# Ep46 "Who says you're dead?"

An episode of [Inner Cosmos with David Eagleman](https://invisiblenetwork.ai/podcast/1677842672), 12 Feb 2024, 49 min.

Audio: https://podtrac.com/pts/redirect.mp3/traffic.omny.fm/d/clips/e73c998e-6e60-432f-8610-ae210140c5b1/534dc725-2971-42a1-b1bf-afaa0107416e/67774597-6562-4b67-8c8e-b113008ec077/audio.mp3?utm_source=Podcast&in_playlist=bee00526-7528-4581-b6b6-afaa01083a3d

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.

## Transcript

[0:05] Speaker 1: How do you know when a person is dead? I mean,
[0:08] Speaker 1: it seems like a straightforward problem, but this is often
[0:11] Speaker 1: a very complex issue, both medically and legally, because, as
[0:16] Speaker 1: we'll see in this episode, death is not an event
[0:20] Speaker 1: but a process. So where do the medical and legal
[0:23] Speaker 1: systems face off against one another in this question? Can
[0:28] Speaker 1: a person be declared legally dead even though he's very
[0:31] Speaker 1: much alive. Why in twenty eleven did an enormous number
[0:35] Speaker 1: of families choose to pull their loved ones off life
[0:39] Speaker 1: support just before the new year? And what does this
[0:42] Speaker 1: have to do with getting buried alive or with your
[0:45] Speaker 1: family's religious beliefs, or whether someone's head stays alive after
[0:50] Speaker 1: the guillotine. Welcome to Inner Cosmos with me David Eagleman.
[0:57] Speaker 1: I'm a neuroscientist and author at Stance, and in these
[1:01] Speaker 1: episodes we sail deeply into our three pound universe to
[1:04] Speaker 1: understand why and how our lives look the way they do.
[1:18] Speaker 1: Today's episode is about the science, the ethics, and the
[1:23] Speaker 1: questions about the end of life, What qualifies as death,
[1:28] Speaker 1: who gets to say that you are dead? And what
[1:31] Speaker 1: is the future of this? Okay, so let's start with
[1:35] Speaker 1: something that's perhaps macabre and unexpected. But if you're a
[1:40] Speaker 1: modern adult and you die suddenly, you have all these
[1:44] Speaker 1: bill pay and credit card payments and automatic withdrawals that
[1:47] Speaker 1: are scheduled, and your finances might keep on trucking for
[1:51] Speaker 1: a while. You may even receive some auto deposits into
[1:55] Speaker 1: your bank account, And with all the comings and goings,
[1:58] Speaker 1: it would look to someone who didn't know that you're
[2:00] Speaker 1: still making transactions. And if you happened to have some
[2:04] Speaker 1: pre scheduled emails that you'd previously written, those might go out,
[2:08] Speaker 1: and various legal things get triggered at different points, and
[2:11] Speaker 1: it will probably look for a little while like you're
[2:15] Speaker 1: still making stuff happen in the world. And I was
[2:18] Speaker 1: thinking about this the other day as an analogy to
[2:21] Speaker 1: what happens with your biology. Generally speaking, death is declared
[2:27] Speaker 1: when a heart stops beating and or someone stops breathing.
[2:32] Speaker 1: But even though we think about death like a binary event,
[2:35] Speaker 1: there's no central command center in the body that says, okay,
[2:40] Speaker 1: now we're done. Everyone stop working. Because the body is
[2:44] Speaker 1: made of literally trillions of cells, and all of their
[2:48] Speaker 1: chemical signals are connected and intricate cascades and loops and
[2:53] Speaker 1: when something stops running, these nested feedback loops tend to
[2:59] Speaker 1: bump things back to the normal range. We have this compensation. Now,
[3:03] Speaker 1: at some point the whole show grinds to a halt.
[3:07] Speaker 1: The compensatory mechanisms can't keep up with the catastrophic failure
[3:13] Speaker 1: of loop after loop that stops working, and eventually the
[3:17] Speaker 1: whole system stops. But death is not a moment in time.
[3:21] Speaker 1: It is a process. In other words, the individual cells
[3:26] Speaker 1: don't necessarily know that the heart has stopped or the
[3:30] Speaker 1: brain has stopped its cognitive whirlwind of activity, so they
[3:34] Speaker 1: just keep trucking along for as long as they can.
[3:37] Speaker 1: So here's an analogy so we can think about this.
[3:40] Speaker 1: Imagine you are a space alien that's looking down on
[3:44] Speaker 1: the Earth and you see a large blobby organism moving
[3:50] Speaker 1: towards some fortress. And then the blobby organism extends two
[3:56] Speaker 1: arms around the fortress and starts to squeeze it. But
[3:59] Speaker 1: then some explosions go off and the organism stops moving.
[4:03] Speaker 1: It seems to die. But then you use your alien
[4:07] Speaker 1: telescope to zoom in more closely, and for the first time,
[4:11] Speaker 1: you notice a single warrior running up the hill, turning
[4:15] Speaker 1: back swinging his sword, falling to his knees in lamentations,
[4:19] Speaker 1: and regaining his footing and running towards the fortress again.
[4:23] Speaker 1: So you start panning your telescope round and you notice
[4:26] Speaker 1: a dozen of these rogue swordsmen in different locations around
[4:30] Speaker 1: the battlefield. And that's when you realize that the blobby
[4:34] Speaker 1: organism who came upon the fortress was actually composed of
[4:39] Speaker 1: lots of little individual agents, all of whom worked in
[4:43] Speaker 1: concert and maybe had hierarchies and rules of engagement and
[4:47] Speaker 1: backup plans such that even when most of the army
[4:51] Speaker 1: was killed, that didn't necessitate that every part stopped the
[4:56] Speaker 1: survival of individual warriors. Suddenly, rev feels that the blob
[5:01] Speaker 1: was made of these little swordsmen all along, even though
[5:04] Speaker 1: that was difficult to see. And this is what happens biologically.
[5:09] Speaker 1: We are made up of cells that operate together. This
[5:13] Speaker 1: is what makes a person or any animal. Trillions of
[5:17] Speaker 1: cells collaborating to make this giant creature that moves around
[5:22] Speaker 1: and finds other collections of cells to eat and take
[5:25] Speaker 1: their energy. And researchers have made recent discoveries about cells
[5:30] Speaker 1: that stay alive and actually get more active well after
[5:35] Speaker 1: the rest of the body has been declared dead. In
[5:38] Speaker 1: other words, these little swordsmen warriors that are still running
[5:41] Speaker 1: around even after the blob has stopped. For example, some
[5:47] Speaker 1: researchers at University of Illinois Chicago looked at little pieces
[5:51] Speaker 1: of fresh brain that get removed during brain surgery, and
[5:55] Speaker 1: they looked at these either right when the tissue was
[5:58] Speaker 1: removed or at different times after the removal. So they
[6:02] Speaker 1: called this a simulated death experiment, and their point was
[6:06] Speaker 1: to think about what happens when tissue gets separated and dies.
