Oh Death Where Art Thou?

Not so long ago life and death were so simple: If the heart was beating the person was alive, otherwise s/he was dead. Then the medical profession discovered how to restart the heart if it had not been quiescent too long. This was followed rapidly by the Heart-Lung machine that enabled the deliberate stoppage of the heart to permit open heart surgery. Since the body was not alive by the old definition, but would be alive in the near future, the concept of "Clinical Death" was developed. Not a good choice of words since it falsely implies a state of death.

This was only the beginning. Rapidly, transplant techniques and mechanical replacements were developed for many major organs. Hormone therapy and intravenous feeding permitted life to continue without other organs. Where will it all end? At present the only organs that are not replaceable, in some sense, are those of the brain. In the not too distant future, it may be possible to sustain a decapitated head with complete intellectual and emotional capabilities. Possibly parts of the brain, such as the stem, conceivably could be replaced.

So, how to define death in the midst of this rapidly changing medical technology? The tradition religious views are of little help. Is death of the brain the only true definition of death? Then, truly what constitutes brain death? Is a body in Cryonics suspension alive or dead: Proponents insist on "alive" but many people are doubtful. Few people would describe Henrietta Lacks as alive although the HeLa cell cultures thrive more than 60 years after her death.

The brain is not a single organ: Many organs with diverse functions are contained in the Brain Structure. Medical procedures have been developed for examining patients in coma and for patients exhibiting the symptom of brain death. No one test such as EEG or PET is alone sufficient for declaring brain death.

And now we come to a truly gray area. What is the persistent vegetative state (PVS) and what are the appropriate medical ethics surrounding it. In PVS, the body is awake, but exhibits no awareness, intelligent activity, or emotions. Almost always there is evidence of extensive damage to parts of the brain except the brain stem. This is in sharp contrast to individuals in coma who are asleep but exhibit near normal brain activity. A clinical examination; without support of CT scan, PET, EEG, and other tests; cannot produce a definitive diagnosis. Even with these test the diagnosis can be uncertain. But, if the state persists for more than a few months, recovery of intellectual functions is extremely doubtful. Contrast this with coma where the patient is not awake, but recoveries have occurred after several years. Should a person in PVS be declared brain dead? The present definition of brain death excludes PVS since the brain stem is functional.

Who should decide the fate of persons diagnosed as brain dead or in PVS?

  • The person?
  • The doctors?
  • The family?
  • The insurance companies?
  • The courts?
  • The medical examiner/coroner?
  • The legislators?

If the person has a living will his/her preferences should be observed wherever possible. However, the determination that the conditions of the living will have been met must be resolved. Some individual or group must have the responsibility for this resolution.

Without a living will, the decision can become contentious. Any individual with a potential conflict of interest should not be responsible for the decision. Individual with conflict of interest include:

  • The doctors - they are supposed to preserve life.
  • The family - hope for recovery, passing with dignity, financial gain.
  • The life insurance companies - maintain premium payments.
  • The health insurance companies - terminate payments.
  • The courts - subject to political manipulation.
  • The legislators - subject to public opinion.

This leaves only the medical examiner. The medical (coroner) examiner normally determines the cause of death - this additional responsibility in only a small increase - conceptually at least. In my opinion, the coroner should have the primary responsibility for determining the medical state of the individual and the permissible medical options. When the diagnosis of PVS, or other an ambiguous condition, has been made by a doctor, the coroner would review the case, order additional test as appropriate, and issue his/her conclusions. If the conclusion is that no reasonable possibly of recovery exists, then - and only then - should discontinuance of medical support be permitted. The final decision to discontinue support would be by the person with power of medical attorney. However, if the decision is to continue support, the health insurance company might decide to stop benefits unless the policy contains a rider for support beyond the point of any reasonable chance of recovery.

This resolution will not satisfy everyone and possible not satisfy anyone - not even me in all cases. However, I feel that it is the best alternative in cases of probable brain death.



© Copyright 2005-2016 D E Pauley