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ASPECTS OF ORGANTRANSPLANTATIONDAVI D PRI CEde montfort uni vers i ty, lei ces terpubli shed by the press syndi cate of the uni versi ty of cambri dgeThe Pitt Building, Trumpington Street, Cambridge, United Kingdomcambri dge uni versi ty pressThe Edinburgh Building, Cambridge, cb2 2ru, UK www.cup.cam.ac.uk40 West 20th Street, New York, ny 100114211, USA www.cup.org10 Stamford Road, Oakleigh, Melbourne 3166, AustraliaRuiz de Alarco n 13, 28014 Madrid, Spain#David Price 2000This book is in copyright. Subject to statutory exception and to the provisions ofrelevant collective licensing agreements, no reproduction of any part may take placewithout the written permission of Cambridge University Press.First published 2000Printed in the United Kingdom at the University Press, CambridgeTypeface 10.5pt/14pt Minion. System 3b2 [ce]A catalogue record for this book is available from the British LibraryLibrary of Congress Cataloguing in Publication dataPrice, David P. T.Legal and ethical aspects of organ transplantation / David Price.p. cm.Includes index.ISBN 0 521 65164 6 (hardback)1. Transplantation of organs, tissues, etc. Law and legislation.2. Transplantation of organs, tissues, etc. Moral and ethical aspects.I. Title.K3611.T7P75 2001174'25dc21 00024475isbn 0 521 65164 6 hardbackCONTENTSPreface page ixTable of legislation xTable of cases xvIntroduction 1part icadaveri c organ donor transplantati onIntroduction to cadaveric organ transplantation 231 Why and when is a potential donor a cadaver? 402 Organ procurement systems 833 Interests in the corpse 1214 The maintenance and preservation of the cadaver 1595 The treatment of potential donors prior to death 172part i ili vi ng donor organ transplantati onIntroduction to living donor organ transplantation 2176 The rationale and limits of living donor organ transplantation 2307 Informed consent to living organ donation 2698 Contentious classes of donors 314viipart i i igeneral i ssues9 Commerce 36710 Recipients 418Conclusion 466Index 484viii Contents1Why and when is a potential donor a cadaver?`What is so intricate, so entangled as death?'John Donne, 1628Few other issues pertaining to transplantation have generated as manyquandaries and as much attention as the `Gordian knot' of death, whoseessence is of crucial importance to the very existence and success ofcadaveric transplantation programmes. Moreover, the character of applic-able regulatory regimes hinges directly upon the dichotomy betweencadaveric and living donation created by it. The so-called `dead donor'rule requires that vital organs be removed only from cadaveric donors.Duties to respect the autonomy and to avoid malecent treatment of thedonor take on a very different hue and import in the event of theindividual's death. It has been alleged that certain classes of donors havegenerally been located in the wrong `camp' (for example anencephalicsand non-heart-beating donors) resulting in the application of inap-propriate principles for procurement.1Whilst the dead donor rule hasitself recently become a subject of re-appraisal, debated in a followingchapter, its contemporary signicance is indisputable and pivotal.There are dilemmas here attaching to both `heart-beating' donors and,the increasingly popular, `non-heart-beating' (asystolic) donors. Theformer depend upon the relatively modern notion of brain death asmarking the end of life of the individual human being, the practical effectof which can be illustrated by comparing volumes of transplants betweennations. In Japan, which until recently shied away from the notion ofbrain death, the mean annual volume of cadaver kidney transplants was1See D. Vawters, `Ethical Frameworks for Live and Cadaveric Organ Donation' in B. Spielman(ed.), Organ and Tissue Donation: Ethical, Legal and Policy Issues, Southern Illinois UniversityPress, Carbondale, 1997, at 53.40approximately 200, contrasted with, for instance, 1,600 in the UnitedKingdom and 8,000 in the United States. Moreover, multi-organ trans-plantation, and thoracic organ transplantation in particular, is practicallyruled out in its absence.2Whilst most nations of the world now endorsebrain death as the death of the individual, some societies have been slowto accept it (for instance Denmark, Poland and Japan) and some societiesstill either wholly or partially reject it (for example, China, Iran, Israel andKorea). Despite what has been described as a `remarkable consensus'having generally developed supporting brain death, Miles observes that `Itis ironic that so soon after the medical and legal legitimisation of theconcept of brain death, whole-brain criteria for death seem to bedisintegrating neurologically, clinically, and socially.'3Whilst this isundoubtedly an overstatement, brain death indeed continues to generatesignicant controversy, both conceptually and pragmatically.Paradoxically, whilst brain death has attracted criticism and scrutinybecause of its supposed departure from traditional notions of death, non-heart-beating donor (NHBD) protocols have attracted at least as muchcriticism for their supposed reliance upon orthodox cardiopulmonarydeterminants of death. Whilst not a thesis on the meaning and determina-tion of death in general terms, this chapter will debate the validity of braindeath and cardiopulmonary standards of death due to their centrality totransplantation practices, and will additionally consider proposals toextend neurological formulations of death to the realms of higher braindeath, because of the greater inclusiveness of certain classes of potentialorgan donors resulting therefrom. It then remains to consider the mostappropriate form of legal regulation of these matters.A convenient ction?Although in `pre-technological' days, traditional cardiorespiratory/cardiopulmonary perceptions of death were employed, as Gervais states,Until we developed the power to maintain cardiac and respiratoryfunctions mechanically, there was really no need to scrutinise the2For instance, up until 1990, when Denmark passed legislation adopting brain death, manypatients were sent abroad to receive heart and lung transplants.3S. Miles, `Death in a Technological and Pluralistic Culture' in S. Youngner, R. Arnold andR. Schapiro (eds.), The Denition of Death: Contemporary Controversies, Johns HopkinsUniversity Press, Baltimore, 1999, 310.41 Why and when is a potential donor a cadaver?conceptual underpinnings of our decision to declare a person dead whenhis heart and lungs ceased functioning: heart and lung failure brought onthe failure of all the other major organ systems almost immediately. Hencethe whole individual appeared to die at once.4Thus, different notions of death tended to coalesce. But whilst kidneysand corneas might still be viable for transplantation for a short time aftercirculation had ceased, organs such as hearts and lungs, more vulnerableto hypoxia, essentially required a still-beating heart at explantation inorder to function properly post-transplant. However, the application ofthe technology to facilitate such a (heart-beating) state then begged thequestion about the continued legal status of the individual whose respira-tion and circulation had been maintained. Indeed, because of suchuncertainty, until well into the latter half of the twentieth century theintegrity of the dead body was typically preserved until the point in timewhen all critical functions of the body had necessarily ceased.5TheAustralian Law Reform Commission (ALRC) once commented that `thepractice of transplantation forces the close attention of the community tothe subject of death and in many cases greater accuracy and care to bebrought to bear in determining that death has occurred'.6Evans, however,notes that `Of the [other] kinds of death-behaviour, there is only onewhere haste [of this kind] is usual for the successful procurement oftransplantable organs, time is of the essence.'7Moreover, it is alleged bysome that the global movement towards endorsement of brain death hasbeen entirely driven, even manipulated, by the necessities of transplanta-tion. Indeed, Evans and Hill have accused that `There is, of course, noneed for a so-called ``brain death'' criterion of death except for thepurposes of organ transplantation, specically the provision of hearts,livers and lungs.'8Singer has pronounced brain death a `convenient4See K. Gervais, Redening Death, Yale University