Redefining death

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It's Unexplainable.

I'm Noam Hasenfeld.

And on today's episode, Bird Pinkerton and Brian Resnick are talking about death.

So just a quick warning before we get going.

They're tackling the idea in general, but they do talk about the death of a young girl.

There's also a discussion about some experiments done on dead animals.

If that's not for you, we understand.

According to Bob Drug,

death used to be pretty obvious.

Up until about the 1950s, there was no confusion about what death meant.

Bob's a bioethicist who thinks a lot about what death means.

And he says that for a long time, it meant that you weren't breathing, your heart had stopped, you were stiff, and you were, you know, blue or gray.

It was so clear that one researcher I spoke to told me in the early 1900s

People weren't really writing down textbook definitions of death.

They were more interested in telling people how to test for it.

Like you could put a mirror in front of someone's mouth to see if it fogged up, and if it didn't fog up, they weren't breathing and were therefore probably dead.

But by the 1950s, technological breakthroughs were starting to confuse the issue here.

So inventions like the mechanical ventilator, which could breathe for people if their lungs failed.

And there was a famous article in 1959 by French neurophysiologists who were the first to write about patients in the ICUs in France who had such devastating brain injury that they could not live without the ventilator.

But when the ventilator was used and you could breathe for them, they also didn't die.

They went on and lived and lived and lived.

And they referred to this as a state in French called coma des passé or beyond coma.

These scientists were being confronted with something that ethicists like Bob grapple with a lot.

This idea that Death is not like a light switch where a body just switches off.

It's a process.

So if an important organ like your brain fails completely, then your lungs stop breathing as a result, which cuts off your body's supply of oxygen.

Your other organs like your liver, your kidneys, your heart, they shut down.

Eventually, the individual cells in those organs die.

But it's not instantaneous.

Like it takes a little bit of time.

And these ventilators, they were coming in and they were interrupting that process part of the way through.

And so suddenly people had to figure out when exactly in that process the death actually happened.

And this began this conversation about: are there different ways that humans might be dead?

That conversation eventually evolved into a decades-long quest to figure out whether there are actually different ways to determine death and to pin down what the definition of death is.

Like when in the process of dying can we declare someone dead?

It's a question that people are still grappling with today, and one that technology is only going to further complicate going forward.

In the US, one of the first attempts to address this definition of death question happened in the 1960s.

And it actually started with a whole new medical breakthrough.

Well, 62 62 days ago, a new phrase hit the world headlines: heart transplant.

In December 1967, Dr.

Christian Bernard performed the first heart transplant in Cape Town.

A young woman suffered a brain injury in a car accident.

She was put on a ventilator.

And her father decided to let surgeons take her heart and put it into a middle-aged man who had coronary artery disease.

So this was the beginning of serious organ transplantation.

This came on the heels of the first kidney transplant in the 1950s.

And transplants revolutionized medicine.

But after the praise came the criticism.

This heart transplant raised yet more questions for doctors and surgeons and ethicists.

At first, it was no more than a murmur.

Today it can be heard around the world.

Questions like, when you took the heart out of the donor and put it into the recipient, was the donor dead?

Because that heart was beating.

In the U.S.

and in other countries, this question had actually been a roadblock to attempting heart transplant surgery to begin with.

So while the operation was allowed to go ahead in South Africa, there were questions internationally about whether or not this woman had been killed.

Soon it became clear that the medical world was divided.

And this new heart transplant question was tangled up in the questions about what to do with patients on ventilators that were still unresolved.

Like in some parts of the world, if you took somebody off a ventilator, you were killing them.

So finally, in the U.S., someone decided to try and come up with some answers.

Henry Beecher was an anesthesiologist at Harvard Medical School, and he immediately recognized an opportunity for career advancement here.

Beecher gathered together a committee, brought in some experts, and their goal was to work out what to do with the ventilated patients in the ICUs and to figure out whether it was ethical to take transplant organs from patients.

In 1968, they outlined something they called an irreversible coma, which was like the first draft of what we now call brain death.

So this idea that if your brain has stopped functioning completely and you're never going to wake wake up, that should be considered as death.

And this irreversible coma idea wasn't just academic.

It wasn't just a paper drawn up by some Harvard committee.