[6:11] Speaker 1: And what they found after the tissue is removed is
[6:14] Speaker 1: that some brain cells actually increase their activity. These cells
[6:18] Speaker 1: will often grow really large and they sprout long finger
[6:22] Speaker 1: like processes for several hours after death. Now, in some
[6:26] Speaker 1: sense this is not too surprising, because these are glial
[6:29] Speaker 1: cells in the brain whose job is to take care
[6:33] Speaker 1: of inflammation. But the researchers pointed out that most people
[6:37] Speaker 1: don't even look at the brain after death because they
[6:40] Speaker 1: assume that everything dies. But in fact, eighty percent of
[6:44] Speaker 1: the genes being expressed kept on being expressed at their
[6:48] Speaker 1: normal levels. Twenty four hours later. A few genes had
[6:52] Speaker 1: their expression levels go down, but there was a third
[6:54] Speaker 1: group of genes, which they called zombie genes, whose activity
[6:59] Speaker 1: went up, and as a result, you have all these
[7:02] Speaker 1: cells still running around and doing stuff. And if we
[7:06] Speaker 1: zoom out our camera, we find that different organs keep
[7:10] Speaker 1: functioning for different amounts of time. So, for example, at
[7:13] Speaker 1: some point we would say the brain is dead. That's
[7:17] Speaker 1: followed a little later by the heart. Then the liver
[7:20] Speaker 1: dies next, then the kidneys and pancreas can last another
[7:24] Speaker 1: hour past that before they die, and other parts of
[7:27] Speaker 1: your body like your heart valves, and the corneas of
[7:30] Speaker 1: your eyes and your tendons and your skin that's still
[7:34] Speaker 1: alive after about a day. So the idea that everything
[7:38] Speaker 1: stops when you die is not correct. Returning to the
[7:42] Speaker 1: space alien analogy, imagine that the medics come in to
[7:46] Speaker 1: take care of the fallen warriors, and so there's still
[7:48] Speaker 1: lots of activity even after the main army has fallen.
[7:53] Speaker 1: But it gets even weirder when we talk about things
[7:56] Speaker 1: that the larger level of the creature. And there's been
[7:59] Speaker 1: a history of asking these questions. For example, you might
[8:03] Speaker 1: think that death is really clear if say a person
[8:08] Speaker 1: has had their head cut off with a guillotine, I'm
[8:10] Speaker 1: going to dive into that issue in a future episode
[8:13] Speaker 1: because the whole thing is so wacky and fascinating. But
[8:17] Speaker 1: I'll just mention now that in the eighteen hundreds, when
[8:20] Speaker 1: the guillotine was very popular, people got interested in this
[8:23] Speaker 1: question of whether the head can stay conscious after separation
[8:28] Speaker 1: from the body, and what they would do is pick
[8:31] Speaker 1: up the freshly severed head and try to get it
[8:34] Speaker 1: to talk or at least blink its eyes on command.
[8:38] Speaker 1: And at that time, other scientists were trying things like
[8:42] Speaker 1: taking a decapitated head from a German shepherd dog and
[8:46] Speaker 1: reattaching it to the blood supply of another dog to
[8:50] Speaker 1: see if simply restoring blood flow through the brain was
[8:54] Speaker 1: enough to restore its function. So stay tuned for that episode.
[8:59] Speaker 1: But what these experiment it's highlight is that this question
[9:02] Speaker 1: of where to draw the line between life and death
[9:05] Speaker 1: has been with us a long time, and in modern
[9:08] Speaker 1: times we have things like the field of cryogenics, which
[9:12] Speaker 1: is the art of freezing a body after death, so
[9:16] Speaker 1: it has a chance of being revived by future scientists
[9:20] Speaker 1: who might know how to do that, even though we
[9:23] Speaker 1: don't know now. In the field of cryogenics, it's popular
[9:27] Speaker 1: to sometimes just save the head and get rid of
[9:29] Speaker 1: the body, and the assumption or the hope really is
[9:33] Speaker 1: that that can be sufficient, and that if you are
[9:36] Speaker 1: maintained at ninety six degrees below freezing, then you're not
[9:40] Speaker 1: actually dead, but you're in a state of suspended animation
[9:45] Speaker 1: and can eventually be rebooted. So why does all this matter,
[9:50] Speaker 1: this question of where to draw the line between life
[9:53] Speaker 1: and death. Well, first of all, it matters for the
[9:56] Speaker 1: medical system, and we see cases come up all the
[9:59] Speaker 1: time in hot hospitals where there is confusion or disagreement
[10:03] Speaker 1: about how to make the call. There was a case
[10:07] Speaker 1: in Texas where the doctors told a man that his son,
[10:11] Speaker 1: who had been in a coma, would never return back
[10:14] Speaker 1: to consciousness, and so the doctors wanted to make the
[10:17] Speaker 1: call to remove the young man from life support, and
[10:20] Speaker 1: the father was so distraught that he pulled a gun
[10:24] Speaker 1: on the doctors and medical staff and wouldn't let them
[10:27] Speaker 1: near his son in the hospital bed, And so the
[10:30] Speaker 1: police were immediately dispatched and this man was arrested and
[10:33] Speaker 1: put in jail for eleven months. But incredibly, the son
[10:38] Speaker 1: enjoyed a full recovery and once the father was released
[10:42] Speaker 1: from jail. The two of them were happily reunited. All
[10:46] Speaker 1: of this points to the difficulty in determining when a
[10:50] Speaker 1: body has died irreversibly, and the question of life and
[10:55] Speaker 1: death matters enormously for legal systems because so much pivots
[11:00] Speaker 1: on whether a person is considered alive or dead in
[11:03] Speaker 1: the eyes of the law. How do we know when
[11:06] Speaker 1: that line has been crossed? So there are so many
[11:10] Speaker 1: fascinating medical and legal and ethical issues around deciding when
[11:15] Speaker 1: a person has died, and those viewpoints don't always align,
[11:20] Speaker 1: and perhaps surprisingly they often conflict badly. And add to
[11:24] Speaker 1: this particular religious practices that people have and business issues
[11:30] Speaker 1: like tax implications, and what you have is a fascinating
[11:33] Speaker 1: set of questions that arise. So that's what I want
[11:36] Speaker 1: to talk about today. How we as a society make
[11:40] Speaker 1: that call and how should we so To dig into this,
[11:44] Speaker 1: I called up my friend and colleague, Jacob Appel. Now,
[11:48] Speaker 1: Jacob is a very accomplished thinker and writer and man
[11:51] Speaker 1: of many talents. He has seven graduate degrees, but for
[11:55] Speaker 1: today's episode, the two most salient are his law degree
[11:59] Speaker 1: from Harvard and his medical degree from Columbia. Jacob works
[12:04] Speaker 1: as an emergency room psychiatrist in the Mount Sinai Health System,
[12:08] Speaker 1: and he also serves as the director of Ethics Education.
[12:12] Speaker 1: So I called him up to talk with him about
[12:15] Speaker 1: the question of how we as a society should think
[12:19] Speaker 1: about making the tough calls about whether a person should
[12:23] Speaker 1: be declared dead or not, and the complexities that lurk
[12:27] Speaker 1: inside that seemingly simple question, complexities that are scientific and
[12:32] Speaker 1: legal and cultural. How do the medical and the legal
[12:40] Speaker 1: systems decide when you are dead?
[12:44] Speaker 2: Well, it's interesting because the medical and legal systems have
[12:46] Speaker 2: very different histories and very different approaches. As a legal concept,
[12:51] Speaker 2: being dead has significant implications not just for you, but
[12:55] Speaker 2: for your loved ones and for society. So, for example,
[12:57] Speaker 2: if you're dead, your spouse can re marry, your heirrors
[13:02] Speaker 2: can inherit, You stop getting social Security. So, whatever your
[13:06] Speaker 2: biological status, if you're declared dead, it can have significant
[13:09] Speaker 2: implications for the.
[13:10] Speaker 3: World and for you as well.
[13:11] Speaker 2: I'm reminded several years ago a man from Romania had
[13:16] Speaker 2: gone to work in Turkey, and he'd been gone for
[13:18] Speaker 2: a long time.
[13:19] Speaker 3: His wife couldn't find him.
[13:20] Speaker 2: She had him legally declared dead, and then he came
[13:23] Speaker 2: back as a surprise, and he couldn't run an apartment
[13:26] Speaker 2: or get a job his casement all the way to
[13:28] Speaker 2: the Romanian Supreme Court because he was legally dead and nobody,
[13:31] Speaker 2: even though he was standing in front of him, would
[13:33] Speaker 2: overrule us. And I will mention also legally there are
[13:36] Speaker 2: these gray areas. So for example, if you were lost
[13:39] Speaker 2: to see historically, how did we know how long you
[13:42] Speaker 2: had it be gone before you were dead? And there
[13:44] Speaker 2: were different rules for how much time had it passed
[13:47] Speaker 2: before they could give away your property versus not having
[13:50] Speaker 2: rights over your children.
