Sociocultural approaches help us understand the different ways in which people conceptualize and comprehend death. But they do not address a very fundamental question: How do we determine that someone has died? The medical and legal commu­nities have grappled with this question for centuries and continue to do so today. Let’s see what the current answers are.

Determining when death occurs has always been subjective. For hundreds of years, people accepted and applied the criteria that now define clinical death: lack of heartbeat and respiration. Today, however, the most widely accepted criteria are those that char­acterize whole-brain death. In 1981 the President’s Commission for the Ethical Study of Problems in Medicine and Biomedical and Behavioral Research established several criteria still used today that must be met for the determination of whole-brain death:

• No spontaneous movement in response to any stimuli

• No spontaneous respirations for at least one hour

• Total lack of responsiveness to even the most painful stimuli

• No eye movements, blinking, or pupil responses

• No postural activity, swallowing, yawning, or vocalizing

• No motor reflexes

• A flat electroencephalogram (EEG) for at least 10 minutes

• No change in any of these criteria when they are tested again 24 hours later

For a person to be declared dead, all eight criteria must be met. Moreover, other conditions that might mimic death—such as deep coma, hypothermia, or drug overdose—must be ruled out. Finally, accord­ing to most hospitals, the lack of brain activity must occur both in the brainstem, which involves vegeta­tive functions such as heartbeat and respiration, and in the cortex, which involves higher processes such as thinking. In the United States all 50 states and the District of Columbia use the whole-brain standard to define death.

It is possible for a person’s cortical functioning to cease while brainstem activity continues; this is a persistent vegetative state, from which the person does not recover. This condition can occur follow­ing disruption of the blood flow to the brain, a severe head injury, or a drug overdose. Persistent vegetative state allows for spontaneous heartbeat and respiration, but not for consciousness. The whole-brain standard does not permit a declaration of death for someone who is in a persistent veg­etative state. Because of conditions like persistent vegetative state, family members sometimes face difficult ethical decisions concerning care for the individual. These issues are the focus of the next section.

Some philosophers and scientists argue that the whole-brain standard does not reflect current research on brain functioning, especially with regard to those functions of the cortex that make us “human,” as opposed to those in the brainstem that control basic functions in us and in other liv­ing beings (e. g., Capron, 2001; Steen, 2007; Truog,

2004) . Advocates of this view argue for using a higher-brain standard, according to which death is the irreversible cessation of the capacity for consciousness. This standard is often met prior to whole-brain death. Thus, a patient in a perma­nent coma or persistent vegetative state meets the higher-brain, but not the whole-brain, standard of death.