Diametros 16 (2019), 60: 72–78
doi: 10.13153/diam.1244




– Doyen Nguyen –



Abstract: This discussion note aims to address the two points which Lizza raises regarding my critique of his paper “Defining Death: Beyond Biology,” namely that I mistakenly attribute a Lockean view to his ‘higher brain death’ position and that, with respect to the ‘brain death’ controversy, both the notions of the organism as a whole and somatic integration are unclear and vague. First, it is known from the writings of constitutionalist scholars that the constitution view of human persons, a theory which Lizza also holds, has its roots in John Locke’s thought. Second, contrary to Lizza’s claims, the notions of the organism as a whole and somatic integration are both more than adequately described in the biomedical and biophilosophical literature.

Keywords: constitution theory, Lockean view, organism as a whole, life-constitutive integration, ‘higher brain death’.

Published online: 30 September 2018



In response to the critiques of his paper “Defining Death: Beyond Biology,”[1] Lizza wrote a long rebuttal, “In Defense of Brain Death: Replies to Don Marquis, Michael Nair-Collins, Doyen Nguyen and Laura Specker Sullivan.”[2] With respect to my article, “A Holistic Understanding of Death: Ontological and Medical Considerations,”[3] Lizza’s rebuttal consists of two main points: (i) he argues again that the concept of ‘human organism as a whole’ is vague,[4] and (ii) from his perspective, I “mistakenly attribute a Lockean view” to his consciousness-related or ‘higher brain’ formulation of death.[5] In particular, Lizza states explicitly that he holds the constitutive view of human persons.[6] I appreciate Lizza’s efforts and wish to address both of these points.



1. Lizza’s view of human persons


On the one hand, Lizza refers to “human persons [as] substantive beings;”[7] while, on the other, he insists that his view of human persons is a constitutive view, and that such a view is not Lockean. The term ‘substantive beings’ in itself necessarily implies a substance view of human persons, that is, the classical Aristotelian-Thomistic metaphysical anthropology which some scholars have reformulated in contemporary language.[8] Since Lizza, just like other proponents of the ‘higher brain death’ position, does not hold this view,[9] it is rather puzzling that he refers to human persons as substantive beings.

Lizza’s exposition of his theory in his 2006 book relies heavily on David Wiggins’s Sameness and Substance in which Wiggins introduces the idea of constitution.[10] Of note is the fact that this is a work permeated with neo-Lockean tendencies which Wiggins himself completely recants in his subsequent 2001 work, Sameness and Substance Renewed.[11]

Lizza indicates that he holds the constitution view of person. What is constitution? According to Baker, a materialist philosopher and firm proponent of constitution theory, “constitution is not identity [… but] a relation of unity intermediate between identity and separate existence.”[12] With respect to humans, the main thesis of constitution is that “human persons are constituted by bodies, without being identical to the bodies that constitute them.”[13] The relation between a person and his/her body is no different from that “between stones and monument, between lumps of clay and statues.”[14] The terms ‘bodies,’ ‘human animals,’ and ‘human organisms’ are used interchangeably by constitutionalist scholars. Thus, in Lizza’s own formulation, constitution means that “human persons are substantive beings constituted by, but not identical to, human organisms.”[15] This is the fundamental tenet of constitution theory, which Lizza shares with other constitutionalist scholars including Wiggins and Baker, even though he disagrees with them on certain specific aspects of the constitution theory itself.[16] Hand in hand with this tenet is the centrality of the ‘first-person perspective,’[17] which Lizza also upholds and to which he adds the moral and cultural dimensions. Emphasis on the ‘first person perspective,’ in turn, implies an emphasis of consciousness and cognitive functions over the biological, material dimensions of human persons.

