Read more: 鈥�Death: A special report on the inevitable鈥�
IT IS now easier to be declared dead than at any time in human history. The standards have fallen so low that your heart can be beating, your brain can be sending out brainwaves, and the doctor can still declare you an ex-person. The good news: only about 1 per cent of the population is subject to minimal death criteria. The bad news: if you fall into this 1 per cent, you may be vivisected.
But we鈥檙e getting ahead of our story.
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The question 鈥淲hen is a person dead?鈥� has troubled us for thousands of years. It is not a trivial matter, especially to the person about to be buried or cremated. So we look for what we believe to be foolproof clues. Is there a central organ that when it stops functioning means a human is dead? Is there a set of behaviours that signals with certainty that a human has shuffled off this mortal coil, kicked the bucket, expired?
In ancient Egypt the buck stopped at the embalmer. The ancient Greeks knew that many conditions mimicked death. Their test was to cut off a finger before cremation.
Medieval Europeans became increasingly uncertain about who was dead and who was alive as the literature began to fill with accounts of premature burial. The difficulties were underscored by the anatomy theatres that sprang up across Europe in the 1500s to the 1700s, where anatomists would perform public dissections on executed prisoners. The performances sometimes demonstrated that the stars of the show were not quite dead. An anatomist might extract a heart, hold it aloft, and be greeted with gasps because it was still beating. One anatomist, Niccol貌 Massa, asked to be left unburied for two days 鈥渢o avoid any mistake鈥�.
The 18th century saw the beginning of two important trends. First was the medicalisation of death. Doctors began to appear at the bedside of the dying to administer opiates, and as the boundary between death and life became more confused, medical technologies were introduced to tell the difference. During the next two centuries, innovations were developed that revealed signs of life in those previously thought to be deceased: artificial respiration, smelling salts, electric shocks, the stethoscope, microphones to amplify chest sounds, radiographic fluoroscopy to detect the motion of vital organs, and the ophthalmoscope to examine the circulation of blood in the retina.
The second important trend in this era was a shift from what today we would call cardiopulmonary death towards brain death. There was no such term as 鈥渂rain death鈥� then, but doctors talked about 鈥渟ensation鈥� and 鈥渨ill鈥� as the measure of a human.
The concept of brain death played a major role in one of the most extraordinary medical advances of the 20th century. In 1954, surgeon Joseph Murray performed the first successful solid organ transplant, transferring a kidney between living identical twin brothers. It was not long before organs were being transplanted from dead donors into living ones.
This remarkable technology promised to save lives, but it faced a major problem: stale organs. You can use live donors for kidney transplants because people have two kidneys and can lope along on one. But for other organs, you need a dead donor. When a person dies, however, organs are deprived of oxygen.
In 1968, a team of 13 men formed the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, and devised a clever plan to solve the problem. Why not declare dead some of the patients on ventilators in intensive care units, and harvest their organs? These patients were in a deep coma but not dead. Their hearts were still beating. If the ventilator was kept in place even after they were declared dead, their organs would continue to be bathed in blood right up to the moment the surgeons needed them. Voila.
That鈥檚 precisely what the Harvard committee did. It defined a second form of death, what one doctor calls 鈥減retty dead.鈥� Up to that point, doctors had used the cardiopulmonary standard: when your heart stopped beating and you stopped breathing, you were dead. Now there was 鈥渄eath lite鈥�, created for the benefit of the transplant industry.
The original Harvard criteria were frighteningly simple, requiring a test shorter than an eye exam. The patient must simply be 鈥渦nreceptive鈥�, showing 鈥渘o movements鈥� and 鈥渘o reflexes鈥�. Rudimentary clinical tests determined this, such as ice water in the ears, a flashlight in the eyes, cotton swabs touched to the eyeball or reflex tests ().
Then comes an 鈥渁pnea test鈥�. The ventilator is disconnected and the doctors see whether the patient can breathe unaided. If not, he is brain dead. Here鈥檚 the scary part. Then the ventilator is reconnected. People talk about 鈥減ulling the plug鈥�, but the opposite happens. Few people realise this. Nor do they realise that their 鈥渄o not resuscitate鈥� orders or living wills no longer have legal sway. Once declared brain dead, you are legally dead and your legal rights go down the drain.
The Harvard criteria ran into trouble almost immediately. The committee did no patient studies, and cited none. In the early 1970s, two studies on actual patients showed that the brains of 鈥渂rain-dead鈥� people were not always dead. The Harvard tests only indicate whether the brain stem is dead, not the neocortex, the part of the brain where consciousness is most likely seated.
The Harvard criteria did, however, specify a test to make sure this part of the brain was also nonfunctioning: an EEG. What patient studies showed was that some of these otherwise brain-dead people were producing brainwaves on the EEG. If the brain was dead, what was waving? This problem was easily solved: doctors were told to skip the EEG.
Then in 1981 came the US Uniform Determination of Death Act. It declared that brain death was legal death. The act stated that the 鈥渆ntire brain鈥� must be dead, but left exam techniques to the doctors, who rarely test the cortex.
Even these low standards proved not low enough. Doctors noticed that some brain-dead organ donors (鈥渂eating-heart cadavers鈥� in the parlance) were moving about slightly, and exhibiting reflexes. They were violating two of the Harvard criteria: no movement and no reflexes. In the US, this was easily solved by changing the standards. In 1995, the American Academy of Neurologists stated that you could move about somewhat and display reflexes and still qualify as brain dead.
鈥淒octors noticed that beating-heart cadavers were moving about and exhibiting reflexes鈥�
In 2000, The Lancet published a study of 38 brain-dead patients, 15 of whom were still moving in the first 24 hours after being declared dead (). Another study of 144 beating-heart cadavers found that 79 had retained their reflexes after death (). One doctor advises hospitals not to let the families of brain-dead donors see their loved ones after death is declared for fear they鈥檒l see these movements.
Through more than 4000 years of history, we have learned that human life is tenacious, and many signs of death are misleading. Yet today, we dissect for their organs patients who in any era before 1968 would be considered very much alive.
Keep in mind, though, that only about 1 per cent of the population is declared dead based on brain-death criteria. And if you are not an organ donor, it won鈥檛 matter. The ventilator will not be reconnected, and you will be allowed to die a normal cardiopulmonary death, because morticians will not embalm or bury a brain-dead body. They are not idiots.