[13:51] Speaker 3: So you can be dead for one purpose and alive
[13:53] Speaker 3: for another.
[13:54] Speaker 1: Wasn't there some sixteenth century French soldier that this happened
[13:59] Speaker 1: to last name Gear?
[14:01] Speaker 2: Yeah, there's a great movie, The Return of Martin Gear,
[14:04] Speaker 2: which is a classic case of this, where someone allegedly
[14:08] Speaker 2: I believe it was in one hundred Years War, came
[14:11] Speaker 2: back after being lost in battle. It turned out he
[14:13] Speaker 2: actually wasn't the person who claimed he was. But there
[14:16] Speaker 2: were a number of famous cases like this over the years,
[14:18] Speaker 2: and as a famous poem by Tennyson about Enoch Arden,
[14:23] Speaker 2: hence the term that has come into the English language
[14:25] Speaker 2: Enoch Arden laws which the laws would refer to how
[14:28] Speaker 2: long you have to be missing before you're dead.
[14:30] Speaker 1: Wow. Okay, So from the legal point of view, there
[14:34] Speaker 1: are all these things to be considered, including, for example,
[14:38] Speaker 1: tax laws. Can you just mention what happened between the
[14:42] Speaker 1: two nine and twenty eleven?
[14:44] Speaker 3: Oh?
[14:44] Speaker 2: Absolutely, So the Bush administration had enacted tax laws that
[14:49] Speaker 2: gave people a significant tax break on their inheritance, and
[14:53] Speaker 2: they were going to expire at some point, and people's
[14:55] Speaker 2: inheritance taxes would go up substantially as a result of
[14:58] Speaker 2: which many people who were at the end of life
[15:00] Speaker 2: life on life support or their families want at their
[15:02] Speaker 2: life support terminated before January first, when their taxes would double.
[15:07] Speaker 3: At an entire boutique corner of a major New.
[15:10] Speaker 2: York City law firm is actually devoted specifically to this practice.
[15:14] Speaker 1: Right, So, somebody was on life support and the adult
[15:18] Speaker 1: children would say, look, it's December, let's go ahead and
[15:22] Speaker 1: pull this now so that he dies before January first.
[15:27] Speaker 2: Yeah, they would say, Grandpa would much rather die on
[15:30] Speaker 2: December thirtieth and leave one hundred billion dollars to his
[15:33] Speaker 2: grandkids than die on January second. Still unloose it. Two
[15:37] Speaker 2: days later, and leave them nothing. And honestly, I can't
[15:40] Speaker 2: argue with that.
[15:41] Speaker 1: Yeah, So how do hospital ethics boards deal with questions
[15:46] Speaker 1: like that? Sure?
[15:48] Speaker 2: Are so most decisions in hospitals or recommendations, you're done
[15:51] Speaker 2: by committee. So you have an ethics committee, You have
[15:54] Speaker 2: a consultant who actually gathers the information and presents it
[15:56] Speaker 2: to the committee, which consist of experts in a range
[15:59] Speaker 2: of different fields, so not just medicine, surgery, pediatrics, but
[16:03] Speaker 2: social work, nursing, the hospital chaplain. They sort of build
[16:07] Speaker 2: a consensus and then obviously, if you can't build a
[16:10] Speaker 2: consensus or can't get the family on board, then cases
[16:13] Speaker 2: end up going to court, and ultimately, in cases like this,
[16:15] Speaker 2: the court usually will decide looking at all the evidence
[16:18] Speaker 2: brought before them.
[16:19] Speaker 1: Okay, and so there are all these legal considerations, what
[16:22] Speaker 1: are the medical considerations when we think about what is death?
[16:26] Speaker 2: Sure, and the medical considerations are actually just as complex.
[16:30] Speaker 2: In an earlier era, you probably have seen movies like
[16:35] Speaker 2: The Cursed Living Dead, where people are believed dead and
[16:37] Speaker 2: then they come back to life suddenly, and people who
[16:39] Speaker 2: are afraid of being buried alive.
[16:41] Speaker 3: It was actually a fairly.
[16:44] Speaker 2: Ineffective diagnostic tool to be certain someone was dead, they
[16:48] Speaker 2: would do things like hold up a mirror to your
[16:50] Speaker 2: mouth and see if there was actually vapor on it,
[16:52] Speaker 2: to see if you were breathing.
[16:53] Speaker 3: So they made mistakes.
[16:56] Speaker 1: So actually this actually happened where people were buried alive.
[17:00] Speaker 2: Yes, I mean it wasn't a common occurrence, but it
[17:03] Speaker 2: did happen. I will add, as strangers who may sound
[17:07] Speaker 2: it still happens occasionally. Today you hear these stories about
[17:10] Speaker 2: people who show up in the morgue or show up
[17:12] Speaker 2: in a funeral home and suddenly they wake up. Usually,
[17:16] Speaker 2: I will add, by the way, those people are still
[17:18] Speaker 2: in a very bad shape and they don't make it
[17:19] Speaker 2: in the long run. I don't know of any case
[17:21] Speaker 2: to people who have actually been to the morgue and
[17:23] Speaker 2: then got home and good health. But people have gone
[17:26] Speaker 2: and they started breathing and ended up backing the ice
[17:28] Speaker 2: you before, So that should give us pause.
[17:31] Speaker 1: How does that happen currently? Is it in areas where
[17:34] Speaker 1: there's not good medical diagnosis of what has happened?
[17:40] Speaker 3: I wouldn't be that critical.
[17:41] Speaker 2: I would say it's a very hard There are a
[17:42] Speaker 2: whole bunch of different tests for determining whether someone is dead.
[17:45] Speaker 2: Now and different diagnostic tools and doctors do their best.
[17:48] Speaker 2: And sometimes if you're barely breathing, and if your pulses
[17:52] Speaker 2: very sporadic and they catch you a couple of times
[17:54] Speaker 2: at the wrong moment, maybe you get unlucky.
[17:57] Speaker 3: I will add often this.
[17:58] Speaker 2: Does occur in the developing world, where maybe their diagnostic
[18:01] Speaker 2: tools are not as strong. I don't know of any
[18:03] Speaker 2: cases in New York City with my luck, I'll be
[18:05] Speaker 2: the first.
[18:08] Speaker 1: Okay, So back to a few decades ago or a
[18:11] Speaker 1: century ago. So you hold a mirror to the mouth
[18:13] Speaker 1: and you see if there's fog on the mirror, and
[18:16] Speaker 1: then what happened.
[18:18] Speaker 2: So eventually we did no enough about anatomy to recognize
[18:21] Speaker 2: cardiac and pulmonary death. Cardiopulmonary death, you stop breathing and
[18:25] Speaker 2: you don't get a pulse for a propracted period of time,
[18:28] Speaker 2: we accept that you're dead.
[18:29] Speaker 1: Like how long? What's a protracted period?
[18:32] Speaker 3: That depended on the doctor.
[18:35] Speaker 2: Honestly, if you're not breathing or you know, a pulse
[18:38] Speaker 2: for a good ten to fifteen minutes, the odds of
[18:40] Speaker 2: you reviving naturally on your own get pretty darn low.
[18:43] Speaker 2: When you get much past that, your odds for surviving
[18:46] Speaker 2: in a way that is meaningfully cognitive or very low
[18:49] Speaker 2: and most people stop at some point, stop crying. But
[18:51] Speaker 2: that was the diagnostic tool back then. I will add,
[18:54] Speaker 2: by the way, that most people historically back then were
[18:57] Speaker 2: in very bad shape by the time they reached that pointing.
[18:59] Speaker 2: It's been other death bed for hours or days or weeks.
[19:03] Speaker 1: So what happened next?