It had real-world consequences.

In the U.S., states have a lot of power over public health and welfare laws, which includes determining when death happens in their boundaries.

And at least some states decided to put this new concept on their books.

The problem was that not all the states decided to do this.

The dilemma was that you could be alive in one state and dead in another, and that didn't seem to make sense.

So in the 1980s, about a decade later, there was this push to figure out one definition of death, like one definition that everyone in the United States could work with.

And to do that, to figure that out, people turned, once again, to a committee.

A group called the Uniform Law Commission, whose job is to sort of suggest standardized laws for all the states to adopt.

This commission pulled together a lot of information about death, the best advice from doctors and lawyers, and they boiled everything down to a single page.

One very clear, simple answer.

And it said, basically, that there are two different things that are both equally valid definitions of death.

One is cardiorespiratory death, which is where your heart stops and you stop breathing.

This is the death we're all familiar with, how like 98% of us will die.

Heart and lungs stop, your organs fail, you go cold.

It's the kind of death where a paramedic can declare you dead on the scene.

And then the other is death by neurological criteria, or what we call brain death.

In the definition, they call this the quote, irreversible cessation of all functions of the entire brain, including the brainstem.

So your whole brain needs to be unresponsive.

And what the diagnosis of brain death establishes, we believe, is that the person will never regain consciousness and will never breathe on their own again.

That we actually includes Bob, who also works in pediatric intensive care.

And when doctors like Bob have a patient lying on a ventilator, totally unresponsive and in a persistent coma, they have a few things to look for when they are diagnosing brain death.

The patient has to be unable to breathe without a machine, and they have to have no brainstem reflexes.

So physicians run a series of tests and which tests can vary a bit by state, but it's stuff like shine a flashlight into a person's eyes and see if their pupils constrict and you stick

a tube down their throat and see if they cough.

In some states a nurse can do these tests, in others only a physician can do them or even sometimes only a trained specialist like a neurologist.

But overall they're testing for pain responses and looking for stuff like eye motion and gag reflexes as well, like things that people do if they have any kind of brain function.

There are further tests that can also be done.

So, there are blood vessel scans to see if there's any blood flow to the brain, ultrasounds to see if blood in the brain is pulsing the way that it should.

And all of these tests, all together, are designed to help people like Bob figure out whether there's any possibility of the brain recovering or the patient ever waking up again.

And if they have no brainstem reflexes and their brain isn't sending any signals to breathe, then according to our best current science, their brain is gone.

And in my state, Massachusetts, and arguably every other state, that means you are legally dead.

And we fill out the death certificate at that point.

So as Bob says, all 50 states do recognize some form of brain death now, with a lot of them adopting the language from the definition.

And so at first glance, it seems like the definition has achieved its goal.

Like all the states are on approximately the same page about what death is, and there is one clear standard for everyone in the U.S.

Except, no matter how hard people try, brain death refuses to be as simple as the death where your heart and lungs stop.

Like when Bob says that brain death means you are legally dead in his state and arguably every other state, that arguably is because the small nuances between the states have created complications, which became very clear on a national stage back in 2013 with the story of Jahiah McMath.

More details now on the Jahih McMath case.

It started December 9th when the 13-year-old Oakland girl went in for tonsil surgery.

When she was in the recovery room after surgery, she started to have bleeding into her mouth.

Her parents tried to get the attention of the nurses, etc.

And unfortunately, the response was delayed.

And by the time people really recognized what was going on, she'd had a cardiac arrest.

She was resuscitated.

They were able to get a heartbeat back, but she had very severe brain damage.

Three days later, she was declared brain dead after complications that she was put on life support.

The initial tests were then reinforced by further testing done by outside physicians.

Dr.

Paul Fisher is with Stanford Lucille Packard Children's Hospital.

He says Jahai has no response to facial pain, no gag reflexes, no reflexes in her arms or legs, and a complete absence of brainstem and cerebral function.

But the family isn't giving up.

Jahiah McMath's family did not accept that she was dead.

The fundamental conflict circles around different notions of death.

Her parents said, you know, wait a minute, why is she dead?

According to a New Yorker article, the family's frustrations were made worse by their sense that the brain damage was the result of negligence and their view that her lack of care was connected to her race.

