Retrospective on the future: brain death and evolving legal regimes for tissue replacement technology.

In North America, the medico-legal definition of death has played an important role in facilitating organ transplantation. In the quarter century since the initial proposal of "brain death" criteria, acceptance of the criteria has helped standardize medical practice for the termination of life support, organ procurement and post-mortem donor patient management. In the author's view, it has provided a foundation for the reflection and judgments of North American courts in so-called "right to die" cases and even criminal trials; it has helped some families with loved ones who lie in a coma. Some would say that the new death standard has, in practice, advanced the societal value for human life. The author argues, however, that even with such benefits the new standard raises daunting "second generational questions" for law, medicine and bioethics. Seen in a broader perspective, brain death stands as one of the many fundamental pillars in the legal regime which North American society has erected to govem modem tissue replacement technology. The author demonstrates how this currently evolving regime parallels previous and foreshadows emerging legal regimes for the therapeutic transfer of human tissue, bodily parts and substances. En Am6rique du Nord, la d6finition m6dicale et juridique de la mort joue un r6le important dans les transplantations d'organes. Depuis vingt-cinq ans, l'adoption du concept de < mort c6r6brale >> a aid6 ]a m6decine dans plusieurs domaines, comme Ia cessation de traitement, l'obtention et le don d'organes. L'auteur nous dit que ce concept a guid6 ]a r6flexion et les jugements des tribunaux nordam6ricains dars des causes dites << droit de mourir >> et m~me dans des proc~s criminels; il a 6galement aid6 des families dont un des membres 6tait dans le coma. Certains seraient tent6s de dire que l'adoption du crit~re de ]a mort c6rdbrale a eu pour effet de prot6ger davantage la vie. L'auteur pr6tend cependant que cette d6finition de la mort n'est pas sans poser d'importants problmes en droit, en m6decine et en bio6thique. Dans une perspective plus large, la mort c6r6brale constitue un 06ment fondamental du r6gime juridique nord-am6ricain r6gissant la technologie modeme de remplacement des tissus. L'auteur termine en examinant les liens entre le r6gime actuel et les r6gimes pr6c6dents et futurs en mati~re de transplantation th6rapeutique de tissus, parties et substances du corps humain.