[19:05] Speaker 2: So there were technological developments in medical science that allowed
[19:09] Speaker 2: us to check for cardiopulmonary death basically to figure out
[19:13] Speaker 2: whether or not your heart was still beating, whether your
[19:15] Speaker 2: lungs were still breathing, And that was the test for many,
[19:18] Speaker 2: many years until the nineteen sixties. And if you stop
[19:21] Speaker 2: breathing and if your heartstep beating, you were dead. And that,
[19:25] Speaker 2: I will add, by the way, is the test still
[19:27] Speaker 2: used in some religious communities, in some cultural traditions. Starting
[19:31] Speaker 2: in the late nineteen sixties with the advent of organ transplant,
[19:37] Speaker 2: which meant there was a need to harvest organs or
[19:39] Speaker 2: procure organs from the individuals as quickly as possible, and
[19:44] Speaker 2: the rise of artificial ventilation and later artificial heart support,
[19:49] Speaker 2: which meant that people could be kept alive for months
[19:52] Speaker 2: or even a year or two on a respirat or
[19:54] Speaker 2: on a ventilator. That created the challenge of how did
[19:57] Speaker 2: we know when these individuals were dead? And there was
[20:00] Speaker 2: a debate over whether brain death should be acceptable, and
[20:03] Speaker 2: the ultimate decision was made by a committee of experts
[20:06] Speaker 2: at Harvard that has been adopted widely that whole brain
[20:10] Speaker 2: death would be the standard. So, if you have two
[20:12] Speaker 2: flat EEGs, your brain stops functioning entirely, you are now
[20:17] Speaker 2: legally dead in every state. I will add New Jersey,
[20:22] Speaker 2: and to a lesser degree under some circumstances. New York
[20:24] Speaker 2: allows people with a religious belief only in cardiopulmonary death
[20:28] Speaker 2: to opt out of that standard, but other states do not.
[20:31] Speaker 1: So give me an example of having a religious belief
[20:34] Speaker 1: and how that might change the decision that a family makes.
[20:38] Speaker 3: Sure.
[20:39] Speaker 2: So let us say that my grandfather is on a
[20:43] Speaker 2: ventilator which is artificial. One support and intet to buy
[20:46] Speaker 2: that which is a machimee that for a short period
[20:49] Speaker 2: of time to fairly late the period of time. Now
[20:51] Speaker 2: with new technology can replace the heart, so it's entirely artificial.
[20:55] Speaker 2: And yet he has two flat egs. His brain is
[21:00] Speaker 2: showing no function at all. In New Jersey. If I
[21:03] Speaker 2: have a religious tradition that says that only cardiopulmonary depth
[21:07] Speaker 2: is alive. In theory, I could raise the funds to
[21:11] Speaker 2: bring that individual home to my living room and keep
[21:14] Speaker 2: them on ventilator support and buy bad support until they
[21:17] Speaker 2: can no longer support their cart and lungs with those machines,
[21:21] Speaker 2: which could be a year.
[21:23] Speaker 1: And this happens sometimes right where someone takes a person home.
[21:28] Speaker 3: It is rare, but it has happened.
[21:31] Speaker 2: I believe there was a famous case in Utah, a
[21:33] Speaker 2: Jesse Kutchin case where it has happened. In addition to
[21:36] Speaker 2: which there have been cases where people the Johi McMath
[21:39] Speaker 2: case may be the most known, who were what was
[21:42] Speaker 2: presumed to be a state of brain depth for families
[21:45] Speaker 2: who do not accept that definition, who brought their relatives
[21:48] Speaker 2: to New Jersey to then replace the facilities that keep
[21:51] Speaker 2: people who are alive in a cardiopulmonary manner but is
[21:54] Speaker 2: ceased by the brain death standard alive.
[21:57] Speaker 1: And what's the reason that people do this. It's because
[22:00] Speaker 1: their religioustration tells them even though they're on a bivalve
[22:05] Speaker 1: and there on a ventilator, they do they think the
[22:09] Speaker 1: person could come back, or they have other issues. I
[22:11] Speaker 1: know you wrote once about somebody's belief in reincarnation and
[22:15] Speaker 1: how that affected.
[22:17] Speaker 2: So there are two different categories of people, and we
[22:20] Speaker 2: might treat the cases the same way or differently.
[22:22] Speaker 3: There are those.
[22:23] Speaker 2: Individuals who truly believe that their relative is going to
[22:26] Speaker 2: revive themselves, even though the data, overwhelmingly from past practice
[22:31] Speaker 2: says that's not going to happen, and they're hoping for
[22:34] Speaker 2: a miracle.
[22:34] Speaker 3: So to speak.
[22:35] Speaker 2: There are other individuals who may say, you know, I
[22:38] Speaker 2: understand that my grandfather isn't really going to wake up again,
[22:42] Speaker 2: but either I, or more appropriately, he had a deep
[22:46] Speaker 2: religious belief that it was important to die of quote
[22:48] Speaker 2: unquote natural causes or if you believe in reincarnation, to
[22:52] Speaker 2: die at a certain time, and I want to fulfill
[22:54] Speaker 2: his wish, even though I understand that by your standard
[22:57] Speaker 2: he's dead. By a religious standard of our book, our Bible,
[23:01] Speaker 2: or tradition, he's not dead, and I want to wait
[23:03] Speaker 2: the process out.
[23:04] Speaker 3: I'll add one more thought on that it's okay, which.
[23:07] Speaker 2: Is you also might want to ask the question, does
[23:09] Speaker 2: it matter whether if someone's been declared brain dead you're
[23:12] Speaker 2: willing to pay for it when you take them home,
[23:14] Speaker 2: whether you're asking the taxpayers to put the bill for it,
[23:17] Speaker 2: because then the vast majority of us would say, the
[23:20] Speaker 2: taxpayers are paying to keep a dead person on a
[23:23] Speaker 2: life support system in your living room. And the other
[23:25] Speaker 2: thing to think about is there's something inappropriate or grotesque
[23:28] Speaker 2: about it. If I were to want to bring my
[23:30] Speaker 2: grandmother home embalmed like Lenin on display in his tomb
[23:34] Speaker 2: and prop work in my living room, our society would
[23:36] Speaker 2: not let me do that, not just for public health reasons,
[23:39] Speaker 2: but probably for reasons of what we would call common
[23:41] Speaker 2: decency or horem or appropriateness.
[23:44] Speaker 3: Some would argue, this is not that different.
[23:46] Speaker 1: And how does this work in terms of making decisions
[23:49] Speaker 1: for somebody else. Let's say that somebody is in critical condition.
[23:52] Speaker 1: It doesn't look likely they'll recover, but maybe there's some
[23:54] Speaker 1: extreme measures you can take that involve amputations and other things,
[24:00] Speaker 1: and a decision has to be made about whether that
[24:02] Speaker 1: person would want that kind of heroic medical treatment with
[24:08] Speaker 1: the possible consequences. How does a hospital make the decision
[24:13] Speaker 1: about that?
[24:14] Speaker 2: So, while there is some variation among state laws, the
[24:18] Speaker 2: general accepted principle in this country is that we use
[24:21] Speaker 2: a substituted judgment or vicarious judgment standard, which if we asked,
[24:25] Speaker 2: what would this person would have wanted if they were
[24:28] Speaker 2: still awake and lucid and able to express an opinion.
[24:31] Speaker 2: The only two groups of people we don't use that
[24:33] Speaker 2: approach for are children, where parents can decide based on
[24:37] Speaker 2: what they perceive to be the best interest within certain
[24:40] Speaker 2: societal parameters, and people who've never had the capacity or
[24:43] Speaker 2: ability to make that decision. We view it as too
[24:45] Speaker 2: far elite to say you were born with a such
[24:48] Speaker 2: a significant cognitive impairment that you could never understand his question.
[24:51] Speaker 2: But if you hadn't been bored in that way, what
[24:53] Speaker 2: would you want to have had done.
[24:55] Speaker 3: I've actually been critical of that latter approach.