It is not the scope of this rejoinder to point out the many serious difficulties raised by the constitution view. It suffices to indicate, however, that this theory belongs to the category of a psychological approach to personal identity. It understands personal identity in terms of psychological continuity rather than biological continuity while embracing ‘person essentialism’ in the attempt to explain the relationship between human persons and the bodies associated with them.[18] At this juncture, one needs to ask an important question: from which school of thought does the constitution view arise? The work of Wiggins in 1980 is Lockean; Baker’s Persons and Bodies: A Constitution View is also explicitly Lockean, and the fundamental tenet of the constitution theory is none other than “John Locke’s view that continuants are numerically distinct from their constituting hunks of matter.”[19] Put plainly, the constitution view of human persons has its origin in John Locke’s thought. It is thus rather surprising that Lizza claims that I mistakenly attributed a Lockean view to him. The legacy of Locke’s thought can have a diversity of manifestations in contemporary thinking, that is, its embodiment may be found in strands of thought other than that of Derek Parfitt.

Lizza’s constitutive view of human persons in defense of the ‘higher brain death’ position basically downgrades the bodily or biological dimension of the human person, and gives primacy to the cognitive, moral, and social-cultural dimensions instead. Such an argument directly contradicts the principle agere sequitur esse. Every human person has to come into existence first, before developing or acquiring any other dimensions of personhood.


2. An Abbreviated Account of the Organism as a Whole and of Integration


Lizza claims that the notions of organism as a whole and somatic integration are unclear and vague. Any scholar versed in contemporary biophilosophy would disagree with this claim, however. Below is a simplified and abbreviated account of the organism as a whole and its related concept of integration.[20]

“The organism as a whole is an independent living unit completed in itself, [… identifiable by] four characteristics: completion, auto-finality, indivisibility, and identity.”[21] The term ‘organism as a whole’ or ‘organism’ tout court designates a living corporeal entity. Autofinality means that the organism’s most fundamental telos is its own self-preservation, which requires two fundamental activities: (i) a continuous two-way communication between the organism and its environment, namely the intake of nutrients and excretion of waste, and (ii) continuous metabolic activity which, understood in the broad sense, involves complex, interrelated, and ordered processes occurring in diverse parts of the body, from the molecular/microscopic to the macroscopic level. Metabolism thus understood is a characteristic immanent to the organism, and an element indispensable to organismic integration and autopoiesis, both of which are inherently connected to the phenomenon of life. Hence, metabolism is indispensable to life.

For warm-blooded animals like human beings, a clear evidence of life is the maintenance of body temperature, which the layman recognizes as ‘warm, pink flesh.’ Hans Jonas is one of the rare philosophers who recognizes the central role of metabolism in all living organisms: by virtue of its metabolism, an organism (e.g., a human person) “is never the same materially and yet persists as its same self, by not remaining the same matter.”[22] Put simply, metabolism accounts for the identity of the human organism, and thus the identity of the human person through time.

Most importantly, the organism remains an organism as a whole despite the loss of some of its parts or subsystems, so long as it can continue functioning, even with technological assistance. In Bernat’s own words, “individual subsystems may be replaced (such as, by pacemakers, ventilators, pressor) without changing the status of the organism as a whole.”[23] What remains unknown is exactly how many subsystems or parts a human person can lose and yet still remain a functioning organism as a whole. What is certain, however, is that as long as the person manifests the two fundamental activities mentioned above, the person is alive.

The term ‘integration’ and its counterpart, ‘disintegration,’ are widely mentioned in the ‘brain death’ literature. In this regard, the only satisfactory philosophical account of organismic integration is that provided by Alan Shewmon.[24] Shewmon’s account integrates Aristotelian-Thomistic metaphysics, contemporary biophilosophical concepts, and empirical medical evidence. Shewmon recognizes that integration consists of two broad categories: (i) life-maintaining integration, which comprises health-maintaining and survival-promoting integration, and (ii) life-constitutive integration. As the more encompassing and foundational dimension of integration, life-constitutive integration is that which “makes a body to be alive and to be a whole” [italics original].[25] It “is the result of complex networks of fundamental metabolic activities throughout the body.”[26] The whole of such activities is an ordered process of biological anti-entropy which involves:


