death

death Reports of the first human heart transplants in 1967 made controversy over the definition of death seem as unprecedented as heart transplantation itself — a radically new issue produced by a radically new technology. But disagreements over the meaning of death long predated the 1960s, and such debates never were simply products of new technical knowledge. From the intense fear in the eighteenth and nineteenth centuries that people were being mistakenly buried alive, to current controversies over brain death, death has long been a contested and changing construct, shaped by scientific discoveries in resuscitation and vivisection, the changing social powers of the medical profession, and changing cultural values. If death means the end of life, defining death implies defining life — a long-contentious issue indeed.

1740–1880

For much of the eighteenth and nineteenth centuries, an intense fear of ‘premature burial’ haunted Western culture, from the tales of Edgar Allen Poe to European laws that imposed long waiting periods before interment. This concern was neither an isolated curiosity nor an outbreak of mass hysteria. Rather, it reflected major changes in the concept of death itself, prompted in large part by new scientific discoveries in resuscitation and experimental vivisection. For example, beginning in the 1740s a series of widely-publicized cases demonstrated that breathing and heartbeats could be restarted after they had stopped. To make sense of such resuscitations, London physician John Fothergill proposed that suspended animation was a curable form of death. Like a machine, life could be turned off and on; reanimation was a form of resurrection. However Fothergill's view was rejected by such vitalists as Scottish medical theorist William Cullen (1710–90). Cullen redefined death, not as the actual cessation of heart and lung functions, but as the loss of the potential for muscle and nerve activity (‘irritability’ and ‘sensibility’). His approach reconciled resuscitation with the belief that death was by definition irreversible. However, it offered no way of diagnosing when this vital potential had been lost, and thus no way of knowing for certain when resuscitation efforts should be ended. Others rejected both these new definitions of death, denying that ‘suspended animation’ was real. They postulated that undetectable levels of heart and lung activity must by definitions have been continuously present in all cases of successful resuscitation.

The mid seventeenth-century discovery that the heart and lungs could be maintained alive in an animal that had been decapitated also challenged concepts of death, by dramatizing the distinction between the death of an organism and the death of its component parts. The guillotine, invented by a doctor to make execution swifter and more humane, also seemed to demonstrate that human heads and bodies could show signs of separate life. Based on such observations, many eighteenth-century medical writers concluded that death was not a single event but a long process taking place at a succession of physiological levels, and that death could not be diagnosed with certainty until the process had concluded with decomposition of body tissues. Such doctors' doubts about their own ability to diagnose or define death played a key role in triggering the cultural concern that people were being buried alive.

However, the specific fear of premature burial was not simply a product of medical uncertainty. To make sure that their bodies would be dead before burial, some people requested that they be cremated or embalmed. Their terror of being buried alive was more than simply a fear of being mistaken for dead. Romantic fascination with the claustrophobia of isolated helpless confinement, anti-Semitic opposition to traditional Jewish rapid interments, and post-Enlightenment doubts about the afterlife helped shape medical uncertainty about death into the specific horror of being buried too soon.

1880–1960

While the fear of premature burial was triggered by the discoveries of eighteenth-century scientists and physicians, late nineteenth-century doctors generally concluded that new technologies, from the stethoscope to X-rays had solved the problem of diagnosing death. These new instruments did not resolve any of the underlying conceptual controversies over the meaning of death, but an unprecedented faith in technology, from the 1880s through the first half of the twentieth century, led both the medical profession and much of the lay public to stop expressing concern over the persisting philosophical uncertainties. The fear of premature burial never disappeared, but it was largely relegated to such marginal organizations as the Association for the Prevention of Premature Burial, an international group of vitalists, anti-vivisectionists, and anti-bacteriologists, united by their opposition to the growing philosophical materialism and social power of twentieth-century medicine. Women also were disproportionately active in this movement. Some opposed the new technological medicine for undermining nineteenth-century women's efforts to integrate moral and physical healing. Others worried that women were particularly at risk of premature burial, because women were believed to be especially susceptible to fainting spells, catatonic fits, and spiritual trances that mimicked death.