[24:57] Speaker 2: Because in that situation we use a societal best interest standard,
[25:01] Speaker 2: what society would think is in your best interests. I
[25:04] Speaker 2: have argued that for certain communities, let's say you're an Amish,
[25:07] Speaker 2: Mennonite or a Casidic Jew, it might be more appropriate
[25:10] Speaker 2: to ask what would be the best interest standard in
[25:13] Speaker 2: your community, because it doesn't seem too far a bridge
[25:16] Speaker 2: for me to say, if you were born a Mennonite,
[25:18] Speaker 2: you would want what a Menonite tradition speaks to not
[25:21] Speaker 2: be overall societal standard.
[25:24] Speaker 1: Tell me about what happened during Hurricane Katrina with the
[25:27] Speaker 1: ventilators and what that means.
[25:30] Speaker 2: Sure, so, I think during Hurricane Katrina there was a
[25:35] Speaker 2: medical crisis where they had patients who were ventilators who
[25:38] Speaker 2: needed them to stay alive, and a number of questions
[25:41] Speaker 2: around end of life arose. One the medical teams for
[25:45] Speaker 2: safety had to leave some of these patients. Some of
[25:47] Speaker 2: them could not be evacuated, and they had to decide
[25:50] Speaker 2: whether or not to continue them on life support, whether
[25:53] Speaker 2: or not to use morphine or other techniques to ease
[25:57] Speaker 2: their suffering that could have the risk of death. Into trial,
[26:00] Speaker 2: there was a doctor Poe was actually put on trial
[26:02] Speaker 2: and eventually acquitted for her role in this.
[26:04] Speaker 3: These were not easy.
[26:05] Speaker 1: Questions, right, because the decision she made was, you know,
[26:09] Speaker 1: if we are going to run out of power, then
[26:12] Speaker 1: people will suffer if they don't have the ventilator on anymore,
[26:16] Speaker 1: and so do we pull the plug before we run
[26:20] Speaker 1: out of power? Was that the issue?
[26:23] Speaker 2: I mean, that was what she was accused of doing.
[26:26] Speaker 2: As she describes it. I believe she would say she
[26:29] Speaker 2: was giving people morphine or other medication with a dual
[26:32] Speaker 2: intent that might have ended their life as a result,
[26:35] Speaker 2: but the primary goal was to ease their suffering. And
[26:38] Speaker 2: in palliative care and end of life decision making, we
[26:40] Speaker 2: often do recognize this concept of dual intent. We may
[26:44] Speaker 2: intend to do one thing that inadvertently is a different consequence,
[26:47] Speaker 2: but intending to relieve suffering that leads to death, we
[26:50] Speaker 2: view conceptually is very different from intending to cause death.
[27:10] Speaker 1: Okay, so the way we make decisions about death now
[27:13] Speaker 1: has to do in part with this concept of irreversibility.
[27:18] Speaker 1: And my question to you is how do you think
[27:21] Speaker 1: about this in terms of the new technologies that are
[27:24] Speaker 1: coming along and change that definition of irreversibility.
[27:31] Speaker 2: I mean, this comes up not just with defining death,
[27:33] Speaker 2: but an all end of life decision making. So people
[27:38] Speaker 2: may be toward the end of life and have what
[27:41] Speaker 2: we call it terminal prognosis, but there's no way to
[27:43] Speaker 2: be certain that a new technology will develop that can
[27:46] Speaker 2: cure their illness. And there have been cases now of
[27:48] Speaker 2: people with rare cancers that seemed to one hundred percent fatal
[27:52] Speaker 2: they always had been before, where new immunotherapies suddenly appear
[27:56] Speaker 2: in the market or emerge as experimental treatments that then
[27:59] Speaker 2: save their lives.
[28:00] Speaker 3: And who are we to.
[28:01] Speaker 2: Take away someone's hope, which is why we generally defer
[28:04] Speaker 2: to what the patient's wishes are. And that also creates
[28:06] Speaker 2: an economic challenge, because we may know society that almost
[28:11] Speaker 2: everyone in this situation dies, or even that so far
[28:13] Speaker 2: everybody has. But who are we to take away hope
[28:16] Speaker 2: from the veryous one number of people who want to
[28:18] Speaker 2: be the teals, so to speak, and not the bell.
[28:21] Speaker 3: I can give you a very concrete example of this.
[28:23] Speaker 2: I don't know if it's still true, but there was
[28:25] Speaker 2: a time when if you went on the internet, let's
[28:27] Speaker 2: say you were diagnosed with ALS blue garage disease and
[28:30] Speaker 2: typed in prognosis ALS blue garage disease on Google, the
[28:35] Speaker 2: first picture that came up was not lou Garage.
[28:37] Speaker 3: It was Stephen Hawking.
[28:39] Speaker 2: The physicists who lived I'm guessing thirty forty years with
[28:43] Speaker 2: the illness, even though the vast majority of people died.
[28:46] Speaker 3: Within a few years.
[28:47] Speaker 2: And once you see that, it's hard to make any
[28:49] Speaker 2: meaning out of statements like a certain percentage of Medicare
[28:52] Speaker 2: or Medicaid dollars are spent in a certain period toward
[28:54] Speaker 2: the end of life, because as I always ask the
[28:57] Speaker 2: medical students after I explain that, I say, if if
[29:00] Speaker 2: you're in the last six months of life, raise your
[29:02] Speaker 2: hand now.
[29:03] Speaker 3: And obviously we don't know.
[29:05] Speaker 1: So Jacob, when you think about the question of irreversibility,
[29:08] Speaker 1: what do you think about cryogenics?
[29:11] Speaker 2: So I'm not one who can say that cryogenics will
[29:14] Speaker 2: never work, though my guess is there will be other
[29:17] Speaker 2: technologies that will be developed beforehand that may be far
[29:19] Speaker 2: more effective at life lengthening, or life preserving, or even reversibility.
[29:25] Speaker 2: I can say that nothing I have seen suggests that
[29:27] Speaker 2: criogenics as it works now is very effective. I would
[29:30] Speaker 2: not suggest having your head caught off now in storage somewhere.
[29:34] Speaker 1: What else are you seeing that seems like it could
[29:37] Speaker 1: be more effective?
[29:39] Speaker 2: I mean, I think at some point, and this is
[29:41] Speaker 2: obviously in a far fetched way, many many years in
[29:44] Speaker 2: the future, we may be able to download people's personality,
[29:48] Speaker 2: download their brands into some kind of system A computer
[29:52] Speaker 2: might be too simplistical word, but some kind of extra
[29:55] Speaker 2: intelligence system that can then reprogram individualism in a way
[29:58] Speaker 2: That is not something I would say that you should
[30:00] Speaker 2: bank on in your lifetime or mind. I think we're
[30:02] Speaker 2: far better off focusing on technologies that can extend human
[30:06] Speaker 2: life as it exists now. And I will add even
[30:09] Speaker 2: beyond that, we may ultimately have that technology to transfer
[30:13] Speaker 2: heads from one individual or a brand from individual into
[30:16] Speaker 2: bodies of another, but again we are nowhere near prime
[30:19] Speaker 2: time on that. I know there's an Italian sturage, and
[30:21] Speaker 2: thinking about doing that, I would be very reluctant to
[30:24] Speaker 2: try that procedure because not only the possibility will work,
[30:27] Speaker 2: which the possibility, what would suffer immensely during the process.
[30:31] Speaker 1: I think maybe it was Paul Broca. Somebody actually did
[30:35] Speaker 1: this with German shepherd dogs, where they cut off one
[30:38] Speaker 1: head and attached to the vasculature to the heart of
[30:41] Speaker 1: another dog and kept the head alive that way.
[30:46] Speaker 2: I'm not sure if it always broke up, but a
[30:47] Speaker 2: number of different people have done this over the years,
[30:50] Speaker 2: with more or less suctatistic with various animals, So the
[30:54] Speaker 2: theoretical concept is there. There obviously are both a number
[30:58] Speaker 2: of logistical premises is in terms of attaching neurop tissue,
[31:02] Speaker 2: and also a large number of ethical dilemmas. It's very
[31:06] Speaker 2: I don't want to say easy, but it's much more
[31:08] Speaker 2: easy to get decided to accept killing a German shepherd
[31:10] Speaker 2: to say of another German shepherd.
