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Death, Hume, Emotions, And The Essential Role Of The Physician

Eric Karl Oermann
Published 2014 · Medicine, Psychology
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In their latest work together on brain death, Truog and Miller (2014) state that they want to bring “conceptual coherence” as well as address several “practical implications” surrounding brain death (Truog 2014). Despite the somewhat controversial nature of the authors’ fundamental claim, that we should separate the legal and biological definitions of death, their pragmatic motivation behind making this claim should be applauded. Controversies surrounding brain death and the cessation of life support are a common occurrence in the neuroscience intensive care unit (NSICU), and almost no other issue is as contentious or as stressful for both families and health care personnel. The bioethics of brain death are complicated. The tenebrous nature of the brain along with modern medical technology makes establishing a nonarbitrary definition of brain death difficult if not impossible (Shewmon 2001). While there exists a clear societal and legal need for a bright-line definition of brain death, as Dresser noted in the President’s Council meeting on the topic of brain death, “wherever we draw that bright line, not everyone will be happy” (President’s Council on Bioethics [PCBE] 2007). Despite these ethical difficulties, we should still seek pragmatic solutions to alleviating the human suffering caused by brain death. Motivated by the authors’ pragmatism and David Hume’s observations on the will, we suggest that an essential and often understated role in helping individuals and families deal with brain death is emotional guidance from the treating physicians. Book II of David Hume’s Treatise of Human Nature is dedicated to describing “the passions” (emotions) and arguing that they are the prime mover of human actions, with reasons being supplied post facto by the mind to justify the actions that the passions motivate (Hume 2000). Without delving into the details of Hume or his arguments, it is worth noting that a growing body of scientific and economic evidence supports his basic claim that emotions underpin a certain degree of human decision making (Cohen 2005; Hanoch 2002). When confronted with death in an intensive care setting, many individuals respond emotionally, and whether we accept Hume or not, these emotions invariably play a role in the decision making surrounding brain death. By acknowledging these emotions, and engaging them at an early stage, physicians can potentially shape the future outcome of brain death conversations and thereby avoid ethical disasters like those mentioned by the authors (Truog and Miller 2014). Studies of ICU-associated deaths have shown that families are at a high risk of posttraumatic stress disorder (PTSD) and stress from both economic and caregiving factors (Covinsky, Goldman et al. 1994; Azoulay, Pochard et al. 2005). One of the most commonly cited difficulties with brain death is that families do not understand it, and experience cognitive dissonance between the emotional impact of being told a someone is dead and the appearance of a living body (Long, Sque et al. 2008). Research into organ donation has also shown that families respond best to discussions of brain death when they are lead by an attending physician and when families have had time to absorb the emotional impact of brain death (Vane, Sartorelli et al. 2001). It is not only good medical practice for physicians to undertake this emotional guidance, then, but it is also an ethical duty stemming from the doctor’s fiduciary relationship between the physician, the patient, and the patient’s family or decision makers (Carlet, Thijs et al. 2004; Pellegrino 1988; Pellegrino 2001). To aid physicians in this task we suggest adopting a Humean perspective that recognizes these emotional factors as being the most significant determinants of the outcome of future decision making. It is easy for emotions to be ignored in the deluge of medical data and easily conveyed facts surrounding intensive care unit (ICU) care and brain death. A proper Humean approach emphasizes the
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