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Struggling to Define Death

Posted: 10/04/10 08:30 AM ET

Back in 2009, a Dartmouth neuroscientist named Craig Bennett was fed up with the increasingly
strong dogma surrounding studies of the human experience that used functional magnetic resonance imaging (fMRI). The public had grown to accept headlines that described the findings of recent studies: Men literally see women as objects, we're all actually racist and humans are hardwired for religion, altruism or monogamy. The studies themselves were increasingly designed to cultivate such headlines.

Bennett satirized these soft studies by putting a 3.5-pound salmon, a dead one, in an MRI machine and showing it pictures of humans with an array of facial expressions. With each, Bennett asked the dead fish what emotion it thought the photo showed. Bennett had a surprise in store. Functional scans found slight electrical activity in the fish's brain, which further demonstrated his point. "If I were a ridiculous researcher, I'd say, 'A dead salmon perceiving humans can tell their emotional state,'" he told Wired magazine.

His study (though mostly unnoticed) also underscored a larger issue facing the world right now. We have at our disposal technology that can detect the most profoundly minute signals of life. And yet, we have not yet reached the point where we can bring those signals back to any kind of meaningful level of consciousness once they've disappeared. We are still, in the second decade of the 21st century, unable to revive dead things, human, salmon or otherwise.

Perhaps most hauntingly, these machines challenge our definition of death. We've reached this weird point in human history where we've created technology that has leapfrogged over our traditional methods of distinguishing life, like looking for signs of respiration and feeling for a pulse. We cannot be sure whether those signals are life and are helpless to do anything but observe them. But we can sustain them, and it is in this ability that we reach our current conundrum: We have no idea when death occurs.

This problem is a contemporary one. In centuries past, the problem of defining death was insignificant, aside from the fear of being buried alive, which still loomed large on the minds of those approaching death. George Washington instructed his body be laid out for two days before being entombed, just in case. Frederic Chopin asked to be fully cut open prior to being buried. Safety coffins, a subcategory of caskets appeared in the 17th to 19th centuries. These caskets were generally outfitted with a bell attached to a string hanging down to the deceased's hand or some other means of alerting the living topside that a premature burial had indeed taken place.

Death was death, and there was no real need to define when it took place.

Then two advances -- organ transplantation and life-sustaining technology -- converged in the middle of the 20th century to give us urgent reasons to come up with an acceptable definition of death. We could now artificially maintain the mechanisms of life -- respiration and heartbeat -- in a person whose brain no longer functioned, ostensibly until the person died of old age. But what purpose does it serve to maintain the life of a terminally unconscious patient, especially after it became possible to transfer that person's organs into another person who could put them to good use?

Since science is incapable of quantifying when death occurs, it turned to society for guidance. The 1970s saw a spate of piecemeal legislation, as states created their own definitions of death. Those that did emphasized brain death. In 1981, a council of medical ethicists convened by Jimmy Carter supported this idea of brain-centered death, and the remaining states followed suit.

There is yet no federal definition of death, and there are actually a couple of ways that death can legally take place today. Cardiopulmonary death -- the cessation of a spontaneous heartbeat -- remains an accepted definition of death, but quantifying the moment of death still remains elusive. In 1997, an Institutes of Medicine panel decided that five minutes after the cessation of heartbeat was the moment of death. This choice was arbitrary and sentimental, however. Worse, during this time, the heart is starved of oxygen, and what was a viable transplant organ five minutes earlier becomes useless.

The other organ of life, the brain, has also proved prickly as a means of determining death. The focus for brain death has long been the brain stem, which controls the most basic functions like breathing. Medical science established rigorous criteria for brain stem death. Patients who are subjected to these tests have ice water squirted into their ears, have a tube introduced in their esophagus to induce gagging and are twice taken off ventilators to determine apnea, among other tests.

The problem is, again, some people who are apparently dead can still show the most primitive signs of life. We arrived at the most recent incarnation of the question of death, something like: If your lungs are moving, does that really mean you're still alive?

Last year, the President's Council on Bioethics answered no. Death is now the end of engagement with the world around us. If widely adopted, this idea would end the ventilator debate. A human engaged in the act of breathing does so for survival, a human whose lungs rise and fall does so because of the pressure exerted by a machine. He is no longer engaged in the act of survival and is therefore dead.