[31:12] Speaker 3: They get used to kill one person to say of
[31:13] Speaker 3: another person.
[31:15] Speaker 1: That's right, Although as I as I understand it, it's
[31:19] Speaker 1: the idea is taking somebody who is brain dead but
[31:22] Speaker 1: their body is still functioning, and then taking somebody else
[31:25] Speaker 1: who has a functioning brain. But let's say they're quadriplegic
[31:29] Speaker 1: and their body is degrading. So it's somebody who is
[31:32] Speaker 1: already judged to be dead by brain dead standards. Is
[31:36] Speaker 1: the first body?
[31:39] Speaker 2: Absolutely, I mean that that is the theoretical approach. The
[31:43] Speaker 2: obviously both logistical challenges in terms of what if you
[31:47] Speaker 2: have a mismatch of heads and bodies, and the ethical
[31:50] Speaker 2: questions of who this person legally is going forward and
[31:54] Speaker 2: how they relate to their one family versus the other
[31:57] Speaker 2: inheritance whose fingerprints to the have in a legal sense
[32:01] Speaker 2: becomes very very complicated, very very quickly. I'm not saying
[32:04] Speaker 2: this issue can't be solved. I would say we want
[32:07] Speaker 2: to solve these questions before we start using the technology,
[32:10] Speaker 2: or we're going to find yourself painted into a very
[32:12] Speaker 2: unpleasant quarter.
[32:14] Speaker 1: Yes, So let me come back to that question about
[32:17] Speaker 1: how committees at hospitals, how ethics committees make this decision.
[32:21] Speaker 1: You pointed out that ethics committees are made up of
[32:24] Speaker 1: many different points of view. What have you seen is
[32:28] Speaker 1: the most contentious argument that you have come across.
[32:34] Speaker 2: I can tell you that speaking more broadly, because I
[32:37] Speaker 2: don't want to reveal now Sini's confidential epics debates, but
[32:39] Speaker 2: historically the most controversial issue in epics committees has related
[32:44] Speaker 2: to a very specific scenario that occurred over and over
[32:47] Speaker 2: again throughout this country from nineteen seventies through the nineteen nineties,
[32:51] Speaker 2: and how to do with patients who were in accidents
[32:54] Speaker 2: with C three S force bibal fractures so they would
[32:57] Speaker 2: never be able to breathe again on their own, never
[32:59] Speaker 2: be able to to move below their neck on their own,
[33:01] Speaker 2: and they would wake up from his accidents and say,
[33:04] Speaker 2: I don't want to live like this, turn my life
[33:05] Speaker 2: support off, and palliative care would say we need to
[33:10] Speaker 2: respect their autonomous wishes. They don't want to suffer. And
[33:13] Speaker 2: psychiatry would say, but we know that a certain percentage
[33:17] Speaker 2: of people, approximately half who we do talk into staying
[33:21] Speaker 2: alive and do therapy with after a year are actually
[33:25] Speaker 2: glad they stayed alive and take meaningful value in their life.
[33:27] Speaker 2: And they point out, for example, the Superman actor Christopher
[33:30] Speaker 2: Reeve and Pallid of Care would cut back and say, yes,
[33:33] Speaker 2: but we know that the other half or not, and
[33:35] Speaker 2: the interest to the other half to not suffer existentially
[33:38] Speaker 2: outweigh those of the first half to have a meaningful
[33:41] Speaker 2: life in the long run. And this was a deeply
[33:43] Speaker 2: heated debate which there's no conceptually correct answer. You can't
[33:48] Speaker 2: reduce it to any level where there's a right answer.
[33:50] Speaker 2: I can tell you in practice, palliad of care has
[33:53] Speaker 2: won misbattle.
[33:54] Speaker 1: Ah And what was it with Christopher Reeve? Which way
[33:58] Speaker 1: did he go on that he was happy that he
[33:59] Speaker 1: had stay alive.
[34:01] Speaker 3: After a year?
[34:01] Speaker 2: Even I think before a year he'd was very grateful
[34:03] Speaker 2: to have stayed live and he brought great meaning to
[34:05] Speaker 2: his life and helped others. But I will add, if
[34:08] Speaker 2: you're Superman and you have a loving family and a
[34:12] Speaker 2: great deal of financials for it and amazing doctors, it
[34:14] Speaker 2: may be easier to find that comfort zone than if
[34:17] Speaker 2: you're indigent. If you don't have social support if you
[34:20] Speaker 2: don't have good medical care, if you're in a back
[34:22] Speaker 2: room somewhere in a nursing facility. So I think the
[34:25] Speaker 2: other major issue that is the end of life, which
[34:27] Speaker 2: we've only touched on the iceberg tip of the iceberg
[34:30] Speaker 2: up so far. He is medical aid and dying, which
[34:33] Speaker 2: has become a national debate over when, if ever, people
[34:36] Speaker 2: can choose to end their own lives. And there's a
[34:38] Speaker 2: slow consensus building that people with terminal illness, terminal physical
[34:42] Speaker 2: illness should be able to end their own lives if
[34:45] Speaker 2: they have a diagnosis of als or cancer and they're
[34:48] Speaker 2: not going to survive a prolonged period of time. And
[34:50] Speaker 2: we've seen from one state, Oregon in the nineteen nineties
[34:53] Speaker 2: to I believe it's now ten jurisdictions to legalize this,
[34:56] Speaker 2: and the trend going forward is to expand this. However,
[34:59] Speaker 2: we have really not come to terms with a question
[35:02] Speaker 2: of people who are not suffering physically but suffering psychiatrically
[35:07] Speaker 2: or existentially. And for example, we've seen this heated debate
[35:11] Speaker 2: in Colorado over patients with anarettia who have not responded
[35:15] Speaker 2: to treatment over a very long period of time should
[35:17] Speaker 2: be able to turn down refeeding or turn down nutritional support,
[35:23] Speaker 2: even if it means the end of their life, and
[35:24] Speaker 2: the way we would let a patient with a kidney
[35:26] Speaker 2: problem turn down dialysis let themselves die.
[35:29] Speaker 3: And we're going to see this question more and more.
[35:31] Speaker 2: Obviously, if you show up in the emergency room and
[35:34] Speaker 2: you've broken up with your prom date and you take
[35:36] Speaker 2: it over as a tile and all, I don't think
[35:37] Speaker 2: any Risgilble person would say, well, you've had a long,
[35:39] Speaker 2: meaningful life, you should be able to make this decision.
[35:42] Speaker 2: On the other head, if you've had depression for forty
[35:45] Speaker 2: years and you've suffered and no treatment is worked after
[35:48] Speaker 2: every intervention and you say, if you could help me,
[35:51] Speaker 2: I want that, But since you can't, please let me
[35:53] Speaker 2: in my life.
[35:54] Speaker 3: It's a harder question.
[35:56] Speaker 1: And why do you see these questions coming up more
[35:58] Speaker 1: and more?
[36:00] Speaker 2: Well, I think they've come up in part because patients
[36:02] Speaker 2: are raising these issues and the clinical practice. Patients often
[36:06] Speaker 2: will say, doctor, I've done everything you've asked me to do.
[36:09] Speaker 2: I'm in that very small percentage of people who simply
[36:11] Speaker 2: don't respond to treatment, whether it's for psychosis or for
[36:16] Speaker 2: depression or for anxiety. I wish I did but I've
[36:19] Speaker 2: waited you out for forty years and there hasn't been
[36:21] Speaker 2: a new technology. I don't want to wait any longer.
[36:24] Speaker 2: And you've actually seen a handful of countries, Canada most recently,
[36:28] Speaker 2: adopt legalization.
