A MATTER OF DEATH AND LIFE

Life: Defining the Beginning by the End (Maureen L. Condic, May 2003, First Things)

The question of when and under precisely what conditions people are viewed as ?dead? has itself been the subject of considerable debate. Traditionally, the medical profession considered a person dead when his heart stopped beating--a condition that rapidly results in the death of the cells of the body due to loss of blood flow. As the life-saving potential of organ transplants became increasingly apparent in the 1960s, the medical community undertook a reexamination of the medical standards for death. Waiting until the heart stops beating results in considerable damage to otherwise transplantable organs. After a long and contentious debate, a new standard of death was proposed in 1968 that defined ?brain death? as the critical difference between living persons and corpses, a standard that is now widely (although not universally) accepted throughout the world.

Brain death occurs when there has been irreversible damage to the brain, resulting in a complete and permanent failure of brain function. Following the death of the brain, the person stops thinking, sensing, moving, breathing, or performing any other function, although many of the cells in the brain remain ?alive? following loss of brain function. The heart can continue to beat spontaneously for some time following death of the brain (even hearts that have been entirely removed from the body will continue to beat for a surprisingly long period), but eventually the heart ceases to function due to loss of oxygen. The advantage of brain death as a legal and medical definition for the end of life is that the quality of organs for transplant can be maintained by maintaining artificial respiration. So long as oxygen is artificially supplied, the heart will continue to beat and the other organs of the body will be maintained in the same state they were prior to death of the brain.

Defining death as the irreversible loss of brain function remains for some a controversial decision. The fact that the cells and organs of the body can be maintained after the death of the individual is a disturbing concept. The feeling that corpses are being kept artificially ?alive? as medical zombies for the convenient culture of transplantable organs can be quite discomforting, especially when the body in question is that of a loved one. Nonetheless, it is important to realize that this state of affairs is essentially no different from what occurs naturally following death by any means. On a cellular and molecular level, nothing changes in the instant of death. Immediately following death, most of the cells in the body are still alive, and for a time at least, they continue to function normally. Maintaining heartbeat and artificial respiration simply extends this period of time. Once the ?plug is pulled,? and the corpse is left to its own devices, the cells and organs of the body undergo the same slow death by oxygen deprivation they would have experienced had medical science not intervened.

What has been lost at death is not merely the activity of the brain or the heart, but more importantly the ability of the body?s parts (organs and cells) to function together as an integrated whole. Failure of a critical organ results in the breakdown of the body?s overall coordinated activity, despite the continued normal function (or ?life?) of other organs. Although cells of the brain are still alive following brain death, they cease to work together in a coordinated manner to function as a brain should. Because the brain is not directing the lungs to contract, the heart is deprived of oxygen and stops beating. Subsequently, all of the organs that are dependent on the heart for blood flow cease to function as well. The order of events can vary considerably (the heart can cease to function, resulting in death of the brain, for example), but the net effect is the same. Death occurs when the body ceases to act in a coordinated manner to support the continued healthy function of all bodily organs. Cellular life may continue for some time following the loss of integrated bodily function, but once the ability to act in a coordinated manner has been lost, ?life? cannot be restored to a corpse--no matter how ?alive? the cells composing the body may yet be.

It is often asserted that the relevant feature of brain death is not the loss of integrated bodily function, but rather the loss of higher-order brain activities, including consciousness. However, this view does not reflect the current legal understanding of death. The inadequacy of equating death with the loss of cognitive function can be seen by considering the difference between brain death and ?persistent vegetative state? or irreversible coma. Individuals who have entered a persistent vegetative state due to injury or disease have lost all higher brain functions and are incapable of consciousness. Nonetheless, integrated bodily function is maintained in these patients due to the continued activity of lower-order brain centers. Although such patients are clearly in a lamentable medical state, they are also clearly alive; converting such patients into corpses requires some form of euthanasia.

