February 12, 2024 • 48 mins
Can a person be declared legally dead even though he is very much alive? In December of 2010, why did a number of families choose to pull their loved ones off life support just before the new year? How do doctors decide when you've died, and how is it different from how lawyers decide? How is death a process rather than an event? What does any of this have to do with getting buried alive, your family's religious beliefs, or whether a head stays alive after the guillotine? Join Eagleman and guest Jacob Appel, an emergency room psychiatrist and head of ethics, for an episode about the science and the questions about death -- including who's domain it is to call it, and where this is all heading.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
How do you know when a person is dead? I mean,
it seems like a straightforward problem, but this is often
a very complex issue, both medically and legally, because, as
we'll see in this episode, death is not an event
but a process. So where do the medical and legal
systems face off against one another in this question? Can
(00:28):
a person be declared legally dead even though he's very
much alive. Why in twenty eleven did an enormous number
of families choose to pull their loved ones off life
support just before the new year? And what does this
have to do with getting buried alive or with your
family's religious beliefs, or whether someone's head stays alive after
(00:50):
the guillotine. Welcome to Inner Cosmos with me David Eagleman.
I'm a neuroscientist and author at Stance, and in these
episodes we sail deeply into our three pound universe to
understand why and how our lives look the way they do.
(01:18):
Today's episode is about the science, the ethics, and the
questions about the end of life, What qualifies as death,
who gets to say that you are dead? And what
is the future of this? Okay, so let's start with
something that's perhaps macabre and unexpected. But if you're a
(01:40):
modern adult and you die suddenly, you have all these
bill pay and credit card payments and automatic withdrawals that
are scheduled, and your finances might keep on trucking for
a while. You may even receive some auto deposits into
your bank account, And with all the comings and goings,
it would look to someone who didn't know that you're
(02:00):
still making transactions. And if you happened to have some
pre scheduled emails that you'd previously written, those might go out,
and various legal things get triggered at different points, and
it will probably look for a little while like you're
still making stuff happen in the world. And I was
thinking about this the other day as an analogy to
(02:21):
what happens with your biology. Generally speaking, death is declared
when a heart stops beating and or someone stops breathing.
But even though we think about death like a binary event,
there's no central command center in the body that says, okay,
now we're done. Everyone stop working. Because the body is
(02:44):
made of literally trillions of cells, and all of their
chemical signals are connected and intricate cascades and loops and
when something stops running, these nested feedback loops tend to
bump things back to the normal range. We have this compensation. Now,
at some point the whole show grinds to a halt.
(03:07):
The compensatory mechanisms can't keep up with the catastrophic failure
of loop after loop that stops working, and eventually the
whole system stops. But death is not a moment in time.
It is a process. In other words, the individual cells
don't necessarily know that the heart has stopped or the
(03:30):
brain has stopped its cognitive whirlwind of activity, so they
just keep trucking along for as long as they can.
So here's an analogy so we can think about this.
Imagine you are a space alien that's looking down on
the Earth and you see a large blobby organism moving
(03:50):
towards some fortress. And then the blobby organism extends two
arms around the fortress and starts to squeeze it. But
then some explosions go off and the organism stops moving.
It seems to die. But then you use your alien
telescope to zoom in more closely, and for the first time,
(04:11):
you notice a single warrior running up the hill, turning
back swinging his sword, falling to his knees in lamentations,
and regaining his footing and running towards the fortress again.
So you start panning your telescope round and you notice
a dozen of these rogue swordsmen in different locations around
the battlefield. And that's when you realize that the blobby
(04:34):
organism who came upon the fortress was actually composed of
lots of little individual agents, all of whom worked in
concert and maybe had hierarchies and rules of engagement and
backup plans such that even when most of the army
was killed, that didn't necessitate that every part stopped the
(04:56):
survival of individual warriors. Suddenly, rev feels that the blob
was made of these little swordsmen all along, even though
that was difficult to see. And this is what happens biologically.
We are made up of cells that operate together. This
is what makes a person or any animal. Trillions of
(05:17):
cells collaborating to make this giant creature that moves around
and finds other collections of cells to eat and take
their energy. And researchers have made recent discoveries about cells
that stay alive and actually get more active well after
the rest of the body has been declared dead. In
(05:38):
other words, these little swordsmen warriors that are still running
around even after the blob has stopped. For example, some
researchers at University of Illinois Chicago looked at little pieces
of fresh brain that get removed during brain surgery, and
they looked at these either right when the tissue was
(05:58):
removed or at different times after the removal. So they
called this a simulated death experiment, and their point was
to think about what happens when tissue gets separated and dies.
And what they found after the tissue is removed is
that some brain cells actually increase their activity. These cells
will often grow really large and they sprout long finger
(06:22):
like processes for several hours after death. Now, in some
sense this is not too surprising, because these are glial
cells in the brain whose job is to take care
of inflammation. But the researchers pointed out that most people
don't even look at the brain after death because they
assume that everything dies. But in fact, eighty percent of
(06:44):
the genes being expressed kept on being expressed at their
normal levels. Twenty four hours later. A few genes had
their expression levels go down, but there was a third
group of genes, which they called zombie genes, whose activity
went up, and as a result, you have all these
cells still running around and doing stuff. And if we
(07:06):
zoom out our camera, we find that different organs keep
functioning for different amounts of time. So, for example, at
some point we would say the brain is dead. That's
followed a little later by the heart. Then the liver
dies next, then the kidneys and pancreas can last another
hour past that before they die, and other parts of
(07:27):
your body like your heart valves, and the corneas of
your eyes and your tendons and your skin that's still
alive after about a day. So the idea that everything
stops when you die is not correct. Returning to the
space alien analogy, imagine that the medics come in to
take care of the fallen warriors, and so there's still
(07:48):
lots of activity even after the main army has fallen.
But it gets even weirder when we talk about things
that the larger level of the creature. And there's been
a history of asking these questions. For example, you might
think that death is really clear if say a person
has had their head cut off with a guillotine, I'm
(08:10):
going to dive into that issue in a future episode
because the whole thing is so wacky and fascinating. But
I'll just mention now that in the eighteen hundreds, when
the guillotine was very popular, people got interested in this
question of whether the head can stay conscious after separation
from the body, and what they would do is pick
(08:31):
up the freshly severed head and try to get it
to talk or at least blink its eyes on command.
And at that time, other scientists were trying things like
taking a decapitated head from a German shepherd dog and
reattaching it to the blood supply of another dog to
see if simply restoring blood flow through the brain was
(08:54):
enough to restore its function. So stay tuned for that episode.
But what these experiment it's highlight is that this question
of where to draw the line between life and death
has been with us a long time, and in modern
times we have things like the field of cryogenics, which
is the art of freezing a body after death, so
(09:16):
it has a chance of being revived by future scientists
who might know how to do that, even though we
don't know now. In the field of cryogenics, it's popular
to sometimes just save the head and get rid of
the body, and the assumption or the hope really is
that that can be sufficient, and that if you are
maintained at ninety six degrees below freezing, then you're not
(09:40):
actually dead, but you're in a state of suspended animation
and can eventually be rebooted. So why does all this matter,
this question of where to draw the line between life
and death. Well, first of all, it matters for the
medical system, and we see cases come up all the
time in hot hospitals where there is confusion or disagreement
(10:03):
about how to make the call. There was a case
in Texas where the doctors told a man that his son,
who had been in a coma, would never return back
to consciousness, and so the doctors wanted to make the
call to remove the young man from life support, and
the father was so distraught that he pulled a gun
(10:24):
on the doctors and medical staff and wouldn't let them
near his son in the hospital bed, And so the
police were immediately dispatched and this man was arrested and
put in jail for eleven months. But incredibly, the son
enjoyed a full recovery and once the father was released
from jail. The two of them were happily reunited. All
(10:46):
of this points to the difficulty in determining when a
body has died irreversibly, and the question of life and
death matters enormously for legal systems because so much pivots
on whether a person is considered alive or dead in
the eyes of the law. How do we know when
that line has been crossed? So there are so many
(11:10):
fascinating medical and legal and ethical issues around deciding when
a person has died, and those viewpoints don't always align,
and perhaps surprisingly they often conflict badly. And add to
this particular religious practices that people have and business issues
like tax implications, and what you have is a fascinating
(11:33):
set of questions that arise. So that's what I want
to talk about today. How we as a society make
that call and how should we so To dig into this,
I called up my friend and colleague, Jacob Appel. Now,
Jacob is a very accomplished thinker and writer and man
of many talents. He has seven graduate degrees, but for
(11:55):
today's episode, the two most salient are his law degree
from Harvard and his medical degree from Columbia. Jacob works
as an emergency room psychiatrist in the Mount Sinai Health System,
and he also serves as the director of Ethics Education.
So I called him up to talk with him about
the question of how we as a society should think
(12:19):
about making the tough calls about whether a person should
be declared dead or not, and the complexities that lurk
inside that seemingly simple question, complexities that are scientific and
legal and cultural. How do the medical and the legal
(12:40):
systems decide when you are dead?
Speaker 2 (12:44):
Well, it's interesting because the medical and legal systems have
very different histories and very different approaches. As a legal concept,
being dead has significant implications not just for you, but
for your loved ones and for society. So, for example,
if you're dead, your spouse can re marry, your heirrors
can inherit, You stop getting social Security. So, whatever your
(13:06):
biological status, if you're declared dead, it can have significant
implications for the.
Speaker 3 (13:10):
World and for you as well.
Speaker 2 (13:11):
I'm reminded several years ago a man from Romania had
gone to work in Turkey, and he'd been gone for
a long time.
Speaker 3 (13:19):
His wife couldn't find him.
Speaker 2 (13:20):
She had him legally declared dead, and then he came
back as a surprise, and he couldn't run an apartment
or get a job his casement all the way to
the Romanian Supreme Court because he was legally dead and nobody,
even though he was standing in front of him, would
overrule us. And I will mention also legally there are
these gray areas. So for example, if you were lost
to see historically, how did we know how long you
(13:42):
had it be gone before you were dead? And there
were different rules for how much time had it passed
before they could give away your property versus not having
rights over your children.
Speaker 3 (13:51):
So you can be dead for one purpose and alive
for another.
Speaker 1 (13:54):
Wasn't there some sixteenth century French soldier that this happened
to last name Gear?
