Our technology has caused us to radically redefine our concept of death. The advent of the mechanical ventilator greatly prolonged our ability to preserve vital functions in comatose patients. We now have a arsenal of drugs that maintain the function of very sick hearts. In fact, we now have machines that can actually pump blood and oxygenate it on their own, called extra-corporeal membrane oxygenation. It is often used in babies with severe lung disease.

Death has historically, and continues legally, to be defined as the presence of the heartbeat. This technology presents a unique challenge to this idea. Technically, it we use a heart/lung machine during an open heart operation, we are operating on a dead patient. Thus the surgeon, legally if not in actuality, is raising the dead with the operation. Is this playing God, or was the patient really dead A legal rethinking of the matter was inevitable.

Mechanical life support comes at great expense, but can be a life saving marvel. Inevitably, the question came along, should we forever artificially support breathing for people who won’t wake up. In 1968, Harvard Medical School put out a paper defining the concept of irreversible coma. Theoretically, if we knew, really knew, when someone in a coma was never going to awake again, we could then know that artificial maintenance of vital signs is a futile effort and could ethically pull the plug.

In 1976 just such a case came along, Karen Ann Quinlan. She was injured in an automobile accident and sent into a coma for several years. Her parents asked the hospital to discontinue care, they refused and a landmark court battle ensued. This lead to a presidential commission study in 1981 which lead to the concept of brain death.

In brain death, all brain activity has ceased and is completely nonfunctional. The idea is that without any higher consciousness we don’t really have life any more. We are dead, period, end of story, heartbeat or no. This is a radical and new concept. It has developed just within my lifetime. In has met with great resistance and can be fraught with moral dangers.

After all, aren’t animals considered living even without consciousness, at least not human consciousness? What happens in the case of locked in syndrome for example. In this condition the patient is fully conscious but completely paralyzed, or “locked in” They feel pain, are aware of everything going on around them, but cannot communicate. While it is certainly debatable whether it is merciful or cruel to pull the plug on this individual, they are undoubtedly not dead.

In my youth, Metallica put out a famous song one describing a soldier with this condition during WWI for the movie Johnny Got His Gun. The video can be seen here.

For this reason, the concept of life, consciousness, spirit remaining with the body, great pains have been taken to separate brain death from coma. Legally, a brain dead person, someone who meets strict neurologic testing criteria, to verify complete and total irreversible absence of brain function, is completely, legally dead. They have no right to continuing life support for their corpse. Short of a Lazarus event, they are never coming back. The spirit is assumed to have left the building, and yet the heart beats on.

They cannot have the most minuscule reflex of the most primitive part of the brain present or they will not meet the criteria. This is not a concept easily comprehended by the public. I have heard of families fighting tooth and nail, issuing death threats to staff, in some very emotional and perhaps poorly handled cases. I have seen brain dead patients kept on support for weeks awaiting legal proceedings. To family desperate for a recovery and sick with grief, life support is supporting life. It seems completely reasonable from their point of view. For someone who lacks particular trust in the institution this arrangement just feels wrong. It doesn’t help that it is the brain dead patients that we harvest organs from for transplantation. There is a genuine conflict of interest there and the situation becomes very delicate. I strongly support organ transplantation, but that is because I believe in brain death as a bright line and moral protection. Of course, having the bright line leads to necessity of rationing organs, but I’ll save that for a later post.

This construct caused some intense theological debates. The Orthodox Jewish and Islamic communities remain intensely divided on this issue even today. The 1981 commission report concluded that the criteria was acceptable to Catholic and Protestant conceptions of death, but others disagree. The Pope declared that this concept “does not fall within the concept of the church.” So they have been left to sort it out themselves, with most agreeing with the commission. However essays have been written with an opposing Catholic view.

The question really comes down to where one thinks the spirit is tied to the body. Is it only in the mind, or the entire body itself. Critics cite the examples of women who have been declared brain dead and remained on life support up to 200 days to carry the pregnancy to term. If the spirit and the mind are separate things, how do we sort this out? I have expressed before the Mormon concept of ensoulment, that there is a point in development where the spirit unites with its developing body. When does the spirit leave its degenerated body. My theory is that the human brain and complementary spirit version are linked. I have to think when that link is severed, the spirit goes free. I haven’t the faintest idea how to test or prove this, however. Perhaps this is an occupational hazard, the tendency to view the body as a machine. I can conceive a beating heart, functioning, if artificially powered lungs and living cells as an empty shell, or even as in the extreme cases sited above, as an incubator providing for a new life. I am curious as to how others feel about this.

Even accepting perhaps that a spirit is still tied to a brain dead body, is this life really a life worth living? I have felt quite comfortable in expressing to many families that sometimes we just have to accept that God may be calling someone home. So much of our desparate medical search to beat nature over the head is rooted in selfishness. We don’t want to let go. Honestly, if I’m on the machine, I want to go home to that God who gave me life. It seems much more pleasant. What do you think?

Advertisements