Chapter 2

Review of Related Literature

It is understandable that we want to know what death is. This need for knowledge

is irrespective of religious, scientific, social and philosophical standpoints and death will

come to us all. Yet, with the evolving definitions of death and unresolved philosophical

questions, it may be better to ask ‘why do we need to determine death?’ Through much of

history the point of death was considered to be that at which the spirit left the body;

diagnosis of death was a primarily religious concern. However, the recognition in the 17th

century of ‘apparent death’, a condition of deep unresponsiveness that mimicked death but

was reversible, created a profound fear amongst the public of premature burial, and this in

turn prompted greater involvement of medical practitioners and the slow evolution of the

physiological criteria used to define death by our current standards.1

In the Philippines, Republic Act 7170 or AN ACT AUTHORIZING THE

LEGACY OR DONATION OF ALL OR PART OF A HUMAN BODY AFTER DEATH

FOR SPECIFIED PURPOSES or the Organ Donation Act defined Death as the irreversible

cessation of circulatory and respiratory functions or the irreversible cessation of all

functions of the entire brain, including the brain stem. A person shall be medically and

legally dead if either:

1
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606434/#sec4-1751143715569021title
(Accessed: May10,2018).

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 (1) In the opinion of the attending physician, based on the acceptable standards of

medical practice, there is an absence of natural respiratory and cardiac functions and,

attempts at resuscitation would not be successful in restoring those functions. In this case,

death shall be deemed to have occurred at the time these functions ceased; or

(2) In the opinion of the consulting physician, concurred in by the attending

physician, that on the basis of acceptable standards of medical practice, there is an

irreversible cessation of all brain functions; and considering the absence of such functions,

further attempts at resuscitation or continued supportive maintenance would not be

successful in resorting such natural functions. In this case, death shall be deemed to have

occurred at the time when these conditions first appeared.2

In the case of Alano v Magud-Logmao, the issue that the court resolved was

whether or not the removal of the patient’s organs was legal. In deciding the case in the

affirmative, the court held that the internal organs of the deceased were removed only after

he had been declared brain dead; thus the emotional pain suffered by respondent due to the

death of her son cannot be in any way be attributed to petitioner. Neither can the court find

evidence or second to show that respondent’s emotional suffering at the sight of the pitiful

state in which she found her son’s lifeless body be categorically attributed to petitioner’s

conduct. 3

Thus, there can be no cavil that petitioners employed reasonable means to

disseminate notifications intended to reach the relatives of the deceased. The only question

2
https://www.lawphil.net/statutes/repacts/ra1992/ra_7170_1992.html , accessed May 18,
2018.
3
Alano v Magud-Logmao, GR No. 1755540 April 7, 2014.

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that remains pertains to the sufficiency of time allotted for notices to reach the relatives of

the deceased.

If respondent failed to immediately receive notice of her son’s death because the

notices did not properly state the name or identity of the deceased, fault cannot be laid at

petitioner’s door. The trial and appellate courts found that it was the EAMC, who recorded

the wrong information regarding the deceased’s identity to NKTI. The NKTI could not

have obtained the information about his name from the patient, because as found by the

lower courts, the deceased was already unconscious by the time he was brought to NKTI.

The death of the person shall be determined in accordance with the acceptable

standards of medical practice and shall be diagnosed separately by the attending physician

and another consulting physician, both of whom must be appropriately qualified and

suitably experienced in the care of such parties. The death shall be recorded in the patient's

medical record.4

An in-depth analysis of terminology that describes the process of death has been

recently conducted by Bernat.5 Current practice mandates a period of 5 min after cardiac

arrest before death is diagnosed. This delay serves two purposes: first, it allows the

generation of hypoxic brain stem damage sufficient to meet the neurological criteria and

second it ensures ‘irreversibility’. However, the evidence for this is based on little more

than case reports and a lack of observed spontaneous reversal after this time. It is clear

4 Ibid.
5
Bernat, JL. On Noncongruence Between the Concept and Determination of death.

Hastings Center Rep 2013; 43: 25–33.

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however, that with support, 5 min is not enough to produce such severe damage to the brain

stem that the neurological criteria would be met. Most, if not all, ICU clinicians will have

seen effective cardiorespiratory resuscitation commenced after greater than 5 min of full

arrest lead to if not a full recovery, then one that would defy the brain stem criteria. One

must conclude that death in these circumstances is very much subject to the physician’s

volition.

The President’s Council on Bioethics Report ‘Controversies In The Determination Of

Death’6 aimed to align neurological death with the more common cardiorespiratory

definition under a common final set of criteria which both mechanisms of dying would

satisfy. The Council defined death in terms of the loss of the essential functions of a life,

which it defined as follows:

1. Openness to the world, that is, receptivity to stimuli and signals from the

surrounding environment.

2. The ability to act upon the world to obtain selectively what it needs.

3. The basic felt need that drives the organism to act as it must, to obtain what it needs

and what its openness reveals to be available.

The Anencephalic Infant as an Organ Donor- In recent years, pediatric organ

transplantation has become an increasingly viable option for giving critically ill children

the opportunity for a healthy life.19 However, as with adult trans- plantation, the supply of

usable organs has not kept up with the ever increasing demand.0 Among children younger

than two years of age registered to receive transplants, an estimated 30-50 percent die

before organs become available. As scientific technology improves, these numbers will

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only increase, and in legislatures and hospitals around the country, the search is on for new

sources of viable organs. In light of the universally fatal nature of anencephaly, and the

fact that apart from their neurological malformation, their organs are presumed suitable for

transplantation, it is not surprising that many are looking to anencephalic as one way to

alleviate this shortage. However, a number of factors combine to make this an impractical

solution.

The main problem is that since most anencephalic infants die from

cardiorespiratory failure, by the time they are declared dead, their organs have become

medically unsuitable for trans- plantation due to inadequate perfusion.2 Customary medical

care includes warmth and feeding with no major medical interventions, but if their organs

are to be harvested while still usable, a change in the standard of treatment is necessary.

Four approaches had been proposed for obtaining organs from anencephalics:

(1) Entails resuscitation at birth and maintenance of intensive care to protect organ

viability until total brain death occurs;

(2) Customary medical care is administered to the infant until signs of impending

cardiorespiratory death develop. At that point, the child is given maximum life

support and monitored for loss of brain function. If brain stem activity appears

absent, the infant is evaluated as a potential organ source;

(3) Gradually cooling the anencephalic newborn's body to protect the organs from

ischemia. This effort to preserve the organs could also hasten death and may be

viewed by some as a form of killing. This type of approach is sometimes justified

as falling under the "doctrine of double effect," a term applied to medical

procedures that can have simultaneous good and bad effects. Such procedures are

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 generally acceptable, but only when they are performed with the intent of

promoting the good effect, and there is a compelling reason to allow the bad.

(4) Removal of organs from an anencephalic child without waiting for determination

of either heart of brain death on grounds that these infants are brain absent.

While these first three approaches are arguably within the bounds of current law

regarding the definition of death, available evidence suggests that their utility in producing

viable organs for transplant is negligible, as they are generally unsuccessful.This fourth

approach is the one advocated by the parents of Baby Theresa. Adopting this approach

would require a change in the legal definition of death, or the creation of a special legal

exception for anencephalic infants that would allow physicians to remove vital organs

before total brain death has occurred.6

6
Field DR, Gates EA, Creasy RK, et al. Maternal brain death during

pregnancy. JAMA 1988; 260: 816–822.

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