Defining Death Down

Ironically, or maybe not, as one scientific establishment raises alarms about what it perceives to be dire threats to the planet, another is posing demonstrable threats to individual human lives.

The trove of e-mails written by climate scientists at East Anglia University in England that was made public last month seems to implicate some of those professionals as having sought to alter data and suppress evidence about global warming. The e-mails certainly show that scientists can be as spiteful, conniving and deceptive as anyone else. Global warming skeptics have seized upon the e-mails’ revelations to promote their skepticism; whether it is warranted or not remains an open question.

But another idea, this one promoted by much of the medical establishment, presents a clear and present danger.

“Decisions are made every day in this country to withdraw and remove people from life support,” says a doctor quoted by Dr. Sanjay Gupta in his book “Cheating Death,” “without really giving them a chance.” And, as was recently reported in the New York Times, “terminal sedation” – administering drugs to alleviate pain but thereby hastening death – has been embraced by many medical professionals. Life, quite literally, isn’t what it used to be.

Then there are the patients who are in what is called a “vegetative state” – showing no responses to stimuli beyond muscle reflexes. In several highly publicized cases, some have awoken, even after many years, from their seeming obliviousness. Most, though, do not; and many are removed from life support and deprived of water and nutrition. But calculating percentages begs the larger question – whether such people are, whatever their physical limitations, in their “vegetative” states, in fact alive.

“Many doctors harbor a therapeutic nihilism about such patients,” writes Dr. Ford Vox, a resident physician at Washington University in St. Louis, in the Washington Post, “but this research should give us good reason to keep our minds open.”

The research to which he refers includes that of neuroscientist Dr. Adrian Owen of Cambridge, who analyzed the real-time brain activity of a young woman in a vegetative state five months after a car accident. Utilizing digital processing of EEG readings that reveal unique, reproducible signals, he reported in 2006 in Science that the patient, whose only visible response to the external world was occasionally fixating on an object, was able to follow complex commands with her mind, imagining playing tennis and walking through the rooms of her home. Owen found similarly remarkable results in at least three other patients.

There is, moreover, also a “minimally conscious state” (MCS), estimated to be ten times as prevalent as the more recognized vegetative one. And, Dr. Vox maintains, “about one-third of the time, ‘vegetative’ patients are minimally conscious or even better.”

In November, 2008, using EEG readings, Dr. Steven Laureys, a neurologist at the University of Liege in Belgium demonstrated that some low-level MCS patients were able to follow basic instructions – counting familiar and unfamiliar names played randomly into headphones.

And, at the Moss Rehabilitation Research Institute, Dr. John Whyte is studying the seemingly paradoxical fact that the sedative Ambien apparently causes some vegetative patients to perk up to MCS or higher states.

All that should be sufficient to give pause to would-be plug-pullers. But a variety of factors – most notably, perhaps, the shortage of organs for transplantation – is pushing some physicians to call a life a life, even if it hasn’t yet been fully lived.

Writing recently in the New York Times Magazine, Dr. Darshak Sanghavi, chief of pediatric cardiology at the University of Massachusetts Medical School, asserts that medical professionals “have handled [the] paradoxical situation” that an organ donor must be dead but the needed organ alive “by fashioning a category of people with beating hearts” to be regarded “as if they had rigor mortis.”

Such “dead” people with pulses – sometimes brain-damaged but not necessarily meeting the criteria of “brain death” – who are assisted in their breathing by a machine are candidates for “donation after cardiac death” (DCD). Where that procedure is chosen, the patient’s breathing tube is removed in an operating room. If breathing ceases naturally and the heart stops within an hour, five minutes are counted off. The interval is not based on any research; it was the best-guess decision of a panel of experts in 1997. If the heart does not resume beating by the five-minute buzzer, the patient is declared legally dead and his organs harvested – despite demonstrable brain activity.

Dr. Sanghavi reports further that, in 2004, Dr. Mark Boucek, a pediatric cardiologist at Denver Children’s Hospital, decided to write a “far more aggressive DCD protocol,” revising the five-minute rule down to three minutes. Then, when that didn’t yield the desired results, he re- revised it to just over a minute.

“Doctors have created a new class of potential organ donors who are not dead but dying,” writes Dr. Sanghavi. “By arbitrarily drawing a line between death and life – five minutes after the heart stops – they [doctors] have raised difficult ethical questions. Are they merely acknowledging death or hastening it in their zeal to save others’ lives?” He leaves the question hanging in the air.