This is a momentous move; the heritage of our collective fear of being buried alive has prompted us for decades to err on the side of caution, to prevent even the slightest possibility that those physicians who harvest organs are actually taking them from living people. This newest concept of brain death signals that we have reached the point where we are opting to no longer believe our eyes, but to put our faith instead in the idea that death is something we are not yet able to detect.

 
Back in 2009, a Dartmouth neuroscientist named Craig Bennett was fed up with the increasingly strong dogma surrounding studies of the human experience that used functional magnetic resonance imaging (...
Back in 2009, a Dartmouth neuroscientist named Craig Bennett was fed up with the increasingly strong dogma surrounding studies of the human experience that used functional magnetic resonance imaging (...
 
 
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HUFFPOST SUPER USER
smoovejef
Karma is my God
01:40 AM on 10/09/2010
Forget defining the process of death; focus on the experience. It is unique for most people, but almost no one wishes to die alone. It is a time where dignity & respect should be afforded to the dying, the dead and those left behind who loved or cherished them. For the dead, their struggle in this life has ended; it is the living who must cope with the loss, the emptiness left behind. Comfort the dying, but support the living. The rest will work itself out in time.
12:47 PM on 10/05/2010
Death and dying is arguably the most feared aspect of living. Now to figure out a way to use this for political gains!

Oh wait, they already have ...
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OtayPanky
You're welcome
06:38 PM on 10/04/2010
"I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description ["hard-core pornography"]; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it, and the motion picture involved in this case is not that. ”

— Justice Potter Stewart, concurring opinion in Jacobellis v. Ohio 378 U.S. 184 (1964), regarding possible obscenity in The Lovers.

---

Works for sex. Works for death.
03:54 AM on 10/05/2010
Brilliant!
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HUFFPOST COMMUNITY MODERATOR
moonflowerjewelry
Buy American made, no excuses.
03:51 PM on 10/04/2010
Much like the debate about when life begins, it is another time where somepeople want government intervention, even as they cry crocodile tears about "big guvment."
Many, many years ago I chose to abort a fetus with anencephaly: a mass of cells that looks like a baby but lacks a brain. I generally don't talk about it because everyonce in awhile I'll get the nosy do-gooder telling me that I should have carried to term and given a proper burial to IT. Not their business one way or another. Do not resuscitate orders are frequently ignored as hospitals do not want the liability "just in case" - so even as we try to plan ahead and maintain our dignity or not have our families be burdened with astronomical bills to give artificial life to the already deceased.
Seems like the brain-life thingy is a murky issue with no small amount of opportunity for someone to milk the debate for personal gain (political power, a "moral" pulpit, etc)
12:27 PM on 10/05/2010
moonflowerjewelry: I am so sorry for the awful decision you had to make. I was, at one time a special ed substitute teacher and your story brought to mind a little girl in my class that was born with the same problem as your child's. The school bus would pick her up, bring her to public school, then we would transfer her from her chair, to a mat on the floor, we had to learn to feed her using a tube into her stomach and then take her to other classrooms, with regular students to give her the advantage of an education. I thought how horrible for this child, then realized since she has only a brain stem and no brain how is this child going to learn anything ever. I felt very sorry for the parents, since this was their only child and what are they going through also. I don't know when life begins or ends but in a case such as this, is this really life? and what kind of quality is it? You are absolutely correct in telling nosy people that it is not their business. That was a decision only you can make. I may be pro life but, in this case, I can see your struggle in your decision and that it was not an easy one..
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TheIndependenceParty
Cranky yankee and a rehabilitated ex-Republican
03:27 PM on 10/04/2010
I have performed the apnea test many times on patients with severe brain injuries being considered for transplantation, and been at the bedside when the "caloric test" is administered with ice water flushed into the ear canals. I viewed those tests as an agreement between the patient and the doctors, by virtue of the patient's request to be an organ donor, that they are adequate to be their accepted definition of a point of death for the patient. Fair enough, and as you point out, it allows the patient to donate such sensitive organs as the heart and lungs, ... in great need, but easily damaged in the case of the heart, when oxygen fails to reach it for a few minutes.