Press, New Haven, 1986, at 2.5The practices of anatomists and medical schools with regard to cadavers typically require no`living' tissue and thus no urgency as regards the timing of death.6Australian Law Reform Commission, Human Tissue Transplants, Report No. 7, Canberra,1977, para. 127, at 59.7M. Evans, `Against Brain-stem Death' in R. Gillon (ed.), Principles of Health Care Ethics, JohnWiley, Chichester, 1994, 1041 at 1044.8See D. Evans and D. Hill, `The Brain Stems of Organ Donors are Not Dead' (1989) (August)Catholic Medical Quarterly 113 at 114. Seifert states even more trenchantly that `The onlycogent pragmatic motive for introducing the criterion of brain death is its purpose of allowingorgan-transplantations without the need to commit active euthanasia or manslaughter bykilling persons who are still alive': see J. Seifert, `Is ``Brain Death'' Actually Death?' (1993) 76Monist 175 at 178.42 Cadaveric organ transplantationction'9and Taylor describes it as a `social construct' created for whollyutilitarian (that is transplantation) purposes.10These are potent chargesrequiring that any denition of death operative in this sphere beindependently supportable on sound ethical and public policy grounds.Expediency cannot be a total justication in itself, but as Birnbacherobserves, `the practical usefulness of a criterion is no reason to doubt itsadequacy'.11The evolution of brain deathIn the fties, when transplantation considerations were not directlyimplicated,12the (ventilator) technology was already developing to allowpatients whose brains were totally dead13to have their breathing andheartbeat maintained for a substantial period of time, coinciding with arapid increase in acquired knowledge of the physiology of the brain,14outof which the notion of brain death evolved.15Clinicians began at this timeto doubt the traditional criteria for establishing death and the value ofventilating all such patients to asystole (cardiac standstill). Acceptance ofthe clinical notion of brain death did not necessarily imply any normativeproposition as to whether an individual whose brain had died was deadhowever.16This further deductive step was not long in being forthcoming9P. Singer, Rethinking Life and Death, Oxford University Press, Oxford, 1994, at 35.10R. Taylor, `Reexamining the Denition and Criteria of Death' (1997) 17(3) Seminars inNeurology 265.11D. Birnbacher, `Philosophical Arguments for Accepting the Brain Death Criterion' inG. Collins, J. Dubernard, W. Land and G. Persijn (eds.), Procurement, Preservation andAllocation of Vascularized Organs, Kluwer, Dordrecht, 1997, 339 at 341.12Jennett notes that a further ten years were to elapse from the identication of the concept of`coma depasse' before the UK transplant rate exceeded even one per week: B. Jennett, `BrainDeath' (1981) 53 British Journal of Anaesthesiology 1111.13As autopsy frequently undeniably substantiated.14In 1959, a group of neurophysiologists and neurosurgeons in Lyons rst described acondition termed `death of the central nervous system': see M. Jouvet, `Diagnostic electro-souscorticographique de la mort du systeme nerveux central au cours de certains comas'(1959) II Electroencephalography and Clinical Neurophysiology 805.15Two Parisian neurologists dubbed the condition `coma depasse' (beyond coma) later thatsame year: see P. Mollaret and M. Goulon, `Le coma depasse (memoire preliminaire)' (1959)101 Review of Neurology 3.16The Danish Council of Ethics developed a perspective of a `death process' which began when,inter alia, the brain had died, but which only ended when all three functions, circulatory,respiratory and brain, had all denitely ceased. However, in order not to impede organtransplantation, it would nevertheless be permissible to prolong the death process to that endand to remove organs for transplantation after brain death had occurred: see Danish Councilof Ethics Report, The Criteria of Death, Copenhagen, December 1988.43 Why and when is a potential donor a cadaver?though. In 1968, an Ad Hoc Committee of the Harvard Medical SchoolReport argued, although without any supporting rationale, that anindividual whose brain had irreversibly ceased to function should beconsidered dead.17A brain death formulation was also adopted in Augustof the same year by the World Medical Association as part of theDeclaration of Sydney.18In the UK in January 1976, the Conference ofMedical Royal Colleges published a memorandum on `The Diagnosis ofBrain Death', identifying with the concept of brain death, with theostensible principal purpose of establishing criteria justifying the removalof a patient from a ventilator.19A further memorandum from the MedicalRoyal Colleges in January 1979 took the further step of equating the deathof the brain with the death of the individual.20Evans and Hill have arguedthat transplantation concerns were the sole reason for the attempt by theMedical Royal Colleges in Britain to enforce acceptance of its version ofbrain death, and state: `Contrary to what some have claimed, it wasnever necessary to certify death prior to discontinuing futile and unkindlife-support measures.'21Although neither memorandum specicallyalluded to transplantation, these perceptions were fostered when thememoranda were incorporated into Cadaveric Organs for Transplantation(A Code of Practice including the Diagnosis of Brain Death) issued in1983.22The Code of Practice issued by the Department of Health in 1998softens this association slightly by reversing the emphasis, being entitled ACode of Practice for the Diagnosis of Brain Stem Death: Including Guidelinesfor the Identication and Management of Potential Organ and Tissue17`A Denition of Irreversible Coma', Report of the Ad Hoc Committee of the Harvard MedicalSchool to Examine the Denition of Brain Death (1968) 205 Journal of the American MedicalAssociation 337.1822nd World Medical Assembly, adopted 9 August 1968.19(1976)(ii) British Medical Journal 1187 and (1976)(ii) Lancet 1069. These recommendationswere very similar to the Minnesota Code for Brain Death formulated by Mohandas and Chouin 1971.20Conference of Medical Royal Colleges and their Faculties in the United Kingdom,`Memorandum on the Diagnosis of Death' (1979)(i) British Medical Journal 332; Conferenceof Medical Royal Colleges and their Faculties in the United Kingdom, `Diagnosis of Death'(1979)(i) Lancet 261.21Evans and Hill, `The Brain Stems of Organ Donors are Not Dead', at 114.22Cadaveric Organs for Transplantation (A Code of Practice including the Diagnosis of BrainDeath), Health Departments of Great Britain and Northern Ireland, 1983. Julius Koreinpreviously accused the British Code of linking the diagnosis of brain death `irretrievably withtransplantation': see J. Korein, `Diagnosis of Brain Death' (1980) 281 British Medical Journal1424.44 Cadaveric organ transplantationDonors!23It is indeed very likely that transplantation concerns were atleast in the background of the policy-makers' minds at this time, if not inthe forefront. In the US, the evolution of the notion of brain death wasexplicitly motivated in part by transplantation considerations, althoughthe Harvard Committee in particular attempted to play down such aconnection.24McCullagh is nonetheless right to assert that the notion ofbrain death was not, in the rst instance, a contrivance to facilitate theidentication of subjects who would be suitable donors of transplantableorgans, as considerable doubt did exist at that time as regarded the legalityof such withdrawal of life-supporting measures.25But it was nevertheless afactor, as such legal doubt resulted in the removal of organs from brain-dead donors typically taking place only once asystole had occurred withconsequent potential organ damage.26This historical excursus, however,tells us little about the legitimacy of a determination of death foundedupon brain death.Concepts, standards, criteria and testsThe rationale for the adoption of (that is the concept underpinning) anyparticular standard(s) of death has typically remained unarticulated, butas Gervais rightly observes, `behind the use of any criterion for declaringdeath there lies what I shall call a decision of signicance, that is, adecision that there is a certain feature (or cluster of features) whosepermanent absence constitutes the death of the person'.27Thus, there isan a priori issue as to what death means, posed by Veatch in terms of:`What is so essential