Speaker 2 (14:01):
Yeah, there's a great movie, The Return of Martin Gear,
which is a classic case of this, where someone allegedly
I believe it was in one hundred Years War, came
back after being lost in battle. It turned out he
actually wasn't the person who claimed he was. But there
were a number of famous cases like this over the years,
and as a famous poem by Tennyson about Enoch Arden,
(14:23):
hence the term that has come into the English language
Enoch Arden laws which the laws would refer to how
long you have to be missing before you're dead.
Speaker 1 (14:30):
Wow. Okay, So from the legal point of view, there
are all these things to be considered, including, for example,
tax laws. Can you just mention what happened between the
two nine and twenty eleven?
Speaker 3 (14:44):
Oh?
Speaker 2 (14:44):
Absolutely, So the Bush administration had enacted tax laws that
gave people a significant tax break on their inheritance, and
they were going to expire at some point, and people's
inheritance taxes would go up substantially as a result of
which many people who were at the end of life
life on life support or their families want at their
life support terminated before January first, when their taxes would double.
Speaker 3 (15:07):
At an entire boutique corner of a major New.
Speaker 2 (15:10):
York City law firm is actually devoted specifically to this practice.
Speaker 1 (15:14):
Right, So, somebody was on life support and the adult
children would say, look, it's December, let's go ahead and
pull this now so that he dies before January first.
Speaker 2 (15:27):
Yeah, they would say, Grandpa would much rather die on
December thirtieth and leave one hundred billion dollars to his
grandkids than die on January second. Still unloose it. Two
days later, and leave them nothing. And honestly, I can't
argue with that.
Speaker 1 (15:41):
Yeah, So how do hospital ethics boards deal with questions
like that? Sure?
Speaker 2 (15:48):
Are so most decisions in hospitals or recommendations, you're done
by committee. So you have an ethics committee, You have
a consultant who actually gathers the information and presents it
to the committee, which consist of experts in a range
of different fields, so not just medicine, surgery, pediatrics, but
social work, nursing, the hospital chaplain. They sort of build
a consensus and then obviously, if you can't build a
(16:10):
consensus or can't get the family on board, then cases
end up going to court, and ultimately, in cases like this,
the court usually will decide looking at all the evidence
brought before them.
Speaker 1 (16:19):
Okay, and so there are all these legal considerations, what
are the medical considerations when we think about what is death?
Speaker 2 (16:26):
Sure, and the medical considerations are actually just as complex.
In an earlier era, you probably have seen movies like
The Cursed Living Dead, where people are believed dead and
then they come back to life suddenly, and people who
are afraid of being buried alive.
Speaker 3 (16:41):
It was actually a fairly.
Speaker 2 (16:44):
Ineffective diagnostic tool to be certain someone was dead, they
would do things like hold up a mirror to your
mouth and see if there was actually vapor on it,
to see if you were breathing.
Speaker 3 (16:53):
So they made mistakes.
Speaker 1 (16:56):
So actually this actually happened where people were buried alive.
Speaker 2 (17:00):
Yes, I mean it wasn't a common occurrence, but it
did happen. I will add, as strangers who may sound
it still happens occasionally. Today you hear these stories about
people who show up in the morgue or show up
in a funeral home and suddenly they wake up. Usually,
I will add, by the way, those people are still
in a very bad shape and they don't make it
in the long run. I don't know of any case
(17:21):
to people who have actually been to the morgue and
then got home and good health. But people have gone
and they started breathing and ended up backing the ice
you before, So that should give us pause.
Speaker 1 (17:31):
How does that happen currently? Is it in areas where
there's not good medical diagnosis of what has happened?
Speaker 3 (17:40):
I wouldn't be that critical.
Speaker 2 (17:41):
I would say it's a very hard There are a
whole bunch of different tests for determining whether someone is dead.
Now and different diagnostic tools and doctors do their best.
And sometimes if you're barely breathing, and if your pulses
very sporadic and they catch you a couple of times
at the wrong moment, maybe you get unlucky.
Speaker 3 (17:57):
I will add often this.
Speaker 2 (17:58):
Does occur in the developing world, where maybe their diagnostic
tools are not as strong. I don't know of any
cases in New York City with my luck, I'll be
the first.
Speaker 1 (18:08):
Okay, So back to a few decades ago or a
century ago. So you hold a mirror to the mouth
and you see if there's fog on the mirror, and
then what happened.
Speaker 2 (18:18):
So eventually we did no enough about anatomy to recognize
cardiac and pulmonary death. Cardiopulmonary death, you stop breathing and
you don't get a pulse for a propracted period of time,
we accept that you're dead.
Speaker 1 (18:29):
Like how long? What's a protracted period?
Speaker 3 (18:32):
That depended on the doctor.
Speaker 2 (18:35):
Honestly, if you're not breathing or you know, a pulse
for a good ten to fifteen minutes, the odds of
you reviving naturally on your own get pretty darn low.
When you get much past that, your odds for surviving
in a way that is meaningfully cognitive or very low
and most people stop at some point, stop crying. But
that was the diagnostic tool back then. I will add,
by the way, that most people historically back then were
(18:57):
in very bad shape by the time they reached that pointing.
It's been other death bed for hours or days or weeks.
Speaker 1 (19:03):
So what happened next?
Speaker 2 (19:05):
So there were technological developments in medical science that allowed
us to check for cardiopulmonary death basically to figure out
whether or not your heart was still beating, whether your
lungs were still breathing, And that was the test for many,
many years until the nineteen sixties. And if you stop
breathing and if your heartstep beating, you were dead. And that,
(19:25):
I will add, by the way, is the test still
used in some religious communities, in some cultural traditions. Starting
in the late nineteen sixties with the advent of organ transplant,
which meant there was a need to harvest organs or
procure organs from the individuals as quickly as possible, and
the rise of artificial ventilation and later artificial heart support,
(19:49):
which meant that people could be kept alive for months
or even a year or two on a respirat or
on a ventilator. That created the challenge of how did
we know when these individuals were dead? And there was
a debate over whether brain death should be acceptable, and
the ultimate decision was made by a committee of experts
at Harvard that has been adopted widely that whole brain
(20:10):
death would be the standard. So, if you have two
flat EEGs, your brain stops functioning entirely, you are now
legally dead in every state. I will add New Jersey,
and to a lesser degree under some circumstances. New York
allows people with a religious belief only in cardiopulmonary death
to opt out of that standard, but other states do not.
Speaker 1 (20:31):
So give me an example of having a religious belief
and how that might change the decision that a family makes.
Speaker 3 (20:38):
Sure.
Speaker 2 (20:39):
So let us say that my grandfather is on a
ventilator which is artificial. One support and intet to buy
that which is a machimee that for a short period
of time to fairly late the period of time. Now
with new technology can replace the heart, so it's entirely artificial.
And yet he has two flat egs. His brain is
(21:00):
showing no function at all. In New Jersey. If I
have a religious tradition that says that only cardiopulmonary depth
is alive. In theory, I could raise the funds to
bring that individual home to my living room and keep
them on ventilator support and buy bad support until they
can no longer support their cart and lungs with those machines,
(21:21):
which could be a year.
Speaker 1 (21:23):
And this happens sometimes right where someone takes a person home.
Speaker 3 (21:28):
It is rare, but it has happened.
Speaker 2 (21:31):
I believe there was a famous case in Utah, a
Jesse Kutchin case where it has happened. In addition to
which there have been cases where people the Johi McMath
case may be the most known, who were what was
presumed to be a state of brain depth for families
who do not accept that definition, who brought their relatives
to New Jersey to then replace the facilities that keep
(21:51):
people who are alive in a cardiopulmonary manner but is
ceased by the brain death standard alive.
Speaker 1 (21:57):
And what's the reason that people do this. It's because
their religioustration tells them even though they're on a bivalve
and there on a ventilator, they do they think the
person could come back, or they have other issues. I
know you wrote once about somebody's belief in reincarnation and
how that affected.
Speaker 2 (22:17):
So there are two different categories of people, and we
might treat the cases the same way or differently.
Speaker 3 (22:22):
There are those.
Speaker 2 (22:23):
Individuals who truly believe that their relative is going to
revive themselves, even though the data, overwhelmingly from past practice
says that's not going to happen, and they're hoping for
a miracle.
Speaker 3 (22:34):
So to speak.
Speaker 2 (22:35):
There are other individuals who may say, you know, I
understand that my grandfather isn't really going to wake up again,
but either I, or more appropriately, he had a deep
religious belief that it was important to die of quote
unquote natural causes or if you believe in reincarnation, to
die at a certain time, and I want to fulfill
his wish, even though I understand that by your standard
(22:57):
he's dead. By a religious standard of our book, our Bible,
or tradition, he's not dead, and I want to wait
the process out.
Speaker 3 (23:04):
I'll add one more thought on that it's okay, which.
Speaker 2 (23:07):
Is you also might want to ask the question, does
it matter whether if someone's been declared brain dead you're
willing to pay for it when you take them home,
whether you're asking the taxpayers to put the bill for it,
because then the vast majority of us would say, the
taxpayers are paying to keep a dead person on a
life support system in your living room. And the other
thing to think about is there's something inappropriate or grotesque
(23:28):
about it. If I were to want to bring my
grandmother home embalmed like Lenin on display in his tomb
and prop work in my living room, our society would
not let me do that, not just for public health reasons,
but probably for reasons of what we would call common
decency or horem or appropriateness.
Speaker 3 (23:44):
Some would argue, this is not that different.
Speaker 1 (23:46):
And how does this work in terms of making decisions
for somebody else. Let's say that somebody is in critical condition.
It doesn't look likely they'll recover, but maybe there's some
extreme measures you can take that involve amputations and other things,
and a decision has to be made about whether that
person would want that kind of heroic medical treatment with
(24:08):
the possible consequences. How does a hospital make the decision
about that?
Speaker 2 (24:14):
So, while there is some variation among state laws, the
general accepted principle in this country is that we use
a substituted judgment or vicarious judgment standard, which if we asked,
what would this person would have wanted if they were
still awake and lucid and able to express an opinion.
The only two groups of people we don't use that
approach for are children, where parents can decide based on
(24:37):
what they perceive to be the best interest within certain
societal parameters, and people who've never had the capacity or
ability to make that decision. We view it as too
far elite to say you were born with a such
a significant cognitive impairment that you could never understand his question.
But if you hadn't been bored in that way, what
would you want to have had done.
Speaker 3 (24:55):
I've actually been critical of that latter approach.
