Death: Metaphysical and Epistemological

A little while ago I attended a workshop held by the Philosophy of Medicine research group at King’s College London. The focus of the day was on ‘Death’ and as one point I made a comment about how our discussion was, in my view rightly, beginning to range across what John Searle might call ‘brute’ and ‘social’ facts. In this particular case the ‘brute facts’ could have been understood to be some of the philosophical arguments we had discussed as well as the largely implicit or assumed biological facts, or biological metaphysics, of death. In contrast the ‘social facts’ would be related to our cultural acceptance of death as a part of life; our ability to discuss death and plan for our own and that of others; the way in which we handle death in hospitals and elsewhere; the way in which death is written into law, professional guidelines and in actual (clinical) practices. In the break another of the days attendees asked me how death could be a social construct and I am afraid I did a rather bad job of answering. I think this is because it wasn’t exactly what I was trying to say with my comment and because the concept of death isn’t really something I focus on in my research, although it was a minor topic of concern when I undertook the MA in Health Care Ethics at Leeds.

The debate about Organ Donation and elective ventilation that has occurred over the past week or so (see previous blog post) has led me to revisit the idea of death as a social construct. The discussion that took place on the Moral Maze, particularly that between Janet Radcliffe Richards and Melanie Phillips,* prompted me to consider if death-as-a-social-construct could be more fully understood by reflecting on the difference between the metaphysics of death and the epistemology of death.

The first thing to note is that social constructs are not, as seems to be commonly assumed, simply things a culture or society has chosen to believe, or has in some way ‘made up.’ Social constructs are embedded in social and cultural norms, beliefs and practices but they are not therefore to be understood as essentially or easily mutable. Gender is a social construct but when an individual’s gender is at odds with their biological sex it is their sex that gives way not their gender. The power of social constructs is precisely in the degree to which they are immutable at the level of the individual. Furthermore social constructs are not simply epiphenomenal on certain ‘natural’ facts but can interact with them in complex and indeterminate ways. Gender is not merely epiphenomenal on sex but is intertwined with it. Indeed one might reflect on the metaphysics and the epistemology of sex and gender in a manner not dissimilar to the below discussion about death (indeed I have done so in a paper published by Quest, a postgraduate e-journal [.pdf]). Similarly, in suggesting death is in some way socially constructed I am not proposing that it doesn’t really exist, or that we don’t really die (although, in some senses, that is what Epicurus is suggesting and no one gives him a hard time about it!) Rather I am suggesting that our social and cultural understanding of death, including our scientific understanding of death, is not exactly, or simply, or merely, or solely, ‘objective’ but is also interestingly ‘constructed’ which is (really) to say nothing more that our understanding of death is meaningful and not simply factual.

The second thing to note is that the word ‘metaphysics’ can be used in (at least) two different ways. The first is in the sense of the trans-physical or the above, the more than or the not - physical. We could refer to this as the supernatural. The idea of an immaterial soul is one example of such metaphysical thinking. Another example might be some ideas of personhood. Determining when someone is and is not a person has been of great concern to bioethicists and there are a variety of ways of understanding the term. Those that admit of no real physical, biological or socio-cultural criteria against which it can be determined i.e. those that look like a stand in for ‘the soul’ are also metaphysical in this sense. The other sense of metaphysical is, for current purposes, most easily rendered as ‘what things are really like’ or ‘an accurate description of (physical) reality.’ In this sense biological science offers one kind of metaphysical picture. But there may be others, and they may be related. Conceptions of personhood that are reliant on physical properties or abilities of human organisms are one such example.

The third thing to note is that epistemology is about how we know things. Our current favored way of knowing things is through science. Biology is one such science and we might understand medicine to be an ‘applied’ science or as a professional practice based on and in scientific knowledge. However the scientific approach rules out metaphysics in the first sense as, methodologically, it limits itself to the physical, natural and empirical world. Some people misunderstand this to mean that science in some way disproves god, the soul or metaphysics. It doesn’t, it just rules it out methodologically, it ignores it as part of its approach to knowing the world. (Of course further philosophical arguments, either alone or coupled with science, might rule out metaphysical, greater-than-physical, ideas such as god or the soul per se, but the point is that science alone does not).

