When does life really end?

Dick Teresi on when and how the medical community decides someone is dead, and the possibility cadavers can feel pain
On the debate over when life really ends, and the possibility cadavers can feel pain
Photograph by Tim Gray/Getty Images

Dick Teresi is the former editor of Science Digest and author of The Undead, an unsettling inquiry into the demands of organ transplanting, and when and how the medical community decides someone is dead.

Q: You began this project to explore how death is now determined, assuming that medical advances have surely pinned down the moment a person dies. What did you find?

A: That determining death has been a problem since the beginning of civilization. In ancient times, doctors and others who mistakenly called a living person dead were often stoned. Death was not the domain of doctors; it was too important to be left to them. People set up vigils over their relatives and friends to make sure they were dead, because one of the worst things one could do was bury a living person. Doctors became more involved, but the real change occurred in 1968: a committee of 13 men at Harvard Medical School endorsed brain death as legal death, and this became U.S. law in 1981. Doctors were now the sole arbiters of who is dead and who is alive, and they lowered the bar for death—it is now easier to be declared dead than any time in human history.

Q: Some of what you report is disturbing, especially the way doctors rushed to embrace the concept of brain death, even ignoring the brain-wave evidence of EEGs when they proved inconvenient. Why was that?

A: It’s all about the organs. The brain-dead are legally, but not biologically, dead. Their brain stems aren’t working, but vital organs still function—you’ll pee, maintain your body temperature, and your wounds will continue to heal. You may—it’s not certain, but you might—feel pain during surgery. You’re in this weird undead zone. It’s during that time your organs are taken. Why not wait until you’re dead-dead? Because the transplant people want your heart to continue beating, to keep the organs supplied with oxygen and nutrients, to make the organs more usable for their customers.

Q: Yet it’s all done in the name of a higher cause, renewed life for very sick people—in the U.S., 7,000 die annually on organ wait-lists.

A: I was at Good Housekeeping back in the ’70s and, as an editor, ran an article on: here’s how you can donate your organs! It seemed like a wonderful thing. Space-age, magic almost. But now I find the denial among doctors overwhelming. When I read the original Harvard report from 1968, I was just amazed at how there was nothing there: no patients looked at, no data cited. These guys were just winging it, just making it up about when your brain died. It didn’t stand up to subsequent studies. And while the report has no medical data, it is clear about motivation: to free up organs for transplant.

Q: Did everyone go along with this?

A: There are some excellent people, not very many, picking it apart, including Margaret Lock, an anthropologist at McGill, who has done a lot of writing on the topic of rights for donors, and how we marginalize donors to the benefit of recipients.

Q: Do you think the situation in Canada is much like the U.S.?

A: It sounds identical.

Q: So death is decided not by biological but by philosophical, and even economic, criteria?

A: In lieu of a better term, it’s postmodern death. Or maybe the best word here is practical: “You’re dead when we want you to be dead.” Here’s the unfortunate thing: the technology to be biologically precise is there, but doctors don’t really want to use it. One reason is it’s cumbersome, time-consuming, expensive. But the second reason is we don’t want to know. We’ve got this guy, he’s brain-dead, we’ve thrown ice water in his ear and turned off his ventilator and he hasn’t been able to breathe on his own, so he’s dead. But if we did a nice blood-flow study of his brain to see if it was still kicking, that might destroy this fine diagnosis. We’re talking about huge sums of money. The average transplant costs maybe $750,000, and we’re getting about three to 3.3 organs per body, so that body is worth more than $2 million to the transplant industry. Do we really want to run another test? Delay the optimum time for harvesting the organs? Take a chance on stopping the harvest? There’s also ambition. Transplants are a really cool thing to do. A transplant surgeon is at the top of the food chain.

Q: You don’t have to throw money into the equation to see the compelling drive for organs, which links tightly to what you call doctors’ secular religion. They don’t believe the brain-dead have “personhood,” that they are alive in any real sense, not in the way the dying patients who need the organs are alive.

