When does life end, and begin?

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.

5 thoughts on “When does life end, and begin?”

  1. I’m always suspicious of that word ‘heroic’ when it comes to medicine as it usually means it is the doctor who wants to be the hero regardless of what the patient or their family might think. Of course there is always the exception, the one who has a ‘miraculous recovery’ and this tends to make the rest of us think that medicine can indeed work miracles every time. No-one ever asks the who don’t experience the miracle for their opinion.

    But an interesting post in the light of the death of Ariel Sharon recently. Eight years in a coma felt like a desperate act somehow and rather undignified.


  2. Our biomedical technology changes what can be POTENTIALLY done, but that does not mean that it SHOULD be used. I use a simple baseline to reflect on bioethical conundrums, and it is simply, “How would this event play out in 1880?” It’s not all that long ago, but before exotic medical procedures. In both of these cases, in Terry Schiavo’s case, they would all be NATURALLY dead. The use of any other life-prolonging technology is OPTIONAL.


  3. Doctors like to win. As long as the patient is hooked up to something and there is a heartbeat, it’s chalked up as a WIN.

    I find this disgusting. Lex and I agreed, if either of us is brain-dead and those infernal tubes are making us breathe and be fed, the plug must be pulled after everyone in family gets to say goodbye.

    Incidentally, I have excluded my Fundie sister from this “family” list, as she will just pull my legally dead arm up and down like a water pump and say, “Do you accept Jesus Christ as your Lord and Savior??” until my face makes a twitch or something. This could prolong things by a day or so! So she is not invited.

    She was also prohibited from our mom’s deathbed for the same reason, believe it or not. We two sisters had to agree that we wouldn’t call her in Virginia until it seemed like she was ready to go. I approached Mom’s bedside and said, “You have about five or six hours; Beth called and we couldn’t tell her what you said.”

    Mom died two hours later. Such is the power of God and stubbornness of my mother! Grotesquely yours, Amy


  4. Unfortunately, the only person in the Munoz case who would really know whether these *heroic* measures to save the baby are valid is the mother. And she cannot speak for herself. True, she has the right to have an abortion, but perhaps she would want her body to be a host if it meant saving her child. Truly an ethical dilemma. If it were my daughter and grandchild, I’d want to give it a chance.


  5. The American Academy of Neurology states that of the adults in a persistent vegetative state for three months after brain trauma, 35 percent will die within a year after the injury. Another 30 percent will go into a permanent vegetative state, 19 percent will recover with severe disabilities, and 16 percent will recover with a moderate or minimal disability. If they remain in a persistent vegetative state for six months, 32 percent will die, 52 percent will go on to a permanent vegetative state, 12 percent will recover with severe disabilities, and 4 percent will recover with moderate or minimal disability. Nontraumatic brain damage markedly decreases the chance of any recovery. After such patients have been in PVS three months, only 6 percent will recover with severe disabilities and 1 percent will recover with a moderate or minimal disability. After six months, no adults who remain in that state recover.


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