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Controversies in the Determination of Death

Letter of Transmittal

The President’s Council on Bioethics
1425 New York Avenue, NW, Suite C100
Washington, D.C. 20005
January 2009

The President
The White House
Washington, D.C.

Dear Mr. President,

I am pleased to present to you a white paper by the President's Council on Bioethics entitled Controversies in the Determination of Death . It is the report of an inquiry that was occasioned by another forthcoming Council report on ethical questions in organ transplantation. The two reports are linked ethically: most of the organs procured for transplantation in this country come from deceased donors who have been declared dead in accord with the neurological standard.

This white paper by the Council is primarily concerned with a careful analysis of the ethical questions raised by the neurological standard, i.e. , the clinical determination of “whole brain death.” This standard was defended in 1981 by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. In that report, the Commission also proposed a model statute to foster uniformity in law and medical practice nationwide. Since then, the neurological standard has been accepted as one of two valid standards for determining death and has been adopted in many countries throughout the world. (The other accepted standard is the older, traditional cardiopulmonary standard.)

In recent years, however, controversy has arisen about the clinical and ethical validity of the neurological standard. Some think it too restrictive to meet the need for transplantable organs; others fear that “whole brain death” may not be the equivalent of the death of the human being; still others believe that, in the face of any uncertainty, it is ethically prudent to re-examine the concept and the evidence critically.

In this white paper, the Council has given careful consideration to contending positions in this controversy. After reviewing the relevant literature and the testimony of many experts, followed by intensive discussion between and among its members, the Council has concluded that the neurological standard remains valid. Some Council members, however, believe that a better philosophical rationale than the one proposed by the President's Commission of 1981 should be adopted. A few Council members argue that there is sufficient uncertainty about the neurological standard to warrant an alternative approach to the care of the “brain dead” human being and the question of organ procurement.

The Council presents this study in the spirit of your original Executive Order to “…facilitate a greater understanding of bioethical issues.” By re-examining the neurological standard and placing it within its clinical, historical, and ethical context and by critically analyzing arguments for and against its validity, the Council believes it has fulfilled this mandate. The Council also hopes that this white paper will help the public and its policymakers to reflect on a matter of profound human significance in such a way that the dignity of the human person will be preserved. Only in this way can the benefits of modern technology be realized within ethical constraints.


Edmund D. Pellegrino, M.D. Chairman

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