But beyond that particular definition, designed for precision to allow transplantation, death has seemed to me to be quite easy to determine. It is the point at which the observations we all agree are life, ... meaningful signs of life and its constantly interactive aspects, ... reach a point where they grow so faint as to be unobservable. The dead salmon in the MRI is an example, ... bombard previous living tissue with radio waves in magnetic fields such as those in MRI's, and a slab of beef might twitch, ... but it is not living.

And so we agree, and disagree, in order to draw a legal line in time. What came before it was life, and in its absence death.
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Carbon Forteetoo
Not enough characters to say anything clev
02:04 PM on 10/04/2010
Once we are able to transfer a human "mind" into a human built computer equivalent, and assuming that the transfer has included the same level of conscious awareness as the person had when they lived in their original, organic human brain...is that computer-stored mind now considered a live person?

Next question: Will Dr. McCoy be able to return Spock's brain to his original body before he loses the knowledge to perform the transplant operation?

Follow up: Brain? Brain! What is brain?!?!
04:12 PM on 10/04/2010
If you transfer the contents of your "mind" to a computer, will a zombie still want to eat it? Or will he go after the computer?
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Marcus01
It all just seems like it's real
09:36 PM on 10/05/2010
Anyway you pose it, a no-brainer is still a no-brainer.
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Damiano Iocovozzi MSN NP
01:59 PM on 10/04/2010
The article bravely asks, "How many angels can dance on the head of a pin?" Totally irrelevant as the organism can still be maintained artificially, even after cerebral brain liquefaction occurs, but does that constitute a human life? There are biomedical ethical standards to say what life is and it boils down to this: can one give and receive love? Does a brain dead organism whose brain stem still allows him to breathe and make his heart work a human being anymore? The higher standard does apply: can he give and receive love? The cerebrum is the seat of the personality and when it's dead, it doesn't regenerate. Consider, the US still foolishly wastes 1.2 trillion USD on medical futility for those past all cures, all remissions, reprieves from advanced age or dementia. That amount of money could give free and basic health care to every living human on the planet. There is no point in pursuing cure orientations for those beyond benefit as evidenced by the scientific signs of weight loss, lowering albumin, prealbumin levels and rising CRP levels over a period of time. For those who will be naturally finishing their lives within six months, hospice or palliative care at home is the sane and compassionate alternative to medically futile protocols as they actually cause more human suffering. For every living creature, there is a beginning and end on this planet. Please visit my free blogs and web page at soonerorlaterbook.com
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johnnybic
Seeking to impose the gay agenda since 1971
04:29 PM on 10/04/2010
I appreciate your effort here, but your standard of "can one give or receive love" begs a similar angels-on-head-of pin question: How do you measure that? As a former hospital chaplain, I witnessed both sides of the issue. One patient with CHF had a firm DNR order. We had talked about it at length--she believed that when she was no longer able to breathe on her own without the aid of machinery, it would be time to let go. When the time came, she changed her mind. She literally begged to be connected to a respirator. On the other hand, one woman who had a self-describer "vitalist" bias rooted in her religious beliefs wanted everything done. When the pain medications made her "loopy" and unable to communicate with her family and loved ones, she finally decided no more treatment.
One family member asked me if he should stop visiting his severely demented mother who no longer recognized him. I asked him how she responded when he visited her and his reply was telling: "She doesn't have any idea who I am but she seems to perk up when she sees me, happy to have a visitor." He had his answer. As long as dilettantes like Ms. Palin voice their idiotic concerns about "death panels" there will be no progress. We need to continue the conversation and learn to be comfortable with uncertainty, recognizing the most common color here is grey, not black or white.
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Damiano Iocovozzi MSN NP
05:41 PM on 10/04/2010
Dear Mr. Bic, I'm describing brain death as described by the President's Commission for Study of Ethical Problems in Medicine (defining Death). Your examples also sounded like they could still be able to give and receive love, even if one was demented. With a DNR order, one can change one's mind at the last minute, same with hospice. Another point of consideration is the application of the six generic medical goals to each case: restoration of health, relief of symptoms, restoration of function or partial restoration of function, saving or prolonging a life, education and counseling & avoiding harm. The grey areas you speak about become clearer when the goals of medicine are realistically measured against a patient's condition. Medical futility occurs when the goals are forgotten or not applied.In the case of your woman who begged for intubation, death was just put off for a little while. Neither life support nor code blues heal nor cure; they're just extreme band aids which, in the long term, put off the inevitable for a short time period. People like Palin like to trot out nonsense to stop intelligent conversation like ours. However, these discussions have a long history in biomedical ethics. I didn't coin the criteria for life as the ability to receive or give love. That idea comes from the great philosophers of the age of enlightenment. If you've more questions about ethics, get Jonsen, Siegler and Winslade's Clinical Ethics and do come to my web page at soonerorlaterbook.com.
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HeevenSteven
20 Minutes into the future.
01:20 PM on 10/04/2010
".... Death is now the end of engagement with the world around us.."