Speaker 2 (24:57):
Because in that situation we use a societal best interest standard,
what society would think is in your best interests. I
have argued that for certain communities, let's say you're an Amish,
Mennonite or a Casidic Jew, it might be more appropriate
to ask what would be the best interest standard in
your community, because it doesn't seem too far a bridge
for me to say, if you were born a Mennonite,
(25:18):
you would want what a Menonite tradition speaks to not
be overall societal standard.
Speaker 1 (25:24):
Tell me about what happened during Hurricane Katrina with the
ventilators and what that means.
Speaker 2 (25:30):
Sure, so, I think during Hurricane Katrina there was a
medical crisis where they had patients who were ventilators who
needed them to stay alive, and a number of questions
around end of life arose. One the medical teams for
safety had to leave some of these patients. Some of
them could not be evacuated, and they had to decide
whether or not to continue them on life support, whether
(25:53):
or not to use morphine or other techniques to ease
their suffering that could have the risk of death. Into trial,
there was a doctor Poe was actually put on trial
and eventually acquitted for her role in this.
Speaker 3 (26:04):
These were not easy.
Speaker 1 (26:05):
Questions, right, because the decision she made was, you know,
if we are going to run out of power, then
people will suffer if they don't have the ventilator on anymore,
and so do we pull the plug before we run
out of power? Was that the issue?
Speaker 2 (26:23):
I mean, that was what she was accused of doing.
As she describes it. I believe she would say she
was giving people morphine or other medication with a dual
intent that might have ended their life as a result,
but the primary goal was to ease their suffering. And
in palliative care and end of life decision making, we
often do recognize this concept of dual intent. We may
(26:44):
intend to do one thing that inadvertently is a different consequence,
but intending to relieve suffering that leads to death, we
view conceptually is very different from intending to cause death.
Speaker 1 (27:10):
Okay, so the way we make decisions about death now
has to do in part with this concept of irreversibility.
And my question to you is how do you think
about this in terms of the new technologies that are
coming along and change that definition of irreversibility.
Speaker 2 (27:31):
I mean, this comes up not just with defining death,
but an all end of life decision making. So people
may be toward the end of life and have what
we call it terminal prognosis, but there's no way to
be certain that a new technology will develop that can
cure their illness. And there have been cases now of
people with rare cancers that seemed to one hundred percent fatal
(27:52):
they always had been before, where new immunotherapies suddenly appear
in the market or emerge as experimental treatments that then
save their lives.
Speaker 3 (28:00):
And who are we to.
Speaker 2 (28:01):
Take away someone's hope, which is why we generally defer
to what the patient's wishes are. And that also creates
an economic challenge, because we may know society that almost
everyone in this situation dies, or even that so far
everybody has. But who are we to take away hope
from the veryous one number of people who want to
be the teals, so to speak, and not the bell.
Speaker 3 (28:21):
I can give you a very concrete example of this.
Speaker 2 (28:23):
I don't know if it's still true, but there was
a time when if you went on the internet, let's
say you were diagnosed with ALS blue garage disease and
typed in prognosis ALS blue garage disease on Google, the
first picture that came up was not lou Garage.
Speaker 3 (28:37):
It was Stephen Hawking.
Speaker 2 (28:39):
The physicists who lived I'm guessing thirty forty years with
the illness, even though the vast majority of people died.
Speaker 3 (28:46):
Within a few years.
Speaker 2 (28:47):
And once you see that, it's hard to make any
meaning out of statements like a certain percentage of Medicare
or Medicaid dollars are spent in a certain period toward
the end of life, because as I always ask the
medical students after I explain that, I say, if if
you're in the last six months of life, raise your
hand now.
Speaker 3 (29:03):
And obviously we don't know.
Speaker 1 (29:05):
So Jacob, when you think about the question of irreversibility,
what do you think about cryogenics?
Speaker 2 (29:11):
So I'm not one who can say that cryogenics will
never work, though my guess is there will be other
technologies that will be developed beforehand that may be far
more effective at life lengthening, or life preserving, or even reversibility.
I can say that nothing I have seen suggests that
criogenics as it works now is very effective. I would
not suggest having your head caught off now in storage somewhere.
Speaker 1 (29:34):
What else are you seeing that seems like it could
be more effective?
Speaker 2 (29:39):
I mean, I think at some point, and this is
obviously in a far fetched way, many many years in
the future, we may be able to download people's personality,
download their brands into some kind of system A computer
might be too simplistical word, but some kind of extra
intelligence system that can then reprogram individualism in a way
That is not something I would say that you should
(30:00):
bank on in your lifetime or mind. I think we're
far better off focusing on technologies that can extend human
life as it exists now. And I will add even
beyond that, we may ultimately have that technology to transfer
heads from one individual or a brand from individual into
bodies of another, but again we are nowhere near prime
time on that. I know there's an Italian sturage, and
(30:21):
thinking about doing that, I would be very reluctant to
try that procedure because not only the possibility will work,
which the possibility, what would suffer immensely during the process.
Speaker 1 (30:31):
I think maybe it was Paul Broca. Somebody actually did
this with German shepherd dogs, where they cut off one
head and attached to the vasculature to the heart of
another dog and kept the head alive that way.
Speaker 2 (30:46):
I'm not sure if it always broke up, but a
number of different people have done this over the years,
with more or less suctatistic with various animals, So the
theoretical concept is there. There obviously are both a number
of logistical premises is in terms of attaching neurop tissue,
and also a large number of ethical dilemmas. It's very
(31:06):
I don't want to say easy, but it's much more
easy to get decided to accept killing a German shepherd
to say of another German shepherd.
Speaker 3 (31:12):
They get used to kill one person to say of
another person.
Speaker 1 (31:15):
That's right, Although as I as I understand it, it's
the idea is taking somebody who is brain dead but
their body is still functioning, and then taking somebody else
who has a functioning brain. But let's say they're quadriplegic
and their body is degrading. So it's somebody who is
already judged to be dead by brain dead standards. Is
(31:36):
the first body?
Speaker 2 (31:39):
Absolutely, I mean that that is the theoretical approach. The
obviously both logistical challenges in terms of what if you
have a mismatch of heads and bodies, and the ethical
questions of who this person legally is going forward and
how they relate to their one family versus the other
inheritance whose fingerprints to the have in a legal sense
(32:01):
becomes very very complicated, very very quickly. I'm not saying
this issue can't be solved. I would say we want
to solve these questions before we start using the technology,
or we're going to find yourself painted into a very
unpleasant quarter.
Speaker 1 (32:14):
Yes, So let me come back to that question about
how committees at hospitals, how ethics committees make this decision.
You pointed out that ethics committees are made up of
many different points of view. What have you seen is
the most contentious argument that you have come across.
Speaker 2 (32:34):
I can tell you that speaking more broadly, because I
don't want to reveal now Sini's confidential epics debates, but
historically the most controversial issue in epics committees has related
to a very specific scenario that occurred over and over
again throughout this country from nineteen seventies through the nineteen nineties,
and how to do with patients who were in accidents
(32:54):
with C three S force bibal fractures so they would
never be able to breathe again on their own, never
be able to to move below their neck on their own,
and they would wake up from his accidents and say,
I don't want to live like this, turn my life
support off, and palliative care would say we need to
respect their autonomous wishes. They don't want to suffer. And
psychiatry would say, but we know that a certain percentage
(33:17):
of people, approximately half who we do talk into staying
alive and do therapy with after a year are actually
glad they stayed alive and take meaningful value in their life.
And they point out, for example, the Superman actor Christopher
Reeve and Pallid of Care would cut back and say, yes,
but we know that the other half or not, and
the interest to the other half to not suffer existentially
(33:38):
outweigh those of the first half to have a meaningful
life in the long run. And this was a deeply
heated debate which there's no conceptually correct answer. You can't
reduce it to any level where there's a right answer.
I can tell you in practice, palliad of care has
won misbattle.
Speaker 1 (33:54):
Ah And what was it with Christopher Reeve? Which way
did he go on that he was happy that he
had stay alive.
Speaker 3 (34:01):
After a year?
Speaker 2 (34:01):
Even I think before a year he'd was very grateful
to have stayed live and he brought great meaning to
his life and helped others. But I will add, if
you're Superman and you have a loving family and a
great deal of financials for it and amazing doctors, it
may be easier to find that comfort zone than if
you're indigent. If you don't have social support if you
don't have good medical care, if you're in a back
(34:22):
room somewhere in a nursing facility. So I think the
other major issue that is the end of life, which
we've only touched on the iceberg tip of the iceberg
up so far. He is medical aid and dying, which
has become a national debate over when, if ever, people
can choose to end their own lives. And there's a
slow consensus building that people with terminal illness, terminal physical
(34:42):
illness should be able to end their own lives if
they have a diagnosis of als or cancer and they're
not going to survive a prolonged period of time. And
we've seen from one state, Oregon in the nineteen nineties
to I believe it's now ten jurisdictions to legalize this,
and the trend going forward is to expand this. However,
we have really not come to terms with a question
of people who are not suffering physically but suffering psychiatrically
(35:07):
or existentially. And for example, we've seen this heated debate
in Colorado over patients with anarettia who have not responded
to treatment over a very long period of time should
be able to turn down refeeding or turn down nutritional support,
even if it means the end of their life, and
the way we would let a patient with a kidney
problem turn down dialysis let themselves die.
Speaker 3 (35:29):
And we're going to see this question more and more.
Speaker 2 (35:31):
Obviously, if you show up in the emergency room and
you've broken up with your prom date and you take
it over as a tile and all, I don't think
any Risgilble person would say, well, you've had a long,
meaningful life, you should be able to make this decision.
On the other head, if you've had depression for forty
years and you've suffered and no treatment is worked after
every intervention and you say, if you could help me,
I want that, But since you can't, please let me
(35:53):
in my life.
Speaker 3 (35:54):
It's a harder question.
Speaker 1 (35:56):
And why do you see these questions coming up more
and more?
Speaker 2 (36:00):
Well, I think they've come up in part because patients
are raising these issues and the clinical practice. Patients often
will say, doctor, I've done everything you've asked me to do.
I'm in that very small percentage of people who simply
don't respond to treatment, whether it's for psychosis or for
depression or for anxiety. I wish I did but I've
waited you out for forty years and there hasn't been
(36:21):
a new technology. I don't want to wait any longer.
And you've actually seen a handful of countries, Canada most recently,
adopt legalization.
Speaker 1 (36:31):
And so what do hospital ethics committees decide on these
or is it just a very contentious issue or people disagree?
