 Van Melsen, A. G.: The Philosophy of Nature. Pittsburgh, Duquesne University Press, 2nd ed., 1959. 64 Koren, H. J.: An Introduction to the Philosophy of Nature. Pittsburgh, Duquesne University Press, 1962. 65 Koren, H. J., (ed.) : Readings in the Philosophy of Nature. Westminster, MD., Newman Press, 1965. 66Hoenen, P.: The Philosophical Nature of Physical Bodies. West Springs, IN., West Baden College, 1955, :tlBAlN DEATH, VEGETATIVE STATE, AND DEMENTIA 37 tions which will be made are equally valid for other philosoph· cal systems. According to Aristotle and St. Thomas, all existing things are wha.t they are in virtue of two co-principles of being: prime matter (pure potency) and substantial form (specifying the essence of the thing). These constitute the substance. This, together with accidents (properties), constitutes the actual existing thing. This conception of physical nature is called hylomorphism (from the Greek "hyle "=matter, "morphe" =form) . In the case of living things, it is the substantial form which specifies their essence precisely as living; i.e., substantial form is the vital principle which organizes the material components into a functioning unity, which cannot be reduced to the mere sum of its parts. What differentiates living from non-living things is that the former are capable of "moving themselves," whereas inanimate things must be moved by another .71· 72 This "motion" includes not only local motion but also other immanent accidental changes such as growth, changes in shape, etc. Modern biology supports the notion of substantial form, insofar as there is a constant dynamic turnover of the individual molecules and atoms comprising all the tissues of a living body, including the nervous system 73 • 74 and 61 Walshe, F.: Further Critical Studies in Neurology and Other Essays and Addresses. Baltimore, Williams & Wilkins, 1965, Chaps. 7 and 9, pp. 157-178, 196-218. 68 Jaki, S. L.: Brain, Mind and Computers. South Bend, IN. Gateway, 1969. 69 Jaki, S. L.: The Relevance of Physics. Chicago, University of Chicago Press, 1966, Chap. 7, "Physics and Biology," pp. 283-329. 10 Grene, M.: Individuals and their Kinds: .Aristotelian Foundations of Biology. In Spicker SF. (ed): Organism, Medicbe, and ,Metaphysics. Boston, Reidel, 1978, pp. 121-136. · n Koren, H. J.: An Introduction to the Philosophy of Animate Nature. St. Louis, Herder, 1955, pp. 14-38. 12 Aquinas, T.: Summa Theologiae, I, q. 18, a. 1. 1s Norton, W. T.: Formation, Structure, and Biochemistry of Myelin. In Siegel, G. J., Albers, R. W., Agranoff, B. ,V., Katzman, R. (eds.): Basic Neurochemistry. 3rd ed., Boston, Little, Brown & Co., 1981, Chap. 4, pp. 81>87. 74 Gardner, J. M., Fambrough, D. M.: Metabolism of Cell Surface· Receptors: Possible Roles in Cell Sensitivity and Responses to Activators. In b. ALAN slIEWM:O'.N,M:.b. even bone. 75 After a while, none of the original atoms 'remains. In spite of this, the organism is still the same individual, because what does remain the same at the atomic/molecular level is the relationship among the atoms and molecules, i.e., the form of the body. A mathematical analysis of life processes, such as that given by Varela, 76 also leads to some conclusions which are much more in accord with hylomorphism than with mechanism, even though the author is more a mechanist than a Thomist. He uses the term " a.utopoiesis " or " autopoietic machine " to define the essence of living things: " An autopoietic machine continously generates and specifies its own organization through its operation as a system of production of its own components, and does this in an endless turnover of components under conditions of continuous perturbation and compensation of perturbations. Therefore, an autopoietic machine is a homeostatic (or rather a relations-static) system that has its own organization (defining network of relations) as the fundamental invariant." (fn. 76, p. 13) An intriguing conclusion is that the mathematical representation of inanimate dynamic systems (i.e., sets of recursive differential equations) is inadequate as a complete description of the autopoiesis of living organisms. (fn. 76, pp. 204-206) While lacking any reference to hylomorphism, such a formulation definitely places the essence of an organism on a higher level than the mere (accidental) interaction of its parts, and equates it with a global organizational principle, which seems to be identical to what Aristotle and St. Thomas would call the substantial form. Substantial forms which convey the property of vitality to matter are called by Aristotle and St. Thomas "souls '' (animae), which term is used in a broader, more technical Goldberger, R. F., Yamamoto, K. R. (eds.): Biological Regulation and Development. New York, Plenum, 1982, pp. 299-339. 75 Ross, G.: Essentials of Human Physiology. 2nd ed., Chicago, Year Book Medical Puhl., 1982, pp. 649-650. 76 Varela, F. J.: Principles of Biological Autonomy. New York, North Holland, 1979. [Series in General Systems Research Vol. 2]. BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 89 sense than we are accustomed to in modern everyday parlance. Depending upon the level of complexity of the organism, souls may be vegetative (the life-principles of plants) , animal (which provide in addition sensation and mobility), and human (which provide in addition the spiritual faculties of intellect and will). In higher organisms, all the lower powers are still operative; in fact, the higher faculties are always built upon, and depend for their proper functioning upon, the lower ones. The human soul, therefore, provides not only the spiritual faculties, but also specifies the sensorimotor faculties proper to the animal level and the nutrient and trophic functions proper to the vegetative level. Although these levels of functioning are conceptually quite distinct, there are not three different souls in a human being, but one soul, which harmoniously unites the vegetative, sensitive, and spiritual levels into an individual person. 77 • 78 When one material substance is transformed into another, a substantial change takes place. The original substantial form vanishes (reverts to the potency of prime matter) and a new one instantaneously supersedes it (is educed from the potency of prime matter) .79 • so Substantial changes are brought about through a sequence of critical accidental changes. Minor accidental alterations, such as heating, stretching, etc., do not affect the original essence. If, however, some accidents are changed so as to render the matter incompatible with the original essence, then the original organizing principle, or substantial form, is lost. It is important not to fall into the trap of trying to construct a mental image of forms emerging from and descending into prime matter, as though they were things themselves which took up physical space. 81 • 82 It is meaningless 11 Gilson, E.: The Christian Philosophy of St. Thomas Aquinas. New York, Random House, 1956, pp. 187-222. 1s Aquinas, T.: Summa Theologiae. I, q. 76, aa. 3 & 4. 79 Aquinas, T.: Summa Contra Gentiles. bk. II, ch. 86. so Aquinas, T.: Quaestiones Disputatae de Spiritualibus Creaturis. a. 2, ad 8. 81 Koren [64], pp. 45-47., 82Aquinas T.: VII Metaphysiconim Commentarii, lect. 71 µo, 40 D. ALAN SHEWMON, M.D. to ask " where did the form go," since it is not a thing itself, and has no existence apart from matter. It would be just as meaningless as to ask where the form of a symphony went after the performance was over. The only exception to this is the human soul, which, because of its spiritual faculties of intellect and will, transcends the physical realm (even though it depends upon the internal senses for its normal functioning). Unlike vegetative and animal souls, which revert to the potency of prime matter at death, the human soul continues to subsist independently of matter. 83 Nevertheless, this is an unnatural state, in which the nutritive and sensitive powers remain only virtual, 84 and the incorporeal soul, as substantial form of the body, remains incomplete until the final resurrection of the body .85 Such a conception obviously has little to do with the Platonic notion of death being a liberation of the soul from a kind of unnatural imprisonment in the body. Sometimes multiple new forms are educed during a substantial change, resulting in a mixture of things, where there had previously been one thing. What the new form or forms will be is determined by the accidents at the time of the substantial change, i.e., whichever substance is (or substances are) most compatible with the new accidental properties at the critical moment of substantial change. 86 • 87 Thus, substantial changes are instantaneous, even though the accidental changes are continuous, and we cannot empirically determine the precise moment of substantial change, since what we observe through our senses are the accidents. 88 In the case of vegetative organisms, a substantial change constitutes the death of the organism. Without the unifying vital principle, the component chemicals of the organism proceed to react with each other in an uncoordinated manner, sa Aquinas, T.: Summa Theologiae. I, q. 75, a. 2. 84 Aquinas, T.: Summa Theologiae. I, q. 77, a. 8. ss Koren [71], pp. 280-282. ss Koren [64], pp. 48, 49. s1 Glenn, P. J.: Cosmology. St. Louis, Herder, 1941, p 165. 6$ Glenn r87l pp. 39, 163 183, BltAIN DEATH, VEGETATIVE STAT£, AND DEMENTIA 41 resulting in decay. Thus the one original substantial form becomes replaced by a myriad of inanimate forms of various chemical substances, initially accidently juxtaposed in the general shape of the original organism. In the case of higher forms of life, such as animals and man, the accidental changes immediately responsible for death are usually also changes which attack the unifying principle at the vegetative level: i.e., irreversible loss of integrity of the cells throughout the body. As the soul quits the body, the body becomes a great mixture of chemicals. However, suppose the accidental changes attacked the essence of the organism at a level higher than vegetative. There is no a priori reason to exclude the possibility of a higher level soul being superseded by a lower level soul, rather than by a mixture of inanimate forms. In fact, instances of substantial change from one living thing into another do occur in nature, albeit much less commonly than substantial changes to the inanimate level (i.e., decay). Many plants and certain lower animals, such as starfish and planaria, have the capacity for severed parts to grow into new complete organisms. 89 - 93 Here we observe the multiplication of living substantial forms through the mere physical separation. of parts, as opposed to the ordinary route of natural reproduction. The severed part loses participation in the original organism's substantial form, but instead of decaying, it has enough functional unity of its own to stay alive and to develop into a whole organism again. The functional unity indicates that a new substantial form was actualized at the moment of separation of the part. 89 Van Melsen 90 Goss, [63], p. 129. Principles of Regeneration_ New York, Academic Press, 1969. 91 Rose, S. M.: Regeneration: Key to Understanding Normal and Abnormal Growth and Development. New York, Appleton-Century-Crofts, 1970. 02 Thornton, C. S., Bromley, S. C., (eds.): Vertebrate Regeneration. Stroudsburg, PA. Dowden, Hutchinson, & Ross, 1973. 9s Slack, J. M. W.: Regeneration and the Second Anatomy of Animals. In Subtelny, S., Green, P. B. (eds.) : Developmental Order: Its Origin and Regulation. New York, Liss, 1982, pp. 423-436. R. J.: 42 D. ALAN SHEWMON, M.D. Even more interesting for our purposes is the fact that parts severed from higher animals may also continue to live, but with a substantial form quite different from that of the original animal. For example, a wide variety of cells (such as skin fibrolasts, 94 certain blood cells,95 and even brain cells 96 may be taken from an animal or a human, and kept alive in a nutrient culture medium. Not only that, but they tend to grow and multiply into new generations of the same type of cell. These cells are obviously living substances, on the same level of existence as naturally occurring one-celled organisms. Even though they may have been derived from a human body, they are certainly not new human beings. Although such a phenomenon is not encountered in everyday life by most people, its possibility in the controlled environment of a laboratory is certainly not incomprehensible. St. Thomas would have explained that the new, lower, form was virtually present in the original, higher form. 97 • 98 In a compound substance, the "virtual presence" of the more elementary substantial forms is defined as an " active potentiality; " i.e., in contrast to the " passive potentiality " of prime matter to any form, the " active potentiality " of the elemental forms virtually present in a compound is responsible for the natural tendency for things to change only in certain ways, as opposed to randomly or chaotically. Virtual elementary forms contribute some, but not all, of their properties to a compound. 99 • 100 (If they contributed all of their properties, there would be no compound substance at all, but a mixture of the elementary 94 Adams, R. P.: Cell Culture for Biochemists. 1980 [Vol. 8 of Work, T. S., Burdon, R. H. (eds.): Amsterdam, Elsevier, Laboratory Techniques in Biochemistry and Molecular Biology]. 95 Glick, J. L.: Fundamentals of Human Lymphoid Cell Culture. New York, Marcel Dekker, 1980. 96 Fedoroff, S., Hertz, L. (eds.) : Cell, Tissue, and Organs Cultures in N eurobiology. New York, Academic Press, 1977. n1 Aquinas, T.: Summa Theologiae. I, q. 76 a. 4, ad 4. 98 Aquinas, T.: Quaestiones Disputatae de Anima. a. 9, ad 10. 99 Koren [64], pp. 51, 62. 100 Glenn [87], pp. 163, 164. BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 43 substances.) This concept of virtual presence is perhaps more familiar these days at the level of quantum mechanics. For example, the substantial form of an electron is virtually (not actually) present in an atom, and the substantial form of an oxygen atom is virtually present in a water molecule. 101 • i<12 When an accidental change occurs that is just sufficient to result in a substantial change, the latent (virtual) forms are the ones which become actualized. Thus many vegetative souls (corresponding to each individual cell of the body) are virtually present in a living body, and under the proper circumstances may become actual. Such substantial transformations from one level of life to another may go in the other direction as well. Just as the individual oxygen and hydrogen atoms become only virtual when they fuse into a water molecule, so does the water molecule vanish into "virtuality" when it is drunk by an animal and begins to participate in the vital functions of the animal. Similarly, a fibroblast growing in culture loses its own individual vegetative substantial form when transplanted back into the donor person, becoming " reinformed " by that human soul. In the case of a larger piece of tissue, such as a kidney awaiting transplantation (temporarily kept alive in a nutrient oxygenated bath) , this is not a single unified living organism, as the fibroblast, but rather a conglomerate of many independently living kidney cells, each with its own substantial form. Upon successful transplantation, the forms of all these cells become only virtually present again in the human soul. HYLOMORPHISM AND BRAIN DEATH From all of the above, it is clear that the range of possible "souls" is not limited to those which occur naturally, but also includes countless varieties made possible through modem technology, such as tissue culture laborntories. By removing a 101 Hoenen [66], nos. 240-246, 248-252, 255 a·d. P.: Hylomorphism: The Virtual Presence of Substantial Forms. In Koren [65], Chap. 33, pp. 191-205. 