When does life end, and begin?

An individual is dead when he or she “has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.

lifeanddeathI had this very good friend in college named Lynn, who I started thinking about recently after I read two disturbing news stories. We met in the autumn of 1975, and within a year of that, she and I had made a pact that if either of us were seriously injured or ill to the point where the quality of life was gone, then the other would pull the plug, literally, if necessary. This was at a time before living wills and health care proxies and the like were common.

I was reading this terrible story about 13-year-old Jahi McMath in Oakland, CA, who has been brain dead since December 12, “three days after she underwent a tonsillectomy and adenoidectomy.” She’s been moved to a facility in New York.

As the article notes:

While laymen tend to use the words “coma” and “brain dead” interchangeably, in medicine they mean very different things.

“Coma” is the broader term used to describe a prolonged state of unconsciousness, according to the Mayo Clinic. Outwardly, it resembles sleep. Doctors may sometimes purposefully put a patient into a coma to give the brain time to heal. Comas rarely last longer than a couple of weeks…; patients can fully regain consciousness or may transition from a coma into a persistent vegetative state.

Someone in a persistent vegetative state has lost most higher cognitive function, but his or her brain shows some activity. The patient may open their eyes or exhibit small movements, but cannot speak or respond to commands, according to the National Institutes of Health. Some patients can recover from this state, according to the NIH.

A persistent vegetative state would describe the infamous case of Terri Schiavo, a “legal struggle involving prolonged life support … that lasted from 1990 to 2005,” and managed to involve Congress and President George W. Bush.

If I were in that state, I’d be OK with my health care proxy pulling the plug on me, thank you.

Both these situations are different from brain death: According to the Uniform Determination of Death Act, an individual is dead when he or she “has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.”

What that essentially means is that the brain, an extremely complex organ, no longer helps the patient function.

Thus, brain dead, as I understand it, means DEAD. You can keep the organs going for a bit artificially, so that out-of-town family can be by the bedside and ready themselves for the loss. The ventilator, at least in the short term, also makes it possible to harvest organs for transplant.

Yes, I will be an organ donor.

I was talking with a nurse friend of mine, who notes that when the ventilator keeps blood and oxygen pumping around the body artificially to keep the organs functioning, the skin looking pink and warm, even though the person is dead. But it cannot do this for an extended period before organs start to fail.

The other case I read about:

At 33, Marlise Munoz was brain-dead after collapsing on her kitchen floor in November from what appeared to be a blood clot in her lungs.

But as her parents and her husband prepared to say their final goodbyes in the intensive care unit at John Peter Smith Hospital [in Fort Worth, TX] and to honor her wish not to be left on life support, they were stunned when a doctor told them the hospital was not going to comply with their instructions. Mrs. Munoz was 14 weeks pregnant, the doctor said, and Texas is one of more than two dozen states that prohibit, with varying degrees of strictness, medical officials from cutting off life support to a pregnant patient.

Her case has become a strange collision of law, medicine, the ethics of end-of-life care and the issues swirling around abortion — when life begins and how it should be valued.

In the six weeks and counting, if she is in fact brain dead, one must assume organ deterioration, which certainly must affect a not yet viable fetus.

Two sad stories, to be sure. I was talking to my PCP (doctor) a few months ago, who notes that these extraordinary, “heroic” measures are factors that drive up the cost of health care for everyone.
Related: How Doctors Die: It’s Not Like the Rest of Us, But It Should Be.


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