Speaker 2 (36:39):
Well, it's not yet a contentious issue in the United States,
because no American state lets you make this choice yet.
But I imagine now that Canada and several European countries
have changed their rules in the last year or two,
we're going to see at least debate over this coming forward.
Speaker 3 (36:52):
In the United States.
Speaker 2 (36:53):
I were to hear colleges discussing this and this widespread disagreement.
Speaker 1 (36:58):
So what's going on in the United States? Is medical
assistant suicide for someone who is physically ill, right, but
not mentally exactly? Okay?
Speaker 2 (37:07):
Yeah, and I will add in all the cases in
the United States, we do not have a euphenagia program.
We do not end someone's life if they can't make
the choice on their own. We only have a program
where we will prescribe your medication to let you choose death.
When the time comes. In my own experience, having talked
to many patients, and this may surprise people, be people
who benefit from this option the most are people who
(37:28):
never use it and people who know that if things
got bad enough, they could make this choice, which actually
gives them hope to keep on fighting their illness. It's paradoxical,
but it's really a stunning phenomena, fascinating.
Speaker 1 (37:43):
How does it work? Sorry, so they're prescribed the medication
that are actually given them, medication where they can pull
the ripcord if they want to. Is that the idea?
Speaker 2 (37:53):
Yeah, So a doctor will write you a prescription and
you fill the prescription after a number of safeguards, an
interview with a psychiatrist. I mean, you can choose whether
to take this medication that will end your life in
a very peaceful way. In some states people actually have
going away parties, so to speak, where they bring their
friends and family, which is not that different from how
death was in the nineteenth century, when people often had
(38:13):
diseases that were terminal, where they would be on a
deathbed and their friends and family would come to say goodbye.
Now we've sanitized death in a way. People die in hospitals.
I think as a medical resident, the most disconcerting experience
ever was showing up in a hospital room at five
in the morning, six in the morning to see a
patient you've seen the night before, and finding the room empty,
(38:33):
which the patient had passed away overnight and completely sanitized
and stripped down, like a hotel room where sometimes even
they already brought the next patient into the bed, which
are very different and in some ways dehumanizing process. I
understand why that may be necessary with the economic forces
in medicine right now, better than having the living person
waiting on a gurning and a foyer, but it's still unsettling.
Speaker 1 (38:57):
Give me a sense of how people did used to die.
Speaker 2 (39:01):
So often if you had a terminal illness by cancer
or heart disease, there were far fewer treatments in there
are today, So you're running time, so to speak, between
when you got ill and when you would die and
when you would make lucidity before you die would actually
be longer, so people would have a sense they were dying,
and they could call their family together. They could call
the priests for the last rites, or the minister to
(39:23):
say a blessing or of a rabbi to say farewell.
Speaker 3 (39:26):
They could rewrite their will.
Speaker 2 (39:28):
There are all sorts of both cases in mystery novels
in the nineteenth and early twentieth century about rewriting wills.
And that's because people have this window that we really
don't have today, because people live until their bodies essence
shut down.
Speaker 3 (39:41):
I think a related question.
Speaker 2 (39:44):
Is so George Church, who's a biologist at Guganticist d
at Harvard, talked about the prospect of bringing back not
just people who've been deceased, bringing back species that have
been deceased, and specifically human species. I made species like
Neanderthal man, and that raises a whole set of complex
related questions of its own, of what rights Neanderthals would
(40:07):
have in the context of human society, whether bringing the
back would cause them existential suffering, whether they would have
the same rights as Homo sapiens. But in the relation
to this context, it also risk the possibility of bringing
back Neanderthals who are not Homo sapiens and using bare
bodies to transplant human heads into which might plausibly be
(40:29):
doable at some point in the future, and raise really
complex ethical questions.
Speaker 1 (40:51):
Let me ask you this you're a psychiatrist, among other things,
what would you do if you were assigned the revivification
of a Neanderthal man and you were the first person
in the room when he wakes up. Now, obviously you
wouldn't share the same language, So what would you try
to do to reduce existential suffering on his part?
Speaker 2 (41:13):
I think first I would try to reduce existential suffering
on my part by standing behind something very large, because
my census Neanderthals waking up in this situation might not.
Speaker 3 (41:23):
Be very friendly.
Speaker 2 (41:25):
But beyond that, I think the real answers we don't
know in the same way we don't know how to
communicate with dolphins, so they may have a very sophisticated
language of their own. We may have any idea how
to communicate or appreciate the emotional response of a Neanderthal man.
It's taken us many, many years to understand in a
most rudimentary way the relationships human beings have with other
(41:46):
high word er apes like a relige, chimpanzees or arangutans.
Neanderthals will be intellectually far more sophisticated. Are going to
be a puzzile we first made them. If we first
made them.
Speaker 1 (41:56):
So what would you actually do if you were assigned that.
Speaker 2 (42:00):
Job as a psychiatrist. I would probably wait. I would
probably do nothing until I first see how this revived
creature responds to me and take cues from them in
the same way I would do seeing any other patient
in the emergency room. And I I am not comparing
any of my patients to Neanderthal men, though they may
compare me to one. But I do think it's important
(42:22):
first take cues from your patients, to take cues from
other individuals what they expect from you. And that's what
I think the wisest course of action would be.
Speaker 1 (42:32):
Great, God, this is going to be a Hollywood screenplay
that we should write, Okay, any any other thing.
Speaker 2 (42:39):
And I think that covers my end of life thinking.
I have lots of other issues I can always.
Speaker 3 (42:44):
Talk about, but.
Speaker 1 (42:47):
Give me, give me a sense of one.
Speaker 3 (42:49):
Sure. I think one issue that is related but distinct.
Speaker 2 (42:54):
Is the situation of conjoined twins who wish one twin
wishes to be separated and the other twin does not
wish to be separated because of the risk involved in
the procedure.
Speaker 3 (43:04):
And you have a situation.
Speaker 2 (43:05):
Where one person's life is at stake for the other person,
the autonomy and welfare of their being is at stake,
And there's no easy way to resolve that question. And
it sort of brings to bear all of the different
ethical issues we have raveled with his society bioethically over
the last fifty years, and that it's one of the
only questions in bioethics, by the way, where not only
do I not have a path to help people move forward,
(43:27):
I have no visceral sense of what the right answer
is either. I feel like if I'm not in that situation,
I can't even think about how to approach it.
Speaker 1 (43:34):
Wow, are there other situations where one person's life would
be in danger if something happened that would help another person?
There must be other situations that are analogous.
Speaker 2 (43:46):
Yeah, I mean there's the famous case of Shimp versus McFall,
where there were two cousins and one of them made
a bone marrow transplant and his cousin was the only
person in the entire world with a bone marrow transplant
that could match him that he needed to save his life.
And he did not have a negative relationship with his cousin,
but they weren't particularly close and he went to his
cousin and said, please give me the bone marrow transplant,
(44:08):
and the bone mara trus plant was not high risk,
but it had some risk in some discomfort. And his
cousin said, no, I don't owe you that. And then
he went before the court and said, I'm going to
die without this bone marrow. It's not that much of
an inconvenience or risk to my cousin. Please make him
do it. And the court said no, and I believe
he died.
Speaker 1 (44:26):
Oh do you know anything about what the cousin's reasoning
was beyond the inconvenience.
Speaker 2 (44:34):
I don't think, and I am not an expert in
his case, but I don't think the cousin had a
great deal of health literacy. And the cousin was someone
who was a fairly suspicious of medicing a baseline. So
no matter how many times you might tell him he's
got a high risk procedure, it's not so clear he
really believed that.
Speaker 1 (44:47):
Okay, incredible, And.
Speaker 2 (44:51):
I will add, by the way, even though that seems
like a shocking case, every single one of us has
the ability to save the life of a stranger.
Speaker 3 (44:59):
You can give a a.
Speaker 2 (45:00):
Kidney or part of a liver, and some people do
altruistically and save someone's life, someone who will otherwise die,
and the vast majority of us, for reasons, whether wise or.
Speaker 3 (45:11):
Not wise, choose not to. So in some sense we're
all mister ship.
Speaker 2 (45:18):
Yeah, and we all risk being mister McFall too.
Speaker 3 (45:22):
At some point we should not forget right.
Speaker 1 (45:25):
So what do you advise your students on that front?
Speaker 2 (45:30):
I mean, I think I advised them in the same
way by advised students about every ethical issue, which is
I can't tell you what the right answer is. The
two things that are important, actually, there are three things
that are important. The first one is recognized and said
it is an ethical issue, many of the difficult problems
that arise in medical ethics, or because no one matter
how wise or well attention, actually recognize this is an
ethical challenge. The second thing that's really important is that
(45:54):
when you start with a certain premise, you want to
logically come to a conclusion based on that premise. So
at some point between your premise in your conclusion a
miracle happens here, so to speak, you want to.
Speaker 3 (46:03):
Go back to square one.
Speaker 2 (46:05):
And then finally, I say, once you reach those two premises,
the final step is to recognize that very well intentioned
people with very good values come to very different answers
about this questions from starting with different premises and different
cultural beliefs and values of their own, and the goal
is to understand them and respect them even if you
don't agree with them, because they're not fools simply because
(46:27):
they disagree with you. And I think our society as
a whole would be a much better place we were
able to agree to disagree with mutual respect, and we
actually would be able to find a lot more common
ground at the corners of a lot of issues where
there might be a lot of overlap.
Speaker 1 (46:44):
So that was my interview with Jacob Appel, one of
a very small group of people who can equally address
both the medical and legal and ethical aspects of death
and the complexities at the interface. What I hope you've
gathered from today's episode is that the issue of declaring
death is not straightforward, and often we find the most
(47:06):
complex cases at the intersection of medical and legal systems,
and zooming out to the beginning, I just want to
remind us that although we think of death as binary,
it's often much more complex and we are always going
to be confronted with these problems. As technology improves, we're
going to be able to rescue a life from different
(47:28):
states that would have been previously impossible to reverse or
even imagine reversing. And so as biology marches along each
year into the future, the answer to the question of
when you are dead is one that will change along
in lockstep, and in two hundred years we might find
(47:49):
our current answers unpalatable and inconceivable. But in any case,
in each generation, with each landscape of new technology, we
have to con continually revisit this question, where do we
draw the line between life and death? Go to Eagleman
(48:12):
dot com slash podcast for more information and to find
further reading. Send me an email at podcasts at eagleman
dot com with questions or discussions, and I'll be making
an episode soon in which I address those. Until next time,
I'm David Eagleman, and this is Inner Cosmos.