102 Hoenen, 44 D. ALAN SHEWMON, M.D. living fibroblast or kidney, one or more new, lower-order living substances come into being, without in any way destroying the unifying principle of the original person (i.e., killing him) . This fact can help us arrive at an understanding of brain death through the back door, as it were, by leading us to consider the following question: how much tissue can be removed from the original body and kept independently alive, without killing the person? Another way of phrasing it might be: what is the minimum part of the human body still capable of supporting the human essence? Suppose that instead of removing just a fibroblast from the body, we remove an entire limb, but with surgical care, so that the limb's main blood vessels are connected to a cardiopulmonary bypass machine as well as a hemodialysis machine. The severed part is no longer informde by the person's soul, but neither is it inanimate matter. Like the donor kidney, it is an aggregate of many living cells, each with its own vegetative soul. Apart from the person's body they do not constitute a functional unity, so there is no one substantial form of the severed limb as a whole. The original person is still alive, however, with the same soul as before, even though the quantity of matter informed by that soul is now somewhat less. Now suppose this person were unfortunate enough also to have his other three limbs amputated and kept alive in the same way. Then his kidneys were removed, so that he required regular hemodialysis. Although he is no longer in the best of health, he is obviously still alive and the same person as before. Now his intestines are removed, and he has to receive all his nutrition and fluids intravenously. At this point he is placed on a cardiopulmonary bypass machine, so that his heart and lungs may be excised without ill effect. The liver is also taken, . and his blood is purified by perfusion through a pig liver in series with the bypass machine. Air is forced through his trachea, permitting him to speak with us. As he describes his feelings about all of this, it is undeniable that he is still alive and still the same person as before. Since the functions of all BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 45 the vital organs except the brain are now subserved by mechanical devices, the torso has become a superfluous shell and may be surgically removed from the neck without any detriment to the patient. Of course, all the machines are now reconnected to the blood vessels of the neck. In order to preserve communication with the patient, the nerves to the larynx are carefully preserved, and the continuous flow of air is maintained through the trachea. Although now reduced to only a head and neck, this is still the same person as before, as he himself will attest if we ask him. In the meantime, all the removed parts have been connected to machines to keep them alive as well. Suppose we now remove his eyes and ears. Though blind and deaf, he still continues to talk: to us about his memories, imaginations, thoughts, desires, and emotions. Since all that is needed for him to communicate with us is the speech apparatus, we could proceed to dissect away (humanely, of course, under local or general anesthesia) the parts of the head and neck not involved with speech: the skin, the skull and spinal bones, spinal cord, and most of the neck muscles. Now his body is reduced to a brain, mouth, trachea, and larynx, still kept alive by the same machines as before. If we now remove the speech apparatus, we would lose all contad with him, but would hardly kill him. He would continue thinking, remembering, imagining, and wishing just as before, but it would all be kept to himself, due to his inability to communicate. His body is now reduced to his brain alone, floating in a warm solution and connected to the cardiopulmonary, dialysis and parenteral nutrition machines. Since that function which distinguishes animal from vegetable, namely consciousness, is still present, no substantial change has yet been induced by all this mutilation. The spiritual soul is still there, informing what little volume of matter remains. Let us pause for a moment to return our consideration to the various body parts which have been removed and kept alive, each with its own set of cardiopulmonary, dialysis, and nu- 46 D. ALAN SHEWMON, M.D. tritional machines. It is obvious that at this point whatever is done to them will have no effect upon the person. They could be discarded or surgically reanastomosed one to the other, and it would make no difference. For that matter, they might just as well have been removed en bloc, rather than one by one. A careful neurosurgeon could have done this by opening the skull and connecting the main blood vessels of the brain to the bypass machine, all the while avoiding bleeding from the cut vessels. Then all the cranial nerves and the spinal cord would be severed and the intact living brain carefully shelled out of the skull and placed in its nutrient bath. The skull would then be replaced and the scalp sutured back together. It should be evident that, is spite of appearances, such surgery would not constitute "removing the brain from the person's body." A more accurate description would be " removing the skin, muscles, bones, visceral organs, and eyes from the person's body," since afterwards the person's body is his brain. This being the case, what then is this removed flesh, which looks so much like a human body, but is not? It has a heart that pumps blood through it. Its lungs, moved by a mechanical ventilator, provide gas exchange. Its kidneys and liver cleanse the blood of waste products. Its stomach and intestines, fed via a nasogastric tube, provide nourishment. Its blood cells fight infections in the usual manner. Its wounds heal normally. It is clearly something more than a mere aggregate of individual fibroblasts and other types of cells, as the isolated limb and kidney were. It possesses a certain degree of functional unity at the vegetative level. In other words, it is a vegetative organism in its own right, with its own substantial form. At the moment of separation from the body (now only the brain) , this form became actualized from its previous virtuality in the spiritual soul, just as in the case with the fibroblast. Now this brainless vegetative substance, which looks like a human body but is not, is exactly what one is dealing with in a case of brain death. The only difference is that, with the latter, the agent which removed the brain was not a surgeon BRAIN DEA'l'H, VEGETATIVE STATE, AND DEMENTIA ·47 but nature. In our macabre laboratory, it is evident that the person will die, not when we disconnect the respirator from the vegetative human-looking organism, but when we disconnect the machines from the floating brain. It should therefore be equally evident that, in the natural context, a person will die (and his spiritual soul will leave the body) the moment his brain dies, irrespective of whether the rest of the body maintains some vegetative integrity or not. The notion that the brain is the crucial organ which determines the body's compatibility or incompatibility with the human soul is also perfectly consistent with the tradition of the Catholic Church regarding the baptism of two-headed infant " monsters." For centuries, it has been considered proper to administer two baptisms absolutely if the monster had two chests and heads. If there were two chests and one head, or one chest and two heads, there would be one absolute and one conditional baptism. 103 Thus, even long before medical science clarified the respective functions of the heart and the brain, the Church had manifested its openness to the possibility that the brain alone could be the critical organ for determining the presence or absence of a human soul. If there should be two baptisms, then it also follows that death of one of the heads would constitute the death of a person, even though the body it was attached to remains alive (as his sibling's body). The notion of brain death as death of the person is therefore perfectly in keeping with the Church's traditional criteria for enumerating souls in the context of bizarre medical circumstances. The same conclusion is also reached by one of the few Thomistic theologians who have written specifically about brain death. 104 HYLOMORPIDSM AND PERSISTENT VEGETATIVE STATE Let us not yet kill the floating brain, however, so as to see 10a Merkelbach, B. H.: Summa 1'heologiae Moralis. mentis. Montreal, Desclee de Brouwer, 1949, p. 133. 104 Moraczewski & Showalter [19], pp. 15-18. Vol. III: De Sacra- 48 D. ALAN SHEWMON, M.D. how much of it can be removed without interfering with the person's consciousness. We may begin with the lower brainstem (i.e., including the lower pons and the medulla oblongata), which subserves a number of visceral functions (such as blood pressure, respiration, digestive tract motility, etc.) , but which is not essential for consciousness. 105 Without any visceral organs to regulate, the lower brainstem is obviously of no use to the person, and can be innocuously removed. But consider if we had simply left it in the vegetative body in the first place, and only removed the brain above it. Now the vegetative body no longer needs mechanical ventilatory support, since the lower brainstem causes it to breathe spontaneously (although hardly normally). This body is now identical to what one encounters in the severest cases of persistent vegetative state. Whether the rest of the brain is removed by a surgeon or by natural causes, in either case what remains is no longer the body of a person. In our laboratory, the person is still alive across the room with his reduced body, consisting of the cerebral hemispheres plus upper brainstem. If circulatory support were stopped to this brain, the person would then die. But this is precisely what has already happened in the naturally occurring persistent vegetative state. This state, therefore, like that of brain death, implies that the person has already died. The moment the brain cells in the hemispheres and upper brainstem become irreversibly damaged, the body is rendered incompatible with the human essence, forcing a substantial change. The spiritual soul departs and a vegetative soul is actualized, which had been virtually present all along in the vegetative aspects of the original human soul. There is no reason not to extend our dissection of the person's brain still further, as long as we preserve the structures which mediate his consciousness. Under ordinary circumstances, these critical structures are the reticular activating system in the upper brainstem plus at least one cerebral 10s Plum & Posner [34], pp. 15, 28, BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 49 hemisphere. 106 • 10,1 At the present time it is not known with certitude whether consciousness requires specific patterns of neural activity in both reticular system, and cerebral hemispheres, or whether the latter alone suffice (the reticular system providing merely nonspecific facilitation to the hemispheres). The second possibility is analogous to the relationship between a battery and a radio. The production of music does not depend upon that particular battery; one could even do just as well with a non-battery power supply, such as an electric wallsocket. What is specifically necessary for the production of music is the electronic circuitry of the radio itself. The battery is merely one way of facilitating the functioning of this circuitry. There is to date some evidence, though hardly definitive, that the reticular activating system plays such a subsidiary, facilitatory role relative to the cerebral hemispheres. In man unilateral lesions of the brainstem reticular system do not impair conscionsness. 108 • 109 Judging from the human cases reported, the precise location of the lesion within the reticular system does not seem to matter much, but rather the volume of tissue. This would seem to indicate a great amount of redundancy and nonspecificity in the output of the reticular system to the cerebral hemispheres. Of special interest is the fact that, in animals, if multiple smaller lesions are made gradually over a number of days, essentially the entire brainstem reticular system can be destroyed without interfering with the animal's consciousness. This is presumably due to func& Posner [34], pp. 1-29. M.: Mechanisms underlying Cortical Activation: Neuronal Organization and Properties of the Midbrain Reticular Core and Intralaminar Thalamic Nuclei. In Pompeiano, 0., Ajmone-Marsan C., (eds.): Brain Mechanisms of Perceptual Awareness and Purposeful Behavior. New York, Raven, 1981, pp. 327-378 [International Brain Research Organization Monograph Series, Vol. 8]. , 10s Plum & Posner [34], p. 28. 109 Chase, T. N., Moretti, L., Prensky, A. L.: Clinical and electroencephalographic manifestations of vascular lesions, of, the pons. Neurology (Minneap.) 18:3157-368, 1968. 10e Plum 101 Steriade, 50 D. ALAN SHEWMON, M.D. tional reorganization above the lesion, probably within the thalamus. 110 • 111 This result argues even more strongly in favor of a nonspecific facilitatory role of the reticular system upon the hemispheres. It is always dangerous to extrapolate from animal data to humans. There is, however, at least one report in the medical literature of three patients whose consciousness could be sustained by electrical stimulation, after a brainstem stroke had destroyed the midbrain reticular activating system. 112 Since the patients were still deeply comatose after a number of days, an experimental operation was performed in desperation. Tiny electrodes were inserted in the brain at sites above the destructive lesion and involved in the diffuse nonspecific system of projections of the thalamus to the cortex. After intermittent stimulation over a number of days, the investigators " were able to raise the level of consciousness to such a degree that the patients opened their eyes, looked around, performed spontaneous movements of the limbs, and seemed to recognize their relatives, even to the point that they cried out when their relatives tried to leave the room ... In two cases ... the improvement of the level of consciousness stopped at the end of the stimulation period." Fortunately, for humanitarian reasons, such stories are few and far between. Nevertheless, even a single such report provides a rather remarkable insight into how nonspecific a role the reticular system most likely plays in consciousness. If something so gross as a wire electrode in the thalamus is capable of making up for the lack of brainstem input to the cerebral hemispheres, it is reasonable to conclude that the hemispheres alone contain the structures which are both necessary and sufficient for human consciousness. 110 Hass, W. K., Hawkins, R. A.: Bilateral reticular formation lesions causing coma: their effects on regional cerebral blood flow, glucose utilization and oxidative metabolism. In Korein [5], pp. 105-109. :1:11 Adametz, J. H.: Rate of recovery of functioning in cats with rostral reticular lesions. J. Neurosurg. 16 :85-98, 1959. 112 Hassler, R.: Basal Ganglia Systems Regulating Mental Activity. Int. ,J. Neurol. 