Then the Tea Party is dead!
12:38 PM on 10/05/2010
No it's alive and well! Come November you will see just how alive.
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HUFFPOST COMMUNITY MODERATOR
KateInMT
May you stay forever young.
04:34 PM on 10/07/2010
Uh huh, alive as that salmon in the MRI machine. ;)
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HUFFPOST SUPER USER
Ljilja
http://graciouslivingdaybyday.com/
12:47 PM on 10/04/2010
You bring up some excellent points. The technology is making strides much more quickly than medical ethics.

We need to rationally discuss these issues and come to some kind of agreement as a society. It is too heavy a burden to leave for doctors and individual family members to make on their own.

http://graciouslivingdaybyday.com/
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Damiano Iocovozzi MSN NP
06:16 PM on 10/04/2010
These issues have a long history of discussion since the Age of Enlightenment philosophers like Immanuel Kant and Jeremy Bentham. There are already in place the six generic goals of medicine which I explained in a post above. Most ethical problems arrive, not from a plethora of new technology, but rather from a lack of using established biomedical decision-making methods when an ethical dilemma arises. Actually, ethics is easy when you use all six medical goals vis-a-vis a particular patient case. Scientifically, are there changes in labs (albumin, pre-albumin, CRP), weight loss, fragility etc? Most ICU beds are filled with dying patients because nobody was paying attention to those goals and no one is seeing a dying person there for many reasons: financial, guilt, stigma of death etc. For a person past cures or remissions or advanced old age or dementia, the only achievable medical goals are doing no harm, education and advice about diagnoses and relieving symptoms. These goals can be achieved in the home setting under hospice or in a palliative care program. There is no benefit to the patient nor the society to pursue medical futility and a cure orientation even when somebody screams lawsuit. You cannot put up to a vote a millennia of established philosophical thought to come to some sort of agreement with people who do not know philosophy and its normative branch of biomedical ethics. Damiano de Sano Iocovozzi MSN FNP CNS soonerorlaterbook.com
12:06 PM on 10/04/2010
I do not know how I feel about euthanasia.On one hand people who are dying who are in terrible pain.should have some sort of release.On the other I do not want parents of Downs and disabled children ever to have the right to say"you are just a bother so I am getting rid of you".
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HUFFPOST COMMUNITY MODERATOR
moonflowerjewelry
Buy American made, no excuses.
03:41 PM on 10/04/2010
An adult should be able to choose this for themself if they so desire, much the same as "no-resuscitate" order. Much different than a person choosing for them, or choosing for a disabled child. Apples and oranges.
11:36 AM on 10/04/2010
There will always be those who think you have to do everything humanly possible to prolong life, even if your just fertilizing the vegetable that has no chance of ever developing. I've had to have a dog with a tumor put down when the suffering got too bad. For humans, you can issue a directive not to be put on machines and be kept comfortable, be kept "alive" with all means possible, or do yourself in.

Same debate rages at the other end of the spectrum. Some think life begins when a sperm hits an egg, others want further development. Either way, we have people that want to enforce their moral view of life and death.