How do you know when a person is dead? I mean,
it seems like a straightforward problem, but this is often
a very complex issue, both medically and legally, because, as
we'll see in this episode, death is not an event
but a process. So where do the medical and legal
systems face off against one another in this question? Can
(00:28):
a person be declared legally dead even though he's very
much alive. Why in twenty eleven did an enormous number
of families choose to pull their loved ones off life
support just before the new year? And what does this
have to do with getting buried alive or with your
family's religious beliefs, or whether someone's head stays alive after
(00:50):
the guillotine. Welcome to Inner Cosmos with me David Eagleman.
I'm a neuroscientist and author at Stance, and in these
episodes we sail deeply into our three pound universe to
understand why and how our lives look the way they do.
(01:18):
Today's episode is about the science, the ethics, and the
questions about the end of life, What qualifies as death,
who gets to say that you are dead? And what
is the future of this? Okay, so let's start with
something that's perhaps macabre and unexpected. But if you're a
(01:40):
modern adult and you die suddenly, you have all these
bill pay and credit card payments and automatic withdrawals that
are scheduled, and your finances might keep on trucking for
a while. You may even receive some auto deposits into
your bank account, And with all the comings and goings,
it would look to someone who didn't know that you're
(02:00):
still making transactions. And if you happened to have some
pre scheduled emails that you'd previously written, those might go out,
and various legal things get triggered at different points, and
it will probably look for a little while like you're
still making stuff happen in the world. And I was
thinking about this the other day as an analogy to
(02:21):
what happens with your biology. Generally speaking, death is declared
when a heart stops beating and or someone stops breathing.
But even though we think about death like a binary event,
there's no central command center in the body that says, okay,
now we're done. Everyone stop working. Because the body is
(02:44):
made of literally trillions of cells, and all of their
chemical signals are connected and intricate cascades and loops and
when something stops running, these nested feedback loops tend to
bump things back to the normal range. We have this compensation. Now,
at some point the whole show grinds to a halt.
(03:07):
The compensatory mechanisms can't keep up with the catastrophic failure
of loop after loop that stops working, and eventually the
whole system stops. But death is not a moment in time.
It is a process. In other words, the individual cells
don't necessarily know that the heart has stopped or the
(03:30):
brain has stopped its cognitive whirlwind of activity, so they
just keep trucking along for as long as they can.
So here's an analogy so we can think about this.
Imagine you are a space alien that's looking down on
the Earth and you see a large blobby organism moving
(03:50):
towards some fortress. And then the blobby organism extends two
arms around the fortress and starts to squeeze it. But
then some explosions go off and the organism stops moving.
It seems to die. But then you use your alien
telescope to zoom in more closely, and for the first time,
(04:11):
you notice a single warrior running up the hill, turning
back swinging his sword, falling to his knees in lamentations,
and regaining his footing and running towards the fortress again.
So you start panning your telescope round and you notice
a dozen of these rogue swordsmen in different locations around
the battlefield. And that's when you realize that the blobby
(04:34):
organism who came upon the fortress was actually composed of
lots of little individual agents, all of whom worked in
concert and maybe had hierarchies and rules of engagement and
backup plans such that even when most of the army
was killed, that didn't necessitate that every part stopped the
(04:56):
survival of individual warriors. Suddenly, rev feels that the blob
was made of these little swordsmen all along, even though
that was difficult to see. And this is what happens biologically.
We are made up of cells that operate together. This
is what makes a person or any animal. Trillions of
(05:17):
cells collaborating to make this giant creature that moves around
and finds other collections of cells to eat and take
their energy. And researchers have made recent discoveries about cells
that stay alive and actually get more active well after
the rest of the body has been declared dead. In
(05:38):
other words, these little swordsmen warriors that are still running
around even after the blob has stopped. For example, some
researchers at University of Illinois Chicago looked at little pieces
of fresh brain that get removed during brain surgery, and
they looked at these either right when the tissue was
(05:58):
removed or at different times after the removal. So they
called this a simulated death experiment, and their point was
to think about what happens when tissue gets separated and dies.
And what they found after the tissue is removed is
that some brain cells actually increase their activity. These cells
will often grow really large and they sprout long finger
(06:22):
like processes for several hours after death. Now, in some
sense this is not too surprising, because these are glial
cells in the brain whose job is to take care
of inflammation. But the researchers pointed out that most people
don't even look at the brain after death because they
assume that everything dies. But in fact, eighty percent of
(06:44):
the genes being expressed kept on being expressed at their
normal levels. Twenty four hours later. A few genes had
their expression levels go down, but there was a third
group of genes, which they called zombie genes, whose activity
went up, and as a result, you have all these
cells still running around and doing stuff. And if we
(07:06):
zoom out our camera, we find that different organs keep
functioning for different amounts of time. So, for example, at
some point we would say the brain is dead. That's
followed a little later by the heart. Then the liver
dies next, then the kidneys and pancreas can last another
hour past that before they die, and other parts of
(07:27):
your body like your heart valves, and the corneas of
your eyes and your tendons and your skin that's still
alive after about a day. So the idea that everything
stops when you die is not correct. Returning to the
space alien analogy, imagine that the medics come in to
take care of the fallen warriors, and so there's still
(07:48):
lots of activity even after the main army has fallen.
But it gets even weirder when we talk about things
that the larger level of the creature. And there's been
a history of asking these questions. For example, you might
think that death is really clear if say a person
has had their head cut off with a guillotine, I'm
(08:10):
going to dive into that issue in a future episode
because the whole thing is so wacky and fascinating. But
I'll just mention now that in the eighteen hundreds, when
the guillotine was very popular, people got interested in this
question of whether the head can stay conscious after separation
from the body, and what they would do is pick
(08:31):
up the freshly severed head and try to get it
to talk or at least blink its eyes on command.
And at that time, other scientists were trying things like
taking a decapitated head from a German shepherd dog and
reattaching it to the blood supply of another dog to
see if simply restoring blood flow through the brain was
(08:54):
enough to restore its function. So stay tuned for that episode.
But what these experiment it's highlight is that this question
of where to draw the line between life and death
has been with us a long time, and in modern
times we have things like the field of cryogenics, which
is the art of freezing a body after death, so
(09:16):
it has a chance of being revived by future scientists
who might know how to do that, even though we
don't know now. In the field of cryogenics, it's popular
to sometimes just save the head and get rid of
the body, and the assumption or the hope really is
that that can be sufficient, and that if you are
maintained at ninety six degrees below freezing, then you're not
(09:40):
actually dead, but you're in a state of suspended animation
and can eventually be rebooted. So why does all this matter,
this question of where to draw the line between life
and death. Well, first of all, it matters for the
medical system, and we see cases come up all the
time in hot hospitals where there is confusion or disagreement
(10:03):
about how to make the call. There was a case
in Texas where the doctors told a man that his son,
who had been in a coma, would never return back
to consciousness, and so the doctors wanted to make the
call to remove the young man from life support, and
the father was so distraught that he pulled a gun
(10:24):
on the doctors and medical staff and wouldn't let them
near his son in the hospital bed, And so the
police were immediately dispatched and this man was arrested and
put in jail for eleven months. But incredibly, the son
enjoyed a full recovery and once the father was released
from jail. The two of them were happily reunited. All
(10:46):
of this points to the difficulty in determining when a
body has died irreversibly, and the question of life and
death matters enormously for legal systems because so much pivots
on whether a person is considered alive or dead in
the eyes of the law. How do we know when
that line has been crossed? So there are so many
(11:10):
fascinating medical and legal and ethical issues around deciding when
a person has died, and those viewpoints don't always align,
and perhaps surprisingly they often conflict badly. And add to
this particular religious practices that people have and business issues
like tax implications, and what you have is a fascinating
(11:33):
set of questions that arise. So that's what I want
to talk about today. How we as a society make
that call and how should we so To dig into this,
I called up my friend and colleague, Jacob Appel. Now,
Jacob is a very accomplished thinker and writer and man
of many talents. He has seven graduate degrees, but for
(11:55):
today's episode, the two most salient are his law degree
from Harvard and his medical degree from Columbia. Jacob works
as an emergency room psychiatrist in the Mount Sinai Health System,
and he also serves as the director of Ethics Education.
So I called him up to talk with him about
the question of how we as a society should think
(12:19):
about making the tough calls about whether a person should
be declared dead or not, and the complexities that lurk
inside that seemingly simple question, complexities that are scientific and
legal and cultural. How do the medical and the legal
(12:40):
systems decide when you are dead?
Speaker 2 (12:44):
Well, it's interesting because the medical and legal systems have
very different histories and very different approaches. As a legal concept,
being dead has significant implications not just for you, but
for your loved ones and for society. So, for example,
if you're dead, your spouse can re marry, your heirrors
can inherit, You stop getting social Security. So, whatever your
(13:06):
biological status, if you're declared dead, it can have significant
implications for the.
Speaker 3 (13:10):
World and for you as well.
Speaker 2 (13:11):
I'm reminded several years ago a man from Romania had
gone to work in Turkey, and he'd been gone for
a long time.
Speaker 3 (13:19):
His wife couldn't find him.
Speaker 2 (13:20):
She had him legally declared dead, and then he came
back as a surprise, and he couldn't run an apartment
or get a job his casement all the way to
the Romanian Supreme Court because he was legally dead and nobody,
even though he was standing in front of him, would
overrule us. And I will mention also legally there are
these gray areas. So for example, if you were lost
to see historically, how did we know how long you
(13:42):
had it be gone before you were dead? And there
were different rules for how much time had it passed
before they could give away your property versus not having
rights over your children.
Speaker 3 (13:51):
So you can be dead for one purpose and alive
for another.
Speaker 1 (13:54):
Wasn't there some sixteenth century French soldier that this happened
to last name Gear?
Speaker 2 (14:01):
Yeah, there's a great movie, The Return of Martin Gear,
which is a classic case of this, where someone allegedly
I believe it was in one hundred Years War, came
back after being lost in battle. It turned out he
actually wasn't the person who claimed he was. But there
were a number of famous cases like this over the years,
and as a famous poem by Tennyson about Enoch Arden,
(14:23):
hence the term that has come into the English language
Enoch Arden laws which the laws would refer to how
long you have to be missing before you're dead.