12:53-72, 1977. BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 51 Let us therefore return to our laboratory and remove not only the person's lower brainstem, but the entire brainstem, and stimulate the cerebral end of his reticular system stump with an electrode. A small continuous electrical stimulation should suffice to maintain his cerebral hemispheres in a state of consciousness, so that he will continue to think, remember, desire, and experience emotions, just as before with the brainstem intact. If the whole brainstem had been left in the vegetating cadaver across the room, one would then have a more typical " persistent vegetative state," in which the body not only breathes spontaneously but also exhibits functions mediated by the upper part of the brainstem, such as spontaneous random eye movements, reflex decorticate posturing of the limbs, primitive oral reflexes such as sucking and grimacing, and apparent sleep/wake cycles. The "awake" periods, however, are not conscious wakefulness, but only the external manifestations of wakefulness, such as opening of the eyes and an alert facial expression, totally without mental content. In spite of the remarkably similar appearance of this body to the original person, it is not the person in a comatose state; the person is in the other corner of the room, conscious of himself through what remains of his body, which is now nothing more than a pair of cerebral hemispheres floating in liquid. If the hemispheres were destroyed, the person would then die. Thus, in naturally occurring cases of persistent vegetative state, in spite of rather complex brainstem functions, the person is still dead, having left behind a cadaver informed by a vegetative soul. As with whole-brain death, this conclusion is also in agreement with that of Thomistic theologian Moraczewski, who, however, regarded it more as a theoretical possibility, without sufficient basis in current neuroanatomical knowledge. An important corollary of the above considerations is that brainstem death (i.e., selective destruction of the brainstem alone, such as from hemo1Thage, tumor, or trauma) does not constitute death of the person. It obviously results, however, in permanent coma, unless some neurosurgical stimulation were D. ALAN SHEWMON, M.D. performed. though this state would not constitute death per se, it would certainly render any life-support systems extraordinary and inappropriate, so that the discontinuation of such support would be just as ethical as in the case of brain death. (It must be emphasized, however, that in actual clinical practice, complete selective brainstem destruction is rare, especially with hemorrhages, which tend to separate rather than destroy nerve fibers, and from which surprising recovery may occur. 113 Physicians, therefore, should not be too quick to conclude that brainstem dysfunction is necessarily permanent. In any case, the person is not yet dead.) HYLOMORPHISM AND DEMENTIA Can this line of reasoning be extended still further, so that the cadaver possesses not only vegetative but also nonhuman animal functions as well? In light of all the above, there should be no a priori reason why it might not be possible. That which distinguishes man from all other animals is his spiritual facul- • ties of intellect and will. Although essentially immaterial, these powers require the proper functioning of the brain, and it is precisely in this that man's intellect differs from that of angels, according to St. Thomas. 114 Man's composite nature requires that sensory information be prepared (through a kind of collation of present experiences, memories, and imaginations) for the abstracting operation of the agent intellect. 115 In scholastic terms, this is the function of the "cogitative sense," or "particular reason," one of the four internal senses. Although analogous to the " estimative sense" in animals, it is unique to man because of its intimate relationship with the spiritual intellect.116 The cogitative sense must also have a motor analog, not specifically mentioned by St. Thomas, which has a similar relationship with the spiritual will; i.e., it translates the com& Posner [34], p. 163. T.: Summa Theologiae. I, q. 75, a. 7. 115 Aquinas, T.: Summa Theologiae. I, q. 78, a. 4. 116 Aquinas, T.: Summa Theologiae .. I, q. 78, a. 4, ad 5. 11a l'lum 114 Aquinas, BRAIN DEATH, VEGETAT'iVE STATE, AND DEMENTIA 58 ·mands of the will into specific patterns of neuronal activity which regulate other parts of the brain, such as those which mediate the memory and imagination, or organize the movements of individual muscle groups. That the internal senses are essential for that power which specifically differentiates man from beast could not have been more stressed by St. Thomas. 111 It is precisely the lack of these higher senses which led him to conclude that an early human embryo is not yet sufficiently disposed to be informed by a spiritual human soul.118 Whether or not one agrees with St. Thomas concerning the details of embryology (this will be taken up at greater length below), it is clearly in perfect keeping with the mind of the Angelic Doctor that loss of these critical brain structures at the opposite end of life should also render the body incompatible with the human essence, and therefore result in a substantial change, i.e., death of the person. Although he was acquainted only with the usual cardiopulmonary manifestations of death, it is clear that his reasons for why death results from respiratory arrest apply just as well ·to brain death and its variations: " The union of soul and body ceases with the cessation of breath, not because this is the means of union, but because of the removal of that disposition by which the body is conditioned for such a union" .119 Elsewhere, as we have already seen, he makes clear that the requisite·" disposition " of which he speaks is that the organ of the internal senses is able to support the proper function.ing of the spiritual intellect. "A body is not necessary to the intellectual soul by reason of its intellectual operation considered as such, but because .of the sensitive power, which requires an organ harmoniously tempered. Therefore the intellectual soul had to be united to such a body, and not to a simple element. . . ." 120 St. Thomas is therefore almost as explicit 117 Aquinas, T.: Summa Theologiae. I, q. 79, a. 4, ad 3; q. 84, a. 6 & 7. ns Aquinas, T.: Summa Theologiae. I, q. 118, a. 2, ad 2. 110 Aquinas, T.: Summa Theologiae. I, q. 76, a. 7, ad 2. 120 Aquinas, T.: Summa Theologiae. I, q. 76, a. 5, ad 2. D. ALAN SHEWMON, M.D. as he could be, within the context of the medical knowledge of his day, in suggesting that respiratory arrest results in death, not because respiration per se is of the essence of life, but because it leads to necrosis of the cerebral hemispheres. At the time of St. Thomas, medical men believed that the organ of the cogitative sense was one of the ventricles in the middle of the head. 121 • 122 Although today we still do not know the exact neuroanatomicaI substrate for the cogitative sense and its motor analog, at least we do know many brain structures which are not necessary for their function, including (alas!) the much beloved ventricles. The work of neurologists . during this century has shed a great deal of light on the importance of the cerebral cortex (the outer mantle of gray matter over the convexity of the brain) for the highest sensorimotor and intellectual functions of man. It is precisely this structure which is lacking in the brains of lower animals, and which increases in size in proportion to the complexity of the behavior of higher animals. 123 -m A traditional way of subdividing areas of the cerebral cortex is into the so-called "primary," "secondary," and "tertiary" areas, the latter two also being known as "association" areas. The primary and secondary sensory and motor cortices, and their specific thalamic and basal ganglia projections, can be lesioned singly or in combination, without loss of intellectual thought or volition. The primary sensory areas are the first 121 .Aquinas, T.: Summa Theologiae. I, q. 78, a. 4. W.: Medieval and Renaissance Contributions to Knowledge of the Brain and its Functions. In: The History and Philosophy of Knowledge of the Brain and its Functions. .An .Anglo-American Symposium [London, July 15-17, 1959]. Oxford, Blackwell, 1958, pp. 95-114. 123 Luria, .A. R.: Higher Cortical Functions in Man. New York, Basic Books, 2nd ed, 1980, pp. 56-63. 124 Rose, S.: The Conscious Brain. Harmondsworth, England, Penguin Books, Revised Ed, 1976. Chap. 6, "The Evolution of Brains and Consciousness," pp. 161-181. 125 Milner,· E.: Human Neural and Behavioral Development; a Relational Inquiry. Springfield, Ill. Thomas, 1967. 12a Geschwind, N.: Disconnexion syndromes in animl\h;. !l.nd man. Bram SS :237-294 1 1965, 122 Pagel, 'BRAIN Dl. ALAN SltEWMdN, M.D. Information from the main three secondary sensory areas of the cortex (visual, somesthetic, and auditory) normally converges in the tertiary association cortex, which is located midway between them, namely in a region comprising the lateral aspect of the parietal lobe and the posterior /inferior portion of the temporal lobe. Here these sensory modalities are fused into a gestalt perception, but there is a major difference between the roles of the left and right hemispheres. Lesions of the left side interfere with serial processes, particularly the analytic, semantic, or meaning, aspects of language and thought, while corresponding lesions of the right hemisphere interfere with synthetic, holistic, and gestalt appreciations. 131 -185 The analogous tertiary association area for motor functions is the anterior portion of frontal lobe. Bilateral prefrontal lobotomy thus results in impaired sequencing of behavior, uninhibited interference from inappropriate distractions, thoughtless impulsivity in actions, and inability to formulate and carry out long-term goals, all resulting in a lack of moral responsibility .186 -142 There are rich connections between the motor and 181 Critchley, M.: The Parietal Lobes_ New York, Hafner, 1971, Chaps. 10, 11, & 13, pp. 326-377, 391-405. 132 Sommerhoff [127], Sect. 9.7 pp. 294-297. 183 Joynt, R. J., Goldstein, M. N.: The Minor Cerebral Hemisphere. In Friedlander, W. J. (ed.): Current Reviews of Higher Nervous System Dysfunction. [Advances in Neurology, Vol. 7] New York, Raven Press, 1975, pp. 147-184. 134 Gazzaniga, M. S., Le Doux, J. E.: The Integrated Mind. New York, Plenum Press, 1978. 135 Wittrock, M. C. (ed.): The Brain and Psychology. New York, Academic Press, 1980, Chaps. 4-7, pp. 141-344. 136 Warren, J. M., Akert, K. (eds.) : The Frontal Granular Cortex and Behavior. New York, McGraw-Hill, 1964. 1a7 Fuster, J. M.: The Prefrontal Cortex. Anatomy, Physiology, and Neuropsychology of the Frontal Lobe. New York, Raven Press, 1980. 1as Pribram, K. H., Luria, A. R. (eds.) : Psychophysiology of the Frontal Lobes. New York, Academic Press, 1973. 139 Damasio, A.: The Frontal Lobes. In Heilman & Valenstein [129], chap. 12, pp. 360-412. HO Hecaen, H., Albert, M. L.: Disorders of Me.ntal Functioning Related to Frontal Lobe Pathology. In Benson D. F., Blumer D. (eds.): Psychiatric Aspects of Neurologic Disease. New York, Grune & Stratton, 1975, Vol. I, Chap. 8, pp. 137-149. BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA .57 sensory tertiary association areas, 143 •145 clearly facilitating the intimate mutual relationship between understanding and volition.146,147 These two tertiary association areas are therefore logical candidates for the neurological substrate of the cogitative sense. Another strong piece of evidence is that they are the only brain structures which are extensively developed in man but not in higher mammals. Moreover, in higher animals, the evaluative or estimative functions subserved by what scholastics call the " estimative sense " 148 a.re mediated by a frontotemporal system of the brain, so that the animal analog of the human cogitative sense is fittingly mediated by the analog of the human tertiary association cortex system. An important aspect of all this which we do not yet know is the relative role of the subcortical gray matter, particularly the thalamus (a large conglomeration of gray matter nuclei situated deep in the middle of the cerebral hemispheres). The tertiary association areas, like the rest of the cerebral cortex, normally function in conjunction with the thalamus and basal ganglia, which communicate with the cortex in a topographic arrangement. 149 It remains to be elucidated whether these latter structures are specifically involved in understanding and volition, acting together with the cortex as an inseparable functional unit, or whether they are merely facilitatory, some141 Blumer, D., Benson, D. F.: Personality Changes with Frontal and Temporal Lobe Lesions. In Benson, D. F., Blumer, D. (eds.) : Psychiatric Aspects of Neurologic Disease. New York, Grune & Stratton, 1975, Vol. I, Chap. 9, pp. 151-170. 142 Hecaen [128], chap. 8, "Disorders due to Frontal Lobe Pathology,'' pp. 354-378. Hs Sommerhoff [127], Sect. 10.3, "Evaluating Functions of the Frontotemporal System" pp. 311-320. 144 Brodal, A.: Neurological Anatomy in Relation to Clinical Medicine. 2nd ed. New York, Oxford Univ. Press, 1969, p. 650. 145 Curtis, B. A., Jacobson, S., Marcus, , E. M.: An Introduction to the Neurosciences. Philadelphia, Saunders, 1972, pp. 461-464. 146 Aquinas, T.: Summa Theologiae. I, q. 82, a. 4. 147 Koren [71], pp. 226-228. 148 Koren [71], pp. 126-12!). 