Defining death: ethical, moral, and legal factors.

• Author: Phipps, William E.

Public policy pertaining to the determination of death has been altered significantly over the past generation. Because of the modification and the resuscitation I received as a result, I was not declared dead when I blacked out during my sudden heart arrest. A retired physician who happened to be nearby was attending me when my hyperventilating lungs abruptly stopped. He later informed me of recalling the instruction he had received a half-century earlier. His medical school professor had said that nothing more can be done to save a patient from dying when there is ventricular fibrillation, a precise diagnosis of my heart's dysfunctionality. Fortunately for me, paramedics quickly arrived and shocked my heart with a defibrillator. When 200 joules surged into my chest, my quivering heart returned to an effective rhythm.

Before the introduction of cardiopulmonary resuscitation (CPR) and electrical devices for jump-starting a non-beating heart, an attending physician could have presumed that cardiac arrest combined with no pulse was an unambiguous sign that a patient no longer was alive. That common sense death criterion virtually had been unquestioned from the beginning of human history until the advent of artificial life-reviving and life-support technology.

The ancients believed that life was centered beneath the ribs. Egyptian morticians carefully preserved the heart because of a cultural assumption that physical resurrection could not occur without it providing vitality to the body. By contrast, the brain was scraped out of the cranium and discarded since they believed it served as little more than a sponge for holding mucus. Biblical writers associated the beginning of a human "soul" with inhalation and the death of that living being with the lungs' final exhalation. Aristotle, one of the first biologists, maintained that "all sanguineous animals have the supreme organ of the sense - faculties in the heart." What we call the psyche comes from psychein, a Greek root meaning to breathe.

Due to our religious, philosophical, and romantic heritage, the throbbing heart has been exalted by the learned and unlearned as the main organ for revealing the crucial signs of life. Generally unrecognized in earlier history was the fact that the human personality, including intellect and emotions, primarily is the product of the brain, rather than the muscle for pumping blood through the body.

During the past generation, a more sophisticated definition of death has supplemented. the cardiopulmonary standard. In the vast majority of cases, the criteria of no beat of the heart and no respiration of the lungs still are useful. However, in numerous instances, these traditional signs of death can be reversed. By the old standard, about 15% of the comatose patients now in American hospitals would be considered dead because their breathing is not spontaneous. Many of them will regain consciousness, so it is misleading to refer to them as "clinically dead." Also., patients undergoing open-heart surgery are kept alive independent of their own cardiopulmonary functioning because oxygenated blood continues to be circulated by heart-bypass pumps.

Had the emergency squad arrived 10 minutes later, my previously undamaged heart possibly still could have been restarted, but by then the neocortex of my brain might have been destroyed from lack of oxygen. After an intravenously administered "clotbuster" drug had done its work, my heart might have functioned properly without my regaining consciousness. Occasionally, the heart of a person who is permanently unconscious continues to beat spontaneously as long as food is ingested to provide the energy for receiving oxygenated blood from the lungs.

After my massive heart attack, my situation could have been similar to that of Karen Quinlan and others who were diagnosed as alive even though they forever were unable to be aware of themselves or their environment. a decade, Quinlan's permanently unconscious body...