Too bad we give our pets more options than humans.
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tinyrainbows
11:34 AM on 10/04/2010
I'll define death for you. Watch the Democratic party the day after the election.
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11:44 AM on 10/04/2010
IN YER DREAMS....
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moonflowerjewelry
Buy American made, no excuses.
03:42 PM on 10/04/2010
...don't bother getting into it with them, it lowers us to their level of petty inanity.
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FDRbyGodDemocrat
Liberal, nerdy, and festively plump.
06:51 PM on 10/07/2010
...as they hold a mirror to the face of the Republican party...
nancynancy
Atheist.
11:25 AM on 10/04/2010
I think this article is already out of date. US researchers are now working out the mechanics of suspended animation (similar to the state of hibernation used by squirrels in winter months) by replacing blood with a cold substance that shuts down brain and cellular activity. This is being tested with pigs, and it is only a matter of time before it is used on humans.
01:28 PM on 10/04/2010
It's a terrible idea! Didn't they ever see Wrath of Khan? That's what happens with suspended animation!
nancynancy
Atheist.
03:11 PM on 10/04/2010
The procedure is being developed to save the lives of soldiers who are traumatically injured on the battlefield and would otherwise die of blood loss.
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medicontheedge
big loud broad
03:06 PM on 10/04/2010
To WHAT end? Live forever? How arrogant! When it's time to go, it's time to go. Stop the madness of keeping people alive no matter how terribly excruciating it is for them.
itolduso
lateral thinker
11:14 AM on 10/04/2010
We must find a better way. I witnessed a 90 year old woman with rectal cancer, her body weakened by multiple rounds of chemo & radiation, the tumor, unstoppable, was finally eating it's way out of her body. Unable to walk, sit-up, eat or drink, or talk- she lay in the hospice bed, where the 'angels' that worked there fought valiently to maintain a dosage of pain medication that would minimize her suffering, but -thanks to our draconian laws- would not 'kill' her. An impossible battle to win- pain ALWAYS breaks through- evidenced when, every so often, a low moan- the only sound she could make- would force itself, from deep inside, and transform itself on it's journey up & out of a face so twisted with agony- into a sound that defies description- a nightmare note of pure horror that haunts me still. We could and would not allow any other creature on this planet to suffer so- and yet for 23 days-a good and decent woman was made to bear this, and her family to witness... because they said it was "not her time". I don't understand it. Medicine interferred with 'her time' by treating with drugs & radiation... how can they stand back when she needed a decent & humane ending?
ydrittmann
Vitter patronizes women.
11:26 AM on 10/04/2010
This happens weekly in our 12 bed ICU. We had a woman for twenty months before she died. Th family limited her pain medicine to pills down her gastric tube.
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CoastalNC
Good thoughts create good things
02:42 PM on 10/04/2010
I cannot understand allowing someone you love to suffer when there are measures that can be taken....it is just beyond me. I sat with my mother for the last 2 weeks of her life, she would not take her pain medication because she was afraid she would become addicted....she was dying and afraid of becoming addicted (religion had convinced her). As soon as she fell into a coma I made sure she had the pain meds she needed and when she started grimacing and I knew it was from pain she was still feeling, I made sure she had additional pain meds provided to me for her. If the pain meds caused her to go a little sooner then I'm glad I was able to help her out of her suffering and I hope that someone will do the same for me if I am ever in that position.
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11:41 AM on 10/04/2010
The christian right in America will never allow sanity to prevail......a humane ending of suffering is out of their comprehension
these people are nuts....they fight science and logic all the way......UNTIL IT SUITS THEM
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Evelyn
10:59 AM on 10/04/2010
Your essay is self-refuting. The fact that people have long feared being buried before they were actually dead shows that it has always been extremely difficult to determine when death has happened, and everyone has always known that.

The revival of especially children who have drowned especially after a fall into icy water shows that complete revival after what looked for all the world like death is quite possible, and doesn't require anything very high-tech to achieve. The custom of holding wakes and sitting with the dead body overnight and for a few days is a folk custom that also shows that people have long known that the line between life, which involves constant regeneration of tissues, and death, which is a one-way arrow pointing down, has never been clear and simple.

The only thing that has changed is the ability and desire to "harvest" one person's organs and implant them in another person. This is supposed to be a warm fuzzy wonderful thing, but it is actually a form of cannibalism. I think that before we go too far in re-defining death, we might want to think a little more carefully about the morality of organ transplantation.
itolduso
lateral thinker
11:31 AM on 10/04/2010
I see transplantation as a higher form of 'communion'. I do not understand the 'morality' of one who chooses to deny that every living organism on the planet is regenerated (consummed) & repurposed at death. It is only humans who interfere with this grand plan by rendering our tissues unfit through chemical embalming and/or locking away in crypts. What a waste.
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cheapNdumb
I never had any problem
01:17 PM on 10/04/2010
soylent green anyone?