In the eyes of Judaism, every moment of human life, even compromised human life, is beyond value, and Jewish law forbids hastening a person’s death to any degree. There is some controversy about whether halacha, or Jewish religious law, considers brain death to constitute death. But no halachic authority permits the withdrawal of life support from a patient whose brain is merely damaged.

The world’s human population is indeed at a turning point. Because whether or not carbon emission-born catastrophe in fact looms, modern medicine’s defining of death downward is clearly upon us.


[Rabbi Shafran is director of public affairs for Agudath Israel of America.]

All Am Echad Resources essays are offered without charge for personal use and sharing, and for publication with permission, provided the above copyright notice is appended.

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6 Responses

  1. Bob Miller says:

    Jewish organizations that have looked favorably on health care legislation now need to reassess their positions. They need to resist vigorously any changes to our system that will make health care rationing more likely. The bleakest side of rationing is health care refusal to the elderly by authorities whose decisions cannot be challenged by the victims-to-be or their next of kin.

    Such organizations often publicly tout their ability to get their constituents goodies from the government (which, by the way, are paid for by taxpaying citizens as a group, not by the tooth fairy). We have to be able to look some gift horses in the mouth in order to resist dangerous levels of control.

  2. K R Heckert says:

    It is important to distinguish – as you do not do in this article – between those who are brain-damaged but will live on indefinitely, with or without help, and those who have received a terminal diagnosis and in which death is unquestionably imminent. A person who is dying of cancer and has at most a few months to live, and is in unbearable pain, should be given whatever medication is necessary to give them relief. This is certainly permitted by halacha. My own mother, who had bone cancer, was given a diagnosis of less than three months to live. Bone cancer is horribly painful, and she was not being medicated enough to prevent her literally crying out in pain whenever she was moved. I asked a sheilah from a Rav recommended by the Agudah, who poskened that in such a case the question of shortening life does not arise so long as the painkiller is given specifically to to reduce pain and not to shorten life.

    Of course, in any such case a specific sheilah should be asked, but people should not assume that it is forbidden. A sheilah should be asked, and the answer carried out. The case of someone who is “in a vegetative state” after an accident, heart attack or drug overdose is an entirely different matter, and should not be confused with the situation in a terminal illness where it is obvious that only a minor miracle could save the patient.

  3. Miriam says:

    We don’t admit it, but health care is inevitably rationed. Each time any high-cost medical situation receives funding, that puts a huge burden on the rest of the system. People think of medical possibilities as being infinite, yet facilities, staff, and funding are ultimately finite.

    Should all 30-year-olds be taxed at 50% for the rest of their lives, in order to funnel those monies for high-cost health care of others? Should doctors and hospitals be forced to cut their fees and increase their output?

    Even the choice of sustaining a vegetative state versus performing an organ transplant is a choice in allocating these fixed resources – both are expensive, and in some cases there is a choice of one life versus another.

    Yes in general Orthodox Jews ask sheilot for specific cases, but in the meantime we are all leaving the big picture to be decided by government, big business, or secular medical ethics boards.

  4. Bob Miller says:

    Miriam asked,
    “Should all 30-year-olds be taxed at 50% for the rest of their lives, in order to funnel those monies for high-cost health care of others? Should doctors and hospitals be forced to cut their fees and increase their output?’

    Where is it written that the medical system should be tax-supported to this extent in the first place? Individuals using savings plans, communities and industries acting together, etc., could probably do better than government without the huge level of waste we now have.

  5. Dr. Zacharowicz says:

    Rabbi Shafran should be commended for raising serious questions about the slippery slope of current secular ‘ethics,’ which permits doctors to shorten the lives of some patients to benefit others in expensive transplants (which also benefit the hospital). For a doctor to remove vital organs of a patient who is not brain dead, after the patient’s heart has stopped beat for a bit more than one minute, is hard to understand from anything but a utlitarian perspective (sacrifice the few to benefit the many), which is anathema–or should be–to so many of us.

    Kudos to Rabbi Shafran, a lone voice in the community, for raising the alarm, yet again, about the Brave New World of end-of-life care.

  6. Miriam says:

    Individuals … could probably do better than government without the huge level of waste we now have.

    Amen to that. But the problem is that usually public discussion of these issues results in public laws, which means government intervention and the subsequent waste.

    In fact we might even be better off without the big insurance companies, too. But systems are very difficult to change much less eliminate.

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