[36:31] Speaker 1: And so what do hospital ethics committees decide on these
[36:35] Speaker 1: or is it just a very contentious issue or people disagree?
[36:39] Speaker 2: Well, it's not yet a contentious issue in the United States,
[36:41] Speaker 2: because no American state lets you make this choice yet.
[36:44] Speaker 2: But I imagine now that Canada and several European countries
[36:47] Speaker 2: have changed their rules in the last year or two,
[36:50] Speaker 2: we're going to see at least debate over this coming forward.
[36:52] Speaker 3: In the United States.
[36:53] Speaker 2: I were to hear colleges discussing this and this widespread disagreement.
[36:58] Speaker 1: So what's going on in the United States? Is medical
[37:01] Speaker 1: assistant suicide for someone who is physically ill, right, but
[37:06] Speaker 1: not mentally exactly? Okay?
[37:07] Speaker 2: Yeah, and I will add in all the cases in
[37:09] Speaker 2: the United States, we do not have a euphenagia program.
[37:13] Speaker 2: We do not end someone's life if they can't make
[37:14] Speaker 2: the choice on their own. We only have a program
[37:16] Speaker 2: where we will prescribe your medication to let you choose death.
[37:19] Speaker 2: When the time comes. In my own experience, having talked
[37:23] Speaker 2: to many patients, and this may surprise people, be people
[37:25] Speaker 2: who benefit from this option the most are people who
[37:28] Speaker 2: never use it and people who know that if things
[37:31] Speaker 2: got bad enough, they could make this choice, which actually
[37:35] Speaker 2: gives them hope to keep on fighting their illness. It's paradoxical,
[37:38] Speaker 2: but it's really a stunning phenomena, fascinating.
[37:43] Speaker 1: How does it work? Sorry, so they're prescribed the medication
[37:46] Speaker 1: that are actually given them, medication where they can pull
[37:49] Speaker 1: the ripcord if they want to. Is that the idea?
[37:53] Speaker 2: Yeah, So a doctor will write you a prescription and
[37:55] Speaker 2: you fill the prescription after a number of safeguards, an
[37:57] Speaker 2: interview with a psychiatrist. I mean, you can choose whether
[38:00] Speaker 2: to take this medication that will end your life in
[38:02] Speaker 2: a very peaceful way. In some states people actually have
[38:05] Speaker 2: going away parties, so to speak, where they bring their
[38:07] Speaker 2: friends and family, which is not that different from how
[38:09] Speaker 2: death was in the nineteenth century, when people often had
[38:13] Speaker 2: diseases that were terminal, where they would be on a
[38:15] Speaker 2: deathbed and their friends and family would come to say goodbye.
[38:18] Speaker 2: Now we've sanitized death in a way. People die in hospitals.
[38:22] Speaker 2: I think as a medical resident, the most disconcerting experience
[38:26] Speaker 2: ever was showing up in a hospital room at five
[38:28] Speaker 2: in the morning, six in the morning to see a
[38:30] Speaker 2: patient you've seen the night before, and finding the room empty,
[38:33] Speaker 2: which the patient had passed away overnight and completely sanitized
[38:36] Speaker 2: and stripped down, like a hotel room where sometimes even
[38:39] Speaker 2: they already brought the next patient into the bed, which
[38:41] Speaker 2: are very different and in some ways dehumanizing process. I
[38:45] Speaker 2: understand why that may be necessary with the economic forces
[38:48] Speaker 2: in medicine right now, better than having the living person
[38:51] Speaker 2: waiting on a gurning and a foyer, but it's still unsettling.
[38:57] Speaker 1: Give me a sense of how people did used to die.
[39:01] Speaker 2: So often if you had a terminal illness by cancer
[39:04] Speaker 2: or heart disease, there were far fewer treatments in there
[39:08] Speaker 2: are today, So you're running time, so to speak, between
[39:11] Speaker 2: when you got ill and when you would die and
[39:13] Speaker 2: when you would make lucidity before you die would actually
[39:15] Speaker 2: be longer, so people would have a sense they were dying,
[39:18] Speaker 2: and they could call their family together. They could call
[39:20] Speaker 2: the priests for the last rites, or the minister to
[39:23] Speaker 2: say a blessing or of a rabbi to say farewell.
[39:26] Speaker 3: They could rewrite their will.
[39:28] Speaker 2: There are all sorts of both cases in mystery novels
[39:30] Speaker 2: in the nineteenth and early twentieth century about rewriting wills.
[39:33] Speaker 2: And that's because people have this window that we really
[39:36] Speaker 2: don't have today, because people live until their bodies essence
[39:40] Speaker 2: shut down.
[39:41] Speaker 3: I think a related question.
[39:44] Speaker 2: Is so George Church, who's a biologist at Guganticist d
[39:50] Speaker 2: at Harvard, talked about the prospect of bringing back not
[39:54] Speaker 2: just people who've been deceased, bringing back species that have
[39:56] Speaker 2: been deceased, and specifically human species. I made species like
[40:00] Speaker 2: Neanderthal man, and that raises a whole set of complex
[40:04] Speaker 2: related questions of its own, of what rights Neanderthals would
[40:07] Speaker 2: have in the context of human society, whether bringing the
[40:10] Speaker 2: back would cause them existential suffering, whether they would have
[40:13] Speaker 2: the same rights as Homo sapiens. But in the relation
[40:16] Speaker 2: to this context, it also risk the possibility of bringing
[40:19] Speaker 2: back Neanderthals who are not Homo sapiens and using bare
[40:24] Speaker 2: bodies to transplant human heads into which might plausibly be
[40:29] Speaker 2: doable at some point in the future, and raise really
[40:32] Speaker 2: complex ethical questions.
[40:51] Speaker 1: Let me ask you this you're a psychiatrist, among other things,
[40:54] Speaker 1: what would you do if you were assigned the revivification
[40:58] Speaker 1: of a Neanderthal man and you were the first person
[41:02] Speaker 1: in the room when he wakes up. Now, obviously you
[41:03] Speaker 1: wouldn't share the same language, So what would you try
[41:06] Speaker 1: to do to reduce existential suffering on his part?
[41:13] Speaker 2: I think first I would try to reduce existential suffering
[41:15] Speaker 2: on my part by standing behind something very large, because
[41:19] Speaker 2: my census Neanderthals waking up in this situation might not.
[41:23] Speaker 3: Be very friendly.
[41:25] Speaker 2: But beyond that, I think the real answers we don't
[41:27] Speaker 2: know in the same way we don't know how to
[41:30] Speaker 2: communicate with dolphins, so they may have a very sophisticated
[41:32] Speaker 2: language of their own. We may have any idea how
[41:35] Speaker 2: to communicate or appreciate the emotional response of a Neanderthal man.
[41:40] Speaker 2: It's taken us many, many years to understand in a
[41:42] Speaker 2: most rudimentary way the relationships human beings have with other
[41:46] Speaker 2: high word er apes like a relige, chimpanzees or arangutans.
[41:50] Speaker 2: Neanderthals will be intellectually far more sophisticated. Are going to
[41:53] Speaker 2: be a puzzile we first made them. If we first
[41:55] Speaker 2: made them.
[41:56] Speaker 1: So what would you actually do if you were assigned that.
[42:00] Speaker 2: Job as a psychiatrist. I would probably wait. I would
[42:04] Speaker 2: probably do nothing until I first see how this revived
[42:08] Speaker 2: creature responds to me and take cues from them in
[42:11] Speaker 2: the same way I would do seeing any other patient
[42:14] Speaker 2: in the emergency room. And I I am not comparing
[42:16] Speaker 2: any of my patients to Neanderthal men, though they may
[42:18] Speaker 2: compare me to one. But I do think it's important
[42:22] Speaker 2: first take cues from your patients, to take cues from
[42:25] Speaker 2: other individuals what they expect from you. And that's what
[42:28] Speaker 2: I think the wisest course of action would be.