Speaker 1 (14:30):
Wow. Okay, So from the legal point of view, there
are all these things to be considered, including, for example,
tax laws. Can you just mention what happened between the
two nine and twenty eleven?
Speaker 3 (14:44):
Oh?
Speaker 2 (14:44):
Absolutely, So the Bush administration had enacted tax laws that
gave people a significant tax break on their inheritance, and
they were going to expire at some point, and people's
inheritance taxes would go up substantially as a result of
which many people who were at the end of life
life on life support or their families want at their
life support terminated before January first, when their taxes would double.
Speaker 3 (15:07):
At an entire boutique corner of a major New.
Speaker 2 (15:10):
York City law firm is actually devoted specifically to this practice.
Speaker 1 (15:14):
Right, So, somebody was on life support and the adult
children would say, look, it's December, let's go ahead and
pull this now so that he dies before January first.
Speaker 2 (15:27):
Yeah, they would say, Grandpa would much rather die on
December thirtieth and leave one hundred billion dollars to his
grandkids than die on January second. Still unloose it. Two
days later, and leave them nothing. And honestly, I can't
argue with that.
Speaker 1 (15:41):
Yeah, So how do hospital ethics boards deal with questions
like that? Sure?
Speaker 2 (15:48):
Are so most decisions in hospitals or recommendations, you're done
by committee. So you have an ethics committee, You have
a consultant who actually gathers the information and presents it
to the committee, which consist of experts in a range
of different fields, so not just medicine, surgery, pediatrics, but
social work, nursing, the hospital chaplain. They sort of build
a consensus and then obviously, if you can't build a
(16:10):
consensus or can't get the family on board, then cases
end up going to court, and ultimately, in cases like this,
the court usually will decide looking at all the evidence
brought before them.
Speaker 1 (16:19):
Okay, and so there are all these legal considerations, what
are the medical considerations when we think about what is death?
Speaker 2 (16:26):
Sure, and the medical considerations are actually just as complex.
In an earlier era, you probably have seen movies like
The Cursed Living Dead, where people are believed dead and
then they come back to life suddenly, and people who
are afraid of being buried alive.
Speaker 3 (16:41):
It was actually a fairly.
Speaker 2 (16:44):
Ineffective diagnostic tool to be certain someone was dead, they
would do things like hold up a mirror to your
mouth and see if there was actually vapor on it,
to see if you were breathing.
Speaker 3 (16:53):
So they made mistakes.
Speaker 1 (16:56):
So actually this actually happened where people were buried alive.
Speaker 2 (17:00):
Yes, I mean it wasn't a common occurrence, but it
did happen. I will add, as strangers who may sound
it still happens occasionally. Today you hear these stories about
people who show up in the morgue or show up
in a funeral home and suddenly they wake up. Usually,
I will add, by the way, those people are still
in a very bad shape and they don't make it
in the long run. I don't know of any case
(17:21):
to people who have actually been to the morgue and
then got home and good health. But people have gone
and they started breathing and ended up backing the ice
you before, So that should give us pause.
Speaker 1 (17:31):
How does that happen currently? Is it in areas where
there's not good medical diagnosis of what has happened?
Speaker 3 (17:40):
I wouldn't be that critical.
Speaker 2 (17:41):
I would say it's a very hard There are a
whole bunch of different tests for determining whether someone is dead.
Now and different diagnostic tools and doctors do their best.
And sometimes if you're barely breathing, and if your pulses
very sporadic and they catch you a couple of times
at the wrong moment, maybe you get unlucky.
Speaker 3 (17:57):
I will add often this.
Speaker 2 (17:58):
Does occur in the developing world, where maybe their diagnostic
tools are not as strong. I don't know of any
cases in New York City with my luck, I'll be
the first.
Speaker 1 (18:08):
Okay, So back to a few decades ago or a
century ago. So you hold a mirror to the mouth
and you see if there's fog on the mirror, and
then what happened.
Speaker 2 (18:18):
So eventually we did no enough about anatomy to recognize
cardiac and pulmonary death. Cardiopulmonary death, you stop breathing and
you don't get a pulse for a propracted period of time,
we accept that you're dead.
Speaker 1 (18:29):
Like how long? What's a protracted period?
Speaker 3 (18:32):
That depended on the doctor.
Speaker 2 (18:35):
Honestly, if you're not breathing or you know, a pulse
for a good ten to fifteen minutes, the odds of
you reviving naturally on your own get pretty darn low.
When you get much past that, your odds for surviving
in a way that is meaningfully cognitive or very low
and most people stop at some point, stop crying. But
that was the diagnostic tool back then. I will add,
by the way, that most people historically back then were
(18:57):
in very bad shape by the time they reached that pointing.
It's been other death bed for hours or days or weeks.
Speaker 1 (19:03):
So what happened next?
Speaker 2 (19:05):
So there were technological developments in medical science that allowed
us to check for cardiopulmonary death basically to figure out
whether or not your heart was still beating, whether your
lungs were still breathing, And that was the test for many,
many years until the nineteen sixties. And if you stop
breathing and if your heartstep beating, you were dead. And that,
(19:25):
I will add, by the way, is the test still
used in some religious communities, in some cultural traditions. Starting
in the late nineteen sixties with the advent of organ transplant,
which meant there was a need to harvest organs or
procure organs from the individuals as quickly as possible, and
the rise of artificial ventilation and later artificial heart support,
(19:49):
which meant that people could be kept alive for months
or even a year or two on a respirat or
on a ventilator. That created the challenge of how did
we know when these individuals were dead? And there was
a debate over whether brain death should be acceptable, and
the ultimate decision was made by a committee of experts
at Harvard that has been adopted widely that whole brain
(20:10):
death would be the standard. So, if you have two
flat EEGs, your brain stops functioning entirely, you are now
legally dead in every state. I will add New Jersey,
and to a lesser degree under some circumstances. New York
allows people with a religious belief only in cardiopulmonary death
to opt out of that standard, but other states do not.
Speaker 1 (20:31):
So give me an example of having a religious belief
and how that might change the decision that a family makes.
Speaker 3 (20:38):
Sure.
Speaker 2 (20:39):
So let us say that my grandfather is on a
ventilator which is artificial. One support and intet to buy
that which is a machimee that for a short period
of time to fairly late the period of time. Now
with new technology can replace the heart, so it's entirely artificial.
And yet he has two flat egs. His brain is
(21:00):
showing no function at all. In New Jersey. If I
have a religious tradition that says that only cardiopulmonary depth
is alive. In theory, I could raise the funds to
bring that individual home to my living room and keep
them on ventilator support and buy bad support until they
can no longer support their cart and lungs with those machines,
(21:21):
which could be a year.
Speaker 1 (21:23):
And this happens sometimes right where someone takes a person home.
Speaker 3 (21:28):
It is rare, but it has happened.
Speaker 2 (21:31):
I believe there was a famous case in Utah, a
Jesse Kutchin case where it has happened. In addition to
which there have been cases where people the Johi McMath
case may be the most known, who were what was
presumed to be a state of brain depth for families
who do not accept that definition, who brought their relatives
to New Jersey to then replace the facilities that keep
(21:51):
people who are alive in a cardiopulmonary manner but is
ceased by the brain death standard alive.
Speaker 1 (21:57):
And what's the reason that people do this. It's because
their religioustration tells them even though they're on a bivalve
and there on a ventilator, they do they think the
person could come back, or they have other issues. I
know you wrote once about somebody's belief in reincarnation and
how that affected.
Speaker 2 (22:17):
So there are two different categories of people, and we
might treat the cases the same way or differently.
Speaker 3 (22:22):
There are those.
Speaker 2 (22:23):
Individuals who truly believe that their relative is going to
revive themselves, even though the data, overwhelmingly from past practice
says that's not going to happen, and they're hoping for
a miracle.
Speaker 3 (22:34):
So to speak.
Speaker 2 (22:35):
There are other individuals who may say, you know, I
understand that my grandfather isn't really going to wake up again,
but either I, or more appropriately, he had a deep
religious belief that it was important to die of quote
unquote natural causes or if you believe in reincarnation, to
die at a certain time, and I want to fulfill
his wish, even though I understand that by your standard
(22:57):
he's dead. By a religious standard of our book, our Bible,
or tradition, he's not dead, and I want to wait
the process out.
Speaker 3 (23:04):
I'll add one more thought on that it's okay, which.
Speaker 2 (23:07):
Is you also might want to ask the question, does
it matter whether if someone's been declared brain dead you're
willing to pay for it when you take them home,
whether you're asking the taxpayers to put the bill for it,
because then the vast majority of us would say, the
taxpayers are paying to keep a dead person on a
life support system in your living room. And the other
thing to think about is there's something inappropriate or grotesque
(23:28):
about it. If I were to want to bring my
grandmother home embalmed like Lenin on display in his tomb
and prop work in my living room, our society would
not let me do that, not just for public health reasons,
but probably for reasons of what we would call common
decency or horem or appropriateness.
Speaker 3 (23:44):
Some would argue, this is not that different.
Speaker 1 (23:46):
And how does this work in terms of making decisions
for somebody else. Let's say that somebody is in critical condition.
It doesn't look likely they'll recover, but maybe there's some
extreme measures you can take that involve amputations and other things,
and a decision has to be made about whether that
person would want that kind of heroic medical treatment with
(24:08):
the possible consequences. How does a hospital make the decision
about that?
Speaker 2 (24:14):
So, while there is some variation among state laws, the
general accepted principle in this country is that we use
a substituted judgment or vicarious judgment standard, which if we asked,
what would this person would have wanted if they were
still awake and lucid and able to express an opinion.
The only two groups of people we don't use that
approach for are children, where parents can decide based on
(24:37):
what they perceive to be the best interest within certain
societal parameters, and people who've never had the capacity or
ability to make that decision. We view it as too
far elite to say you were born with a such
a significant cognitive impairment that you could never understand his question.
But if you hadn't been bored in that way, what
would you want to have had done.
Speaker 3 (24:55):
I've actually been critical of that latter approach.
Speaker 2 (24:57):
Because in that situation we use a societal best interest standard,
what society would think is in your best interests. I
have argued that for certain communities, let's say you're an Amish,
Mennonite or a Casidic Jew, it might be more appropriate
to ask what would be the best interest standard in
your community, because it doesn't seem too far a bridge
for me to say, if you were born a Mennonite,
(25:18):
you would want what a Menonite tradition speaks to not
be overall societal standard.
