Death: The blurred line between dead and

alive
 24 October 2012 by Dick Teresi
 Magazine issue 2887. Subscribe and save
 For similar stories, visit the Death Topic Guide

It's now easier than ever to be declared dead – even when you're still moving, sweating, and
there's blood pumping around your body

Read more: "Death: A special report on the inevitable"

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're getting ahead of our story.

The question "When is a person dead?" 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, Niccolò Massa, asked to be left unburied for two days "to avoid any mistake".

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 "brain death" then, but
doctors talked about "sensation" and "will" 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's precisely what the Harvard committee did. It defined a second form of death, what one
doctor calls "pretty dead." 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
"death lite", 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 "unreceptive", showing "no movements" and "no reflexes".
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 (JAMA, vol 205, p 85).

Then comes an "apnea test". The ventilator is disconnected and the doctors see whether the
patient can breathe unaided. If not, he is brain dead. Here's the scary part. Then the ventilator is
reconnected. People talk about "pulling the plug", but the opposite happens. Few people realise
this. Nor do they realise that their "do not resuscitate" 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
"brain-dead" 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 "entire brain" 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 ("beating-heart cadavers" 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.

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 (vol 355, p 206). Another study of 144 beating-
heart cadavers found that 79 had retained their reflexes after death (Journal of Neurology, vol
252, p 106). One doctor advises hospitals not to let the families of brain-dead donors see their
loved ones after death is declared for fear they'll 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't 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.