to our concept of human life such that when it is lost23A Code of Practice for the Diagnosis of Brain Stem Death: Including Guidelines for theIdentication and Management of Potential Organ and Tissue Donors, Department of Health,March 1998.24See discussion by Singer in Rethinking Life and Death, at 247. Fost describes the HarvardCommittee deliberations as `an explicitly utilitarian exercise': see N. Fost, `The Unimportanceof Death' in Youngner et al., The Denition of Death, 161 at 165.25See P. McCullagh, Brain Dead, Brain Absent, Brain Donors, John Wiley & Sons, Chichester,1993, at 8. See also J. Bleich, `Moral Debate and Semantic Sleight of Hand' (1993) 27 SuffolkUniversity Law Review 1171 at 1175.26Whatever the legal doubts, as early as 1957, Pope Pius XII removed (Catholic) religiousimpediments to such a practice, at an international gathering of physicians, surgeons andscientists. He suggested that the soul might have left the body despite the continuedfunctioning of certain organs.27Gervais, Redening Death, at 2.45 Why and when is a potential donor a cadaver?we should treat the individual as dead?'28The expression concept of deathis preferred here to describe this abstraction, as the alternative phrase`denition of death' is frequently used also as a label for legislativeformulations based upon a second-level enquiry as to the physiologicalstate representing (this concept of ) death.29This general physiologicalstate will be designated the standard(s) of death here. For instance, Bernatet al.30support the permanent cessation of functioning of the entire brainas the standard of death, underpinned by a concept of death based uponthe permanent cessation of the functioning of the organism as a whole. Iadopt the term `criteria' to refer to the operational diagnostic criteriarequired to be satised in order to ensure that the physiologicalstandard(s) equating with death exist(s).31Finally, there are the actual`tests' or procedures employed for determining that the criteria for deathexist in the individual instance. This lexicography and ordering is crucialand is succinctly and elegantly summed up by Engelhardt in the statement:`To give a coherent account of how one should determine death, one mustknow what it is no longer to be alive, both in terms of knowing what life isso that it can be gone, as well as where that life is necessarily embodied sothat one can know what tests to cluster under what genre of generalcriteria.'32This fourfold taxonomy is preferred for its exibility and clarityto the more straightforward threefold taxonomies employed by variouscommentators, which display a tendency to conate different categories ofassessment.33In most instances though, there is little to choose betweenthem as where commentators innocuously use the expression `criteria'to additionally include testing procedures for determining death. As28R. Veatch, `The Denition of Death: Ethical, Philosophical, and Policy Confusion' inN. Abrams and M. Buchner (eds.), Medical Ethics, MIT, Cambridge Mass., 1983, 30 at 30.Hans Jonas poses the primary question more pithily in terms of `What counts for life?': seeH. Jonas, `Against the Stream: Comments on the Denition of Death and Redenition ofDeath' in Philosophical Essays: From Ancient Creed to Technological Man, Prentice-Hall,Englewood Cliffs N.J., 1974, 132.29For this reason, I have not simply adopted Bernat et al.'s threefold classication, that is`denition', `criteria' and `tests' of death: see J. Bernat, C. Culver and B. Gert, `On theDenition and Criterion of Death' (1981) 94 Annals of Internal Medicine 389.30Although they term this the `criterion' of death: ibid.31The President's Commission referred to them as `operational criteria': see President'sCommission for the Study of Ethical Problems in Medicine, Dening Death: A Report on theMedical, Legal and Ethical Issues in the Determination of Death, US Government PrintingOfce, Washington D.C., 1981.32H. Engelhardt, `Redening Death' in Youngner et al., The Denition of Death, 319 at 325.33The President's Commission also employed this fourfold classication in preference to themore typical scheme.46 Cadaveric organ transplantationEngelhardt notes, `Operational concerns, it should be noted, bringtogether both criteria for death and tests for death. Criteria for deathfunction as chapter headings for tests, indicating what genre should beemployed as dictated by a denition of death, which gives an account ofwhat it is to be alive and to be embodied.'34But is death a biological matter, a philosophical matter (that is, a `truth'to be discovered, an ontological investigation into the essence of humanlife) or merely an issue of social engineering? This is a subject whichcontinues to generate confusion between combatants. Lord Kilbrandon, ata symposium in the sixties, declared that `the question of what is death . . .is a technical, professional medical matter'.35Indeed, historically themeaning of death was frequently left inexplicit in terms of the law, and leftto the medical profession to decide. The notion of death as a biologicalphenomenon is still one obstinately clung to by many analysts. Taylor forinstance has criticised the notion of brain death as being merely a `legalconstruct' rather than, as he considers it should properly be regarded, abiological phenomenon. By contrast, the President's Commission,36Bernat et al. and Veatch all view the determination of the proper conceptof death as `primarily a philosophical task'. However, this enquiry is notsusceptible to a straightforward response, and it is necessary to haveregard to the taxonomy above to assist us. It hinges on whether we areconsidering the meaning of death itself, the physiological state manifestingit or the criteria and/or tests utilised to establish such a state.The concept of death is clearly a primarily philosophical question. AsVeatch remarks, `No amount of neurological study could possiblydetermine whether those with dead brains should be considered deadpeople. This is a religious, philosophical, ethical, or public policy question,not one of neurological science.'37Singer maintains that `If we choose tomark death at any moment before the body goes stiff and cold (or to be34Engelhardt, `Redening Death', at 327.35Lord Kilbrandon, `Closing Remarks' in G. Wolstenholme and M. O'Connor (eds.), Ethics inMedical Progress: With Special Reference to Transplantation, CIBA Foundation Symposium,J. & A. Churchill, London, 1966, at 213.36See the President's Commission Report, Dening Death, at 55.37R. Veatch, `The Conscience Clause' in Youngner et al., The Denition of Death, 137 at 140. Insimilar vein, Rabbi Bleich states that `Newly formulated criteria of death are no more and noless than determinations of who shall be accorded, or better, who shall be denied, standing asa member of the human community with its attendant rights, entitlements, and claims. Sucha determination is a moral, philosophical, religious, and legal issue. Most emphatically, it isnot a scientic issue': see Bleich, `Moral Debate and Semantic Sleight of Hand', at 1175.47 Why and when is a potential donor a cadaver?really on the safe side, before it begins to rot) we are making an ethicaljudgment.'38But even this assertion incorporates an a priori assumptionthat death is in reality cellular death not some other sort of death. Yet, asthe ALRC noted, `there is, and has always been, a great difference betweenthe questions ``Is he dead?'' and ``Is life extinct in every part of hisbody?'' ', that is between somatic (cellular) death and the death of theindividual.39In some cultures and societies, theological perspectivesdictate responses to this question. Although mainstream religious thoughtin the great majority of jurisdictions has not obstructed acceptance ofbrain death, in Japan for instance reform has only recently been forth-coming due partially to reticence rooted in Confucian ideals, and Shintoand Buddhist thought, which see death as an evolving process. Inaddition, many orthodox Jews, Aborigines and Native Americans placegreat signicance upon the continued functioning of the heart eventoday.40In 1988, the Danish Council of Ethics, in a Report on Death, drewattention to a perceived divide between `scientic' (unseen) and `ordinary'(seen) views of death. It stated that `The concept of death must relate tothe everyday experience', according to which `the identity of the personrelates no less to the body