A follow-up report later found that the hospital had complied with medical standards, but the family did get a lawyer who helped them fight the brain death diagnosis.

And it turns out that there is one state which allows a family to conscientiously object to the diagnosis of brain death, and that's New Jersey.

New Jersey adopted a version of the definition of death that was laid out in the 80s, but the state later added a religious exception.

So a family's religious beliefs were justification enough for hospitals to continue to administer care to patients, even if they'd been declared brain dead.

And so they arranged for her to be flown from California to New Jersey.

And she went into an ICU, and she had a tracheostomy placed in her neck, which was basically a way for her to remain on a ventilator for a long period of time.

And she had a tube surgically placed in her stomach so that she could be fed.

And she went on to live for almost another five years in this state.

In the four and a half year stretch while she was legally brain dead in California, but alive in New Jersey, Jahai McMath's body went through puberty.

She grew taller.

She did not regain consciousness though.

And finally, on June 22nd, 2018, Jahai McMath died in the state of New Jersey.

This time, she died of various complications, including problems with her liver.

And to this day, she has two

death certificates, both of which are apparently valid.

The death certificate in California showing that she died in 2013, the death certificate in New Jersey saying she died in 2018.

Family's attorney Chris Dolan says this death certificate proves that Jahai was alive these past four and a half years.

What Jahai McMath's story shows is that despite all the efforts in the 80s to create a single clear set of standards around death that every state could adhere to, despite the apparent simplicity of a single page with a simple definition, these questions about death still are not fully resolved.

Like a person can still be alive in one state and dead in another.

And there are still people pushing back on the idea that brain death is death at all.

I don't believe there's any large children's hospital in the country that hasn't faced a family who have said the same thing that Jahai McMath's family did, like explain to us why she's dead.

And, you know, we don't believe your explanation and meanwhile there are other people arguing that the definition of brain death should be broader that it shouldn't require the whole brain to be dead but should just be a question of whether someone can regain consciousness or not Bob has had his own set of questions like he co-authored a book a few years ago about whether or not brain death and the death where your heart and lungs stop are really equivalent.

And at the time, he argued that brain death wasn't really death because with life support, people's bodies can keep functioning sometimes for years after they've been declared brain dead.

So I have rethought this.

And, you know, perhaps people might say that I'm intellectually the less because of it.

I kind of think that if your ideas can't evolve over time, you might as well, you know, not have ideas.

So my ideas have evolved.

He's ultimately decided in his own personal bioethics debate that brain death can be considered a legitimate form of death if we say that it's socially constructed and that it reflects what matters to many people about being alive.

But the fact that Bob's ideas have had to evolve and shift, it just shows that this question is not easy.

And no matter what answers bioethicists or physicians or philosophers or religious leaders ultimately come up with,

There's not a way to return to the place we were in before the invention of life support technologies and the possibility of organ donation.

There's no way to go back to the time before we interrupted this process of death, back when death was just

very obvious, self-explanatory death with no pressing need for definitions.

We cannot go back, but we're also still moving forward at the same time, and technology could make death really strange again.

After the break, Brian Resnick on the future of death.

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Isolated organs can be brought to life, even though they've been removed from the animal's corpse sometime after death.

On Unexplainable.

All right, Brian Resnick, science reporter.

Bird Pinkerton, senior science reporter.

I'm science and health editor at Fox.

Okay.

Hi, Brian Resnick, science and health editor at Fox.

Hey, Bird, friend

and co-worker.

What have you got for me?

So you were talking about how

technology's forced us to rewrite our definition of death.

And, you know, listening to your story, I just couldn't stop thinking about a series of experiments that I started hearing about a few years ago.

And these are just the exact type of experiment that could force us to redefine death

again.

Because

maybe, and this is just,

you know, scare quotes, maybe,

but

the experiments are just an early step towards maybe

making death reversible like bringing people back to life

okay so this is this conversation will be mostly sci-fi okay but a lot of science fiction does start with something that is happening in the world today

so this is a series of experiments that have been done on pigs at yale the researchers do it to learn more about organ transplantation and, you know, just like the basics of cell death.

And to learn more about these experiments, I recently talked with one of the researchers involved with the project.

