Defining death

Do you remember the time, it can't have been much more than 10,15 years ago, when the Western world, or that part of it that regularly thrashes over political and religious issues, was racked with the great question, is God dead?

I imagine the question had boggled philosophers and relapsed believers for centuries, but I'm thinking of this recent time when it had passed down as a topic of hectic discussion into news magazines and television debates. I remember one such nightly talk show here in which the host had assembled one or two double-dome intellects – I'm pretty sure that Reinhold Niebuhr, the famous Protestant theologian was there – and, also, by some mishap on the part of the casting director or whoever does the inviting to such sessions, so was Woody Allen.

The discussion was hot and heavy and knotty, till the MC noticed that Mr Allen had been sitting there unconsulted and unheard from. The MC turned with a patronising smile to Mr Allen as you might to a schoolboy who strayed in there by mistake. 'Now, Mr Allen,' he said cheerily, 'Do you have any thoughts on this issue? Is God dead?' Woody Allen adjusted his gnomish spectacles and said right out, 'Not only is God dead, but you can't get a dentist at the weekend.' Well, that pretty much disposed of the whole thing.

In the past few years, with a whole flock of technological advances or, perhaps I should say developments, in medicine, a question has come up that, at first, challenged doctors and nurses, but sooner than later will require an answer from most of us when we ourselves are on the way out or are watching a loved one on the verge of death. The question is, when is a human being dead?

Until 20, 30 years ago, everybody thought he knew. Every play and movie we ever saw showed a doctor first putting his ear to a sick man's chest or pinching a wrist and then gravely shaking his head and gently pulling the sheet over the face of what nobody denied was already a corpse. The standard medical definition accepted everywhere by the medical profession and the courts was 'the irreversible cessation of cardiac and respiratory functions'. The heart had stopped and the patient couldn't breathe.

There was surely no public discussion to challenge this simple test, except, of course, among the clergy of many denominations who accepted the extinguishing of physical life and were talking about the life hereafter, if any. But I've discovered that almost 70 years ago, the inquisitive and incorrigible Baltimore newspaperman, H. L. Mencken, began to ruminate over the well reported fact that one Dr Alexis Carrel, a French surgeon and biologist, was doing some surprising work on preserving tissue outside the body. Long after the heart had ceased to beat and the lungs to swell, Dr Carrel used to cut out obscure parts of the body and keep them alive for months.

This sent Mr Mencken off to the public library to look under the card index, 'Death, Human'. He was surprised to find very few books on the subject and then nearly all of them, he reported, by psychical researchers who regard death as a mere removal from one world to another, or by mystics who appear to believe that it is little more than a sort of illusion.

Old H. L. then put in a solid week in a medical library trying to find out what death was physiologically, just what happened when a man died. Finally, he came on a work published three years earlier in 1916 by a doctor from Cleveland, Ohio, in which Dr George Crile came to the conclusion that death was acidosis, that it was caused by the failure of the organism to maintain the alkalinity necessary to its normal functioning. It was an enterprising theory and generally accepted by the alert medicos of the time. It was enough for Mencken and he wrote no more about it. And, at that, it was a theory a good deal more advanced than anything that billions of us laymen, alive then or now, could offer.

Well, several things have happened lately to shake up the medical profession, the families of the dying, the courts and now the politicians. The birth in California of seven babies, one of them dead, six in critical condition at birth and the sight of these tiny bodies riddled with tubes and plastered with adhesive tape has aroused the grizzly reflection that if they'd been born 20 years ago, they would have died within the hour or the day. You could almost say that their lungs, since they were too small to do their job, were already dead at birth, but they and other vital organs were being kept in desperate working order by doctors who have become expert at keeping the dead quick.

At the same time, there is going on in Providence, Rhode Island, a murder trial, that of a socialite husband of a very rich woman who has been in a hopeless, irreversible coma since December 1980, when, according to the charge of the state of Rhode Island which is prosecuting, she was killed by an injection of insulin. She's being kept alive, or comatose, at enormous daily expense, but since she is not legally dead, the charge is one of attempted murder.