than to the mind', and recommended that thestandard of death should be cessation of respiration and cardiac activity.41This raises questions as to the extent to which policies should reect`ordinary' emotional reactions as opposed to rational thought. MartynEvans contends that our reactions may be morally signicant, evendecisive, here and states: `I don't believe we would display, embalm, buryor cremate someone until her heart had stopped beating because wewould not until then see her as dead', and observes that this obstacle seemsonly not to apply in the sphere of transplantation.42It is suggestedhowever that our intuitions should act as a `check' on our intellectual38See Singer, Rethinking Life and Death, at 32.39See the Australian Law Reform Commission, Human Tissue Transplants, at para. 118.40In the 1970s, Frank Veith asserted that brain death was a concept compatible with all threemajor Western religions, and apart from small factions, this still holds good today: seeF. Veith et al., `New Developments in the Use and Recognition of Brain Death in the UnitedStates and other Countries' (1981) 13 Transplantation Proceedings 689 at 691.41Danish Council of Ethics Report, The Criteria of Death.42Evans, `Against Brain-stem Death', at 1044. See also M. Evans, `A Plea for the Heart' (1990) 4Bioethics 227.48 Cadaveric organ transplantationinclinations, but should not be wholly controlling or sufcient moralguides, even assuming that there is a consensus here.43To some extent, the concept of death to which we subscribe is afunction of whether we hold a `mentalist' or a `physicalist' viewpoint and,to a lesser degree, `dualist' or `monist' views regarding the human mind.Some supporters of mentalist, personhood perspectives on the nature ofhuman life regard the mind as being the critical entity, distinct frommatter, the human body. Others take a similar view but regard the mindas either located within the body or dependent upon the body. On theother hand, those who regard the biological functioning of the body asbeing the primary matter of importance might also regard the mind asbeing distinct from the body or as a part of it. The former in either campdisplay a (Cartesian) dualist perspective, the latter a monist view, and wecan therefore see that a mentalist or physicalist perspective does not initself commit one to any particular standard of death. Devettere notes thateven the neocortical criterion of human death is consistent with somenon-dualistic conceptions of human beings which focus on the humanbody.44We can see in this discussion the process of translation of abstractconceptual notions into a physiological basis for empirical determinationand the variety of variables which might impact on this process. Similardifculties arise in the translation of religious doctrine or teachings insome instances. For example, Rosner illustrates how the two sides in thebrain death debate in Israel under Jewish law line up in polarised fashionbased upon differing interpretations of the pivotal talmudic and otherclassic Jewish sources as regards whether cessation of cardiac as well asrespiratory activity is a prerequisite for death.45Thus, whilst the conceptof death may be a wholly philosophical enquiry, there are biological andmedical determinants to all the remaining levels of enquiry, although as43Angstwurm has stated that `it can prove difcult to understand the permanent and completeloss of brain function as a denitive sign of death. Unlike rigor mortis, livor mortis, and signsof decay and putrefaction, brain death can only be determined and distinguished from thedeath-like state of an intensively treated individual by means of specic tests': seeH. Angstwurm, `Brain Death' in Collins et al., Procurement, Preservation and Allocation, 331at 332.44In particular he cites the work of Alfred North Whitehead and Maurice Merleau-Ponty: seeR. Devettere, `Neocortical Death and Human Death' (1990) 18(12) Law, Medicine andHealth Care 96 at 98100.45See F. Rosner, `The Denition of Death in Jewish Law' in Youngner et al., The Denition ofDeath, at 270.49 Why and when is a potential donor a cadaver?one can see from the above discussion, philosophical perspectives intrudeto some degree on outcomes at nearly every stage.46Process or event?In biological terms death is a process not an event. As Miles puts it,`Biological processes and organ systems shut down over time in individua-lised sequences.'47Indeed, even the brain itself dies in stages. But if onefocuses instead on the individual rather than specic parts of the organismit is easier to conceive of death being an event rather than a process.Indeed, Bernat contends that `Because all organisms must be either aliveor dead, death is an inherently discontinuous and instantaneous event.'48However, the Danish Council of Ethics argued that whilst total destruc-tion of brain function meant the `death process' had begun and wasirreversible, it did not signify that the death process was complete,although it might still be ethically and legally defensible to remove organsfor transplantation at that point.49Bernat et al.'s convincing retort is thata denition of death stipulating that it occurs at a more or less denitetime is preferable to a denition that makes death a process. If we regarddeath as a process, then either the process starts when the person is stillliving, which confuses the `process of death' with the process of dying, forwe all regard someone who is dying as not yet dead, or the `process ofdeath' starts when the person is no longer alive, which confuses death withthe process of disintegration.50Indeed, if the individual was not yet `dead' when such organs wereremoved, he/she must presumably still have been alive and the removal46Bearing in mind the differences in terminology (see note 29), Bernat et al. state that`providing a denition of death is a philosophical task; the choice of criterion is primarilymedical; and the choice of tests . . . is solely a medical matter': see Bernat et al., `On theDenition and Criterion of Death', at 389.47Miles, `Death in a Technological and Pluralistic Society', at 313.48J. Bernat, `A Defense of the Whole-Brain Concept of Death' (1998) 28 Hastings Center Report14 at 16. Engelhardt's suggestion of the notion of different deaths for different purposeswould be extremely difcult to translate into (legal) reality. See also D. Smith, `LegalRecognition of Neocortical Death' (1986) 71 Cornell Law Review 879, and S. Brennan andR. Delgado, `Death: Multiple Denitions or a Single Standard?' (1981) 54 Southern CaliforniaLaw Review 1323.49B. Rix, `Danish Ethics Council Rejects Brain Death as the Criterion of Death' (1990) 16Journal of Medical Ethics 5.50See Bernat et al., `On the Denition and Criterion of Death', at 389.50 Cadaveric organ transplantationwould thus have contravened the dead donor rule.51It is also necessaryfor legal purposes to be able to isolate a moment of death, as the person'slegal status then radically alters and with it attendant rights, claims andentitlements.Legal complicationsWhilst the medical community gradually accepted the phenomenon ofbrain death during the sixties and early seventies, laws and policystatements at that time pretty universally omitted to engage with it, thusleaving substantial uncertainty as to the legal status of the brain-deadpatient. This incertitude coincided with various pathbreaking trans-plantation ventures, notably the series of rst heart transplants performedin the late sixties. Indeed, in the rst such attempted cardiac transplant on3 December 1967 in Cape Town, Christiaan Barnard implicitly relied onbrain death in order to facilitate it.However, whilst legislative statements on (brain) death are almostexclusively a feature of the seventies or later, the question of whatconstituted death arose indirectly in a smattering of early judicialdecisions. These cases were often concerned with matters relating toinsurance claims or the criminal liability of third party assailants. An earlyexample of the latter, which also incidentally implicated the removal oforgans for transplantation, was the British case of R v. Potter in 1963.52Fourteen hours after being admitted to hospital following a head injurysustained in a ght, the patient stopped breathing and was connected toan articial respirator. Twenty-four hours later a kidney was removed(with his wife's consent) and transplanted into another man. Therespirator was