A: Not so fast. One study showed that 35 per cent of the doctors and nurses who worked directly with donors in the hospital believed they were alive, but didn’t care, they thought the organs were more important. And they also believe and frequently state—you’ll see it in every pamphlet from an organ bank—that when you’re brain-dead you’re never coming back. Well, of course you’re not coming back, although in the past some have. Now, though, your liver’s off in Mickey Mantle and your kidneys are being flown to some Kuwaiti oil sheik. You’re not coming back.

Q: You have serious objections to the entire body of language employed in transplants?

A: Oh, absolutely. When I said “harvest” to an organ wrangler—you know, a guy who goes into the hospitals and talks the relatives into donation—he told me, “Don’t ever use ‘harvest,’ that’s a terrible word. An intern once used ‘harvest’ in front of a family and the uncle gave him the middle finger and said, ‘Go harvest this,’ and that was the end of that.” They prefer words like “retrieval” or “recovery.” Another phrase, “pulling the plug,” is quite a misnomer: it’s about unplugging the brain-dead for a few minutes to see if they can breathe on their own, and then the respirator is re-plugged. Then that patient is on “life support,” even though he’s dead.

Q: And then, you write, he starts receiving some of the best medical care of his “life.”

A: Definitely. And the doctors will speak of “resuscitation” when they act to save so-called beating-heart cadavers who experience heart attacks while the transplant team is waiting for tissue tests to come back.

Q: They are worried they might—trying to be precise here—re-die?

A: Re-die, yeah. It’s an Orwellian world. And those brain-dead pregnant mothers, kept on life support while the babies are gestating—one was on there for 107 days—where is the death in brain death? Especially when doctors say the goal is to “prolong maternal life.” One doctor who disputes brain deaths says the brain-dead are “pretty dead,” not dead-dead, just pretty dead.

Q: But dead enough to take out their organs. You found a rather effective policy at work in the District of Columbia?

A: There you can prep a body for organ removal while waiting for permission to complete the task. That means you have already cut open the body and done to it what people fear in organ removal, so—with the damage done—they generally give permission then.

Q: You seem to have provoked a lot of anger among transplant people with your questions, but especially when you asked about the possibility of pain during organ removal. I don’t know what to call this, post-mortem pain?

A: I guess! There’s no name for it, because it’s not supposed to exist. We don’t accept that it’s pain, yet it happens quite regularly that their heart rates will soar, or their blood pressure—just like in regular operations when the patient hasn’t had sufficient painkillers—but the anesthesiologist is not allowed to give anaesthetic. Anesthesiologists are starting to get upset about it, and some of them will not work on a harvest.

Q: What response do you get when you talk to the organ procurement organizations, asking if they have any policy about pain? Is their answer that painkillers will hurt the organs?

A: No, they don’t claim anything, they just use circular reasoning: “You will be dead, dead people don’t feel pain, ergo, you don’t need anaesthetic.”

Q: Giving anaesthetics to beating-heart cadavers indicates they’re not dead?

A: You certainly show there’s doubt. One of the guys who’s very pro-transplant said, “You’re talking about pain in donors. That’s a stupid question. It’s like kicking a stone. Would the stone feel anything?” And I’m thinking, “Does he really want to say that?” I said, “You could at least give anaesthetic as an experiment to a donor who has high blood pressure,” and he got really mad, and said, “Well, I’ve done that.” I said, “Really?” and he said, “Look, if you’re an organ donor, here are the two anaesthetics you should use,” and added, “It’s what I would use if me or a family member were going through a harvest.” I thought, “Wow, that speaks volumes.” And then he said, “But I’m a Harvard anesthesiologist, so they’re probably going to go along with my request. You, I don’t know.” So if you’re in the elite you can have anaesthetic, if not …

Q: You don’t seem to have a philosophical issue with pulling the plug, when people are really beyond recovery, but the problem is when. The interests of the patient and the interests of the organ donor are not at all the same, are they?

A: Absolutely not. For donors you want to wait, for recipients you can’t afford to. There are three groups in the transplant business: recipients, who gain a benefit, the medical community, profiting from a $20-billion business, and then there are the donors who are getting nothing, and they’re ignored.