And most newspaper readers will recall the case of the young woman in New Jersey, Karen Ann Quinlan who, ten years ago, lapsed into a coma induced by drugs and alcohol. Two years later, her family asked the doctors to take her from the respirator that was keeping her in, you might say, a stable coma. The court refused to let this happen but was overturned by New Jersey's Supreme Court. She was taken off the respirator and, incredibly, has remained comatose ever since.

And surely everybody remembers the many months during which, thanks to the ingenuity of modern medicine, Generalissimo Franco was kept alive as a barely sentient vegetable. That grim spectacle and the case of Karen Ann Quinlan, more than any other cases, began to fret the medical profession in the United States with two or three balky and related questions: when does death take place? When can the removal of life-supporting mechanisms be considered malpractice? When, in a word, should mortality be allowed to set in?

The problem is complicated in this country by the fact that there's no national law to solve it, only a teasing variety of state laws. In some states, life is defined as the existence of a heartbeat, in other states, a brainwave.

Now the governor of New York, Mr Mario Cuomo, is about to put before the legislature of this state two new rules that would provide a uniform definition of death and would establish the conditions under which it was legally correct to halt or withdraw life-sustaining devices for the terminally ill.

At present, the attending medical staff of any hospital in New York State may decide informally whether or not to, as we say, pull out the plugs, but nurses often have to do this and there have been times when either one doctor or one nurse, out of religious conviction or some other reluctant motive, won't do it or challenges the hospital to take him or her to court.

It comes out now that throughout New York, as in other states, there is no well-understood common definition of death. Last October New York's highest court simply declared that a patient is legally dead when the brain ceases to function. That sounds simple, but this definition was challenged and the court of appeals ruled that death occurred when, according to accepted medical practice, it is determined that the entire brain's function has irreversibly ceased. Even that's not enough. Some doctors pointed out that the brain has five parts and that two of them might be flickering with life.

Governor Cuomo's new rules take note of this point. Of those five parts, the brain has three – the pons varolii, the midbrain and the medulla oblongata – and these three constitute the brain's stem. When that's gone, so is the patient's life.

So the new rule says precisely, 'Death is the irreversible cessation of all functions of the entire brain including the brain stem'. This proposal will now go to the state legislature and so will the trickier, the more contentious, proposal that to pull out the plugs should require the written consent of the patient, or of a surrogate.

We shall, however, not be certain that everybody agrees when an American is dead until the other 49 states synchronise their watches and their definitions. Meanwhile, the decision about when it is right as well as humane to release the near dead or dying from the miracles of medical technology is still left to the battling legions of families, doctors, nurses, hospital superintendents, priests, humanists.

Some of us still must retain a possibly morbid interest in the question old, young, Mencken asked himself way back there in 1919 – what happens when a person dies? How does it feel? Not surprisingly, after his week's labours in a medical library, he gave us his inimitable answer.

'The hardest thing about death,' he wrote, 'is not that men die tragically, but that most of them die, unlike brave soldiers in the paintings, ridiculously. We die in no such gorgeous, poetical way. We go off in raucous prose. The abominable acidosis of Dr Crile sneaks upon us, gradually paralysing the adrenals, flabbergasting the thyroid, crippling the poor old liver and throwing its fog upon the brain. And we pass into the mental obscurity of infancy and then into the blank unconsciousness of the pre-natal state and, finally, into the condition of undifferentiated protoplasm.

'All the authorities, it is pleasant to know, report that the final scene, though it may be full of horror, is commonly devoid of terror. The dying man doesn't struggle much and he isn't much afraid. As his alkalis give out, he succumbs to a blessed stupidity, his mind fogs, his willpower vanishes, he submits decently, he scarcely gives a damn.'

This transcript was typed from a recording of the original BBC broadcast (© BBC) and not copied from an original script. Because of the risk of mishearing, the BBC cannot vouch for its complete accuracy.

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