then disconnected and it was found that there was nospontaneous respiration or circulation. Although at the subsequentcoroner's inquest it was decided that the removal of the kidney had notcontributed to the death, and the assailant was committed for trial, amedical witness had testied that the man had `virtually died' at the timewhen he was put on the respirator although it would be `legally correct' to51For this, logical, reason clinicians in Denmark refused to remove organs from brain-dead, butnot actually `dead', individuals, for fear of legal repercussions, despite the expressly statedpermissibility of so doing: see B. Rix, `Brain Death, Ethics, and Politics in Denmark' inYoungner et al., The Denition of Death, 227 at 233.52The Times, 26 July 1963; (1963) 31 Medical Legal Journal 195.51 Why and when is a potential donor a cadaver?say that death did not occur until twenty-four hours later, when breathingand heartbeat had ceased, thus suggesting he was not dead when theremoval occurred. At the eventual trial the accused was found guilty onlyof common assault, although charged with manslaughter, suggesting thatthe patient was indeed not legally dead until the respirator was removed,so that the removal of the kidney must presumably have been a criminalbattery. Amongst other things, this case illustrates the ambivalence anduncertainty of judicial decision-making on this issue at that time and ingeneral.53The inherent dangers for surgeons at this time were even more vividlyillustrated by the Wada case in Japan in 1968. A man was pulled from afrozen lake unconscious and declared dead on the basis of brain deathcriteria despite the fact that no law or policy then sanctioned thedetermination of death on brain-related criteria. The following day hisheart was transplanted by Dr Wada into an eighteen-year-old withchronic heart disease who survived for eighty-three days.54Dr Wada wascharged with murder, although the prosecution was ultimately aborteddue to lack of material evidence. This was the only heart transplantperformed in Japan and undoubtedly impeded acceptance of brain deathby Japanese society.55In the United States though, such decisions weremore liberal and less equivocal from the outset. In Tucker v. Lower56in1972, the judge directed a jury in Virginia that they could either apply thetraditional cardiorespiratory standard of death or the brain death standard53Quite a diversity of judicial response resulted however. In the United States, inCommonwealth v. Golston 366 N.E. 2d 744 (Mass. 1977), a person sustained brain deathfollowing an assault. The judge, relying on a brain-death standard, decided that thediscontinuance of treatment by doctors following such a diagnosis did not break the chain ofcausation between the original assault and the victim's death. In Scotland, in the High Courtof Justice, by contrast, in a case decided on similar facts at around the same time, the courtdeclined to adopt a brain-stem standard of death, and held that the person died only after thearticial ventilation was terminated, in Finlayson v. H.M. Advocate [1978] SLT (Notes) 60. InR v. Malcharek; R v. Steel [1981] 1 WLR 691 (CA) the English court adopted the same view asin Golston as regarded causation, but did not conclude as regarded any legal standard(s) ofdeath. See also R v. Kitching and Adams [1976] 6 WWR 697 (Manitoba) and R v. Kinash[1982] Qld R 648 (Qld).54There was signicant doubt whether the patient even really needed a transplant: seeProvisional Commission for the Study on Brain Death and Organ Transplantation, ImportantConsiderations with Respect to Brain Death and Organ Transplants, Japan, 1992.55See K. Hoshino, `Legal Status of Brain Death in Japan' (1993) 7 Bioethics 234, and K. Bai, `TheDenition of Death: The Japanese Attitude and Experience' (1990) 22 TransplantationProceedings 991.56VA No. 2831, May 1972. Brain death was rst accepted judicially in the US in United TrustCo. v. Pyke 427 P. 2d 67 (Cal. 1967).52 Cadaveric organ transplantationin the context of a case where a person's heart was removed fortransplantation purposes immediately after ventilation was stopped, thepatient having been assaulted. The doctors were found not to be liable forcausing the death. Moreover, in a criminal context in California, in Peoplev. Lyons,57it was held that a shooting victim was legally dead prior tobeing used as a transplant donor, despite the continuance of articialrespiration. In spite of the general legal void, clinicians therefore repeat-edly took matters into their own hands, forcing the hand of policy-makers. As in Japan, this sometimes backred, but in most instances itprompted positive action to facilitate transplantation based on braindeath and a protective framework for clinicians.58Of course, in the US themedical profession had embraced the notion of brain death very early onby contrast with many other nations, but even there, as Capron notes, thegreatest pressure for legislation came from physicians concerned aboutthe potential civil or criminal ramications of cadaveric organ donationpractices.59Legislative responsesIn many jurisdictions, the relevant transplant legislation merely refers tothe denition of death established through other legal sources. Forinstance, the UK Human Tissue Act 1961 merely states that a registeredmedical practitioner removing parts of a body must have satised himselfby personal examination of the body that `life is extinct' (in addition tothe physician who certied the death initially).60When life is `extinct'cannot be determined from the statute itself and, due to the absence of astatutory denition elsewhere, case law and medical guidelines wouldneed to be turned to for assistance. The Uniform Anatomical Gift Act inthe United States refers to a `determination of death' and to the `decedent',57Sup. Ct No. 56072, Alameda Co. (Cal. 1974).58Contrast the extrajudicial remark made by the then Dame Elizabeth Butler-Sloss that `Theidea that either Parliament or indeed lawyers should be allowed to get their hands on thisparticular delicate matter lls me with horror, as one of those who might end up trying it'!See C. Pallis, `Brain Stem Death: The Evolution of a Concept' (1987) 55 Medico-Legal Journal84 at 106 (Discussion).59A. Capron, `The Bifurcated Legal Standard for Determining Death: Does it Work?' inYoungner et al., The Denition of Death, 117 at 119. He notes that thirty-six US jurisdictionshave today adopted the Uniform Determination of Death Act incorporating dual standards ofdeath, including the brain-death standard.60In section 4.53 Why and when is a potential donor a cadaver?but the drafters properly decided not to include any further denition inthat (model) law by way of further elaboration.61Virtually all US stateshowever have independent statutes establishing standards of death. Otherjurisdictions by contrast have incorporated the concept of brain deathinto their transplant statutes rather than including it in a discrete piece oflegislation. In fact, three US state laws passed in the seventies actually hada specic standard of death which applied only in the context of organtransplantation, that is West Virginia (1975), Illinois (1975)62andConnecticut (1979). Another example is the 1979 Spanish transplant Lawwhich stipulates63that organs may be removed from deceased persons`After death has been determined on the basis of irreversible brain damagethat is incompatible with life'.64Likewise, the 1996 Romanian transplantstatute states that `Harvesting of tissue and organs from dead persons isallowed only if the brain death has been medically conrmed',65and issupplemented in an Annex by specic criteria for the diagnosis andconrmation of brain death.66The danger is that the perception will begenerated that organ donors are to be handled in different fashion toother patients. Even aspects of testing can be productive of such animpression. In 1984 a Report produced by the Swedish Governmentendorsed destruction of the brain as the standard of death. This was to beascertained by clinical examination alone unless organ transplantationwas anticipated, in which case radiological examination of blood owcessation was required. McCullagh rightly observes that this suggests thatone needs to be more certain about death in some (that is transplant)settings than others.6761See Comment to section 1. It was supposed that implicit reference was made to the denitioncontained in the Uniform