Speaker 1 (25:24):
Tell me about what happened during Hurricane Katrina with the
ventilators and what that means.
Speaker 2 (25:30):
Sure, so, I think during Hurricane Katrina there was a
medical crisis where they had patients who were ventilators who
needed them to stay alive, and a number of questions
around end of life arose. One the medical teams for
safety had to leave some of these patients. Some of
them could not be evacuated, and they had to decide
whether or not to continue them on life support, whether
(25:53):
or not to use morphine or other techniques to ease
their suffering that could have the risk of death. Into trial,
there was a doctor Poe was actually put on trial
and eventually acquitted for her role in this.
Speaker 3 (26:04):
These were not easy.
Speaker 1 (26:05):
Questions, right, because the decision she made was, you know,
if we are going to run out of power, then
people will suffer if they don't have the ventilator on anymore,
and so do we pull the plug before we run
out of power? Was that the issue?
Speaker 2 (26:23):
I mean, that was what she was accused of doing.
As she describes it. I believe she would say she
was giving people morphine or other medication with a dual
intent that might have ended their life as a result,
but the primary goal was to ease their suffering. And
in palliative care and end of life decision making, we
often do recognize this concept of dual intent. We may
(26:44):
intend to do one thing that inadvertently is a different consequence,
but intending to relieve suffering that leads to death, we
view conceptually is very different from intending to cause death.
Speaker 1 (27:10):
Okay, so the way we make decisions about death now
has to do in part with this concept of irreversibility.
And my question to you is how do you think
about this in terms of the new technologies that are
coming along and change that definition of irreversibility.
Speaker 2 (27:31):
I mean, this comes up not just with defining death,
but an all end of life decision making. So people
may be toward the end of life and have what
we call it terminal prognosis, but there's no way to
be certain that a new technology will develop that can
cure their illness. And there have been cases now of
people with rare cancers that seemed to one hundred percent fatal
(27:52):
they always had been before, where new immunotherapies suddenly appear
in the market or emerge as experimental treatments that then
save their lives.
Speaker 3 (28:00):
And who are we to.
Speaker 2 (28:01):
Take away someone's hope, which is why we generally defer
to what the patient's wishes are. And that also creates
an economic challenge, because we may know society that almost
everyone in this situation dies, or even that so far
everybody has. But who are we to take away hope
from the veryous one number of people who want to
be the teals, so to speak, and not the bell.
Speaker 3 (28:21):
I can give you a very concrete example of this.
Speaker 2 (28:23):
I don't know if it's still true, but there was
a time when if you went on the internet, let's
say you were diagnosed with ALS blue garage disease and
typed in prognosis ALS blue garage disease on Google, the
first picture that came up was not lou Garage.
Speaker 3 (28:37):
It was Stephen Hawking.
Speaker 2 (28:39):
The physicists who lived I'm guessing thirty forty years with
the illness, even though the vast majority of people died.
Speaker 3 (28:46):
Within a few years.
Speaker 2 (28:47):
And once you see that, it's hard to make any
meaning out of statements like a certain percentage of Medicare
or Medicaid dollars are spent in a certain period toward
the end of life, because as I always ask the
medical students after I explain that, I say, if if
you're in the last six months of life, raise your
hand now.
Speaker 3 (29:03):
And obviously we don't know.
Speaker 1 (29:05):
So Jacob, when you think about the question of irreversibility,
what do you think about cryogenics?
Speaker 2 (29:11):
So I'm not one who can say that cryogenics will
never work, though my guess is there will be other
technologies that will be developed beforehand that may be far
more effective at life lengthening, or life preserving, or even reversibility.
I can say that nothing I have seen suggests that
criogenics as it works now is very effective. I would
not suggest having your head caught off now in storage somewhere.
Speaker 1 (29:34):
What else are you seeing that seems like it could
be more effective?
Speaker 2 (29:39):
I mean, I think at some point, and this is
obviously in a far fetched way, many many years in
the future, we may be able to download people's personality,
download their brands into some kind of system A computer
might be too simplistical word, but some kind of extra
intelligence system that can then reprogram individualism in a way
That is not something I would say that you should
(30:00):
bank on in your lifetime or mind. I think we're
far better off focusing on technologies that can extend human
life as it exists now. And I will add even
beyond that, we may ultimately have that technology to transfer
heads from one individual or a brand from individual into
bodies of another, but again we are nowhere near prime
time on that. I know there's an Italian sturage, and
(30:21):
thinking about doing that, I would be very reluctant to
try that procedure because not only the possibility will work,
which the possibility, what would suffer immensely during the process.
Speaker 1 (30:31):
I think maybe it was Paul Broca. Somebody actually did
this with German shepherd dogs, where they cut off one
head and attached to the vasculature to the heart of
another dog and kept the head alive that way.
Speaker 2 (30:46):
I'm not sure if it always broke up, but a
number of different people have done this over the years,
with more or less suctatistic with various animals, So the
theoretical concept is there. There obviously are both a number
of logistical premises is in terms of attaching neurop tissue,
and also a large number of ethical dilemmas. It's very
(31:06):
I don't want to say easy, but it's much more
easy to get decided to accept killing a German shepherd
to say of another German shepherd.
Speaker 3 (31:12):
They get used to kill one person to say of
another person.
Speaker 1 (31:15):
That's right, Although as I as I understand it, it's
the idea is taking somebody who is brain dead but
their body is still functioning, and then taking somebody else
who has a functioning brain. But let's say they're quadriplegic
and their body is degrading. So it's somebody who is
already judged to be dead by brain dead standards. Is
(31:36):
the first body?
Speaker 2 (31:39):
Absolutely, I mean that that is the theoretical approach. The
obviously both logistical challenges in terms of what if you
have a mismatch of heads and bodies, and the ethical
questions of who this person legally is going forward and
how they relate to their one family versus the other
inheritance whose fingerprints to the have in a legal sense
(32:01):
becomes very very complicated, very very quickly. I'm not saying
this issue can't be solved. I would say we want
to solve these questions before we start using the technology,
or we're going to find yourself painted into a very
unpleasant quarter.
Speaker 1 (32:14):
Yes, So let me come back to that question about
how committees at hospitals, how ethics committees make this decision.
You pointed out that ethics committees are made up of
many different points of view. What have you seen is
the most contentious argument that you have come across.
Speaker 2 (32:34):
I can tell you that speaking more broadly, because I
don't want to reveal now Sini's confidential epics debates, but
historically the most controversial issue in epics committees has related
to a very specific scenario that occurred over and over
again throughout this country from nineteen seventies through the nineteen nineties,
and how to do with patients who were in accidents
(32:54):
with C three S force bibal fractures so they would
never be able to breathe again on their own, never
be able to to move below their neck on their own,
and they would wake up from his accidents and say,
I don't want to live like this, turn my life
support off, and palliative care would say we need to
respect their autonomous wishes. They don't want to suffer. And
psychiatry would say, but we know that a certain percentage
(33:17):
of people, approximately half who we do talk into staying
alive and do therapy with after a year are actually
glad they stayed alive and take meaningful value in their life.
And they point out, for example, the Superman actor Christopher
Reeve and Pallid of Care would cut back and say, yes,
but we know that the other half or not, and
the interest to the other half to not suffer existentially
(33:38):
outweigh those of the first half to have a meaningful
life in the long run. And this was a deeply
heated debate which there's no conceptually correct answer. You can't
reduce it to any level where there's a right answer.
I can tell you in practice, palliad of care has
won misbattle.
Speaker 1 (33:54):
Ah And what was it with Christopher Reeve? Which way
did he go on that he was happy that he
had stay alive.
Speaker 3 (34:01):
After a year?
Speaker 2 (34:01):
Even I think before a year he'd was very grateful
to have stayed live and he brought great meaning to
his life and helped others. But I will add, if
you're Superman and you have a loving family and a
great deal of financials for it and amazing doctors, it
may be easier to find that comfort zone than if
you're indigent. If you don't have social support if you
don't have good medical care, if you're in a back
(34:22):
room somewhere in a nursing facility. So I think the
other major issue that is the end of life, which
we've only touched on the iceberg tip of the iceberg
up so far. He is medical aid and dying, which
has become a national debate over when, if ever, people
can choose to end their own lives. And there's a
slow consensus building that people with terminal illness, terminal physical
(34:42):
illness should be able to end their own lives if
they have a diagnosis of als or cancer and they're
not going to survive a prolonged period of time. And
we've seen from one state, Oregon in the nineteen nineties
to I believe it's now ten jurisdictions to legalize this,
and the trend going forward is to expand this. However,
we have really not come to terms with a question
of people who are not suffering physically but suffering psychiatrically
(35:07):
or existentially. And for example, we've seen this heated debate
in Colorado over patients with anarettia who have not responded
to treatment over a very long period of time should
be able to turn down refeeding or turn down nutritional support,
even if it means the end of their life, and
the way we would let a patient with a kidney
problem turn down dialysis let themselves die.
Speaker 3 (35:29):
And we're going to see this question more and more.
Speaker 2 (35:31):
Obviously, if you show up in the emergency room and
you've broken up with your prom date and you take
it over as a tile and all, I don't think
any Risgilble person would say, well, you've had a long,
meaningful life, you should be able to make this decision.
On the other head, if you've had depression for forty
years and you've suffered and no treatment is worked after
every intervention and you say, if you could help me,
I want that, But since you can't, please let me
(35:53):
in my life.
Speaker 3 (35:54):
It's a harder question.
Speaker 1 (35:56):
And why do you see these questions coming up more
and more?
Speaker 2 (36:00):
Well, I think they've come up in part because patients
are raising these issues and the clinical practice. Patients often
will say, doctor, I've done everything you've asked me to do.
I'm in that very small percentage of people who simply
don't respond to treatment, whether it's for psychosis or for
depression or for anxiety. I wish I did but I've
waited you out for forty years and there hasn't been
(36:21):
a new technology. I don't want to wait any longer.
And you've actually seen a handful of countries, Canada most recently,
adopt legalization.
Speaker 1 (36:31):
And so what do hospital ethics committees decide on these
or is it just a very contentious issue or people disagree?
Speaker 2 (36:39):
Well, it's not yet a contentious issue in the United States,
because no American state lets you make this choice yet.
But I imagine now that Canada and several European countries
have changed their rules in the last year or two,
we're going to see at least debate over this coming forward.
Speaker 3 (36:52):
In the United States.