[…] crucial biochemical processes powered with energy generated, for the most part, by the oxidation of basic molecular substrates in mitochondria, […] biochemical exchanges within and between all the cells throughout the body or organ, […] long distance exchanges […] accomplished by blood circulation, […] short distance exchanges […] in the extravascular compartment through diffusion. […] The circulation also accomplishes critical energy-maintaining exchanges between the internal milieu and external environment, at specialized interfaces […] (e.g., at the alveoli of the lungs, bringing in oxygen and eliminating carbon dioxide; at the intestinal lining, absorbing molecular substrates for eventual oxidation; at the glomeruli of the kidneys, eliminating soluble wastes, etc.).[27]


The above description by Shewmon corresponds to the previously mentioned general umbrella-notion of metabolism, at the core of which is the production of the high energy adenosine triphosphate molecule in mitochondria.[28] What Shewmon describes is the fundamental phenomenon of life (that is, vegetative life) taking place in every living human person, a process which remains in the background, so to speak, and which is often taken for granted until some serious illness or injury supervenes. The formal principle of this material manifestation of life which is life-constitutive integration is referred to in Scholastic terms as the soul.

As seen in the above paragraph, life-constitutive integration is immanent and dispersed throughout the body, ranging from the microscopic intracellular level to the macroscopic organ-system level. As such, that life-constitutive integration is “intrinsically and absolutely not substitutable” by any man-made technology.[29] Furthermore, empirical evidence has amply shown that the brain is involved in survival-promoting or health-maintaining integration, and not in life-constitutive integration.[30] This is further supported by the fact that rudimentary brain activity does not appear until around the 22nd week of pregnancy.[31] Put bluntly, “the constitutive integration minimally needed for the existence of a rationally ensouled human organism is entirely non-brain mediated” [italics original].[32] For this very reason, ‘brain death,’ whether it is ‘high brain death’ or ‘whole brain death,’ is not synonymous with true death. I agree with Lizza that the determination of death is a practical issue.[33] Since this is the case, which undertaker would be willing to proceed with funeral procedures on individuals with the diagnosis of ‘high brain death,’ or on individuals with the diagnosis of ‘whole brain death’ prior to the removal of their organs?




Baker L.R. (2000), Persons and Bodies: A Constitution View, Cambridge University Press, Cambridge.

Baker L.R. (2002), “Précis of Persons and Bodies: A Constitution View,” Philosophy and Phenomenological Research 64 (3): 592–598.

Bernat J.L., Culver C.M., Gert B. (1981), “On the Definition and Criterion of Death,” Annals of Internal Medicine 94 (3): 389–394.

Bonelli J., Prat E.H., Auner N., Bonelli R. (1993), “Brain Death: Understanding the Organism as a Whole,” Medicina e Morale 49 (3): 497–515.

Degrazia D. (2002), “Are We Essentially Persons? Olson, Baker, and a Reply,” The Philosophical Forum 33 (1): 101–120.

Jonas H. (1966), The Phenomenon of Life: Toward a Philosophical Biology, Harper & Row, New York.

Korein J. (1997), “Ontogenesis of the Brain in the Human Organism: Definitions of Life and Death of the Human Being and Person,” [in:] Advances in Bioethics: New Essays on Abortion and Bioethics, R.B. Edwards (ed), JAI Press, Greenwich (CT): 1–74.

Lizza J.P. (2006), Persons, Humanity, and the Definition of Death, Johns Hopkins University Press, Baltimore (MD).

Lizza J.P. (2018a), “Defining Death: Beyond Biology,” Diametros 55: 1–19.

Lizza J.P. (2018b), “In Defense of Brain Death: Replies to Don Marquis, Michael Nair-Collins, Doyen Nguyen, and Laura Specker Sullivan,” Diametros 55: 68–90.

Moreland J.P., Rae S.B. (2000), Body & Soul: Human Nature & the Crisis in Ethics, InterVarsity Press, Downers Grove (IL).