Determination of Death Act anyhow.62Illinois still has the American Bar Association model brain-death law in effect in its version ofthe Uniform Anatomical Gift Act.63Spanish Law of 27 October 1979 on the Removal and Transplantation of Organs, Article 5(1).64Crown Decree of 22 February 1980, Article 10 implementing the above Law states that`Organs which are required to be viable for transplantation purposes may be removed fromthe cadaver of the deceased person only following determination of brain death, based onsimultaneous observation for at least 30 minutes and persistence for six hours after onset ofcoma of the following signs: (1) absence of cerebral response, with absolute loss ofconsciousness; (2) absence of spontaneous respiration; (3) absence of brain reexes, withmuscular hypotonia and mydriasis; and (4) a ``at'' electroencephalogram, indicating lack ofbioelectrical activity in the brain.'65Law Regarding the Harvesting and the Transplantation of Human Tissues and Organs, Article6(1).66Article 7(1).67McCullagh, Brain Dead, Brain Absent, Brain Donors, at 25.54 Cadaveric organ transplantationA high percentage of jurisdictions now have legislation incorporatingbrain death, although this has only occurred recently in one or two, forexample Denmark68in 1990 and Japan in 1997.69In 1994, Pallis andHarley listed twenty-eight countries70and most US states71as havinglegislation explicitly recognising brain death as the death of the indi-vidual.72The rst legislative initiatives were in Italy in 1967, in the state ofKansas in 1970 and in Finland in 1971. These statutory provisions areeither unitary brain death statutes or contain bifurcated, alternativestandards of death, as was the case under the early Kansas statute.73TheUS Uniform Determination of Death Act (UDDA)74states that `Anindividual who has sustained either [1] irreversible cessation of circulatoryand respiratory functions, or [2] irreversible cessation of all functions ofthe entire brain, including the brain stem, is dead. A determination ofdeath must be made in accordance with accepted medical standards.'75Bernat et al. have criticised the UDDA for creating two separate standardsof death rather than two sets of criteria supporting one unitary standard.76This issue of sole versus dual standards of death is a constantly recurringone. Transplant protocols and legislative provisions display a tendency toconate the distinctions between different levels of enquiry, and perpe-tuate ambiguities. Problems arise in the context of both heart-beating and68Law of 13 June 1990.69See E. Feldman, `Culture, Conict and Cost: Perspectives on Brain Death in Japan' (1994)10(3) International Journal of Technology Assessment in Health Care 447. Up until relativelyrecently, the concept was not accepted in Latvia either.70See C. Pallis and D. Harley, ABC of Brain-stem Death, 2nd edn, BMJ Publishing Group,London, 1995, at 403. Germany, India and Japan should now be added to that list.71All US states now recognise brain death. Twelve states had already done so by 1977 andtwenty-ve had done so by 1981: see D. Jones, `Retrospective on the Future: Brain Death andEvolving Legal Regimes for Tissue Replacement Technology' (19923) 38 McGill Law Journal394.72See C. Pallis, ABC of Brain Stem Death, BMJ Publications, London, 1983, at 267. See alsoA. Walker, Cerebral Death, 2nd edn, Urban & Schwartzenberg, Baltimore, 1981.73Kan. Stat. Ann. @77202.74It superseded the Uniform Determination of Death Act 1978. This 1980 model law is similarto that proposed by the Law Reform Commission of Australia: see Human Tissue Transplants.The omitted reference to cessation of spontaneous respiratory function is relativelyinsignicant in view of the fact that such cessation usually precedes circulatory failure.75This at least ameliorated the position whereby there were seven different death formulationsacross the country, so that one could be actually `raised from the dead' in driving over apertinent state line in order to reach the nearest hospital! The Law resembles the Kansasstatute but contains no reference to mechanical means of support or transplantation.76Although rather inexplicably Bernat himself described this as a `theoretical quibble'! SeeJ. Bernat, `A Defense of the Whole-Brain Concept of Death' (1998) 28 Hastings Center Report14 at 21.55 Why and when is a potential donor a cadaver?non-heart-beating donors. Typically, doubts are generated by the adop-tion of the irreversible cessation of cardiopulmonary function as a relevantfeature in the determination of death. Judicial decisions can howevercreate the same, if not greater, ambivalence and doubt, as British case lawillustrates.In three recent cases, none of which were cases involving transplanta-tion, the courts in England and Wales have unequivocally declared that abrain-stem-dead patient is dead for legal as well as medical purposes. InMail Newspapers v. Express Newspapers77and Re A (A Minor)78the HighCourt held simply that the brain-stem-dead patients concerned were deaddespite the fact that the patients were on ventilatory support at therelevant time.79In Airedale NHS Trust v. Bland80by comparison, theHouse of Lords decided that Tony Bland, who was not ventilatordependent, was not dead as his brain stem was still functioning despitehis permanent vegetative state (PVS) condition. Their Lordships howevermade a number of broad remarks concerning legal and medical denitionsof death. Although Lord Keith explicitly stated that `In the eyes of themedical world and of the law a person is not clinically dead so long as thebrain stem retains its function'81(a view of clinical perceptions not borneout by many of the NHBD protocols discussed below!), this was not acentral facet of the decision and thus amounted to no more than an obiterdictum. Tony Bland could not, in the circumstances of that case, havebeen adjudged dead according to traditional criteria, as his heartbeat andrespiration continued to function spontaneously. This ambiguity was notresolved, indeed it was seemingly compounded, by the initial UK Code ofPractice issued in 1983 which stated that `There is no legal denition ofdeath. Death has traditionally been diagnosed by the irreversible cessationof respiration and heart-beat. This Working Party accepts the view held bythe Conference of Royal Colleges that death can also be diagnosed by77[1987] Fleet Street Reports 90.78[1992] 3 Medical Law Reports 303.79It was fairly recently established as constituting death in Northern Ireland, by the High Courtof Justice in Re T.C. (A Minor) [1994] 2 Medical Law Review 376, so that it was permissible todetach the newborn child from the ventilator.80[1993] 1 All ER 821 (HL).81[1993] 1 All ER 821 at 859C. See also the remarks made by Lord Goff at 865F. Lord Browne-Wilkinson gave an equally clear vision of death in medicine, stating: `In medicine, thecessation of breathing or of heartbeat is no longer death . . . This has led the medicalprofession to redene death in terms of brain-stem death, i.e. the death of that part of thebrain without which the body cannot function at all without assistance': at 878CE.56 Cadaveric organ transplantationthe irreversible cessation of brain-stem function ``brain death'' ' (myemphasis).82This suggests alternative standards of death. The 1998 Code,on the other hand, states that `brain stem death equates with the death ofthe individual'.83Thus, although the common law in Britain wouldappear to favour a unitary standard of (brain) death, the status of personssustaining irreversible cardiopulmonary failure is still uncertain. TheNHBD protocols discussed below drive a wedge between these twoapproaches and illustrate that it is far from a purely `academic' matter.A conservative revision?It may be argued that the traditional cardiorespiratory standard of deathwas largely self-serving based on the irreversible loss of ow of essentialbody uids, and not rooted in any underpinning concept of death thatsuch loss represented. However, many have argued that we had always,maybe only subconsciously and implicitly, alluded to a concept of deathbased on the loss of functioning of the brain. Birnbacher asserts that `Thatis why accepting the brain death criterion does not mean ``redening''death but only recognising one further criterion for the same fact that istraditionally indicated by the criteria of irreversible heart and respirationfailure.'84As the President's Commission put