L ETTER OF T RAN SMITTAL T O

T H E PRESIDEN T OF TH E U N ITED STATES

The President’s Council on Bioethics
1425 New Y ork Avenue, NW, Suite C100
Washington, D C 20005
D ecember 2008
The President
The White House
Washington, D C

D ear Mr. President:

I am pleased to present to you a white paper by the President’s

Council on Bioethics entitled C ontroversies in the D etermination of
D eath. It is the report of an inquiry that was occasioned by another
forthcoming Council report on ethical questions in organ transplan-
tation. 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 neurologi-
cal standard.

This white paper by the Council is primarily concerned with a care-

ful 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 na-
tionwide. 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 ac-
cepted 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
ix
x | L ETTER O F T RANSMITTAL TO THE PRESID ENT

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 uncer-
tainty, 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 rele-
vant 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 ra-
tionale 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 Execu-
tive O rder 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. O nly in this way can the bene-
fits of modern technology be realized within ethical constraints.

Sincerely,

Edmund D . Pellegrino, M.D .

Chairman
 M EMBE RS OF
T H E PRE SIDEN T ’S C OUN CIL ON BIOETH ICS
E DMUN D D. PELLE GRIN O , M.D., C H AIRMAN
Professor Emeritus of Medicine and Medical Ethics, and
Adjunct Professor of Philosophy, G eorgetown University

F LOYD E . BLOOM, M.D.

Professor Emeritus in the Molecular and Integrative Neuro-
science D epartment at The Scripps Research Institute

BE N JAMIN S. C ARSON , SR., M.D.

The Benjamin S. Carson, Sr., M.D ., and D r. Evelyn Spiro,
R.N., Professor of Pediatric Neurosurgery, D irector of Pe-
diatric Neurosurgery, and Professor of Neurosurgery,
O ncology, Plastic Surgery, and Pediatrics, Johns Hopkins
Medical Institutions

R E BE CCA S. D RE SSE R, J.D., M.S.

D aniel Noyes K irby Professor of Law and Professor of
Ethics in Medicine, Washington University, St. Louis

N ICH OLAS N . E BE RSTADT , PH .D.

Henry Wendt Chair in Political Economy, American Enter-
prise Institute

JEAN B. E LSH TAIN , PH .D.

Laura Spelman Rockefeller Professor of Social and Political
Ethics, University of Chicago, and Thomas and D orothy
Leavey Chair in the Foundation of American Freedom,
G eorgetown University

D AN IEL W. F OSTE R, M.D.

John D enis McG arry, Ph.D ., D istinguished Chair in D iabe-
tes and Metabolic Research, University of Texas
Southwestern Medical Center, D allas, TX

xi
xii | MEMBERS O F THE PRESID ENT ’S CO UNCIL O N BIO ETHICS

M ICH AE L S. G AZZAN IGA , PH .D.

D irector of Sage Center for the Study of Mind, University
of California, Santa Barbara

R OBE RT P. G EORGE , J.D., D.PH IL .

McCormick Professor of Jurisprudence and D irector of the
James Madison Program in American Ideals and Institu-
tions, Princeton University

A LFO N SO G ÓMEZ -L OBO , D R. PH IL .

Ryan Family Professor of Metaphysics and Moral Philoso-
phy, G eorgetown University

WILLIAM B. H URLBUT , M.D.

Consulting Professor, Neurology and Neurological Sci-
ences, Stanford Medical Center, Stanford University

D ON ALD W. L AN DRY , M.D., PH .D.

Professor of Medicine, D irector of the D ivision of Experi-
mental Therapeutics, and Chair, D epartment of Medicine,
Columbia University

PE TE R A. L AWLE R, PH .D.
D ana Professor and Chair of the D epartment of G overn-
ment and International Studies, Berry College

PAUL R. M C H UGH , M.D.

University D istinguished Service Professor of Psychiatry,
The Johns Hopkins University School of Medicine

G ILBE RT C. M E ILAE N DE R, PH .D.

Richard and Phyllis D uesenberg Professor of Christian Eth-
ics, Valparaiso University

JAN E T D. R OWLE Y , M.D.

Blum-Riese D istinguished Service Professor of Medicine, of
Molecular G enetics and Cell Biology, and of Human G enet-
ics, Pritzker School of Medicine, University of Chicago