Who is Dead?

The February 5, 2018 New Yorker carried a story of Jahi McMath and her family. In 2013, McMath went into Oakland’s Children’s Hospital for a routine surgery for tonsil removal. After the surgery, she experienced extreme blood loss and her heart stopped beating. Two days later, a doctor declared her brain dead. Her family battled to keep her hooked up to a ventilator and eventually removed her to St. Peter’s Hospital in New Jersey, where a physician can overrule the diagnosis of brain death if “such a declaration would violate the personal religious beliefs of the individual.”1 However, in August 2014, that hospital also discharged her, declaring her brain dead.

Despite all of this, and with support from Dr. Alan Shewmon, the family continued to believe McMath was alive. McMath’s mother, Nailah Winkfield, constantly talked to her and believed that she responded. Her brain scans showed “large areas” of McMath’s cerebrum “structurally intact.”2 Winkfield, her husband Marvin, and McMath’s sister Jordyn continued to provide care in their home until her final hospitalization this summer. McMath died on June 22, 2018 of liver failure, according to the death certificate.

The question of who is alive and who is dead is not new, but the answer is one that has changed historically. In the US, one of the biggest shifts came in August 1968, when a committee consisting mostly of doctors, but also a lawyer, a historian, and a theologian, published an article in the Journal of the American Medical Association, acknowledging that the question of who is dead is problematic.3 “More than medical problems are present. There are moral, ethical, religious, and legal issues.”4

Two images of young people in hospital beds strapped to respirators. One is a metal breast plate hooked up to a tube.
Two types of 20th-century respirator: London County Council Cuirass Respirator (Figure A) and Laffer-Lewis Apparatus (Figure B). (Wellcome Collection)

By 1968, advances in medical technology had begun to allow patients to receive artificial respiration, which can keep the heart beating even when the brain isn’t functioning; thus, the older definition of death occurring at the cessation of a heartbeat had become unreliable. Despite the new criteria the authors developed over the definition of brain death, or “irreversible coma,” the medical determination of death remains complicated by religious, moral, and ethical debates. In a recent article about the debate, Dr. Michael De Georgia acknowledged that “uncertainties [remain] about the boundaries that divide life and death and the relationship between death of the cells and tissues and death of the human being.”5

In the fifty years since the Harvard panel publicized their definition of brain death, specific publicized cases have raised awareness of the complexity of the diagnosis and the difficult real-life decisions family members try to make, with or without input from doctors. In each decade, experts — a Presidential commission or an organization like the American Academy of Neurology — have tried to craft clearer definitions, but the line between life and death remains murky. As in the last five decades, in the late 18th and early 19th centuries, people worried about the difficulty in measuring the line between life and death. Fearful that loved ones would be buried alive, people attached strings and bells to a finger of a person who appeared dead, so that they could detect any movement and commence or continue resuscitation.

The Institution of the Humane Society of the Commonwealth of Massachusetts. (US National Library of Medicine)

There were also societies dedicated to the resuscitation of people who appeared to be dead, for example, the Institution of the Humane Society of the Commonwealth of Massachusetts (Humane Society) founded in 1788 and modeled after the Royal Humane Society of London founded in 1774. The Humane Society’s main purpose was to revive those apparently dead. In Boston and along the coastline, their concern lay first and foremost with the drowned. The London Society’s founders claimed that it had been successful in reviving 790 out of 1300 people “apparently dead from drowning.” The men who brought the Institution to Massachusetts hoped to replicate this effort, restoring loved ones to their friends and family members.

In their first publication, the authors mused about the line between life and death. “From a variety of faithful experiments, and incontestable facts,” they wrote, “it is now considered an established truth, that the total suspension of the vital functions in the animal body is by no means incompatible with life; and consequently, the marks of apparent death may subsist without any necessary implication of an absolute extinction of the animating principle.”6 The fact that society could no longer count on the previously normal determinants of life such as heartbeat and breathing prompted the men who founded the Humane Society to action. They pledged to try everything to revive the drowned, laying out the methods in their pamphlet and including case studies to prove the possibility of success.