it, `breathing and heartbeatare not life itself. They are simply used as signs as one window forviewing a deeper and more complex reality: a triangle of interrelatedsystems with the brain at its apex.'85Indeed, even in Japan the traditionalcriteria were based on not just these two but three `symptoms' andincluded also the dilation of the pupils, indicating that we were alwaysessentially searching for windows into the mind/brain/soul.86McCullaghon the other hand has remarked: `I am not convinced that cessation ofcardiac function, for example, has been traditionally regarded as signifyingdeath because of its consequences for brain function, rather than onaccount of its intrinsic importance.'87There is some force in this, notably82Code of Practice, Cadaveric Organs for Transplantation, at para. 28.83Code of Practice, Diagnosis of Brain Stem Death, at 4.84Birnbacher, `Philosophical Arguments', at 341.85President's Commission Report, Dening Death, Chapter 3, at 33.86Observing dilation of the pupils would seem to have been the practice everywhere (that isabsence of pupillary light response), although not accorded a precise status in ofcialstatements: see Bernat et al., `On the Denition and Criterion of Death', at 392.87McCullagh, Brain Dead, Brain Absent, Brain Donors, at 20.57 Why and when is a potential donor a cadaver?in so far as religious perceptions of death typically focus upon theseparation of the soul from the body, with differences of view as to wherethe locus of the soul can be found. In orthodox Jewish thought, forinstance, reference is made to Genesis,88where it is written: `In whosenostrils was the breath of the spirit of life'.Cold LazarusThe traditional cardiorespiratory standard cannot, it seems, continue tobe supported though, except based upon certain religious beliefs wherearational rather than rational factors predispose one to conclusions.However, irreversible cardiopulmonary cessation should rightly continueto be supported as a proper criterion for the determination that the braindeath standard has been satised. However, as we have seen, somecommentators regard death in purely cellular terms as a wholly biologicalphenomenon. Taylor for instance argues that death occurs at the pointwhen the overall process of bodily disintegration begins, which he takes tobe the point at which the cessation of the circulation of vital uids occurs.Veatch counters though that if the critical function here is the circulationof uids, this is not only simplistic but biologically reductionist and makesno distinction between the human and the human body. He adds: `It canat least be said for the defenders of the idea that death occurs when thesoul departs from the body, that they recognised that a human is morethan his body and some of its lesser functions.'89The isolated functioningof individual parts of the human body does not signify life in the`individual' as opposed to life in that individual part. As Birnbacherobserves, `The physical aspect of death is the disintegration of theorganism rather than the cessation of all life and growth processes in itsparts and subsystems' (my emphasis).90Commentators such as Bernat and Lamb contend that brain death isthe appropriate standard of death because individuals die when theycease to be both conscious and working as an integrated functioning unitas a whole.91The President's Commission contended that `what ismissing in the dead is a cluster of attributes, all of which form part of an88Chapter 7, verse 22.89Veatch, `The Denition of Death', at 32.90Birnbacher, `Philosophical Arguments', at 341.91D. Lamb, Organ Transplants and Ethics, Routledge, London, 1990, at 367.58 Cadaveric organ transplantationorganism's responsiveness to its internal and external environment', thatis either the triangular organ functions of the body (lungs, heart andbrain) have ceased to work as a functional integrated unit, or the brain,as the primary organ of the body, has ceased to be able to regulate thefunctioning of the body.92In Britain, the Royal College of Physicians(RCP) recently advanced a denition of death based upon `The irrever-sible loss of the capacity for consciousness combined with irreversibleloss of the capacity to breathe'.93Pallis and Harley proffer the sameview.94These formulations concededly amount typically to no more thanan ex post facto rationalisation of the prior adoption in practice of braindeath. This is so as regards the RCP in Britain, in much the same waythat Bernat et al.'s formulation rationalised the whole-brain formulationof death developed by the Harvard Committee in the US. In Britain theyhave underpinned a brain-stem death standard and elsewhere a whole-brain death standard.Brain death therefore ordinarily rests on two separate but connectedjustications, that is loss of mental life (cognitive capacity/awareness) andloss of biological functioning. Birnbacher comments thatThe human individual is not only body, but a unity of both physical andmental aspects. To be dead or living is not a property of the human bodybut of the full human individual. It is the human individual as a complexwhole that is born, grows old, and nally dies . . . Life and death are,accordingly, distinguished by the functioning and non-functioning of twosystems: of consciousness and of the physical organism.95Thus, the notion of brain death does not entirely depend upon physic-alism or a mind/body duality. Where higher brain activity controllingconsciousness continued to function but the body had otherwise ceased92President's Commission Report, Dening Death, at 36. Engelhardt states though that `Thishas been the difculty with the strategic ambiguity built into the understanding of themeaning of death forwarded by the President's Commission, which incorporated both a``primary organ view [which] would be satised with a statute that contained only a singlestandard the irreversible cessation of all functions of the entire brain'' and an ``integratedfunctions view [that] would lead one to a denition of death recognising that collapse of theorganism as a whole can be diagnosed through the loss of brain functions as well as throughloss of cardiopulmonary functions'' ': see Engelhardt, `Redening Death', at 325.93Review by a Working Group convened by the Royal College of Physicians, `Criteria for theDiagnosis of Brain Stem Death' (1995) 29(5) Journal of the Royal College of Physicians ofLondon 381.94Pallis and Harley, ABC of Brain-stem Death, at 3.95Birnbacher, `Philosophical Arguments', at 340.59 Why and when is a potential donor a cadaver?

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In 72 career games, which includes the first four years of his career with the Arizona Cardinals, Brown put has 215 catches for 3,230 yards and 22 catches.
Buffalo Bills are revamping their wide receiver corps with the additions of free agents John Brown and Cole Beasley, according to multiple reports.
Brown is expected to sign a three-year, $27 million deal. It looks like that's going to pay off, because Brown was very good for the Ravens previous year, catching 42 passes for 715 yards and five touchdowns.
The Ravens and Brown both expressed a desire to stay together, but Brown's style of play made him an attractive option in what was regarded to be a rather thin wide receiver market. He had a 65 catches for 672 yards and three touchdowns in 2018.
Nsekhe's deal is worth $14.5 million over two years. He averaged 17.0 yards per-catch, showing that ability to go over the top of defenses. Joe Flacco was benched for Lamar Jackson at quarterback. When healthy he's a field-stretcher, someone rocket-armed Bills QB Josh Allen can burn any defence with deep.
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Paid members will be able to download songs, videos, albums as well playlists to their mobile devices for offline listening. The YouTube Music app is available on both, Android and iOS , and can be downloaded off their respective App Stores .
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Spotify now offering free Hulu subscription for its Premium customers
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Grammy Nominated Saxophonist Dave Koz Returns with Summer Horns II Album – Details Here!
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"Summer Horns II From A To Z" is scheduled for release on June 22nd via Concord Records and will be followed by a massive summer tour of North America.