149 Williams, P. L., Warwick, R.: Functional Neuroanatomy of Man. Philadelphia, Saunders, 1975, PP· 891-901, 58 D. ALAN SHEWMON, M.D. what analogous to the role of the reticular activating system mentioned above. Regardless of whether the substrate for the cogitative sense is strictly cortical or combined cortical and thalamic (time will tell) , there is no question that such a neural substrate does indeed exist and includes the tertiary association areas in an essential way. We can therefore proceed to dissect our unfortunate person's living brain still further, removing all the cortical and subcortical areas which are not required for thought and volition. He will probably not even notice it very much, since he is already blind, deaf, numb, and without muscles to move. That is, we remove all the primary and secondary sensory and motor cortex, along with the parts of the thalamus and basal ganglia which are topographically related to them. We may also remove other uninvolved structures such as the hypothalamus. It is uncertain whether such extensive removals might make it more difficult to form sensory imaginations and memories (the extent of the neuroanatomical basis of these two internal senses is not well worked out yet), but in any event, the person would not thereby be rendered unconscious. He would remain there, thinking about himself and wishing that he were not in such a sorry state, cut off from the rest of the world. If these removed parts of the brain are now placed back in the vegetative cadaver in the other corner of the room (rather, if they had been left in to begin with) then the cadaver will possess primitive sensorimotor functions. F'or example, it might be able to walk around the room without bumping into things. Nevertheless, there is no person who is aware of the room or making any act of the will to walk around. The cadaver body could move around like a robot, in a sense, except that it would be a "living robot." Since there are now not only vegetative functions, but also distinctly animal functions, its substantial form must be an animal soul (although not that of any naturally occurring animal) , which was virtually present in the original human spiritual soul. As soon as nonessential parts of the human BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 59 body were removed (i.e., everything but the association cortices and possibly the related parts of the thalamus), they ceased to be informed by the spiritual soul and the virtual animal soul became their life-principle. In the same room, then, is both the original person and a " humanoid " animal, which derived from the person's former body. Clearly, the original person will die as soon as the association cortices are destroyed, regardless of whether the humanoid animal continues to live or not. Therefore, if the same association cortices were to be destroyed through a natural disease process, the result would be the same: the death of the person, even though there is still a humanoid animal body left behind. Let it be clear that, although I keep referring to the tertiary association cortices as the critical structures for the human essence, my basic point is not a neuroanatomical one but a philosophical one: that death of a person can come about through destruction of only those parts of the brain which are necessary for the proper functioning of the intellect and will. If future research were to demonstrate that the only really critical part of the association cortices is the left hemisphere speech area, then we need only replace the phrase " tertiary association cortices " with " left hemisphere speech area " in the above discussion. The basic concept remains just as valid: that the life and death of a person are dependent not upon the whole brain, but upon only a critical part of the cerebral hemispheres. Such a situation is not merely far-fetched theoretical speculation. Selective destruction of the higher cortical areas occurs with some frequency in medicine. Alzheimer's disease is a perfect example of a gradual degeneration of the cortex, affecting primarily the prefrontal and parietal tertiary association cortices.150·151 After the disease has progressed sufficiently, there 1so Cummings, J. L.: Cortical Dementias. In Benson, D. F., Blumer, D. (eds.): Psychiatric Aspects of Neurologic Disease. New York, Grune & Stratton, 1975, Vol. II, Chap. 5, pp. 94-103. 1s1 Benson, D. F., Kuhl, D. E., Phelps, M. E., Cummings, J. L., Tsai, S. Y.: Positron Emission Computed Tomography in the Diagnosis of Dementia. '+rans, Aitl. Ne"\lrol. A,ssoc. l06i68-71, lll81, 60 D. ALAN SHEWMON, M.D. is severe atrophy in these areas (probably from loss of. white matter and synapses, due to loss of the cholinergic cells normally innervating these areas from the nucleus basalis of Meynert, 152 ) while the primary sensory and motor cortices remain relatively uninvolved. Patients at this stage of the illness have sensory perception and can move around, but do not speak or show any evidence of intellectual understanding of their surroundings; their behavior is governed totally by primitive impulses. " Dementia " is really an excellent term for this state, since it indicates that the mind is no longer there. The body has been rendered incompatible with the human essence, so a substantial change must have taken place. The spiritual soul must have left the body, so that the person is now in the next life, while an animal which looks like the former person remains on earth. The following point should be emphasized, lest any room be left for misunderstanding. Because of the functional redundancy within the brain, it is very likely that the extent of brain tissue involved in the normal operation of the internal senses is much greater than the extent of a brain lesion just sufficient to render them permanently inoperable. Thus, if it turns out that the thalamus and association cortex do form an inseparable functional unit, then that very unity implies that a large enough lesion in either cortex or thalamus would undermine their function as effectively as complete destruction of both cortex and thalamus. In other words, the amount of brain which normally subserves the internal senses is not the same as the minimum amount of brain that determines its compatibility or incompatibility with the human essence. Even though neurologic science does not yet know the precise substrate of human consciousness, it matters little for our purposes here; that knowledge is not necessary to be able to state categorically that massive destruction of the cortex alone is sufficient to render the brain unsuitable to support the human soul. ·152 Coyle, J. T., 'Price, D. L., DeLong, M. R.: Alzheimer's Disease: A disorder of cortical cholinergic inmirvation. Science 219: !184-1190 1 1983, BRAIN DEATH, VEGETATIVE STATE, AND i:>EMENTtA 61 In summary, then, the minimum sufficient condition for the death of a person is the irreversible destruction of those parts of the brain necessary for the properly human functions of the spiritual soul, namely intellect and will. This is not to minimize the importance of the spirit in these functions, but to emphasize the need to avoid the opposite error of minimizing the importance of the internal senses, resulting in a warped conception of the human soul as a sort of angel, rather than the substantial form of the body. Whether destruction of these critical. parts of the brain occurs in the context of destruction of all the cells of the body, as in most deaths, or destruction of the entire brain, as in brain death, or destruction of the cerebral hemispheres, as in persistent vegetative state, or simply in isolation, as in severe dementia-it makes no essential difference. In each case the body is rendered incompatible with the human essence, and the spiritual soul is forced to continue subsisting in an unnatural body-less state, until the final resurrection of the body. ANSWERS TO OBJECTIONS Since these bizarre and sad cases are largely a by-product of modern medical technology over the past half-century, it should not be surprising that a rather bizarre thought-experiment, employing the same technology, has been found necessary to clarify the nature of these conditions. There is a strong and perfectly understandable tendency for most nonmedical people (and even many medical people) to think of life and death strictly in terms of its usual cardiopulmonary manifestations. I therefore fully expect that these ideas will meet with initial resistance and misunderstanding by many who are quite legitimately concerned about the general disrespect for life which is evident in our society. Let me, therefore, address in advance some of the major anticipated objections. One might argue, for example, that, since in Alzheimer's disease the gradual degeneration of the brain is a continuous process, there can be no one moment which clearly demarcates b . .AL.AN siIEW:Mo:N,'.M:.b. the presence and absence of the human essence. The same reasoning could be applied, however, to ordinary cardiopulmonary death (only on a shorter time scale), so that one would also have to maintain that there is no clear demarcation between life and death in general, as some actually do claim.158 -155 There is really no contradiction between acknowledging both a continuum of accidental changes leading to death, and an instantaneous substantial change at the moment of irreversibility. When a. lobster is boiled alive, for example, there is a continuum of changes at the molecular level between live lobster and cooked lobster. Nevertheless, there is a critical moment, beyond which the organism's homeostatic systems are unable to compensate for the heat, and its integrity is lost. Whether or not a casual observer of the boiling lobster can identify the precise moment of cellular irreversibility is irrelevant to the fact that there is such a moment. There is no conceptual continuum between reversibility and irreversibility of a disturbance of essential functions. In fact, according to hylomorphism, all substantial changes are instanteous, even though they involve a continuum of accidental change. 156 There is certainly no reason why human death should be any exception. It is simply more difficult to identify the precise moment, when the pathological process is slower, as in Alzheimer's disease. Normally the brain has a great deal of redundancy and reserve, so that loss of a small or even moderate amount of brain tissue does not result in loss of function. But after this functional-anatomical reserve has been completely exhausted, any further destruction of tissue must result in a sudden substantial change. Just because we do not know precisely when the brain is rendered irreversibly incapable of sustaining intellection and volition, it cannot be concluded that such a critical moment does not happen. R. S.: Death: Process or Event? Science 173: 694-698, 1971[ ll], especially p. 22. 155 Gilder, S. S. R: Twenty-second World Medical Assembly [" Declaration of Sidney"] Br. Med. J. 3:493-494 1968. 15a Glenn [87], pp. 39, 163, 183. 153 Morison, 154 Korein BRAIN DEATH:,· VEGinTATi:VE S'l'A'l':E}, AND DEMENTIA 68 The same conclusion is supported by a mathematical representation of living systems. The type of differential equations which are relevant have solutions only when the variable parameters assume certain discrete combinations of values, known as " eigenvalues." To each eigenvalue corresponds a discrete " eigenstate " of the system. For application to living organisms, Varela has coined the term "eigenbehaviors ". 101 This is exactly analogous to the quantum mechanical discontinuities of atomic energy states,158 to which even the nonscientific world has grown accustomed, and it happens for exactly the same reasons mathematically. As a result, even though there may be a continuum of the measurable parameters of an organism (as there is also a continuum in space of possible positions of the electron), the underlying changes of state (which are not seen per se) are discontinuous and instantaneous. A fortiori, the transition from any state of a living organism to some state which is not in the set of that organism's eigenstates would imply a sudden change to something which is no longer that organism. Such mathematical representations of living systems reinforce the hylomorphic notion of substantial change as an instantaneous discontinuity of substantial form underlying a. continuum of accidental changes. Regardless of how slow a terminal illness may be, death is always a discrete momentary event. Another possible objection to this conception of human life and death might be to misinterpret it as actually based upon a Platonic-Cartesian notion of the soul-i.e., as an immaterial substance independent in its own right, but linked somehow to the body-the only new feature being that the location of linkage is no longer held to be the pineal gland. There certainly are contemporary neuro-philosophers who can rightly be accused of this view, such as Wilder Penfield 159 and Sir [76], pp. 170-207. as Saxon, D. S.: Elementary Quantum Mechanics. San Francisco, Holden. . Day, 1968. mo Penfield, W.: The Mystery of Mind. A Critical Study of Consciousness and the Human Brain. Princeton, Princeton University Press, 1975. 157 Varela 64 :b. ALAN SHEWMON, MJj. John Eccles.160 -162 The former conceives of the soul (although without actually using the term) as linked through what he calls the "centrencephalon" (the reticular core of the brainstem and thalamus), while the latter considers it linked primarily through the speech area of the left. hemisphere. These neo-Cartesian theories are examples of how human imagination may interfere with abstract thought. Even without realizing it, we all tend to form mental images of the soul, as a sort of ghost, or vapor, or force, even though we know intellectually that it is no such thing. Such subconscious imaginings tend to bend our thought in the Cartesian direction, unless we explicitly acknowledge and resist the temptation. It is therefore not surprising that certain great figures in the history of the neurosciences, who are not particularly trained in philosophy, should fall into Cartesianism when arguing in favor of the spirituality of man's soul. Such is not the Thomistic notion of soul, upon which this paper is based. There is no contradiction in maintaining on the one hand that (1) the soul, as substantial form of the body, informs all of the body, and is therefore totally present everywhere in the body,163 • 164 and on the other hand that (2) destruction of only an essential part of the body renders it incapable of supporting that substantial form. The original subs.tantial form ceases to inform the entire body, even though the critical change takes place in only a part of it. But because that part pertains to the human essence, a substantial change takes place, not merely an accidental one. This is nothing more than an application to living things of a. general principle of uo Eccles, J. C.: The Human Psyche. The Gifford Lectures. University of Edinburgh, 1978-1979. Springer International, 1980, Lecture 2, "Modules of the neocortex and their role in dualist-interactionism," pp. 27-50. 161 Eccles, J. C.: The Self-Conscious Mind and the Brain. In Popper, K. R., Eccles, J. C.: The Self and its Brain. New York, Springer, 1977, Chap. E7, pp. 355-373. 1e2 McGreer, P. L., Eccles, J. C., McGreer, E. G.; Molecular Neurobiology of the Mammalian Brain. New York, Plenum, 1978, pp. 552-565. 1es Aquinas, T.. : Summa Theologiae. I, q. 76, a. 8 .. 164 Aquinas, T.: Quaestiones Disputatae de Spiritualibus Creaturis, a. 4. BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 65 Aristotelian-Thomistic cosmology. At the inanimate level, for example, an entire molecule undergoes a substantial change when only one part of it is involved· in a chemical reaction. St. Thomas himself applies this principle to human beings as well, referring specifically to the head as the " seat of consciousness," and stating that "no other external part belongs to the integrity of the body in the same wa.y as the head " (underlining mine) .165 My contention that human life and death depend upon the functional integrity of the tertiary association cortices, therefore, has nothing to do with the fallacy of Platonic-Cartesian dualism. Actually, it may be a touch of the Cartesian fallacy which prevents some well-meaning people from accepting the notion of brain death and its variations. They imagine that the soul's ubiquity throughout the body is that of some sort of undifferentiated ghost. With such an image, it is indeed hard to understand why the soul should not be able to experience visual sensation because of its presence in the eyes, or why destruction of only one part of the body could force it to leave the rest of the body. If, however, one keeps clearly in mind the Thomistic notion of soul as the substantial form, or unifying principle, the apparent contradiction between the soul's ubiquity and its spatial heterogeneity of operation vanishes. 166 • 167 One might also object that the view propounded here would imply that a developing embryo is not human because it lacks tertiary association cortices, and that therefore abortion could be justified. This is not the case, however, for several reasons. First, the immorality of abortion is independent of the philosophical debate over the precise moment of animation of the embryo with a spiritual soul, as stressed by the Sacred Congregation for the Doctrine of the Faith. 168 Moreover, St. 165 Aquinas, T.: Summa Theologiae. III, q. 68 a. 11, ad 4. T.: Summa Theologiae. I, q. 76 a. 5, ad 3. 167 Aquinas, T.: Questiones Disputatae de Anima. a. 9, c. & ad 14; a. 10, ad 17. 