Exact moment of death murky, doctor says

A year ago, Terry Schiavo was dying in nearly every living room in America, her face a daily reminder that technology can keep us alive but can't solve our ethical dilemmas. A year later, Schiavo's husband and parents are back on TV pushing books with opposing views of her death. All of which makes this week's "Rethinking Death" conference at the University of Utah particularly relevant.

While death is still an ultimate certainty (something at one level we can't "rethink"), its particulars — when exactly it happens, when exactly it should happen — have grown increasingly fuzzy. Schiavo died last March 31 after a legal battle that eventually drew in the U.S. Congress, the president and the Vatican. But daily in America, said speakers at this week's conference, families and doctors face bioethical questions just as perplexing.

"Society likes to think there's a bright line between life and death," said Dr. Stuart Youngner, a physician and chairman of the Department of Bioethics at Case Western Reserve University. "My argument is that this line is socially constructed." It's clear that a little girl swinging in her back yard on a sunny day is definitely alive, and that Napoleon is definitely dead, he pointed out. But where exactly do people who are "brain dead" fit in?

"All vital functions do not cease simultaneously," Youngner explained. We can substitute and support various body systems, so it's often "not the 'loss of all life' that we insist on," he says. "Life may persist in cells and tissues and organs." Even with the traditional measure of death — the heart stops beating, breathing ceases — the exact moment of death is murky, he says.

"Why do we care about the moment of death?" Youngner asks, and then lists the three main reasons: "organ transplantation, organ transplantation, organ transplantation."

On the one hand there are now some 90,000 people on waiting lists for organs, organs that must still be "viable" in order to be transplantable. On the other hand, we don't want to take organs from a person who is still living. So we have constructed the "brain death" definition. Or, as Youngner says, "we gerrymandered the boundary" of what death is to include "the almost dead, the good as dead, the dead enough, the soon to be dead."

In the late 1960s, with the increased use of ventilators, "brain death" became the standard for organ donation. This was defined as "whole brain death": both loss of cognition and consciousness, as ruled by the "higher brain" functions of the cortex, and loss of the integrative capacity ruled by the brain stem, which controls functions such as breathing.