Dramatic new discoveries, including recoveries from prolonged hypothermia and successful animal head transplants, continued to complicate the era's concepts of death. The resulting uncertainties were widely debated by scientists and the public. Many physiologists agreed with Boston embryologist Charles Minot that organisms were illusory, and that life and death could be defined only at the cellular level. Alternatively, neurologists like Charles Sherrington redefined the life of an organism as the nerve-mediated capacity to integrate organ and tissue functions. Mass culture, from journalism to science fiction, avidly reported these discoveries and disputes. However, unlike in prior centuries, when such scientific developments sparked public panic, in the first half of the twentieth century they were represented as wonderful marvels of modern science, possibly leading to resurrection or immortality. Also, while physiologists, philosophers, and the public continued to ponder the meaning of death, few of this era's practitioners of clinical medicine joined the discussion.

Since 1960

The brain death debates that began in the late 1960s thus did not constitute an unprecedented change in the meaning of death. But the 1960s did mark two new developments: a revival of interest in the issue on the part of clinicians, and a change from optimism to renewed concern on the part of the public. In the late 1960s, several medical leaders such as Harvard University anesthesiologist Henry K. Beecher proposed that patients be declared dead if their brains had irreversibly lost all functioning, even if their other vital functions were being maintained by mechanical ventilators. At first, ‘brain death’ was explained primarily as a means of defending organ transplantation, and of protecting medicine against the era's renewed social criticism of professional authority. But in the early 1980s, this representation of the issue was dramatically reversed. Brain death now was promoted, not as a defence of medical technology against public criticism, but as a defence of the public against that technology's invasive indignities. Redefining death was understood as logically distinct from euthanasia, but each provided a different way to answer the same clinical question: when should a physician stop treating a patient? Growing public support for a ‘right to die’ and ‘death with dignity’ proved crucial to the rapid adoption in the US of the brain death legislation advocated in the 1981 report of the President's Commission on bioethics. To diagnose brain death, the commission specified that the patient must have suffered permanent loss of all brain functions, both ‘higher-brain’ based activities, such as consciousness, and basic brain stem reflexes, such as gagging and pupil constriction. Great Britain adopted slightly different criteria, promoted by Christopher Pallis, under which the permanent loss of brain stem functions was considered sufficient to diagnose brain death.

Despite the success of brain death legislation, the fear of being treated too long was added to, not substituted for, the fear of being abandoned too soon. Mass culture continued to link brain death with organ-stealing doctors, as in the 1977 book and subsequent motion picture Coma. Orthodox Jews, traditionalist Japanese, and ‘right to life’ supporters are all deeply divided over whether to accept any brain-based definition of death. Some African Americans expressed concern that brain death was being used to take organs prematurely from blacks for transplantation to whites.

On the other hand, many philosophers, such as pioneer bioethicist Robert Veatch, attacked ‘whole brain’ legislation as failing to resolve crucial conceptual ambiguities. They promoted various ‘higher-brain’ alternatives that define human death as the permanent loss of consciousness and personal identity — as in the persistent vegetative state.

Thus, while the whole-brain definition of death has won wide acceptance, death remains a controversial and contingent concept, as it has been for centuries, at the intersection of changes in physiological research, medical practice, social structure, and cultural values.

Martin Pernick

Bibliography

Pernick, M. S. (1988). Back from the grave: recurring controversies over defining and diagnosing death in history. In Death: beyond whole-brain criteria, (ed. R. M. Zaner), pp. 17–74. Kluwer Academic Publishers, Dordrecht and Boston.
Pernick, M. S. (1999). Brain death in a cultural context: the reconstruction of death 1967–1981. pp 3–33 In The definition of death, (ed. S. Younger, R. Arnold, and R. Schapiro). Johns Hopkins University Press, Baltimore.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1981). Defining Death. US Government Printing Office, Washington, DC.

See also brain death; coma; corpse; euthanasia; funeral practices; life support; organ donation; resurrection; resuscitation; transplantation; vegetative state; zombie.