Speaker 2 (36:53):
I were to hear colleges discussing this and this widespread disagreement.
Speaker 1 (36:58):
So what's going on in the United States? Is medical
assistant suicide for someone who is physically ill, right, but
not mentally exactly? Okay?
Speaker 2 (37:07):
Yeah, and I will add in all the cases in
the United States, we do not have a euphenagia program.
We do not end someone's life if they can't make
the choice on their own. We only have a program
where we will prescribe your medication to let you choose death.
When the time comes. In my own experience, having talked
to many patients, and this may surprise people, be people
who benefit from this option the most are people who
(37:28):
never use it and people who know that if things
got bad enough, they could make this choice, which actually
gives them hope to keep on fighting their illness. It's paradoxical,
but it's really a stunning phenomena, fascinating.
Speaker 1 (37:43):
How does it work? Sorry, so they're prescribed the medication
that are actually given them, medication where they can pull
the ripcord if they want to. Is that the idea?
Speaker 2 (37:53):
Yeah, So a doctor will write you a prescription and
you fill the prescription after a number of safeguards, an
interview with a psychiatrist. I mean, you can choose whether
to take this medication that will end your life in
a very peaceful way. In some states people actually have
going away parties, so to speak, where they bring their
friends and family, which is not that different from how
death was in the nineteenth century, when people often had
(38:13):
diseases that were terminal, where they would be on a
deathbed and their friends and family would come to say goodbye.
Now we've sanitized death in a way. People die in hospitals.
I think as a medical resident, the most disconcerting experience
ever was showing up in a hospital room at five
in the morning, six in the morning to see a
patient you've seen the night before, and finding the room empty,
(38:33):
which the patient had passed away overnight and completely sanitized
and stripped down, like a hotel room where sometimes even
they already brought the next patient into the bed, which
are very different and in some ways dehumanizing process. I
understand why that may be necessary with the economic forces
in medicine right now, better than having the living person
waiting on a gurning and a foyer, but it's still unsettling.
Speaker 1 (38:57):
Give me a sense of how people did used to die.
Speaker 2 (39:01):
So often if you had a terminal illness by cancer
or heart disease, there were far fewer treatments in there
are today, So you're running time, so to speak, between
when you got ill and when you would die and
when you would make lucidity before you die would actually
be longer, so people would have a sense they were dying,
and they could call their family together. They could call
the priests for the last rites, or the minister to
(39:23):
say a blessing or of a rabbi to say farewell.
Speaker 3 (39:26):
They could rewrite their will.
Speaker 2 (39:28):
There are all sorts of both cases in mystery novels
in the nineteenth and early twentieth century about rewriting wills.
And that's because people have this window that we really
don't have today, because people live until their bodies essence
shut down.
Speaker 3 (39:41):
I think a related question.
Speaker 2 (39:44):
Is so George Church, who's a biologist at Guganticist d
at Harvard, talked about the prospect of bringing back not
just people who've been deceased, bringing back species that have
been deceased, and specifically human species. I made species like
Neanderthal man, and that raises a whole set of complex
related questions of its own, of what rights Neanderthals would
(40:07):
have in the context of human society, whether bringing the
back would cause them existential suffering, whether they would have
the same rights as Homo sapiens. But in the relation
to this context, it also risk the possibility of bringing
back Neanderthals who are not Homo sapiens and using bare
bodies to transplant human heads into which might plausibly be
(40:29):
doable at some point in the future, and raise really
complex ethical questions.
Speaker 1 (40:51):
Let me ask you this you're a psychiatrist, among other things,
what would you do if you were assigned the revivification
of a Neanderthal man and you were the first person
in the room when he wakes up. Now, obviously you
wouldn't share the same language, So what would you try
to do to reduce existential suffering on his part?
Speaker 2 (41:13):
I think first I would try to reduce existential suffering
on my part by standing behind something very large, because
my census Neanderthals waking up in this situation might not.
Speaker 3 (41:23):
Be very friendly.
Speaker 2 (41:25):
But beyond that, I think the real answers we don't
know in the same way we don't know how to
communicate with dolphins, so they may have a very sophisticated
language of their own. We may have any idea how
to communicate or appreciate the emotional response of a Neanderthal man.
It's taken us many, many years to understand in a
most rudimentary way the relationships human beings have with other
(41:46):
high word er apes like a relige, chimpanzees or arangutans.
Neanderthals will be intellectually far more sophisticated. Are going to
be a puzzile we first made them. If we first
made them.
Speaker 1 (41:56):
So what would you actually do if you were assigned that.
Speaker 2 (42:00):
Job as a psychiatrist. I would probably wait. I would
probably do nothing until I first see how this revived
creature responds to me and take cues from them in
the same way I would do seeing any other patient
in the emergency room. And I I am not comparing
any of my patients to Neanderthal men, though they may
compare me to one. But I do think it's important
(42:22):
first take cues from your patients, to take cues from
other individuals what they expect from you. And that's what
I think the wisest course of action would be.
Speaker 1 (42:32):
Great, God, this is going to be a Hollywood screenplay
that we should write, Okay, any any other thing.
Speaker 2 (42:39):
And I think that covers my end of life thinking.
I have lots of other issues I can always.
Speaker 3 (42:44):
Talk about, but.
Speaker 1 (42:47):
Give me, give me a sense of one.
Speaker 3 (42:49):
Sure. I think one issue that is related but distinct.
Speaker 2 (42:54):
Is the situation of conjoined twins who wish one twin
wishes to be separated and the other twin does not
wish to be separated because of the risk involved in
the procedure.
Speaker 3 (43:04):
And you have a situation.
Speaker 2 (43:05):
Where one person's life is at stake for the other person,
the autonomy and welfare of their being is at stake,
And there's no easy way to resolve that question. And
it sort of brings to bear all of the different
ethical issues we have raveled with his society bioethically over
the last fifty years, and that it's one of the
only questions in bioethics, by the way, where not only
do I not have a path to help people move forward,
(43:27):
I have no visceral sense of what the right answer
is either. I feel like if I'm not in that situation,
I can't even think about how to approach it.
Speaker 1 (43:34):
Wow, are there other situations where one person's life would
be in danger if something happened that would help another person?
There must be other situations that are analogous.
Speaker 2 (43:46):
Yeah, I mean there's the famous case of Shimp versus McFall,
where there were two cousins and one of them made
a bone marrow transplant and his cousin was the only
person in the entire world with a bone marrow transplant
that could match him that he needed to save his life.
And he did not have a negative relationship with his cousin,
but they weren't particularly close and he went to his
cousin and said, please give me the bone marrow transplant,
(44:08):
and the bone mara trus plant was not high risk,
but it had some risk in some discomfort. And his
cousin said, no, I don't owe you that. And then
he went before the court and said, I'm going to
die without this bone marrow. It's not that much of
an inconvenience or risk to my cousin. Please make him
do it. And the court said no, and I believe
he died.
Speaker 1 (44:26):
Oh do you know anything about what the cousin's reasoning
was beyond the inconvenience.
Speaker 2 (44:34):
I don't think, and I am not an expert in
his case, but I don't think the cousin had a
great deal of health literacy. And the cousin was someone
who was a fairly suspicious of medicing a baseline. So
no matter how many times you might tell him he's
got a high risk procedure, it's not so clear he
really believed that.
Speaker 1 (44:47):
Okay, incredible, And.
Speaker 2 (44:51):
I will add, by the way, even though that seems
like a shocking case, every single one of us has
the ability to save the life of a stranger.
Speaker 3 (44:59):
You can give a a.
Speaker 2 (45:00):
Kidney or part of a liver, and some people do
altruistically and save someone's life, someone who will otherwise die,
and the vast majority of us, for reasons, whether wise or.
Speaker 3 (45:11):
Not wise, choose not to. So in some sense we're
all mister ship.
Speaker 2 (45:18):
Yeah, and we all risk being mister McFall too.
Speaker 3 (45:22):
At some point we should not forget right.
Speaker 1 (45:25):
So what do you advise your students on that front?
Speaker 2 (45:30):
I mean, I think I advised them in the same
way by advised students about every ethical issue, which is
I can't tell you what the right answer is. The
two things that are important, actually, there are three things
that are important. The first one is recognized and said
it is an ethical issue, many of the difficult problems
that arise in medical ethics, or because no one matter
how wise or well attention, actually recognize this is an
ethical challenge. The second thing that's really important is that
(45:54):
when you start with a certain premise, you want to
logically come to a conclusion based on that premise. So
at some point between your premise in your conclusion a
miracle happens here, so to speak, you want to.
Speaker 3 (46:03):
Go back to square one.
Speaker 2 (46:05):
And then finally, I say, once you reach those two premises,
the final step is to recognize that very well intentioned
people with very good values come to very different answers
about this questions from starting with different premises and different
cultural beliefs and values of their own, and the goal
is to understand them and respect them even if you
don't agree with them, because they're not fools simply because
(46:27):
they disagree with you. And I think our society as
a whole would be a much better place we were
able to agree to disagree with mutual respect, and we
actually would be able to find a lot more common
ground at the corners of a lot of issues where
there might be a lot of overlap.
Speaker 1 (46:44):
So that was my interview with Jacob Appel, one of
a very small group of people who can equally address
both the medical and legal and ethical aspects of death
and the complexities at the interface. What I hope you've
gathered from today's episode is that the issue of declaring
death is not straightforward, and often we find the most
(47:06):
complex cases at the intersection of medical and legal systems,
and zooming out to the beginning, I just want to
remind us that although we think of death as binary,
it's often much more complex and we are always going
to be confronted with these problems. As technology improves, we're
going to be able to rescue a life from different
(47:28):
states that would have been previously impossible to reverse or
even imagine reversing. And so as biology marches along each
year into the future, the answer to the question of
when you are dead is one that will change along
in lockstep, and in two hundred years we might find
(47:49):
our current answers unpalatable and inconceivable. But in any case,
in each generation, with each landscape of new technology, we
have to con continually revisit this question, where do we
draw the line between life and death? Go to Eagleman
(48:12):
dot com slash podcast for more information and to find
further reading. Send me an email at podcasts at eagleman
dot com with questions or discussions, and I'll be making
an episode soon in which I address those. Until next time,
I'm David Eagleman, and this is Inner Cosmos.
Popular Podcasts
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
The Nikki Glaser Podcast
Every week comedian and infamous roaster Nikki Glaser provides a fun, fast-paced, and brutally honest look into current pop-culture and her own personal life.