Society members could not measure brain function; they could only pledge to invest hours of their time working to bring someone back to life. But they had some technology to work with. Society members could build up fires and create an atmosphere capable of warming the body. They could rub the body with cloth or a warming pan and tickle the body with a feather or use snuff “to excite sneezing if possible.” The pamphlets recommended a device called a fumigator to blow tobacco into the bowels to stimulate the body. If there was not a fumigator handy, they could use an everyday tobacco pipe, inserting the stem into the anus and blowing through a cloth into the bowl.7

Illustration in black and white of several thin tubes with nozzles at one end and on the other some have balloons and others fluted openings.
Plans for “Instruments for the recovery of the apparently dead.” This illustration depicts: “The elastic blow-pipe for the lungs, the elastic tube of blue leather for conveying fumes to the Intestines, the elastic tube of black leather for conveying medicines into the stomach, the Fumigator and a bladder and pipe.” (Strongitharm/Wellcome Collection | CC BY)

Their pamphlet urged people to continue all these efforts for several hours without ceasing, even if there was no sign of life, “for it is a vulgar and dangerous opinion to suppose that persons are irrecoverable, because life does not soon make its appearance, and immense numbers of the seemingly dead have been committed to the grave; who might have been RESTORED TO LIFE by resolution and perseverance in the plans of treatment now recommended.”8 Few would want to be burdened with the thought that they had let someone die, or worse, buried someone who may have otherwise been revived.

If a body could be apparently dead for hours and then suddenly revived, who, then, was dead? Putrefaction proved death beyond doubt. If a body had started to decompose, there was no possibility for its revival. One doctor who was interested in the efforts of the Humane Society, Dr. A.F.M. Willich, explained that the unquestionably dead were the aged and those suffering from chronic illness like “long standing consumption, hectic fever, or ulcerations of the breast and lungs” who had no symptoms of life.9

Others could recover, however, including those with serious but possibly passing diseases like smallpox, the drowned and suffocated, and others who had fallen suddenly ill or were injured. Some of these people who appeared to be dead — without a perceivable pulse, respiration, or pupil dilation, and losing the contents of their bowels — could still be revived. Dr. Willich emphasized that infants were in particular danger of only appearing dead.

Resuscitation sometimes worked, which increased people’s fears about making a mistake and giving up too soon. Three years after the Humane Society’s founding, there were enough people brought back from apparent death to walk through the streets of Boston in a procession. The poet Sarah Wentworth Morton wrote a hymn for the reanimated to sing. For Morton, the Humane Society did God’s work, and the reanimated (as she called them) were to dedicate their lives to Him. The last stanza declared, “Since twice to die is ours’ [sic] alone,/ And twice the birth of life to see;/ Oh let us, suppliant at they throne/ Devote our second life to Thee.”10 A parade of those once dead and now alive certainly was a chilling reminder to people that their burden for care was heavy. The same people who walked in the parade might have been buried.

The men who founded the Humane Society, as well as every man, woman, or child who carried an apparently dead body to a warm bed and worked for hours in attempts to revive it, struggled with questions and uncertainty. They did not have the same choices faced by many today, including McMath’s family — to keep the artificial life support systems going or shut them off — but theirs was not an easy task. As the Humane Society stated: “The boundary line between life and death, or the distinguishing signs of the latter, are objects to which the utmost efforts of the human capacity have never yet attained.”

We may have changed our definition of the boundary line with technology but we have not yet, and possibly will never, attain it with any certainty. History shows us the centuries-long struggle but does not make the decisions of families or loved ones any easier.

Notes

  1. Quoted in Ariane Lewis, Katherine Cahn-Fuller, and Arthur Caplan, “Shouldn’t Dead Be Dead?: The Search for a Uniform Definition of Death,” Journal of Law, Medicine & Ethics 45 (2017): 120. Return to text.
  2. Rachel Aviv, “The Death Debate,” New Yorker (5 February 2018), 37. Return to text.
  3. Aviv, “The Death Debates” 35. Return to text.
  4. Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, “A Definition of Irreversible Coma,” Journal of the American Medical Association 252 (1984): 677. Return to text.
  5. Michael A. De Georgia, “History of Brain Death as Death: 1968 to the Present,” Journal of Critical Care 29 (2014), 673. Return to text.
  6. The Institution of the Humane Society of the Commonwealth of Massachusetts: with the Rules for Regulating Said Society, and the Methods of Treatment to be Used with Persons Apparently Dead; with Number of Recent Cases Proving the Happy Effects Thereof (Boston, 1788), 5. Return to text.
  7. Humane Society, 12. Return to text.
  8. Humane Society, 14. Return to text.
  9. A.F.M. Willich, Lectures in Diet and Regimen: Being a Systematic Inquiry into the Most Rational Means of Preserving Health and Prolonging Life (Boston: Manning & Loring, 1800), 136-137. Return to text.
  10. Sarah Wentworth Morton, Reanimation, A Hymn for the Humane Society (Boston, 1791). Return to text.

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