Anyway, what does all this have to do with death and organ donation? Well, when we try to distinguish between the metaphysics of death, whether something or someone is really dead, and the epistemology of death we can get in an awful lot of trouble. The difficulty is the only way to determine if someone is dead is to do so with a certain epistemology in mind and, unfortunately, there are various criteria for doing so. We can see if someone has stopped breathing, or if they have no pulse, we can see if they are ‘stone cold’, or listen to their heart. Or, through a complex set of diagnostic criteria, we can try to determine if their brain stem has ceased to function. However it is not clear if any of these can be taken to indicate that the metaphysical state of death has obtained. People have had their heart restarted, their pulse restored, their temperature raised from freezing. However these ways of knowing, these epistemologies, of death are not conducive to organ transplantation. What is conducive to organ transplantation is the idea of brain (stem) death and, indeed, the introduction of this criterion for death is not unrelated to the beginnings of transplant surgery. We might now think that we could reject all the other criteria, only accept brain stem death as death, and equate the epistemological determination of brain stem death with the metaphysical reality of death.

However restricting death to this criteria can still seem troubling if we consider, first, how it reflects our ‘supernatural’ metaphysical assumptions about death, i.e. breaking the connection between ‘soul’ and body, or the cessation of ‘personhood’ and, second, the fact that other biological organisms die. If we think we have rejected this metaphysical idea of death then it seems strange our scientific criteria would so accurately reflect it. Furthermore, if we think that all biological life dies - human, animal, plant, and microbiological - then it is clear that brain stem death can only be the epistemological determination of death in a human being (and all those beings for whom life is dependent on a brain) and not the metaphysical reality of biological death itself.

What ‘biological death’ might really, i.e. metaphysically, be is the subject of controversy. It might be that there is not one simply account of biological life and, therefore biological death. For example, the sperm and the ova that subsequently form a conceptus and develop into a human being are both biologically alive but neither are the human life that results from their meeting. Perhaps the most convincing view is that life and death of a multi cellular organism is a process of the kind discussed by Becker [1]. If so the point at which the organisms can be said to be alive, or to be dead, is indeterminate and the only determinations that are relevant are not ones which indicate death per se (or metaphysically) but, instead, epistemologically establish the loss of certain functions which are then used as a proxy for death. Such examples might be lack of pulse (for a certain period of time), brain stem death or cardiac death.

The question then becomes not whether these epistemological criteria for the death of a human being accurately reflect the metaphysical state of death per se but whether the criteria are de facto reflections of the death of human beings. In other words the question is whether we might justifiably take the criteria for the epistemological determination of death as death. This means that the epistemological criteria of death reflects not death per se but that some biological function necessary for what we consider important about human life has been irreversible (or irreparable) damaged.  Thus brain stem death indicates that whilst the human body might remain alive, and be kept alive indefinitely, there is no longer any possibility that the person will regain any sort of consciousness. Whilst contemporary epistemological criteria of death are biological criteria they do not reflect the metaphysical biological death but, rather, the metaphysics of human beings as persons, of what it is we consider important or ‘morally relevant’ about human life and, therefore, human death.

In respect of ourselves we have abandoned a purely biological conception of death, if indeed our conception of death was ever purely biological. In part our prompt to do this has been the advent of new biomedical technologies such as organ transplantation but also life support machines that provide artificial ventilation and can maintain the biological human body long after there has ceased to be any possibility of the person returning to consciousness. As it is consciousness, the person, their mind and subjectivity that, in our social and cultural context, is assigned moral relevance most people concur with the epistemological criteria of brain stem death as a stand in for metaphysical death and so mistake it for death per se. However others disagree and so object to the removal of life support from patients with this diagnosis, or in comparable conditions such as those in Persistent Vegetative States (PVS). Furthermore our abhorrence of killing contributes to concerns regarding harvesting organs from those who have not met the epistemological criteria of death. Thus surgeons must wait for a short time following the cessation of cardiac rhythm before beginning to harvest organs from a ‘cardiac death’ donor.

I started out this blog post talking about whether death is a social construction. In this brief conclusion I should make it clear I am not suggesting that we abandon any or all of our epistemological criteria for death. Rather I just wish to point out that we should be under no illusion that those epistemological criteria fully, accurately or exactly reflect either a metaphysical (supernatural) death or a fully-fledged biological conception of death. Epistemological criteria of death pick out what we consider to be the morally relevant feature of human death. In the case of Brain Stem Death it reflects permanent loss of consciousness whilst Cardiac Death reflects the cultural (and emotional) meaning of the heart in out society. Certainly both pick-out a biological phenomena. However it is worth considering if, and to what degree, they also reflect how death is constructed within our wider social and cultural context.

* It is worth listening to the program if for nothing other than the moment when Janet Radcliffe Richards shushes Melanie Phillips and later, in response to Clare Fox, suggesting that they have failed to grasp the basic point she is trying to make. She is right of course, they have - just listen to Claire Fox’s closing remarks - she doesn’t grasp the importance of the epistemological determination of death. 

[1] Becker, L. C. 1975. Human Being: The Boundaries of the Concept. Philosophy and Public Affairs. 4(4): 334–359