16s Sacred Congregation for the Doctrine of the Faith: Declaration QD,. Abortion. Nov, 18, 19.74, Sections 12 & 13, 1;tud footnote 19, 166 Aquinas, 66 D. ALAN SHEWMON, M.D. Thomas, who advocated the theory of succession of souls (" mediate animation ") during embryogenesis 169• 170 (first a vegetative soul, then an animal soul, then a human spiritual soul, as the matter becomes more and more disposed to these substantial forms), would have considered abortion as a serious sin, even if it were not equivalent to homicide. 171 • 172 Furthermore, Ashley, McCarthy, and Moraczewski argue convincingly that St. Thomas held the theory of mediate animation not as a direct conclusion from philosophical principles, but as an application of those principles to the mistaken notion of embryogenesis held by the scientists of his day. 173 Although the moment of animation with a rational soul is still a matter of controversy among philosophers and theologians,1 74 given what we now know concerning genetics and embryology, Thomistic principles are at least perfectly compatible with the notion of animation from the moment of fertilization. Neither does the notion of death advocated he'l'e imply a succession of souls during embryogenesis. What is necessary for the human soul is not the actual functioning of the essential brain structures, but their natural potential for functioning. Someone who is asleep is not dead, even though the functions of intellect and will are suspended. This is because they are only temporarily interrupted; there is no structural damage to their neural substrate, rendering the brain intrinsicaily incapable of those functions. Even a comatose patient who has suffered brain damage, but recovers at least some cognitive functioning, obviously did not sustain sufficient damage to result in a substantial change. For the same reasons, a brainless embryo is quite unlike a brainless adult, since the sub169 Aquinas, T.: Summa Theologiae. I, q. ll8, a. 2, ad 2. 110 Aquinas, T.: Quaestiones Disputatae de Anima. a. ll, ad 2. 111 Dedek, J. F.: Contemporary Medical Ethics. New York, Sheed & Ward, 1975 p. 111. 112 Ashley, B.: A Critique of the Theory of Delayed Hominization. In McCarthy & Moraczewski [173], Appendix I, pp. ll3-133. 173McCarthy, D. G., Moraczewski, A. S.: An Ethical Evaluation of Fetal _Experimentation: An Interdisciplinary Study. St. Louis, Pope John XXIII Medical-Moral Research and Education Center, 1976, pp. F4 pedek [171], pp. .... BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 67 stantial form of the embryo makes its development always tend toward forming those brain structures essential for the operation of the intellect. It is only a temporary absence of functioning, with as full a potential as that of a sleeping person. On the other hand, when the critical areas are destroyed in an already formed brain, they cannot be regenerated, and the body is thereby rendered permanently incompatible with the human essence. Thus, what I propose in no way implies that the embryo is not human, much less that abortion should be considered licit. It could also be objected that this conception of life and death brings with it a tremendous potential for abuse on the part of certain doctors, legislators, and others who lack a respect for human life, and who might use these concepts to justify euthanasia. It is certainly true that there is a potential for abuse, just as almost any truth can be twisted and misapplied. But the truth or falsity of a proposition is not determined by abuse potential. Concerning the practical applications of these ideas in daily medical practice, I would make the following observations and recommendations. First of all, it is my experience that the vast majority of doctors do have sufficient respect for life that they would want to give a comatose patient every chance for recovery, even if the chance is slim (this is true even among doctors who condone abortion). Doctors, and neurologists in particular, are in general quite scrupulous about applying criteria for such conditions as brain death; when errors have been made, they have usually been in the direction of an irrational reluctance to declare brain death in spite of the standard clinical criteria having been met. It should be obvious that the further removed a given case is from ordinary vegetative-level death, the more carefully one must ascertain of destruction of the essential brain tissue. With regard to whole-brain death, accurate diagnostic criteria a.re already fairly straightforward and standardized.175 It is certainly another matter, however, with persistent 175 President's Commission. [IO], pp. 159-166. Also reproduced in JAMA 246:2184-2186, 1981. 68 D. ALAN SHEWMON, M.D. vegetative state. There are no current cr.iteria by which one can ascertain with certainty whether a given vegetative patient is truly irreversible. The medical literature, 116 and especially the popular press, cited in Currie, contain rare but dramatic examples of " hopeless " and " irreversibly comatose " patients recovering fully (at least mentally), sometimes after many monLhs of no improvement. In most cases, " irreversibility " is a prediction based upon statistical considerations, rather than an actual diagnosis. The President's Commission for the study of Ethical Problems in Medicine and Biomedical and Behavioral Research has recently studied this issue,177 and recommended that extensive observation should be made before diagnosing permanent loss of consciousness, and that in cases of hypoxic/ischemic brain damage, at least one month o:f observation should elapse. The appropriateness of the one month figure is supported by a number of studies concerning prognosis o:f patients with nontraumati.c coma. 178 -187 Although there are occasional cases of ua Rosenberg, G. A., Johnson, S. F., Brenner, R. P.: Recovery of cognition after prolonged vegetative state. Ann. Neurol. 2:167-168, 1977. 111 Abram, M. B. et al: Deciding to Forego Life-Sustaining Treatment. U.S. Government Printing Office, March, 1983, pp. 179-180. us Bates, D., Caronna, J. J., Cartlidge, N. E. F., Knill-Jones, R. P., Levy D. E., Shaw, D. A., Plum, F.: A prospective study of non traumatic coma: methods and results in 310 patients. Ann. Neurol. 2:211-220, 1977. 179 Bell, J. A., Hodgson, H.J. F.: Coma after cardiac arrest. Brain 97:361372, 1974. 1so Earnest, M. P., Breckinridge, J. C., Yarnell, P. R., Oliva, P. B.: Quality of survival after out-of-hospital arrest: predictive value of early neurologic evaluation. Neurology (Minneap.) 29: 56-60, 1979. u1 Finklestein, S., Caronna, J. J.: Outcome of coma following cardiac arrest. Neurology (Minneap.) 27:3G7-368, 1977 (abstract). 1s2 Higashi, K., Sakata, Y., Hatano, M., Abiko, S., Ihara, K., Katayama, S., Wakuta, Y., Okamura, T., Ueda, H., Zenke, M., Aoki, H.: Epidemiological studies on patients with a persistent vegetative state. J. Neurol. Neurosurg. Psychiatry 40:876-885, 1977. 1ss Levy, D. E., Bates D., Caronna, J. J., Cartlidge, N. E. F., Knill-Jones, R. P., Lapinski, R. H., Singer, B. H., Shaw, D. A., Plum, F.: Factors influencing recovery from nontraumatic coma. Ann. Intern. Med. 94-293-301, 1981. 184 Snyder 13. D., Itamirez-Lassepas, M., Lippert, D. M.: Neurologic status and prognosis after cardipulmonary arrest: . I. A. retrospective study. Neurology (Minneap.) 27 :807-811, 1977. BRAIN DElATil, VEGETATIVE STATE, AND DEMENTIA 69 significant improvement beyond that period, all investigators unanimously conclude that the vast majority of patients reach their plateau of maximal improvement well before one month, and many propose that reliable prognosis may be made in patients with certain constellations of clinical signs long before that. 188 Coma due to head trauma, however, generally carries a much more optimistic outlook, with most studies finding that continued slow improvement up to a year or more is not uncommon. 189 -103 Patients comatose from acute lesions of the midbrain reticular activating system also frequently continue to improve over months or years. 194 Also, almost all investigators agree that the prognosis of coma in children (especially the younger the child) tends to be much more optimistic than in adults, regardless of etiology; so much so that not even the standard clinical criteria for brain death can be extended to children much below five years of age. 185 Snyder, B. D., Loewenson, R. B., Gumnit, R. J., Hauser, W. A., Leppik, I. E., Ramirez-Lassepas, M.: Neurologic prognosis after cardiopulmonary arrest. II. Level of consciousness. Neurology (NY) 30:52-58, 1980. 186 Willoughby, J. D., Leach, B. G: Relation of neurological findings after cardiac arrest to outcome. Br. Med. J. 3:473-479, 1974. 187 Yarnell, P. R.: Neurological outcome of prolonged coma survivors of out-of-hospital cardiac arrest. Stroke 7: 279-282, 1976. 188 Binnie, C. D., Prior P. F., Lloyd, D. S. L., Scott, D. F., Margerison, J. H.: Encephalographic prediction of fatal anoxic brain damage after resuscitation from cardiac arrest. Br. Med. J. 4 :265-268, 1970. 189 Bricolo, A., Turazzi, S., Feriotti, G.: Prolonged posttraumatic unconsciousness: therapeutic assets and liabilities. J. Neurosurg. 52:625-634, 1980. 190 Jennett, B., Teasdale, G., Braakman, R., Minderhoud, J., Knill-Jones, R.: Predicting outcome in individual patients after severe head injury. Lancet 1: 1031-1034, 1976. 101 Jeannett, B., Teasdale, G., Galbraith, S., Pickard, J., Grant, II., Braakman, R., Avezaat, C. Maas, A., Minderhoud, J., Vecht, C. J., Heiden, J., Small, R., Caton, W. Kurze, T: Severe head injuries in three countries. J. Neural. Neurosurg. Psychiatry 40:291-298, 1977. 192 Jennett, B., Teasdale, B., Braakman, R., Minderhoud, J., Heiden, .r., Kurze, T.: Prognosis of patients with severe head injury. Neurosurgery 4:283-289, 1979. 193 Mandleberg, I. A. Brooks, D. N.: Cognitive recovery after severe head injury. 1. Serial testing on the Wechsler Adult Intelligence Scale. J. Neural. Neurosurg Psychiatry 38: 1121-1126 1975. 194 Br-endler, S. J., Selverstone, B.: Recovery from decerebration. Brain 93 :381-392, 1970. 70 D. ALAN SHEWMON, M.D. Clearly all studies of coma prognosis based upon clinical parameters allow one only to calculate a rough probability-not a certainty-of irreversibility; hence, their criteria should not be used for determination of death in the form of persistent vegetative state. Nevertheless, a very high probability of irreversibility would seem sufficient at least to justify regarding nasogastric feedings, antibiotics, and intensive nursing care as extraordinary means of support, since one of the criteria for the ordinary/ extraordinary distinction is precisely the likelihood of benefit for the patient. 195 Although the President's Commission did not pretend to undertake a metaphysical analysis of persistent vegetative states, it too concluded that artificial feeding and antibiotics should not be considered mandatory in such cases. I would advocate that, in order to make the diagnosis of irreversibility with greater certainty, lack of functional improvement should be coupled with diagnostic imaging studies showing that indeed there is structural loss of essential brain substance. There are no reports in the literature concerning this, since most of the studies of coma prognosis were conducted prior to the era. of CT brain scanning, and the more recent studies do not address the issue systematically. However, it is obvious that, in the most severe cases, after the destroyed cerebral hemispheres have been replaced by fluid over the course of weeks, a CT scan would show precisely the absence of hemispheres. In less severe cases, though, it may still be impossible to determine from CT scans alone whether a critical amount of cortical tissue has been lost. Reports of cases of hydrocephalus (" water on the brain ") with massive loss of brain substance but surprisingly preserved function 196 (as well as the potential for restoration of brain tissue with surgical drainage of the fluid, especially in in195Atkinson, G. M.: Theological History of Catholic Teaching on Prolonging Life. In McCarthy, D. G., Moraczewski, A. S. (eds.): Moral Responsibility in Prolonging Life Decisions. St. Louis, Pope John. Center, 1981, Chap. 7 pp. 95-.115. 196 Lewin, R.: Is your brain really necessary? Science 210: 1232-1234; 1980. BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 71 fants 197 ) should not be interpreted as invalidating the ominous significance of the same degree of tissue loss when caused by hypoxic/ischemic damage. In chronic hydrocephalus the nerve cells of the cortex are relatively preserved, the atrophy being due largely to loss of the myelin insulation around the long white matter fibers which connect the cortical cells with one another, and to some loss of those fibers themselves. Moreover, the slowness of the pathological process permits the brain's "plasticity" to adapt to the changes. In hypoxic/ischemic damage, however, the nerve cells themselves are lost, so that there is nothing left to " plastically" adapt. Perhaps future medical science will discover methods for determining irreversibility much sooner and in a greater number of cases than is currently possible with CT scanning. Until such a. time, however, prudence would dictate that comatose or vegetative patients be given every chance to recover, as long as there is any uncertainty concerning their reversibility. In some types of cases, however, irreversibility can be diagnosed with absolute certainty rather early. For example, persistence of electrical silence on EEG beyond several days would indicate that there are no neurons left in the cerebral cortex (or so few as to have no functional significance). This can be stated categorically, since those patients who have an episode of electrical silence immediately after a cardiac arrest, and who later recover, always show return of EEG activity within a maximum of six hours. 198 Even in cases of drug intoxication severe enough to cause electrical silence, no cases have been reported in which brain activity did not return within two days of admission to the hospital. 199 • 200 A survey of 197 Sutton, L. N., Bruce, D. A., Schut, L.: Hydranencephaly versus maximal hydrocephalus: an important clinical distinction. Neurosurgery 6: 3438, 1980. 198 Spehlman, R.: EEG Primer. Amsterdam, Elsevi:er/North Holland, 1981, pp. 372-373. 199 Allen, N., Burkholder, J., Comiscioni, J.: Clinical criteria of brain death. In Korein [5], p. 77. 200 Bird, T. D., Plum, F.: Recovery from barbiturate overdose coma with a prolonged isoelectric electroencephalogram. (Minneap.) 18 :45q, 460', 1968. b. ALAN SHEWMON, M.D. a large number of electroencephalographers also corroborated this thesis. 