Moreland J., Mitchell J. (1955), “Is the Human Person a Substance or a Property-Thing?” Ethics & Medicine: A Christian Perspective on Issues in Bioethics 11 (3): 50–55.

Nguyen D. (2018a), “A Holistic Understanding of Death: Ontological and Medical Considerations,” Diametros 55: 44–62.

Nguyen D. (2018b), The New Definitions of Death for Organ Donation: A Multidisciplinary Analysis from the Perspective of Christian Ethics, Peter Lang, Bern.

Shewmon D.A. (2001), “The Brain and Somatic Integration: Insights into the Standard Biological Rationale for Equating ‘Brain Death’ with Death,” Journal of Medicine and Philosophy 26 (5): 457–478.

Shewmon D.A. (2012), “You Only Die Once: Why Brain Death Is Not the Death of a Human Being; a Reply to Nicholas Tonti-Filippini,” Communio 39: 422–494.

Sider T. (2002), “Book Review: Persons and Bodies: A Constitution View,” The Journal of Philosophy 99 (1): 45–48.

Strawson P.F. (1964a), Individuals, Routledge, London.

Strawson P.F. (1964b), “Persons,” [in:] Essays in Philosophical Psychology, D.F. Gustafson (ed), Anchor Books, Garden City (NY): 377–403.

Wiggins D. (2001), Sameness and Substance Renewed, Cambridge University Press, Cambridge.




Doyen Nguyen, M.D., S.T.D.

Pontifical University of St. Thomas Aquinas (Angelicum)


1 Largo Angelicum

00184 Rome, Italy

e-mail: btursiopsdn@gmail.com

1Lizza (2018a).

[2]Lizza (2018b).

[3]Nguyen (2018a).

[4]Lizza (2018b): 69; See also Lizza (2018a): 2–3.

[5]Lizza (2018b): 68.

[6]Lizza (2006): 70.

[7]Lizza (2018b): 69.

[8]See Moreland, Mitchell (1995); Moreland, Rae (2000); Strawson (1964a); Strawson (1964b); Wiggins (2001).

[9]See discussion in Nguyen (2018a).

[10]See Lizza (2006): 64–74.

[11]See Wiggins (2001): xiv.

[12]Baker (2000): 27. To philosophers versed in the classical tradition, the idea of constitution may evoke the hylomorphic union of the soul and body (i.e., form and matter, respectively) in which the human soul, being the form which makes the body what it is, is obviously not identical to the body and can have its own separate existence at death, when the once-living body (now a corpse) succumbs to the unrelenting process of disintegration. Most contemporary philosophers, in particular the materialists, do not believe in the existence of the soul, however.

[13]Baker (2002): 592.

[14]Baker (2000): 27.

[15]Lizza (2018b): 69.

[16]See Lizza (2006): 64–80.

[17]See Lizza (2018b): 80–86; Baker (2000): 59–78.

[18]The account is unconvincing, however, because of the many difficulties inherent in the constitution theory itself, including the question “in what does a particular first-person perspective consist?” See, for instance, the detailed critique in Degrazia (2002): 109–120.

[19]Sider (2002): 45–48.

[20]For an in-depth discussion, see Nguyen (2018b): 62–63, 369–425.

[21]Ibidem: 62. See also Bonelli et al. (1993): 4.

[22]Jonas (1966): 76.

[23]Bernat, Culver, Gert (1981): 390.

[24]See Shewmon (2012): 428–448. See also Nguyen (2018b): 398–404.

[25] Shewmon (2012): 435. Shewmon’s emphasis on ‘to be’ reflects the proper understanding that vegetative life is the foundation upon which all the other dimensions of life rest (e.g., the first-person perspective).


[26]Nguyen (2018b): 400.

[27]Ibidem: 436–437.

[28]See Nguyen (2018b): 415.

[29]Shewmon (2012): 440.

[30]See Shewmon (2001).

[31]See Korein (1997): 13–20.

[32]Shewmon (2012): 441–442.

[33]See Lizza (2018b): 69.