Diagnosis Death
My buddy Steve is teaching a religion class called Death and Dying. He called us up last Monday and asked:
Steve: “If I died, and we transplanted my heart into your body, what would happen to my heart?”
Joel: “Well, if I didn’t reject the transplant, nothing would happen to it. There’s no turnover of cardiac cells, so your heart would keep going as long as I lived.”
Steve: “So, part of me would still be living?”
Joel: “Right. Your cells would live on in my body.”
Steve: “And part of me would still be alive. But we don’t use the stoppage of the heart as the end of life anymore.”
Joel: “Nope. It’s all about brain activity now. So we check your reflexes and, if there’s some question, an EEG [Electroencephalogram].”
Steve: “So when did we make that change?”
Joel: “Um, I dunno. I’ll quick look it up.”
Steve: “Great! Class is in forty minutes.”
So I dashed over to my trusty internet portal and found this article from 2003 by Doig and Burgess in the Canadian Journal of Anesthesia, which supplied the answer: we started using EEG readouts to diagnose death in 1968.
But, more interestingly, it discusses how moving from the cessation of heart and lung activity to measuring brain activity was a fairly arbitrary decision, and that relying on EEG readings of brain waves remains a fairly arbitrary measurement.
First of all, the Uniform Determination of Death Act asserts that a patient who has suffered “irreversible cessation of all functions of the entire brain, including the brainstem is dead.” The problem with this seemingly definitive definition is that the clinical diagnosis of death doesn’t actually measure all of the brain’s activity, and many patients who are diagnosed as “brain dead” obviously still have some “lower” brain function, i.e. their brain is still controlling hormone release, body temperature, and even digestion.
But, if there was some point at which so much brain function had been lost that the remaining functioning brain would inevitably and quickly break down, that point could be described as “as good as dead”, right? Kind of like when a heart stops, it might take many hours for all of the cells in the body to actually cease functioning themselves, but they’re inevitably going to die in the near future. So if our current diagnosis of brain death accurately describes such a state, then, arguably, it’s being made correctly.
But it isn't! The article describes a study in which a large number (it’s kind of confusing in the article as to how many) of patients who were diagnosed as “brain dead” but whose cardiovascular system (controlled by the brain) continued to function for weeks to a month.
Okay, but if on an EEG reading there’s no sign of brain activity, then that’s a pretty sound determination of death, eh? But no!, per another study, 11 out of 56 patients who were diagnosed via EEG as brain dead had reemergence of brain activity soon after diagnosis. And I’m not talking about a few fizzes or random waves, but a brainwave pattern that was otherwise indistinguishable from sleep. One patient in this study sustained this sleep-like level of activity for a week.
In his class, Steve talked about four different “planes” of the definition of death. The Physical plane tends to be what western societies are most concerned with, reckoning death as the cessation of life per loss of biological function. This is a tradition bourn out of science, and while our science is pretty good at determining when someone is unrevivable (but not great, see the Terri Schiavo case), that’s obviously not the same as establishing that someone is really and totally dead. I’m reminded of Miracle Max in The Princess Bride: “It turns out your friend is only mostly dead.”
From a medical point of view, this question really impacts organ donation. By the time an organ donor patient no longer has any brain function, and we've checked with an EEG that no brain function has or will reemerge, and we've determined that the brain isn't controlling any of the body's most basic functions, some of the more delicate organs (e.g. the heart) might be too damaged to be used in an organ recipient. On the other hand, a lot of organ donors may be dismayed to learn that doctors are basically taking an, "Eh. They're mostly dead. Let's go get those organs and save some lives with 'em," approach to their gift.
The other planes Steve discussed, each of which could easily be a semester course (or a separate weblog entry!) unto themselves are as or more important than physical death to various other world cultures. I'll ruthlessly paraphrase them even further than Steve did in class:
The second plane was Consciousness, which he summarized (with a lot of discussion to follow) with the question, “Do you have to know you’re alive to be alive?”
The third was Relational, and Steve referenced both the Lakota and the Orthodox Jewish thought that someone is never dead to you as long as there is a relationship tying you together. In the Lakota tradition, they may be transported to another plane of existence, but that’s really all the more reason to keep in touch (“Dear grandson. Am in the spirit world now, and all the humorous postcards were used up, so I hope you enjoy this picture of Unktegila at the lakeshore…”). Or, going the other direction, think of Shylock after Jessica abandons him for her gentile lover. She’s still alive in the physical sense, but she’s at least as dead to Shylock as if her brain had ceased to function.
The fourth plane concerned our relationship with the Spiritual, with the familiar-to-Christians idea that after this life on earth, we will live on in an afterlife.
But what if our heart is still alive and beating back on earth?