My name is David Andrievich, and I'm an associate research scientist at Yale University Department of Neuroscience.

So David is involved in the most recent batch of experiments here on pigs.

There were others beforehand, before he joined the lab.

But basically, they've taken pigs, and for these experiments, the pigs need to be dead.

So they induced cardiac arrest.

Basically, heart would stop pumping blood and we would wait for one hour.

In some experiments, they're dead for an hour.

In others, they're dead for much longer.

And they've tried to see if they can get the cells and various organs to start working again after death.

Okay, so the pigs are dead and they're reviving those dead pigs cells.

Yeah, in various really important organs throughout the body.

Okay, how

do they do that?

So

they take these dead pigs and in certain cases, just their decapitated heads, and they have this special solution, this mixture they've created.

It's called a profusate, which is kind of like this cocktail of chemicals that have oxygen and nutrients and kind of protective things in it.

It contains various vitamins,

electrolytes in order to make cells healthy again.

It's meant to stop the breakdown of cells that happen after death and basically push like the slow down button on the dying process and even maybe reverse some parts of it.

How do they...

Are they just like injecting it?

Yeah, so they have a machine that is kind of like an artificial heart that pumps this through the pig's body, pumps it through like the

circulatory system of the pig.

And then we would eventually evaluate the organs.

And what did they find when they evaluated the organs?

So

they found that under a microscope, a lot of the cells in them looked alive.

We observed electrical activity of the heart, which was interesting.

It looked like some of the cells in the heart had come back to life.

They did things cells are supposed to do.

They like eat glucose.

They made proteins.

They looked like they were turned on.

This is just, it's a lot.

So they've revived these cells.

That's not the same thing as reviving an organ, right?

Or is it just the, is it the...

beginning is it the first step towards something like that yeah this is just a first step but what's really impressive about it is just how broad of a first step is it's been so it wasn't just the heart the muscles when they injected the pig with a certain contrast dye like animals would uh

sort of twitch or move parts of their bodies twitched like the pig moved yeah yeah david played this off cool but i was like were you terrified he was like no but it was interesting but he said it was like intriguing they didn't know what to make of it other than that like the muscles still had some muscly powers.

We did not want to hypothesize what these might indicate.

But most astoundingly, a few years ago, they did some of these experiments on specifically a pig's brain or pig's brain.

Yeah.

And these were the first experiments they did, like actually before David joined the lab.

They were able to make brain cells come back alive in a very similar way.

And

this was so profound because brain cells are thought to like be really sensitive to death.

Like they need a ton of oxygen.

And after you don't get oxygen, brain cells are supposed to like die irretrievably very quickly.

And what this research group said or showed was that maybe not so much.

This is maybe a dumb question.

But did like, did the brain do the equivalent of like a muscle twitch?

Like did the pig wake up?

oh if only but no actually this research group really took a lot of pains to ensure that could not happen so we just wanted to make 100

sure uh that animals would not feel any uh even potential discomfort in some versions of the experiment they use anesthesia but um in the brain experiments they use like a neuronal blocker which prevents like the cells the brain cells from communicating from e with each other you know no one knows what would happen if they didn't use that neuronal blocker but that's, that's,

you know, is that like event, eventually the goal, like to, to wake the animal up or?

Not for this research group.

Okay.

Um, you know, they're focused on preserving organs for research and transplantation, but

this question you're wondering about, like what could happen here in the future, you're not the only one thinking about it.

I think my jaw almost like fell on the ground.

I was just like, what?

What did you do to pigs and how did it work?

And they were dead for four four hours.

And you did what?

And so I had many, many, many questions.

So, this is Nita Farahani.

She's a professor of law and philosophy at Duke and she just thinks about death a lot.

Gosh.

I mean, doesn't everybody at some point start to think about death?

But for Nita, thinking about death is actually a part of her job, thinking about what it is, how to define it.

And she says these experiments on pigs could affect our definition.

You know, even though this group, they have not pulled a full Frankenstein, you know, they haven't reversed death.

It could be the beginnings of something.

She's starting to think about where it could lead.

Like, what would it mean if you could revive a heart sometime after it's dead?

Or more provocatively,

what if you could revive a brain to some degree?

