‘‘What is death?’’ is a classic question that has been much pondered by philosophers and theologians through the centuries. Today, the question has become, ‘‘When is this person dead?’’ Traditionally, this determination was made by observing the lack of respiration, pulse, and response to stimulation as well as by lowered body temperature (hypothermia).
A person was considered to be ‘dying’ when vital functions were failing and his or her doctors conceded there was noting more to be done. This situation changed as a result of three related developments:
(1) longer intervals between onset of illness and death,
(2) life support technology, and
(3) organ transplantation.
Financial considerations are salient in all of these developments: medical care that is prolonged and intensive runs up the expenses, and there are high stakes in the process of organ harvesting and transfer. In the past, deaths often occurred after an acute illness or traumatic injury. People today are more likely to live with a life-threatening illness for months or years. The distinctions between ‘chronic illness,’ ‘terminal illness,’ and ‘dying’ are sometimes blurred. The terminology remains important because people are treated differently in subtle ways when defined as ‘dying.’
Life support technology that maintains respiration and other vital functions has become increasingly available in technologically advanced nations. This technology has helped people recover from acute medical crises. More controversial is its use with patients who are unresponsive and who seem to have little or no chance of recovery. Much confusion surrounds the patient who is unresponsive or nearly so.
The doctors may diagnose brain death, but family members may see a person who looks physically intact and who, in some cases, goes through a sleep–waking cycle, moans, and makes non-purposive movements. The absence of electrical activity and blood circulation in the cerebral cortex signifies the loss of capacity for thought, experience, and purposive behavior that led to the introduction of diagnosis of brain death. The situation is complicated by the fact that vegetative functions can persist if lower centers in the brain stem are still operating.
In recent years it has become more widely acknowledged that the diagnostic situation is even more complex. The patient might be comatose, a condition of deep unconsciousness but with the possibility of intact brain and full recovery. Alternately, the condition might be a transient vegetative state, the lack of mental activity having been caused by drugs, extreme cold, or an injury from which recovery is possible. Yet again, the patient might be in either a persistent or a permanent vegetative state (a judgment made when the condition is of long duration). In the less often discussed minimally responsive state, there are limited signs of awareness, suggesting that the underlying brain damage is not total. Perhaps the most harrowing condition is the locked-in syndrome, in which the patient is immobile and non-responsive – but is conscious and able to communicate through eye movements. (This condition is thought to be rare, but its actual incidence has not been firmly established.)
Differential diagnosis requires a high level of expertise. It is not surprising when people without such expertise and access express varying opinions about the status of the patient. Furthermore, opinions can be influenced by the perceivers’ values and needs. Conflicting interpretations of the non-responsive patient’s situation have often been resolved through discussion. Sometimes, however, they have led to widespread public involvement, including the highest reaches of the executive, legislative, and judicial branches of government. The controversy usually centers on the ethics of continuing or withdrawing life support for a person who is either dead or not dead, depending on the standards applied. The most widely publicized cases have invariably involved young women. This pattern might be taken as another example of age bias in life and death and dying situations.
Organ transplantation has further intensified the question of how death should be defined and determined. Those with a stake in successful organ donations are inclined to define ‘dead’ so as to maximize the harvesting of organs at the earliest possible time. Those involved with the care of a non-responsive patient are inclined to favor more restrictive criteria. Two competent and well-intentioned physicians, then, may have different approaches to defining the same person as either alive or dead, depending on their goals and responsibilities.
The ordeal of grieving and mourning is complicated when the loved one appears to be not yet dead but no longer quite alive. The emotional stress on family and friends makes it difficult for them to carry out their other responsibilities (e.g., parenting, working). As much as they might cherish the patient, they may also feel the need to get on with their own lives, a need that seems in this situation to have been thwarted by medical technology.
