Answering the simple question of whether a person is alive or dead is becoming more complex.
A flurry of recent cases tested how accurately we answer this basic question. Each case involves brain-dead patients. They are unconscious, unable to move or even breathe on their own; the cerebral damage is so severe that their injuries are all irreversible. But because it’s often only their brains that are damaged, with adequate ventilation, nutritional and other medical support, their hearts and other basic vegetative functions can continue.
Legally speaking, the Uniform Definition of Death Act declares them to be dead. It’s been that way for some time now, and it’s this strange confluence that makes these patients ideal organ donors; while their hearts and lungs may still function, removing them doesn’t qualify as murder, since the patient is already dead.
The difficulties begin when we hear Trenton McKinley and Zack Dunlap — young men who were diagnosed as brain dead and almost had their organs removed before doctors realized that they were actually alive — describe how they lived to tell their story, we justifiably shiver. Medicine is complicated and we accept that mistakes may happen, but even about something so basic as figuring out if a person is alive or dead?
Ethicists dismiss these cases as aberrations, arguing that they don’t challenge the irreversible nature of brain death. Something must have gone very wrong, and some error led to misdiagnosing these patients as brain dead when they actually weren’t.
But while perhaps salvaging brain death as a useful medical diagnosis, it’s not terribly reassuring.
The more serious challenge is from a different group of patients. Although they had far less-significant recoveries, these patients were all properly diagnosed as brain dead, and yet managed to recover, even if only temporarily. Some, however, survived for a significant amount of time.
Properly diagnosed brain death is meant to represent a hard line. By definition, death is final. When somebody dies and we “comes back,” we haven’t resurrected the dead, but instead discovered that we were wrong to have initially thought they were dead.
Whatever criteria we select to define death, it requires the irreversible cessation of one or more physiological functions; if that function ultimately returns, it turns out that it wasn’t irreversibly stopped in the first place.
But once that line is breached and we realize that we were wrong about the irreversibility, it throws the whole diagnosis into chaos. Once the line isn’t so bright anymore and it’s possible for a patient to cross back across it, what use is that line in making any meaningful determination?
As Dr. Robert Truog, director of the Center for Bioethics at Harvard Medical School, explains, the truth is that by clarifying some confusion, we can continue to maintain our trust in the medical community.
All neurological injury can be described as part of a spectrum, with brain death pretty near the bottom. At this point, the law draws a clear bright line – describing those above the line as alive and those below as dead.
Biology, however, does not work well with bright lines; it functions more like a continuum.
While the law describes 20/200 vision as legal blindness, biologically speaking, nothing particularly dramatic usually happens at that specific prescription. Instead, a person slowly loses visual acuity over some time, eventually reaching 20/200. So, too, nothing biologically magical happens on a teenager’s 18th birthday from a maturity perspective, even though, legally, that day ushers in a whole new phase of life.
The same is true of brain injury. Patients can live just above the bright line of brain death, not meeting the full diagnostic criteria. They are comatose and ventilator dependent, but all legally alive.
It should come as no surprise then, that there is little biological difference between these patients and those who are functioning just below that line. Even though, legally speaking, the line makes all the difference in the world.
Truog argues that the confusion stems from a failure to appreciate the distinction between the law’s “dependence on bright-line determinations to standardize … societal distinctions” and medicine’s recognition that biology operates on a continuous spectrum. And with the many advances in ICU technology, he predicts that we may start to see this phenomenon occurring more frequently.
But there’s more than just technological advancement that’s challenging the status quo.
As we, as a society, embrace shared medical decision making, we encourage patients and their families to be actively involved in treatment decisions from which they were previously missing. We’ve empowered families to question why a physician is declaring their loved one dead when their heart continues to beat and their body still warm.
Instead of the discussion just ending there, thoughtful families continue to probe further, trying to understand what brain death means and perhaps even questioning why brain death should constitute death at all if many physiological functions are still working.
Some feel threatened by this increased questioning, arguing that when it comes to complicated matters, society is better served by limiting entry to these debates to recognized experts. But this paternalistic approach is being universally rejected, with the increased awareness and recognition that we have much to gain when we open up conversations to people with different values and perspectives than our own.
This is a positive development. Patients and families are asking important questions and learning how to implement their own value systems into their health care. As a liberal democracy, we cherish the diversity of opinion and value systems within our society.
As with all value-laden issues, we’ll have to figure out how to manage conflicting approaches and divergent understandings, particularly regarding something so fundamentally human as defining death. Several approaches have already been offered and there will certainly be more to come.
We shouldn’t be nervous. We’ll figure it out. Medical technology will keep advancing and will present new questions and challenges that we haven’t yet thought of, and we’ll have to figure those out too. But once we recognize that so many issues of medical ethics — including defining death — depend on values and ethical judgments, we can actively choose to invite our entire community to the table with all of its diverse perspectives, and be better equipped to figure it all out.
Sometimes, what initially may appear as a challenge to a fundamental belief is really an opportunity to grow as a society.
David Shabtai is a teacher, medical ethicist and rabbi with a strong interest in medical ethics. See his book.
The views and opinions expressed in this commentary are those of the author and do not reflect the official position of The Daily Caller.
