There is a famous scene in the movie The Princess Bride (1987). Just when we think Westley is dead and unable to save his true love, Miracle Max declares Westley to be “mostly dead.” Miracle Max says, “There is a big difference between mostly dead and all dead: mostly dead is slightly alive.” Similarly, there is concern and confusion that we might be prematurely declaring a patient on life support to be “dead,” when they are very much alive.
It used to be that determining when someone had died was simple. It was called the “cardiopulmonary standard,” which means that the person had stopped breathing, and their heart had stopped beating. But new medical technology allowed us to resuscitate people whose heart had stopped beating. We needed a new medical, legal and ethical standard for determining if a person is “mostly dead” or “truly” dead.
It is a challenge that Christian ethicists have not resolved. I want to explain one widely accepted standard. It’s called “whole brain death,” which means that there is an irreversible loss of functioning in the entire brain. This includes the cortex—which controls our cognitive responses—and the brainstem, which is responsible for our heart rate, breathing, ability to sleep and other reflexes. Because the brain coordinates all of our bodily functions, the “death” of the entire brain is considered to be tantamount to the death of the rest of the body. In most cases, the heart stops beating within a week or less.
“Brain death” is not the same thing as being in a coma or persistent vegetative state. It also does not necessarily mean that the person is dead, because we don’t have scientific tests to determine with precision when the person is truly dead. Occasionally, a person who was declared “brain dead” may miraculously recover.
The difficulty for the family is that if their loved one is on a ventilator, she still looks alive. Technology, and not her brain, is supporting her organ systems, making her heart pump blood, and so on. So, is she “dead” or [just] “mostly dead”? It’s a matter of clinical judgment, but it could be that she has expired, or is so far long in the dying process that her condition is irreversible.
The challenge for the healthcare team is that the family may need time to come to terms with the death. Meanwhile, the team administers high doses of many drugs, and works feverishly to keep the physical body in stasis, such as stabilizing blood pressure and monitoring blood chemistry. But in terms of the body’s ability to recover normal health, this kind of care is futile.
This is an important discussion. It will continue because of the moral imperative of not killing a person, and not declaring a person to be dead who is not. At The Center for Bioethics & Human Dignity, we are engaging some of the best thinkers on this, for the sake of all who are truly still alive.
 Bernard Lo, Resolving Ethical Dilemmas: A Guide for Clinicians, 3rd ed. (Philadelphia: Lippincott Williams & Wilkins, 2005), 144.
 Hannah Furness. “‘Miracle recovery’ of teen declared brain dead by four doctors.” declared brain dead by four doctors,” The Telegraph, April 25, 2012. http://www.telegraph.co.uk/health/healthnews/9223408/Miracle-recovery-of-teen-declared-brain-dead-by-four-doctors.html (accessed Aug 17, 2012).
 For a case study, see Robert D. Orr, Medical Ethics and the Faith Factor (Grand Rapids: Eerdmans, 2009), 222-225.