What Is Life? When Is Death?

Death had always seemed a relatively simple and clearly definable end to life. It came when a man stopped breathing and his heart stopped beating. Today, that definition needs added definition. With mechanical heart and breathing aids, and intravenous feedings, doctors can keep patients technically alive in hospitals for months or even years while they are in a deep coma.

Many physicians now believe that the question "Is this patient dead?" should be answered largely on the basis of his electroencephalogram (EEC or "brain wave") tracings. "Although the heart has been enthroned through the ages as the sacred chalice of life's blood," says Boston's Neurosurgeon Dr. Hannibal Hamlin, "the human spirit is the product of man's brain, not his heart." Yet generally, in legal practice, a pronouncement of death is based only upon the heart's having stopped beating and takes no account of the brain.

Machine as Master. To decide just when the human spirit is gone, just when the intricate machinery should be turned off and the heart allowed to stop, is far more than a legal problem. It involves the doctor as deeply as it does the patient or his anguished kin. Trained from his first day in medical school that his duty is to save and prolong life, the physician may not only resort to extraordinary measures, but he may continue them even after a flat EEG line (meaning no electrical activity in the brain) has persisted so long that there can be no real hope of recovery.

When the physician decides to support the patient with mechanical aids after the EEG has gone flat, says Surgeon Charles F. Zukoski III of the VA Hospital in Nashville, he runs the risk of letting the machine become his master. Slowly but inexorably, the blood pressure will fall until it can no longer support the kidneys or other viral organs. "This," says Dr. Zukoski, "is an agonal type of death. We can carry the prolongation of so-called life too far."

All that the mechanical aids can do after the brain has reached its point of no return, says Dr. Hamlin, is to "maintain the look of life in the face of death." And at frightful cost in both money and emotion. The patient's family, says Harvard's Dr. Robert S. Schwab, suffers cruelly and may have to pay $250 a day for apparatus which is merely sending blood through an organism that is otherwise dead. "When," he asks, "do you pull the plug out and make this expensive equipment available to someone who might live?"

Flexible Rule. At Massachusetts General Hospital, the criterion laid down by Neurologist Schwab is that the EEG must remain flat for about 24 hours, and stay flat despite external stimuli such as a loud noise. There must be no muscular or pupillary reflexes; the patient must have no heartbeat or respiration of his own--only what the machines are providing. "After that," says Dr. Schwab, "the physician in charge can agree to turn off the artificial aids and pronounce the patient dead."

How long the EEG must remain flat depends on circumstances. After barbiturate poisoning or long exposure to extreme cold, a patient might have a flat EEG for several hours and still be capable of full recovery. Dr. Schwab would leave the precise timing to the physician's judgment in each case.

The question of when to "pull the plug" and let death occur has acquired new urgency with the practice of transplanting kidneys and other vital organs. Transplant surgeons want organs as fresh as possible; the chance that a cadaver kidney will work well in the recipient patient is vastly increased if it can be removed immediately after circulation has stopped. But in the U.S., as in most countries, it would be illegal to remove a kidney from a patient who has not yet been pronounced dead.

Sweden's Dr. Clarence Crafoord, one of the world's greatest heart-lung surgeons, caused a public outcry earlier this month when he suggested that a person should be declared dead when a flat EEG pattern shows that his brain has definitely and irrevocably ceased to function. Dr. Crafoord was concerned about truly hopeless cases, but the kin of patients being kept alive with mechanical aids jumped to the conclusion that he meant the devices should be shut off, the patients declared dead, and their organs used for transplants.

This led to worried talk about "cannibalizing" human beings, like airplanes or autos, to get usable spare parts for others. France's National Academy of Medicine added to the furor by proposing that a patient may be adjudged dead if the EEG has shown no brain activity for 48 hours. After that, the academy recommended, surgeons should be allowed to remove vital organs for transplantation even before the artificial circulation is shut off.

No country is yet ready to give such proposals legal sanction. But there is no doubt that modern medical technology leaves present laws, as well as physicians' traditional precepts and practices, out of date on essential matters of life and death.

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