201 Out of 1665 patients with electrocerebral silence, only three recovered, and all three had overdoses of sedative medication. The duration of electrical silence considered necessary to declare irreversibility (thereby absolutely ruling out the possibility of drug overdose as a cause) varied from one electroencephalographer to another, but the vast majority considered 24 hours to be sufficient, while the maximum duration from the entire survey was 48 hours. Given all the above, one could confidently conclude that several days of elec· trical silence in a vegetative patient would indicate essentially total destruction of the neurons of the cerebral cortex, even if the etiology of the coma were not known. It should also be obvious that demonstration of absent blood flow to the cerebral hemispheres (by angiography, radioisotope, or any other method) is incompatible with survival of cortical neurons, regardless of preserved brainstem function. Another condition in which irreversibility of cerebral destruction can be known with certainty is hydranencephaly (not to be confused with the much more common and treatable condition called hydrocephalus mentioned above). The term refers to an externally normal-looking infant, which in utero suffered a devastating stroke or infection, completely destroying the developing cerebral hemispheres, so that by the time of birth there is nothing but water in the head. 202 - 204 Initially these babies behave just like normal infants, because of their intaet brainstems. Over time, however, it becomes evident that they 201 Silverman, D., Saunders, M. G., Schwab, R. S. Masland, R. L.: Cerebral death and the electroencephalogram. Report of the Ad Hoc Committee of the American Electroencaphalographic Society on EEG criteria for determination of cerebral death. JAMA 209: 1505-1510, 1969. 202 Halsey, J. H., Jr., Allen, N., Chamberlin, H. R.: The morphogenesis of hydranencephaly. J. Neurol. Sci. 12:187-217, 1971. 2oa Lemire, R. J., Loeser, J. D., Leech, R. W., Alvord, E., Jr.: Normal and Abnormal Development of the Human Nervous System. Hagerstown, MD., Harper & Row, 1975, pp. 251-253. 204 Menkes, J. H.: Textbook of Child Neurology. 2nd ed., Philadelphia, lie!J. & :Febi15er, 1980, pp. 216-217. BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 73 are not developing any functions dependent upon higher brain structures, and they end up in a spastic, contracted position similar to older people with persistent vegetative state. The condition can be easily diagnosed at birth by transilluminating the head with a flashlight, by CT scan, or by cranial ultrasound. Even though the baby initially behaves normally, we would have to conclude that the baby had actually died in. utero, and that what was born wa.s actually an infant " humanoid animal". If great prudence is required in diagnosing a vegetative state as irreversible, still greater caution and prudence is in order with cases of dementia, given that we do not even know with certainty what the neuroanatomical substrate of the cogitative sense is. Nor do we yet have a technique for determining at what moment the critical degree of brain destruction has occurred. Until such a time when these can be known, demented patients must be given the benefit of the doubt and treated with all the respect and care which any sick human be. ing deserves. 1\foreover, even were these things known, if a person had become demented to the point of having died, leaving behind a " humanoid animal," this animal should not necessarily be killed, out of respect for the fact that it used to be such and such a person. H there were sufficient reasons, however, it would be justified not only to withhold simple means of life support a.s antibiotics and intravenous fluids, but even painlessly to put the animal "to sleep," as is sometimes· · done to beloved pets which are terminally ill. This would not be euthanasia, because we are speaking of some future age when medical technology is advanced enough to determine that the patient has already died. 1 repeat, however, that up until such a time, demented patients must always be given the benefit of the doubt as to their humanity. An interesting question is whether cerebral atrophy is intrinS'ically irreversible; i.e., whether we can so assuredly rule out the possible development of some future technique of making the nerve cells regrow, or of transplanting nerve cells which will make the proper synaptic connections, etc. The 74 D. ALAN SHEWMON, M.D. President's Commission advised that such hypothetical possibilities in the indefinite future should not affect today's decisions concerning life support. While this may be reasonable practical advice concerning extraordinary means, it does not address the quite valid philosophical concern that, if the irreversibility is merely due to present technological limitations, then it would not be true irreversibility, and would therefore not indicate death of the person. It is true tha.t the brain has a remarkable potential for functional recovery, which is greatest in infants and decreases with age. Recovery may occur by means of a wide variety of posincluding formation of new consible physiologic nections (synapses) between nerve cells, alteration of the sensitivities of existing connections, and utilization of " reserve" pathways for that function, which under normal circumstances remain latent. This functional and microanatomical adaptive reorganization of the nervous system is broadly referred to as plasticity, and it is the subject of intense investigation at the present time. 205 ' 209 It is clearly closely tied with the fact that during the normal development of the infant nervous system, 210 · 214 and during learning in general, 215 • 216 ex205 Merzenich, M. M., Kaas, J. H.: Reorganization of mammalian somatosensory cortex following peripheral nerve injury. Trends in Neurosciences 5 :434-437, 1982. 2oa Finger, S., Stein, D. G.: Brain Damage and Recovery. New York, Academic Press 1982. '201 Hecaen [128], chap. 9, "Cerebral Plasticity and Recovery of Function," pp. 379-401. 20s Hunt, R. K., Moscona, A. A., Monroy, A. (eds.): Neural Development, Part III. Neural Specificity Plasticity, and Patterns. New York, Academic Press, 1982. ·209 Finger, S., Stein, D. G.: Brain Damage and· Recovery. Research and Clinical Perspectives. New York, Academic Press, 1982. 210 Lund, R. D.: Development and plasticity of the brain. New York, Oxford Univ. Press, 1978. 211 Kuffer, W. S., Nicholls, J. G.: From Neuron to Brain. Sunderland, Ma.ss. Sinauer, 1976, pp. 373-419. . . 212 Floeter, M. K., Gre!)nough, W. T.: Cerebellar plasticity: modification of Purkinje cell structure by ditiereutial rearing in ll)Onl$eys. Science 229, 1979. 211 Grouse, L. D., Schrier, B. K., Nelson, G:: Effect of vis"Ual .experience BRAIN DEATH, VEGETATIVE STATE, AND DEMENTIA 75 ternal stimuli have a profound effect upon the formation, maintenance, and modulation of synapses in the brain. Moreover, there is indirect evidence that memories are stored as diffuse patterns of synaptic sensitivities organized holographically, 217• 218 providing a plausible theoretical basis for the phenomena of diffuse memory storage, association of memories, and comparison of current sensory information with past experience (of obvious importance for the functioning of the human intellect) . All this carries several implications for our philosophical considerations. For one thing, our personality and lifetime ·of memories are contained in the pattern of synaptic sensitivities in our cerebral cortices. If all the neurons were eliminated and replaced by new ones, whether by transplantation of fetal nerve cells (which has actually been done successfully in animals) 219 ,m or by dedifferentia.tion and multiplication of a few on gene expression during the development of stimulus specificity in cat brain. Exp. Neurol. 64:354-364, 1979. 2'14Edds, M. V., Jr., Gaze, R. M., Schneider, G. E., Irwin, L. N. (eds.): Specificity and Plasticity of Retinotectal Connections. Neurosci. Res. Program Bull., Vol. 17, No. 2, 1979. 21s Shepherd, G. M.: The Synaptic Organization of the Brain. 2nd ed., New York, Oxford Univ. Press, 1979, pp. 75-76, 243-245, 324 328, 336-337, 363, 386. 216 McGreer, P. L., Eccles, J. C., McGreer, E. G.: Molecular Neurobiology of the Mammalian Brain. New York, Plenum, 1978, pp. 410, 501-535. 211 Pribram, K. H.: Languages of the Brain. Experimental Paradoxes and Principles in Neuropsychology. Monterey, CA, Brooks/Cole, 1971, pp. 140-166. 21s Pribram, K., Nuwer, M., Baron, R. J.: The Holographic Hypothesis of Memory Structure in Brain Function and Perception. In Krantz, D. H., Atkinson, R. C., Luce, R. D., Suppes, P. (eds.): Measurement, Psychophysics, and Neural Information Processing. Vol. 2, San Francisco, Freeman, 1974, pp. 416-457. 219 Bjorklund, A., Segal M., Stenevi, U.: Functional reinnervation of rat hippocampus by locus coeruleus implants. Brain Res. 170 :409-426, 1979. 220 Berlow, M. J., Freed W. J., Hoffer, B. J. Seiger, A., Olson, L., Wyatt, R. J.: Brain grafts reduce motor abnormalities produced by destruction of nigrostriatal dopamine system. Science 204:643-647, 1979. 221 Bjorklund, A., Stenevi, U.: Reconstruction of brain circuitries by neural transplants. Trends in Neurosciences 2:301-306, 1979. 222 Fray, P. J., Dunnett, S. B., Iversen, S. D., Bjorklund, A., Stenevi, U.: Nigral transplants reinnervating the dopamine-depleted neostriatum can sustain intracranial self-stimulation. Science 219 :416-419, 1983. 76 D. ALAN SHEWMON, M.D. remaining original neurons, the pattern of synaptic sensitivities would develop from a completely clean experiential slate, beginning from the time of the new Even if proper functional connections could be established for the redevelopment of human language and thought, nothing would remain of the original person's past experiences, personality, talents, etc. It would be just as if the whole brain of a newly born infant were transplanted into the person's head and connected to the spinal cord. The first person is still dead, and the infant now has been given a new (or rather, a used) body. In other words, even if the destroyed brain could hypothetically be reconstituted, it would no longer be the . 90 JAMES ROBERTSON PRICE III The foregoing effort to answer the first question of our critique, " Does human knowing take place in a two component process of experience and interpretation? " was in fact an exercise in the performance of judgment, an exercise of reflective inquiry asking whether or not Katz's interpretation of knowing adequately fits the evidence. The answer is, " No, it does not; knowing includes a third component, namely, judgment." Of course, this judgment may in turn be challenged. It may be objected that, while Katz does not specifically refer to the act of judgment, surely he would not deny that judgments are made. I concede this. The point is that even if Katz were to acknowledge the performance of judgment, if this acknowledgment is not also incorporated in his theoretical reflections on mystical knowing, then, trivial as it may at first appear, this omission significantly misleads his epistemological and ontological conclusions. It may also be objected that, even if Katz were to incorporate the performance of judgment into his theoretical reflections, he might well contend that such judgments occur only as mediated by a particular culture or tradition, and hence, like interpretation, are themselves also without objective ontological status. In reply, I ca.n only suggest, as I did above regarding the example of Notre Dame, that while this objection is not selfcontradictory, it is nevertheless self-destructive. It belies its own performance. I am not contending that judgments are never incorrect. I am not contending that judgments are not culturally mediated. What I am contending is that the performance of judgment itself indicates the possibility, in principle as well as fact, of transcending the limitations of personal of human cognition which can be specified in greater detail through atten· tion to the various operations which make up each level. Lonergan, for example, lists "seeing, hearing, touching, smelling, tasting, inquiring, imagining, understanding, conceiving, formulating, reflecting, marshalling and weighing the evidence, judging, deliberating, evaluating, deciding, speaking, writing." Method in Theology, p. 6. The final five operations listed in fact refer to what_ Lonergan calls the level of decision, the process of deciding the value of what is known and what a<;tion to take in light of that value, THE OBJECTIVITY OF MYSTICAL TRUTH CLAIMS 91 and cultural mediations to grasp what is in fact the case. To object that mystical judgments are culturally mediated and hence without objective ontological status is itself to have ma.de a judgment. More, it is an assertion (if implicit) that one has transcended the limits of interpretation to reach a correct judgment. Indeed, Katz's entire essay is the record of a cognitional performance attempting to supply good reasons and sufficient evidence for why others should judge, as he has, that his interpretation of mystical experience and mystical knowing is the correct one. Here there is no relativism, no pluralism. Instead, there is a strong claim for objectivity. Thus, to affirm with Katz a cognitional theory which either ignores or denies the performance of true judgment is to affirm a position on cognitional theory which, while not self-contradictory, is nevertheless self-destnictive. The very performance of judging as true a. position which denies the possibility of performing true judgments is self-destnictive. It undercuts the position itself and forces it toward the correction of an accurate cognitional theory. 9 This point will be expanded below. Thus, the answer to the first set of questions in the critique may now be summarized. Katz's categorical denial that mystical experience can be the basis for objective knowledge of the real is based upon an inaccurate cognitional theory, one which equates knowing with experience and interpretation. An accurate cognitional theory would objectify knowing as a threefold process of experience, interpretation and judgment. 10 9 Lonergan, Insight pp. 276-277. On the relationship of Lonergan and Kant on epistemological issues, see Giovanni Sala, "The A Priori in Human Knowledge: Kant's Critique of Pure Reason and Lonergan's Insight," The Thomist 40 ( 1976) : 179-221; Hugo Meynell, "Transcendental Subjectivity," The Heythrop Journai, 21 (1980): 153-167. 10 It might reasonably be asked, even if one grants that human knowing is a matter of experiencing, understanding and judging, does mystical knowing follow this pattern? This, of course, can only be decided through a careful examination of the relevant mystical texts. It is my contention that a " mystical intentionality" following this basic pattern does become operative in th.e mystic whose mystical consciousness has become stable and fully '11,iffl)rentiated, It iii! 1tlso m;v contention 1 however 1 th11t JAMES ROBERTSON PRICE Ill The second set of questions will now be addressed, but, before specifically turning to the issue of mystical analysis, it may be helpful to compare in more general terms the epistemological and ontological implications of the two cognitional theories under consideration. As indicated in the example given earlier, one's understanding of what the performance of swimming is will directly affect not only the standards for swimming one establishes, but what one considers to be real swimming. The same is true of knowing except that what is at stake is philosophically of much greater moment. At stake is nothing less than one's understanding of reality and the relationship of human beings to it. For Katz, the real exists, but neither a mystic nor anybody else can ever come to know it. Since knowing is understood to be a matter of my interpretation of my experience, it follows that I can never transcend my own interpretations to know the real in itself. It follows, that is, only on the assumption of Katz's cognitional theory. As it happens, and as can be verified by anyone who attends to the concrete performance of their own knowing, I can and do transcend my own interpretations every time I correctly perform an act of judgment. To be sure, as Katz points out, knowing begins within the subject. Experience is my experience, and understanding is my understanding, and both are mediated by the cultural and linguistic world in which I live. But I can move outside of myself, so to speak, when I affirm through judgment not what I think to be the case, not what I have been taught to be the case, not what I would like to be the case, but what in fact is the case. Again, if some of the archways on Notre Dame are in fact romanesque, I can in principle transcend an initial interpretation which understands sciousness rather than consciousness-as-intentional is the analogy most adequate for explaining the nature of mystical consciousness and its relationship to mystical knowing. Since Katz's concern is exclusively with consciousnessas-intentional, I have not introduced the notion of consciousness-as-consciousness in this essay. For a clarification of this distinction and an examination of its implications for the philosophical and theological analysis of mysticism, see my" Bernard Lonergan and the Foundations of a Contemporary Mystical Theology," Lonerpan Workshop, forthcoming 1985. THE OBJECTIVITY OF MYSTICAL TRUTH CLAIMS 9S them fo be uniformly Gothic. Knowing, in other words, is quite simply the sometimes quite difficult matter of correctly understanding what is so. From this it follows that human beings, mystics and non-mystics alike, are not by the nature of their cognitional processes cut off from knowledge of the real, but rather are by those very processes intentionally oriented toward knowledge of it. It follows also, therefore, that only inattention, or failure in interpretation, or insufficiently critical judgment will subvert that cognitional intentionality. 