Dead as a Doornail?

Brave thee! ay, by the best blood that ever was
broached, and beard thee too. Look on me well: I
have eat no meat these five days; yet, come thou and
thy five men, and if I do not leave you all as dead
as a doornail, I pray God I may never eat grass more.

– Cade in King Henry VI, William Shakespeare

Death is the ultimate binary condition.

Black or white. Alive or dead. Right?

In reality death is not well defined and the definition of death has changed substantially over time.

H.P Lovecraft famously wrote, “That is not dead which can eternal lie. Yet with strange aeons even death may die.” This amounts to a pretty good summary of our current philosophical understanding of death. Death is simply the condition wherein you can not be brought back to life. If you can be brought back, then you weren’t really dead.

The Stanford Encyclopedia of Philosophy provides us a few examples of more nuanced definitions, for example one might suggest that death is “the irreversible cessation of organismic functioning” or the irreversible loss of personhood.” These amount to circular definitions that really don’t tell us anything specific about how to decide when someone is dead. What is “organismic functioning” and how do we know when it is happening? Personhood is of course mostly a legal definition pertaining to rights which are terminated upon death. But if you are brought back to life,  you weren’t really dead.

And we’ve been burying people alive for a long time.

According to Wikipedia, “A safety coffin or security coffin is a coffin fitted with a mechanism to prevent premature burial or allow the occupant to signal that they have been buried alive. A large number of designs for safety coffins were patented during the 18th and 19th centuries and variations on the idea are still available today.” During epidemics some people would fall into coma and appear to be dead. Methods for determining when someone was dead where however crude at best.

For example, in 1899 a law was introduced in New York state requiring all mortuaries to maintain a room where apparently dead people were to be “kept for a certain time” to help prevent premature burial. If you woke up during this time you weren’t dead. Determination of death consisted of simply waiting to see if the person spontaneously woke up. Of course the method was far from foolproof so  safety coffins were developed to allow people that were mistakenly buried alive to call for help and escape.

But things are not much better today. How does a doctor decide when you are actually dead?

It has been known since antiquity that some people will present as if they are dead, but later will awaken. This can result from injury or disease. Throughout history various measures have been used to determine when a person was truly dead therefore. Initially tests for responsiveness such as yanking on the person’s nipples. Tobacco smoke enemas were also used for this purpose.  The idea was of course advanced with the invention of the stethoscope such that persons with very weak heartbeats could now be determined to still be alive. Previously, many people were treated as if they were dead while their heart still beat. But for a long time death was associated with the cessation of the audible beating of the heart and breathing.

Further developments included the ECG or EKG for measuring the heart’s electrical activity. The definition of death became the well known “flatline” or asystole.  Stopped blood circulation has historically proven irreversible in most cases. Wikipedia states, “Prior to the invention of cardiopulmonary resuscitation (CPR), defibrillationepinephrine injection, and other treatments in the 20th century, the absence of blood circulation (and vital functions related to blood circulation) was historically considered to be the official definition of death.”  But the advent of these technologies cardiac arrest came to be called “clinical death” rather than simply “death” to reflect the possibility of post-arrest resuscitation.

Ventricular fibrillation changing to asystole

Further developments allowed for measurement of activity in the brain via the EEG. This led to the modern view which is to look instead at the activity in the brain not the heart. We now know that people with entirely non-functional hearts can be kept alive for extended periods of time. So the brain is the right place to look, but the brain is complex and what exactly constitutes death in the brain is correspondingly unclear.

The Whole Brain Standard requires that organismic functioning and activity cease across the entire brain for a person to be dead. This is the current medical consensus view in the United States and it is understood to be opposed to the organismic view where functioning would have to cease across the entire organism including but not only limited to the brain to diagnose death. The Brain Stem Standard used in some cases in the United Kingdom allows the diagnosis and certification of death “when consciousness and the ability to breathe are permanently lost, regardless of continuing life in the body and parts of the brain“. The thesis is that death of the brain stem alone is sufficient to produce this state. The Higher Brain Standard or Progressive Standard states “human death is the irreversible cessation of the capacity for consciousness”. Death is a diagnosis.

Reality Check: Whether you are alive or dead depends in part on where you are at the time and who gets to decide. And it won’t be you.