[42:32] Speaker 1: Great, God, this is going to be a Hollywood screenplay
[42:35] Speaker 1: that we should write, Okay, any any other thing.
[42:39] Speaker 2: And I think that covers my end of life thinking.
[42:43] Speaker 2: I have lots of other issues I can always.
[42:44] Speaker 3: Talk about, but.
[42:47] Speaker 1: Give me, give me a sense of one.
[42:49] Speaker 3: Sure. I think one issue that is related but distinct.
[42:54] Speaker 2: Is the situation of conjoined twins who wish one twin
[42:58] Speaker 2: wishes to be separated and the other twin does not
[43:01] Speaker 2: wish to be separated because of the risk involved in
[43:03] Speaker 2: the procedure.
[43:04] Speaker 3: And you have a situation.
[43:05] Speaker 2: Where one person's life is at stake for the other person,
[43:08] Speaker 2: the autonomy and welfare of their being is at stake,
[43:11] Speaker 2: And there's no easy way to resolve that question. And
[43:14] Speaker 2: it sort of brings to bear all of the different
[43:16] Speaker 2: ethical issues we have raveled with his society bioethically over
[43:19] Speaker 2: the last fifty years, and that it's one of the
[43:21] Speaker 2: only questions in bioethics, by the way, where not only
[43:24] Speaker 2: do I not have a path to help people move forward,
[43:27] Speaker 2: I have no visceral sense of what the right answer
[43:29] Speaker 2: is either. I feel like if I'm not in that situation,
[43:31] Speaker 2: I can't even think about how to approach it.
[43:34] Speaker 1: Wow, are there other situations where one person's life would
[43:38] Speaker 1: be in danger if something happened that would help another person?
[43:42] Speaker 1: There must be other situations that are analogous.
[43:46] Speaker 2: Yeah, I mean there's the famous case of Shimp versus McFall,
[43:49] Speaker 2: where there were two cousins and one of them made
[43:52] Speaker 2: a bone marrow transplant and his cousin was the only
[43:56] Speaker 2: person in the entire world with a bone marrow transplant
[43:59] Speaker 2: that could match him that he needed to save his life.
[44:01] Speaker 2: And he did not have a negative relationship with his cousin,
[44:03] Speaker 2: but they weren't particularly close and he went to his
[44:06] Speaker 2: cousin and said, please give me the bone marrow transplant,
[44:08] Speaker 2: and the bone mara trus plant was not high risk,
[44:10] Speaker 2: but it had some risk in some discomfort. And his
[44:13] Speaker 2: cousin said, no, I don't owe you that. And then
[44:15] Speaker 2: he went before the court and said, I'm going to
[44:17] Speaker 2: die without this bone marrow. It's not that much of
[44:19] Speaker 2: an inconvenience or risk to my cousin. Please make him
[44:21] Speaker 2: do it. And the court said no, and I believe
[44:24] Speaker 2: he died.
[44:26] Speaker 1: Oh do you know anything about what the cousin's reasoning
[44:30] Speaker 1: was beyond the inconvenience.
[44:34] Speaker 2: I don't think, and I am not an expert in
[44:35] Speaker 2: his case, but I don't think the cousin had a
[44:37] Speaker 2: great deal of health literacy. And the cousin was someone
[44:39] Speaker 2: who was a fairly suspicious of medicing a baseline. So
[44:42] Speaker 2: no matter how many times you might tell him he's
[44:44] Speaker 2: got a high risk procedure, it's not so clear he
[44:46] Speaker 2: really believed that.
[44:47] Speaker 1: Okay, incredible, And.
[44:51] Speaker 2: I will add, by the way, even though that seems
[44:54] Speaker 2: like a shocking case, every single one of us has
[44:56] Speaker 2: the ability to save the life of a stranger.
[44:59] Speaker 3: You can give a a.
[45:00] Speaker 2: Kidney or part of a liver, and some people do
[45:03] Speaker 2: altruistically and save someone's life, someone who will otherwise die,
[45:07] Speaker 2: and the vast majority of us, for reasons, whether wise or.
[45:11] Speaker 3: Not wise, choose not to. So in some sense we're
[45:14] Speaker 3: all mister ship.
[45:18] Speaker 2: Yeah, and we all risk being mister McFall too.
[45:22] Speaker 3: At some point we should not forget right.
[45:25] Speaker 1: So what do you advise your students on that front?
[45:30] Speaker 2: I mean, I think I advised them in the same
[45:32] Speaker 2: way by advised students about every ethical issue, which is
[45:36] Speaker 2: I can't tell you what the right answer is. The
[45:38] Speaker 2: two things that are important, actually, there are three things
[45:40] Speaker 2: that are important. The first one is recognized and said
[45:42] Speaker 2: it is an ethical issue, many of the difficult problems
[45:44] Speaker 2: that arise in medical ethics, or because no one matter
[45:47] Speaker 2: how wise or well attention, actually recognize this is an
[45:50] Speaker 2: ethical challenge. The second thing that's really important is that
[45:54] Speaker 2: when you start with a certain premise, you want to
[45:56] Speaker 2: logically come to a conclusion based on that premise. So
[45:58] Speaker 2: at some point between your premise in your conclusion a
[46:01] Speaker 2: miracle happens here, so to speak, you want to.
[46:03] Speaker 3: Go back to square one.
[46:05] Speaker 2: And then finally, I say, once you reach those two premises,
[46:10] Speaker 2: the final step is to recognize that very well intentioned
[46:13] Speaker 2: people with very good values come to very different answers
[46:16] Speaker 2: about this questions from starting with different premises and different
[46:20] Speaker 2: cultural beliefs and values of their own, and the goal
[46:22] Speaker 2: is to understand them and respect them even if you
[46:24] Speaker 2: don't agree with them, because they're not fools simply because
[46:27] Speaker 2: they disagree with you. And I think our society as
[46:29] Speaker 2: a whole would be a much better place we were
[46:31] Speaker 2: able to agree to disagree with mutual respect, and we
[46:34] Speaker 2: actually would be able to find a lot more common
[46:36] Speaker 2: ground at the corners of a lot of issues where
[46:38] Speaker 2: there might be a lot of overlap.
[46:44] Speaker 1: So that was my interview with Jacob Appel, one of
[46:47] Speaker 1: a very small group of people who can equally address
[46:50] Speaker 1: both the medical and legal and ethical aspects of death
[46:54] Speaker 1: and the complexities at the interface. What I hope you've
[46:58] Speaker 1: gathered from today's episode is that the issue of declaring
[47:02] Speaker 1: death is not straightforward, and often we find the most
[47:06] Speaker 1: complex cases at the intersection of medical and legal systems,
[47:11] Speaker 1: and zooming out to the beginning, I just want to
[47:13] Speaker 1: remind us that although we think of death as binary,
[47:17] Speaker 1: it's often much more complex and we are always going
[47:20] Speaker 1: to be confronted with these problems. As technology improves, we're
[47:25] Speaker 1: going to be able to rescue a life from different
[47:28] Speaker 1: states that would have been previously impossible to reverse or
[47:31] Speaker 1: even imagine reversing. And so as biology marches along each
[47:37] Speaker 1: year into the future, the answer to the question of
[47:41] Speaker 1: when you are dead is one that will change along
[47:44] Speaker 1: in lockstep, and in two hundred years we might find
[47:49] Speaker 1: our current answers unpalatable and inconceivable. But in any case,
[47:54] Speaker 1: in each generation, with each landscape of new technology, we
[47:59] Speaker 1: have to con continually revisit this question, where do we
[48:03] Speaker 1: draw the line between life and death? Go to Eagleman
[48:12] Speaker 1: dot com slash podcast for more information and to find
[48:16] Speaker 1: further reading. Send me an email at podcasts at eagleman
[48:20] Speaker 1: dot com with questions or discussions, and I'll be making
[48:23] Speaker 1: an episode soon in which I address those. Until next time,
[48:29] Speaker 1: I'm David Eagleman, and this is Inner Cosmos.

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