11 With these general considerations in mind, it remains now specifically to consider both how Katz's cognitional theory has misdirected his philosophical analysis of mysticism and to suggest how his epistemological and ontological conclusions can be corrected by attention to a more accurate cognitional theory. In his descriptions of the epistemological conditions of mystical knowing, Katz points out that mystical consciousness is intentional consciousness, that mystical goals are shaped by mystical traditions and that a principal vehicle of this shaping is language in the form of metaphysical doctrine. In short, a mystic's experience is mediated by meaning, and as Katz clearly points out, not all mystical meanings are the same. On these points there is no disagreement. Disagreement lies in Katz's understanding of the real and its relationship to meaning, a disagreement based in differences of cognitional theory. For Katz, human beings in general and mystics in particular live in a world of meaning, a world of interpreted experience. As noted, the fundamental problem is that our interpretations do not disclose the real in itself; they filter and distort it by culturally mediating it. In terms of the cognitional theory advanced here, however, to speak of the real is not to speak of unmediated experiencing, but to speak of apprehending true meaning. 12 Interpretation does not, in principle at least, dis11 See Bernard Lonergan, "The Subject," in A Second Collection, edited by William F. J. Ryan, and Bernard J. Tyrrell, (Philadelphia: Westminster, 1974), pp. 69-86, esp. pp. 70-71. . . . iz See Bernard Lonergan, Method in Theology, pp. 57-99, 'esp. pp. 74-76, and "Dimensions of Meaning," in Collection, edited by Frederick E. Crowe, (New York: He.rder and Herder, 1967) pp. 252-267. 94 JAMES ROBERTSON PRICE tii tort experience; rather, it grasps the intelligibility inherent in it. True meanings, therefore, are interpretations of experience affirmed to be true through the performance of correct judgment. Of course, this is not to say that false meanings cannot be and are not also often affirmed. These, however, are affirmations of what is in fact not the case and so do not belong to the real. 18 The problem of objectivity, then, is not the problem of perceiving unmediated experience; it is the problem of making correct judgments. Thus, with Katz, it can be acknowledged that mystical knowing is mediated by a mystic's tradition, but the epistemological conclusions which follow from that acknowledgment will of necessity be quite different from those advanced by Katz. For instance, if objective knowing is reached by the person who can make correct judgments, epistemological attention must be focused principally on the knower, not on what is to be known. It follows that the person who will most consistently make correct judgments is the one who is willing to entertain and satisfactorily answer all relevant questions which might emerge to qualify or overturn a present interpretation. Such a person will be committed to the truth, whatever its cost, and therefore committed to transcending all the levels of the bias-personal, social, religious, cultural-which thwart that commitment and distort the performance of judgment. Objectivity, understood this way, is authentic subjectivity. 14 A simple distinction may help to clarify this point, for standards of objectivity are typically thought of as external or internal. A measuring stick is an example of an external standard; it can be used to obtain the measurements of a range of objects. If however, one turns from the measuring stick to the care and attention with which a measurement is made, the standard of objectivity is internal. A measurement is in fact as accurate as the one who measures is attentive and careful. My contention is that making correct judgments is like makis Bernard Lonergan, Insight, pp. 499-502, 672-673. Lonergan, .Method in· Theology, p. 265. H THE OBJECTIVITY OF MYSTICAL TRUTH CLAIMS !)/) ing accurate measurements. The knowledge claim is only as valid as the individual is open, intelligent, critical and responsible. The objectivity of the knowing depends on the authenticity of the knower. Thus, from this perspective it can be asserted that, while objective knowing is in principle possible, it cannot be assumed. About certain areas of knowledge one can of course be rather confident, such as which bus to take home or where to find the milk in the corner store. Mistaken judgment in these matters is readily and spontaneously self-correcting. But when one moves into areas of knowing in which the facts that are affirmed are also facts simultaneously affirmed as of significant or ultimate value, areas involving, for instance, one's commitment to one's family, or to one's country, or to one's God, then objective knowing becomes much more elusive and precarious and the various levels of bias much more subtle and potentially dominant. 15 Mystical visions and experiences may be regarded by a given individual as self-authenticating, but the authenticity of that individual is itself not a given. For this reason mystical traditions have always put great stress on the practice of discernment. Nevertheless, it must also be emphasized that it is within the context of a religious life, a life oriented explicitly toward transcendent values, that the highest levels of human authenticity are attained. Only from a thoroughgoing perspective of transcendent value can the commitment to root out all levels of bias be undertaken, sustained, and in even greater degree attained. 16 Indeed, to focus the issue more precisely, if controversially, a strong case could be made that it is within explicitly spiritual and mystical tradi15 It must be noted that for Lonergan, the drive of human consciousness toward knowledge that leads from experience to understanding to judgment finds its terms in a sublation of all three levels in a fourth level of consciousness associated with value. From such a perspective, a full and proper analysis of mystical knowing could not be accomplished without explicit at· tention to the function of values within mystical consciousness. See Loner· gan, Method in.Theology, pp. 36-41; 105-107; 115-117. 10 On this point see John F. Haught, Religion <11nd Self-Acceptance: A Study of the Relationship Between Belief in God and the Desire to Know, (Washington, D.C.: University Press of America, 1980), pp. 143-173. JAMES ROBERTSON PRICE lll tions, commited as they are to rigorous disciplines of physical, mental, emotional and spiritual transformation, that the highest levels of human authenticity are attained. 11 The standard of objectivity, then, is not uninterpreted experience, but the authenticity of the knowing subject. The objective standard employed by the Zen master in judging his disciples is nothing less than the depth and authenticity of his own enlightenment. And of course this is true not only for mystics, but mystical analysts as well. The objectivity of any philosophical analysis will be inevitably related to the analyst's own level of understanding and to the degree of his personal authenticity. Turning now from epistemological considerations to the ontological issues which logically follow, it will be recalled that for Katz mystical doctrines both shape and mirror the experience of different ontological realities. All are held to be equally valid; none can legitimately be regarded as an objective truth claim. As indicated, if knowing is taken to be solely a matter of experience and interpretation, these conclusions inevitably follow. However, if the possibility of correct judgment is acknowledged, then the distinction between correct and incorrect legitimately comes into play and a different set of ontological conclusions emerges. Beliefs, interpretations and understandings quite clearly shape our world. A Manet may paint all of Notre Dame's archways as though they were Gothic, a son may conclude his father does not love him and behave accordingly, a woman may devote her life to a particular understanding of Christianity. These understandings are very real in the proximate sense that they affect one's painting, one's family life, one's religious practice. But under the natural and spontaneous pressure of 11 For an example of this type of argument see John Henry Newman, "Love the Safeguard of Faith .Against Superstition," Sermons, Chiefly on the Theory of Religious Belief (London: Rivington, 1843). For an example of how this claim might be worked out in terms of Lonergan's thought, see James Robertson Price,. "Conversion and the Doctrine of Grace in Bernard Lonergan and John Climacus," Anglican Theological Review, 72 (1980): 338361. THE OBJECTIVITY OF MYSTICAL TRUTH CLAIMS 97 the human mind to ask the question for judgment " Is it true?", each individual can, in principle, attend more carefully to his or her experience, understand it more fully, judge it more adequately and as a result repaint the cathedral, effect a reconciliation with his father, or reform her religious tradition. The rival sets of understanding which result from revised judgments cannot be and are not regarded as of equal validity any more than the Ptolemaic theory of the universe either is or can be regarded as possessing a scientific validity equal to the rival explanation offered by Copernicus. To be sure, the emergence of further relevant questions can never be absolutely ruled out. Nevertheless, it is in principle possible to make an objectively valid statement about the archways of Notre Dame, about one's relationship with one's father, and about mystical reality as well.18 Of course this is not to imply that mystical knowing in all traditions is the same. About this, Katz is surely quite right. It is to imply, however, that, to the extent that the various mystical traditions legitimately pursue correct interpretation, their mystical knowledge will tend to converge or overlap. Thus a precision is necessary regarding Katz's contention that mystics from different traditions know different ontological realities. On the one hand, it can be affirmed with Katz that mystics from different traditions may know different realms of mystical reality, just as Eskimos know glaciers and Pueblo Indians know deserts. But on the other hand, against Katz, it can also be affirmed that mystics from different traditions may know the same mystical reality, and that their respective linguistic and cognitive predispositions do not preclude the possibility either of objective knowing or mutual understanding and correction. Thus, were an Eskimo and a Pueblo Indian both to experience New York City, they could be presumed because of their differing cultural backgrounds to understand it and describe it in quite different ways, but this is l<'or a consideration of this issue in relation to the theories of cont.emporary·: so.ciologists of kno\Vledge, see Hugo Meynell, "On the Limits ·of EJ()ciolo!l'y of Knowledge," Social Studies of Science, 7 (1977) : 489-500, 98 JAMES ROBERTSON PRICE III would not preclude objective knowledge of Manhattan by either of them individually, or, given the requisite effort, the mutual communication, correction and expansion of their understandings through dialogue. The implications of this for the cross-cultural study of mysticism are readily apparent. Cross-cultural analyses will clearly require major collaborative efforts, and, given the explicit recognition of the mediated character of mystical experience, levels of analytical care and sophistication not generally exercised heretofore. Nevertheless, the cognitional theory advanced here leads one to reject Katz's categorical assertion of a strong pluralism among the world's mystical traditions. Instead, it leads one to assert, in a critically grounded fashion, the possibility of a qualified pluralism among mystical traditions, and to affirm not only the validity but the necessity of cross-cultural studies. It offers, in fact, the foundations for a critically grounded philosophia perennis. By way of conclusion, it is important to stress again that the completion of the turn to the subject within mystical analysis is a significant and welcome development, and that in this Katz and others are performing an invaluable service. The intention here has been to join them in their effort to advance the philosophical analysis of mysticism but also to forestall a possible wrong turn in that advance. For, if the recognition of the mediated character of mystical experience can eliminate the facile presumption of a perennial philosophy, so the recognition of an adequate cognitional theory can eliminate the wrong turn that leads not only to the easy assumption of a radical pluralism among the world's mystical traditions, but to the categorical denial of the objectivity of mystical truth claims, and to the effective foreclosure of an important avenue of interreligious and cross-cultural dialogue. This is a wrong turn that must be avoided. 19 JAMES ROBERTSON PRICE III Georgia State University, Atlanta, Georgia. 19 This essay is an expansion of· part of a paper '.J?oronto,December, 1982: · · at Regis· College, ,. .. ON HEIDEGGER AND THE RECOURSE TO POETIC LANGUAGE X ONG THE CONCERNS which link the earlier work of Martin Heidegger (the lectures, articles, and books culminating in the publication of Sein und Zeit in 1927) and the later works (beginning, roughly, with the Wom W esen der Wahrheit of 1933-34, and the Einfuhrung in die M etaphysik, lectures given in 1935) , none has proved more important or controversial than tl;ie question of " poetic " language: its nature, and its place in Heidegger's idiosyncratically original later philosophy. Partisans of either of Heidegger's " styles " of philosophizing may justifiably defend their preferences; but too frequently we are left with the impression of a philosopher who broke with earlier concerns only to embark on a "poetic" career unrelated to philosophy. In the paragraphs that follow, my concern is to sketch certain continuing preoccupations in Heidegger's career which brought him to seek a " poetic " language. The conception of language as inherently "poetic," which informs the later work thematically and stylistically, can be seen as a development of questions already posed in Sein und Zeit. There, Heidegger is already convinced of the non-analytical nature of human language. In the later work, the notion of a poetic language, which he places in its stead, is entwined with his re-reading of the pre-Socratic philosophers; it is central to his own "poetic " style of thinking. It is this conception of philosophy as poetry which has, however, proved so controversial among his critics. Only the most trenchant among them (e.g. Theodor Adorno) have seen that a rejection of the " later " Heidegger must perforce entail substantial disagreement with the problematic raised in Sein und Zeit. In that book, Heidegger speaks of the need for " re-establish- . 