Whomever gets to decide for you (most likely a doctor somewhere you may not  even know today) it is unlikely this person has access to the technical tools they really need to decide if you are finally and irreversibly dead.  The exact boundary of life and death isn’t really known by science. Apparently unresponsive or “brain dead” patients may for example show the ability consciously  respond to commands. In a recent paper in the New England Journal of Medicine, Willful Modulation of Brain Activity in Disorders of Consciousness,  it is reported that “Of the 54 patients enrolled in the study, 5 were able to willfully modulate their brain activity. In three of these patients, additional bedside testing revealed some sign of awareness, but in the other two patients, no voluntary behavior could be detected by means of clinical assessment.”

Until now, these people would be considered “dead” by all of the above brain standards. This research shows that the answer of what constitutes someone being”brain dead” is a bit more complex than previously thought.

[Editors note: for a counter argument, see Cogito Ergo Sum by MRI but be warned about the very bad joke at the end of this article. Some puns are best left unspoken. Really.]

Summary

Alive or Dead? Man with a Wearable Cardioverter Defibrillator

One of the most controversial Transhumanist objectives is entirely overcoming death and achieving immortality. Instead what should  be controversial is our current methods of diagnosing death, our poorly specified working definition of death, and of course the lack of funding for scientific research about the death process. “Death” is actually a legal term with a debatable scientific basis as evidenced by the fact that the definition of death has changed substantially over the past 200 years. The definition has changed as technologies for measuring what is happening in the organism have changed. Therefore our definition of death will continue to change as our technology advances. It might be quite hard to say where the boundary should finally be drawn.

More practically, how should doctors decide when someone is dead and cannot be brought back by any available method? What measurements should be required to support this diagnosis? There isn’t a global consensus on this. Rapid advances in emergency medical practice, neuroscience, the quantified self,  resuscitation technologies, and cryobiology (both cryopreservation and cryosurgery) mean that people previously left for dead will be “brought back” through possibly novel medical techniques. With very rapid advances in all of these areas not all individual medical practitioners will be aware of the latest possibilities. Unless additional funding is provided to study the boundary of life and death, educate medical practitioners, and broadly advance the state of the art we will sadly continue to prematurely bury and dispose of people that are still alive or could have been.


Stanford Encyclopedia of Philosophy Defining Death http://plato.stanford.edu/entries/death-definition/

8 Comments

  1. You misunderstand the purpose of a defibrillator. Fibrillation is a condition of chaotic disorganized electrical activity of the hearts electrical conduction system. The defibrillator stops this by way of an electrical shock causing the cessation of activity thereby allowing the hearts own pacemaker ( the sinus node ) to resume an organized electrical rhythm. It is not medically appropriate to shock a heart in flatline. It would be a waste of time as there is no electrical activity present. Flatline ( asystole ) must be treated with CPR and drug therapy, and has a very low survival rate

    • Thanks for the correction and constructive comment. I will make that correction or add a note to the article. My point is that the definition of death changed as the technology became available. The wearable device does this automatically and without this device the wearer would very possibly die and be left for dead.

  2. And then there is the thing about the soul. Maybe there is no death, technically.

  3. This gave me an interesting (albeit tiny) idea. Legally and semantically, dead is a matter of definition. However, medically, dead is not even a diagnosis. It’s a prognosis, an estimation of the future course of an organism’s health. No matter the current state of an organism, it isn’t really medically dead if it can be reasonably expected to recover with proper available treatment.

    • Interesting point especially given that the doctor declaring someone dead generally doesn’t have the means to actually measure if you are dead or not. For example they probably haven’t performed an fMRI to see if there is brain activity that appears responsive to commands or interactions. Can you sue someone for improperly declaring you dead? It seems you can’t since you are officially dead and have no legal standing.

  4. This put me in mind of the rock star in The Restaurant at the End of the Universe who spends a year dead “for tax reasons”.

  5. You don’t have to accept any such extreme proposition to understand that today’s corpse is tomorrow’s patient.

    Just in my life time I have witnessed this change. The doctor used to listen with a stethoscope to decide when someone was dead. Then, later, they would be hooked up to monitors and we had the classic “flatline” seen in so many movies etc. We now see patients in comas where they are “alive” but unresponsive, and even unable to breath unaided but kept alive with machines. Not long ago these people would have been “dead” as the technology to measure their internal brain activity and maintain organ function did not exist.

  6. *cue Giulio’s ecstatic pronouncements of the inevitable resurrection of all those who ever lived through spacetime engineering*

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