If it turns out that such technology could enable,

you know, the pigs to wake up again or, you know, have have some

sentience of some form,

perception of any form, then we would think, oh, look, here's another technology, just like some medicine can expand our lives, here's another technology that could expand and extend our lifespan and could then change how we define death.

Suddenly death gets really legally complicated.

again.

So all of our definitions right now, they're based on this idea that death moves moves in one direction.

You know, death is not reversible and there is nothing we can do about it.

But if these technologies do make it possible to one day, you know, revive someone, even just momentarily, what does that mean?

Is the corpse actually a corpse?

Can you declare it dead if it could possibly be revived?

There are rights that attach to people when they're alive, and there are regulations that apply when a person is dead about about how you handle a dead body and what obligations exist on physicians for continuing care requirements.

It matters.

Basically, the, you know, the jawdrop for Nita was realizing that we've made this big assumption about death, this irreversibility part, and this technology is challenging that assumption.

And so She wants to think through that and think about

what could be a new language that could take this into account.

So, take the existing definition, which says the irreversible cessation.

Well, what if it's reversible?

Do we need to modify irreversible, which is

like naturally occurring irreversible, or you know, irreversible by the person's body spontaneously on their own?

Like, what is it?

Like, is it just that we haven't described it well, or is it that the line has changed?

So, is this, are these questions that like Nita is actively working on?

Like, what does it look like to

work on these questions, I guess?

Yeah, so Nita is actually actively engaged on

a process that might change laws, might change the definition of death in America.

So, she's involved with the Uniform Laws Commission, which is what,

you know, it's proposed the first round of death laws in the 80s.

So we're doing, just to be clear, another committee in the U.S.

Oh, yeah.

To determine that.

And

she explained it to me.

It's like really bureaucratic sounding.

It's like a years-long process, a lot of committees, a lot of deliberating.

But the goal is that this Uniform Laws Commission can bring to the states a uniform definition of death that could work for the future and, you know, be adopted in every state.

They're just suggesting that and the states don't have to adopt it so so like states don't have to adopt them and i feel like in this particular political climate like it's probably that much more difficult to get people to all agree on what death means or life means or

yeah i have no idea but thresholds lie i i think we can talk about it it's you know funny for like In academic world,

this stuff is all easy to talk through.

But then, you know, could this actually come to pass in the real world?

I don't know.

But that would be interesting to see if there really is a kind of public, you know, debate around this.

But even if it's just in like academic world,

is there a universe where you can get a full definition that sort of like takes into account

everything?

This is the thing.

Like, there's, I don't think there will ever be such thing as a perfect definition of death.

I asked Nita this, like, is it possible to write a definition for all time?

And she said, no.

And she doesn't necessarily want to.

I think we have not reached the limits of human knowledge, and nor have we reached the limits of medicine and what we might be able to do with the human body.

And I hope we continue to overcome many of the afflictions and diseases that affect humanity.

And, you know, we're just at the beginning of the stages of being able to address so many afflictions of the human brain.

And the more we understand about the human brain, the more I hope we'll be able to reverse some of the damage that's caused by neurological disease and disorders, in which case, you know, maybe not.

Maybe it's possible to write the perfect definition within the limits of existing human imagination.

But I hope that humans continue to defy our current limits of human imagination.

This episode was reported and produced by Bird Pinkerton and Brian Resnick.

It was edited by Catherine Wells and Meredith Hodenat with help from Brian.

Music from me, Noam Hasenfeld, mixing and sound design from Christian Ayala, fact-checking from Zoe Mullick, and we had help keeping our heads on straight from Mandingwin.

Special thanks to Rainey Romani and Ben Sarby, who took a lot of time to talk through the nuances of death.

Ben's got a really thorough chapter on the subject in an upcoming book about death called Death Determination by Neurologic Criteria, Areas of Controversy and Consensus.

But if you want to read more about the definition of death in the meantime, he's got a good breakdown in the Journal of Law and the Biosciences.

Brian's also got a great article about the pig research that he wrote in 2019.

You can find that at vox.com slash unexplainable.

If you have thoughts about this episode or ideas for the show, please email us.

We're at unexplainable at vox.com.

We'd also love it if you left us a review or a rating.

Unexplainable is part of the Vox Media Podcast Network, and we'll be back next week.

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