99 100 A. J. CASCARDI ing the science of language on foundations which are ontologically more primordial " than those which dominate Western thought. 1 He is referring specifically to the " basic stock of 'categories of signification'" (ibid.) which have been central to philosophy since the ancient.logos became synonymous with assertion (Aussage). This "basic stock," these "categories of signification," are fundamental to modern analytic philosophy, which takes language as a symbolic form, a " representation " of the world to the mind. If philosophical inquiry was to meet the challenges of which the phenomenologists were already aware, if it was to inquire into "'the things themselves' and attain the status of a problematic which has been cleared up conceptually " (SZ, 166) , then it ought to alter its notion of language in some radical ways. "Attempts to grasp the ' essence of language,'" Heidegger says in Sein und Zeit, "have always taken their orientation from one or another of these items ... the ideas of ' expression,' of ' symbolic form,' of communication as ' assertion,' of the ' patterning ' of life. Even if one were to put these various fragmentary definitions together in syncretist fashion, nothing would be achieved in the way of a fully adequate definition of ' language.' We would still have to do what is decisive here-to work out in advance the ontological-existential whole of the structure of discourse on the basis of the analytic of Dasein " (SZ, 163) . The above reference is crucial becau&e it points up the connection between the ontological-analytical project of Sein unil Zeit and the linguistic question it raises: that a definition of language "from the outside" is not possible, and that even if it were, ·we would not be unburdened of the need to inquire into Dasein. This is the primary task outlined in the book, an inquiry into the nature of Dasein. But that project would perforce be inhibited, Heidegger's work bears out, by a conception i I cite Sein' und Zeit (hereafter, SZ) from the standard English translation by John Macquarrie and Edward Robinson, Being and Time (New York: Har·per and Row, 1962), by reference to the original (German) pagination, noted in that edition; here: SZ, 195. ·· .. oflanguage as a logical-analytical instrument of representation;:: "meaning," as conceived in analysis, is in fact antith'etica'l f<'>' the nature of meaning which attaches to Dasein. " Meaning is an existentiale of Dasein," Heidegger says, " not a property attached to entities, lying ' behind ' them, or floating somewhere in an 'intermediate domain'" (SZ, 151), as analytical philosophy would conceive. References like this to the language of logical analysis are not infrequent in Heidegger's work, both before and after Sein und Zeit. In an essay on " Heidegger and Symbolic Logic," Albert Borgmann traced a concern which runs throughout Heidegger's career, from an early report on "Recent Research in Logic" (1912) to such late works as What Is Called Thinking? 2 In Unterwegs zur Sprache (1959) , he says that the "essence of language refuses to come to language (i.e. be capable of expression through language) in the assertions (Aussagen) we make concerning language," 3 which echoes Sein und Zeit. Analytical philosophy and the language of symbolic logic represent a case of the over-estimation of the " categories " into which the authentic (poetic) logos has degenerated: " Only because at one time the call to thought became event as Myo<;, symbolic logic today is developing into the planetary organizational form of every presentation." • Analytical philosophy and the language of symbolic logic are exemplary of this over-estimation of the categories of thought and of the degeneration of the ancient logos because they rest on the notion of language as a wholly logical form capable of atomistic analysis and sovereign totalization, a com" Heidegger and Symbolic Logic," in Heidegger and 2 Albert Borgmann, Modern Philosophy, ed. Michael Murray (New Haven: Yale University Press, 1978)' pp. 3-22. s See David A. White, Heidegger and the Language of Poetry (Lincoln: University of Nebraska Press, 1968), p. 20, who cites and discusses the line. 4 Was Heisst Denkenf, 2nd ed. (Ttibingen: Max Niemeyer Verlag, 1961), p. 102. The standard translation is What Is Called Thinking?, trans. J .. Glenn Gray and F. Wieck (New York: Harper and Row, 1968). I use Albert Borg1' · instead·· of :mann's rendering of this passage, which· gives i• symboiic " logistics." '.fb} A. ':t. 'ciscARDI :plete reptesehtatibncif the world. The later " poetic;, pro]ect is (dir&fetl against these notions and toward the restoration of ,'h1e1fogos in its original (poetic) guise, not as science and logic have transmitted it to us. But already in Sein und Zeit we find the basis for a reevaluation of the nature of language in Heidegger's acute awareness of the proximity of Dasein and human linguisticality. He devotes special attention to the spatial, temporal, and historical properties of Dasein which belong also to human language. Most important, if our notion of human language is to do justice to understanding, which attaches integrally to Dasein, the analytical notion of language must be rejected. Yet there are limits to the degree to which language can be reevaluated within the framework of Sein und Zeit, with its phenomenological and neo-Kantian remnants (e.g. the turn "zu den Sachen "). If the problems outlined in Sein und Zeit were to be adequately developed, and the history of philosophy changed in their light, the transition to a "poetic" idiom was important. We can say with Heidegger, especially in his later works (and with the pre-Socratics, Parmenides and Heraclitus, in the Heideggerian interpretation), that the practice of philosophy must restore the ancient sense of the logos in its ontological dimension. This requires a repudiation of the language of " assertion," of propositional statement, of " communication," if it is to be complete. Thus Heidegger's later works offer a model for doing philosophy as poetry, in a language responsive to the ancient sense of the logos (i.e. before it became synonymous with logical assertion) . It is widely known that Heidegger found unparalleled resources in Sophocles, Trakl, Holderlin, and Rilke, devoting important works to them. His message is that we must learn a new relationship to language, to be responsive to it, rather than ask that language do the work of logical representation and assertion for us. The question which this philosophy must of course face, and to which Heidegger has been subjected, is whether thinking can in fact become poetry and still remain itself, still conserve its attentiveness to primordial questions (e.g. Being). Heidegger would, answer ON HEIDEGGER AND POETIC LANGUAGE 103 resoundingly that the history of philosophy in the West has in fMt growi1 insensitive to the meaning of Being because it has divorced itself from poetic language. His critics would reject him otl precisely this ground. In the later wotk, Heidegger would go considerably beyond the statement that language and philosophy somehow interpenetrate one anothel', an awateness which was present in Sein und Zeit. Language, as he sees it, is not something of concern to philosophers alone, but is itself primordial to Being. Should philosophy overlook the centrality of language to Being, it will necessarily have strayed from the fundamental question: Why is there? i.e. Why is there not nothing? Language is essential to all that exists: " words are not wrappings in which things are packed for the commerce of those who write and speak. It is in words and language that things first come into being and are." 5 What has happened, though-presumably after the preSocratics-is that man has abused language, has made cheap sloganism of his luminous gift of speech. Consequently, his poetic language is exhausted. The theme is, in its own right, the tuning-fork of modern sensibility, and I will return to it in connection with Adorno and Schoenberg (think of Moses's sluggish, droning cry at the conclusion of Moses und Aaron: " 0 Wort, du Wort, das mir fehlt!") . Our everyday language is, as Heidegger said, " a forgotten and therefore used-up poem." 6 And all this would, in a sense, be the very least, had the corrosion of language not started a deeper, inner rot, a general neglect of Being. The human problem is that man has forgotten Being. His relationship to the world has lost its authenticity: " the misuse of language irt idle talk, in slogans and phrases, destroys our authentic relation to things;" we must seek to ' 1 regain the unimpaired strength of language and 5 An IntroductiOn to Metaphysics, trans. Ralph Manheim (New Haven: Yale University Press, 1959), p. 13; based on lectures given in 1935. 6" Langm1ge," in Poetry, Language, trnns, Albert (New York: Hi:irper and Row, 1971), p .. 208, · r An (ntroductfon fo Met!fP,httsics, p. 13, 104 A. J. CASCARDI Heidegger must be taken absolutely to the letter-or ignored as an eccentric-when he finds in the pre-Socratic philosophers a mode of thinking " more authentic " than anything known to the tradition from Plato to Nietzsche. 8 His reading of the pre-Socratics is " strong," and notoriously selective, concentrating on Heraclitus, Parmenides, and the Anaximander fragment, to the neglect of Pythagoras, Protagoras, Empedocles, and Gorgias. Heidegger sees in the pre-Socratics the possibility of a thinking and of a speaking so authentic that it leads to an astonishing re-encounter with what we have since left to oblivion or neglect: the fact of Being, i.e. that there w anything at all. He sees in the pre-Socratics an anchor of the now divergent masses of language and thinking. The very conception of such a point serves to infuse substantial reserves of hope in the practice of philosophy, insofar as that practice is necessarily language-bound. Heraclitus and, especially, Parmenides are for him the inaugurators of all philosophy; calling them " preSocratic;" he says in What is Called Thinking? is our skewed interpretation of the past, the same as calling Kant a " preHegelian." They represent a thinking which was, in actual form and in root sensibility, " poetic," i.e. authentically responsive to things, reflective rather than scientific. This re-reading of Parmenides is in particular important because it allows a recovery of language for philosophy without falling into the trap of" negative ontology" which the Sophists had laid. In a work like On Nature or on the Non-Existent (now lost, hut recuperahle on the key points) Gorgias argued that language is our prison-house; because we cannot get out-. side of our language, so to speak, we cannot know that anything exists: " I say that nothing exists; then that if it exists it is unknowable; lastly, even if it exists and is knowable, nevertheless it cannot be directly communicated to anyone else." 9 s Heidegger's most important essays on the pre-Socratics are collected as Greek Thinking, trans. David Farrell. Krell and Frank A. Capuzzi (New .York: Harper and Row, 1975). The important discussion of Parmenides is in Was Heisst Denken?, Part II. 9 In Mario Untersteiner, The Sophists, trans. Kathleen Freeman .(Oxford: Bq,sil Blackwell, 1948), p. 145. ]jJarly ON HEIDEGGER AND POETIC LANGUAGE 105 Since in speech we communicate words themselves, and since these are not the same as what exists, he said, (since speech and things are perceived by different organs), we could not hope to communicate anything except speech, and we could never know if anything except speech exists. Parmenides was uncompromising with such sophistical arguments, and this is one reason that· Heidegger regards him so highly. He rejected the vacillating position on both sides of the question of Being; he affirmed that Being is. As Heidegger knows, and says in What Is Called Thinking?, the claim is notoriously difficult to make meaningful for us; this is why Parmenides's arguments, and Heidegger's, should be seen against the background of the Sophists' claims. Parmenides's refutation of them is clearly stated: "I debar you from that way along which wander mortals knowing nothing two headed [in two minds], for perplexity in their bosoms steers their intelligence astray, and they are carried along as deaf as they are blind, amazed, uncritical hordes, by whom To be and Not To be are regarded as the same and not the same, and (for whom) in everything there is a way of opposing stress" (fr. 6; cf. Heraclitus: "that which is in opposition is in concert, and from things that differ comes the most beautiful harmony " fr. 8) .10 Heidegger reads Parmenides to show that we may affirm (pace Gorgias, the sophistical perverter of language) Being over non-Being and recognize the rightful, central place of language in philosophy. Heidegger is as dismayed as Socrates at "idle chatter" (Gerede); he is as outraged at overblown eloquence as Socrates in the Gorgias; and he proposes a radically simple solution. The idea that language should be able to describe the world, and re-present it to man, which stretches from the philosophy of Gorgias to that of the Vienna Circle, is at fault. Instead, we must find a way to refashion our understanding of the fact that human linguisticality and existence belong together, as he already knew in Sein 10 I cite the pre-Socratic fragments according to the translation of Kathlel)n Freeman, Ancilla to the Pre-Socratic Philosophers (Oxford: Basil Blackwell, 1948). 106 A. J. CASCARDI und Zeit. The key insight for the later work, developed in this light, is that man is not simply the language-user but the speaker: " For to be a man is to speak. Man says yes and no only because in his profound essence he is a speaker, the speaker " (Introduction to M etaphysfos, p. 82) . In his quality as speaker, as Heidegger means it, man is also poet. Heidegger's re-reading of the pre-Socratics is important because he finds the reintegration of philosophy and language to be possible under the aegis of poetry, rather than rhetoric; this is where he differsfrom Socl'ates (at least in the Gorgias), who identified rhetoric with sophism, the counter-image of philosophy. And this is where he differs in major ways from his major critics, especially Adorno. Adorno's rejection of Heidegger draws on a broad base, only pertinent parts of which I will discuss here, but it rests on certain fundamental differences in their respective conceptions of the relationship. between language and philosophy. This shows up particularly well in Adorno's recuperation of language for philosophy through the rhetorical rather than the poetic tradition. The idea of philosophy as a. form of " negative " (i.e. nonconceptual) dialectics, which Adorno develops in his major late work, Negativ