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Access Staff
Washingtonian (10/19) Dalphonse, Sherri
Tickets for World Series games in Washington, D.C., may be hard to come by, because there is no general public sale of tickets except for presales. A Washington Nationals spokesperson said seats for the three D.C. World Series games are "extremely limited," although more may be made available. Season-ticket subscribers were able to reserve seats early — first through an opportunity to purchase tickets for every postseason game that might be played in D.C., and more recently in a presale when they could buy extra seats. This left some unable to get two seats together, although single seats and standing room were available. Fans who bought seats to the National League Championship Series against the Cardinals were given an opportunity to participate in a presale of "a limited number of tickets" on Oct. 18, while those who missed this could register for a lottery for a limited number of tickets later the same day. Purchasing season tickets for the 2020 season also could be a sensible move for fans. TicketIQ estimated that the "secondary market get-in price" for Nationals tickets is about $800.
Read the full article on the Washingtonian.
Tags: Sports , News , Stadium
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Kayla Nickles
Work from home wife and mom of two boys (with one on the way), Christian Leader, and writer.
"So do not fear, for I am with you; do not be dismayed, for I am your God. I will strengthen you and help you; I will uphold you with my righteous right hand."
Isaiah 41:10
Terry Ann Adams
Coming Soon


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But Messi should feel singled out, as Pele didn't spare his countryman Neymar from criticism either, not for his football skills, but for his theatre ones.
"He had bad luck because the team didn't win the World Cup and he was branded", Pele told the daily Folha de Sao Paulo. TO start with Pele was a bit diplomatic saying it's a matter of taste of people as to who likes whom. For me Maradona was one of the best. "To compare with Pelé, it has to be someone who shoots well with the left, shoots well with the right, and scores headers".
The comments made by Pele are sure to get the tounges rolling but at the end of the day, it is his point of view.
Pele believes Neymar is a better player than his fellow PSG forward Kylian Mbappe, who won the Best Young Player award as France triumphed at Russian Federation 2018.
With the negative press that has surrounded Paris Saint-Germain superstar Neymar this year, Brazil legend Pele has insisted it is hard to defend the former FC Barcelona attacker.
Both Pele and Maradona have flip-flopped between loving and hating Messi. Much better. (Franz) Beckenbauer, (Johan) Cruyff are also better.
After failing to be selected among the top-3 of the Ballon d'Or finalists for the first time in over a decade, Lionel Messi must now contend with a withering assessment of his talents from Pele.
"You will ask me: 'Was Maradona better than Messi?'" he added.
"It is hard to defend Neymar for all the things he does outside of football..."
"Mbappe? We are really similar, isn't it?" Aged only 19, he is considered one of the finest players in the world already.
O Rei also said he is in better health after some surgeries over the past year, but is not yet 100%.
"You mention several names, but from the last 10 or 15 years, I think Messi's been the most consistent player, without doubt".
"I scored more goals than my father".


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Release Date: 1983 |
Album Rating: 5.0fuck reviewing
That dude in the band pic is fucking ginormous. Hope he does vox.
I'm listening to this now, and it kicks copious amounts of ass
not a fan of their debut, is this better?
its really good
these guys pretty much were the punk scene in portland
Album Rating: 5.0this is their debut ?
yea youre right, whoops
i meant debut LP, it seems like most people mean the first full album when they simply say "debut"
that or im dumb [2]
Album Rating: 5.0yeah it's their best
Album Rating: 5.0I KNOW WHAT'S COMIN I CAN'T WAIT
good review
gonna listen to this later it's been a while
Album Rating: 5.0This winter is going to be a lot of poison idea, a lot of RP and a lot of Scandinavian d-beat
for a huge ice cream eating beer swilling motherfucker pig champion could geetar pretty hard
Album Rating: 5.0Yeah it actually doesn't make physical sense
Album Rating: 5.0Listened for the first time in a while yesterday. US hardcore bible right here
For some reason I haven't heard this yet but this band slays so hard
Album Rating: 4.0so good
Bands: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


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I have simply Cloud Foundry App and I deploy code with
ibmcloud cf push
It works perfect, but I don't want to wait to downloading all of things which IBM cloud uses. I just want to change one file (index.php) and restart the app. Exists some way how can I do it?
173 people are following this question.
IBM Cloud (free account) - Can't create or rename ORG 0 Answers
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Instead of talking about wide strikes and generals, we are doing something else here. We & # 39; Raising the personal level, transferring young adults with special needs is one of the biggest challenges in finding a home for the first time. We're going to talk about what's happening in one of the East Coast states: Connecticut.
Currently, Connecticut has more than two thousand adults with intellectual disabilities. Most of them live with their families, though they desperately want to be independent and live their own lives. Some have waited so long for their primary caregivers – the legal risk of losing their parents.
Connecticut state laws promise to find housing for these people, on the basis of which three of their priority tasks qualify for housing within one year of the priority championship and five years in the lower order. But there is a problem. Waiting list broken. The primary system does not work. No one gets an apartment, and they all just wait.
The first issue is that state law prevents any mentally handicapped person from staying in one of the state and group homes if they are abused, abandoned, or removed from their primary caregivers. There are literally families in Connecticut where the primary caregivers are retiring decades later, and the children with special needs who are caring for them are approaching retirement age.
The second problem is that there is simply no funding for projects that are supposed to develop a waiting list. The state has a billion-dollar budget for the Department of Developmental Disability, and most of it supports the 961 people who currently occupy all the state-of-the-art facilities for adults with disabilities, leaving the other 1,110+. just waiting. One family has spent more than 23 years in a single "wait a year" priority group, and for over two decades has not even listened to their job reserves. Their daughter is now 42 and her parents are about 70.
The third problem & # 39; aging & # 39; process. By the time a person with a disability turns 21, all federal funds that support their education and therapy are simply ending. On the 20th they have speech therapists, occupational therapists, physical therapists, several teachers, counselors, etc. … and on the 21st they have their parents. It puts an unbelievable burden on parents, but it also means that the waiting list is growing every day … and never narrowing.
Fortunately, Connecticut is just one state. Unfortunately, this is not always better. Of the entire population, considering the entire population of people with special needs, 53% of them still live at home with their parents. Another 31% live in auxiliary, supervised or auxiliary homes, 11% live on their own, 3.5% live in foster care, and 1.5% live in state institutions. Regardless of where you live, unfortunately, if you are an adult with special needs, living with your parents is the norm.


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By John Solomon and Buck Sexton
President TrumpDonald John TrumpLawmakers prep ahead of impeachment hearing Democrats gear up for high-stakes Judiciary hearing Warren says she made almost M from legal work over past three decades MORE rattled off many of his favorite Fox News commentators during a 45-minute Oval Office interview.
"The great Lou Dobbs, the great Sean Hannity, the wonderful, great Jeanine Pirro," the president said Tuesday as he named for Hill.TV just a few of his favorite TV news personalities whom he said wanted him to declassify documents in the Russia probe.
He even marveled at how Pirro, a former prosecutor and state judge, reacts to criticism of his presidency. "She takes it so personally," he remarked.
Trump said he values all of their insights but doesn't relish one of their favorite terms for the federal bureaucracy: the "deep state."
While he agrees with the hosts that some career workers at the FBI and other agencies have secretly worked to try to thwart his presidency, he's just not fond of the nickname.
"I don't like to use it because it sounds so conspiratorial, and believe it or not I'm really not a conspiratorial person," he said during the exclusive interview.
Trump may not like the term, but he has used it more than once.
At a rally earlier this month, Trump used it to refer to the anonymous author of an op-ed published in The New York Times, denouncing "un-elected deep state operatives who defy the voters to push their own secret agendas are truly a threat to democracy itself."
He described the "deep state" as a threat to democracy in the Sept. 7 speech.