Despite considerable pressure from the medical community to define persistent vegetative state as a type of brain death (a definition that would both expand the pool of organ donors and eliminate the high medical costs associated with maintaining people in this condition), the courts have repeatedly refused to support persistent vegetative state as a legal definition of death. People whose bodies continue to function in an integrated manner are legally and medically alive, despite their limited (or absent) mental function. Regardless of how one may view the desirability of maintaining patients in a persistent vegetative state (this being an entirely distinct moral and legal question), there is unanimous agreement that such patients are not yet corpses. Even those who advocate the withdrawal of food and water from patients in persistent vegetative state couch their position in terms of the ?right to die,? fully acknowledging that such patients are indeed ?alive.? While the issues surrounding persistent vegetative state are both myriad and complex, the import of this condition for understanding the relationship between mental function and death is clear: the loss of integrated bodily function, not the loss of higher mental ability, is the defining legal characteristic of death.

What does the nature of death tell us about the nature of human life? The medical and legal definition of death draws a clear distinction between living cells and living organisms. Organisms are living beings composed of parts that have separate but mutually dependent functions. While organisms are made of living cells, living cells themselves do not necessarily constitute an organism. The critical difference between a collection of cells and a living organism is the ability of an organism to act in a coordinated manner for the continued health and maintenance of the body as a whole. It is precisely this ability that breaks down at the moment of death, however death might occur. Dead bodies may have plenty of live cells, but their cells no longer function together in a coordinated manner. We can take living organs and cells from dead people for transplant to patients without a breach of ethics precisely because corpses are no longer living human beings. Human life is defined by the ability to function as an integrated whole—not by the mere presence of living human cells.

What does the nature of death tell us about the beginning of human life? From the earliest stages of development, human embryos clearly function as organisms. Embryos are not merely collections of human cells, but living creatures with all the properties that define any organism as distinct from a group of cells; embryos are capable of growing, maturing, maintaining a physiologic balance between various organ systems, adapting to changing circumstances, and repairing injury. Mere groups of human cells do nothing like this under any circumstances. The embryo generates and organizes distinct tissues that function in a coordinated manner to maintain the continued growth and health of the developing body. Even within the fertilized egg itself there are distinct ?parts? that must work together—specialized regions of cytoplasm that will give rise to unique derivatives once the fertilized egg divides into separate cells. Embryos are in full possession of the very characteristic that distinguishes a living human being from a dead one: the ability of all cells in the body to function together as an organism, with all parts acting in an integrated manner for the continued life and health of the body as a whole.

Linking human status to the nature of developing embryos is neither subjective nor open to personal opinion. Human embryos are living human beings precisely because they possess the single defining feature of human life that is lost in the moment of death--the ability to function as a coordinated organism rather than merely as a group of living human cells. [...]

Postnatal humans run very little risk that embryos will someday organize politically to impose restrictions on the rights of ?the born.? However, once society has accepted a particular justification for denying rights to one class of individuals, the same justification can readily be applied to other classes by appealing to the simple argument: ?Society has already determined that form, ability, or preference defines human life and thereby restricts human rights. Why should the same standard not be applied in this case?? In American society and jurisprudence, arguments from accepted precedent carry great emotional and legal force. Society must determine whether it is willing to accept the current subjective and arbitrary basis for determining the status of prenatal human beings as a legitimate precedent for future legislation on human rights.

Embryos are genetically unique human organisms, fully possessing the integrated biologic function that defines human life at all stages of development, continuing throughout adulthood until death. The ability to act as an integrated whole is the only function that departs from our bodies in the moment of death, and is therefore the defining characteristic of ?human life.? This definition does not depend on religious belief or subjective judgment. From the landmark case of Karen Ann Quinlan (1976) on, the courts have consistently upheld organismal function as the legal definition of human life. Failure to apply the same standard that so clearly defines the end of human life to its beginning is both inconsistent and unwarranted.

The conclusion that human life is defined by integrated (organismal) function has wide-reaching implications, both political and moral. While the public domain has limited authority to promote morality, it does have both the power and the responsibility to prevent harm to individuals. A consistent definition of what constitutes human life, both at its beginning and at its end, requires that current legislation dealing with prenatal human life be considered in light of both biological fact and accepted legal precedent regarding the definition of human life. If current legislation enables and supports the killing of human beings based on a scientifically flawed understanding of human life, laws can and should be revised. Clearly, such a
revision would not be without political cost. Yet allowing life-or-death decisions to be based on arbitrary or capricious definitions is also a course of action that is not without considerable social and moral cost.

That term "postnatal humans" is especially clever, eh? Posted by Orrin Judd at May 26, 2003 10:02 AM