When are you dead?

This is a tricky question, where science and religion often hide, or collide. It’s answered in a diversity of ways by different cultures at different times, by different physicians in different hospitals, different shamans in different tribes. Is it when your heart stops working (as in Japan and Shintoism)? When your soul leaves your body (as in Tibet and Buddhism)? When your brain stops working? When a certain part of your brain stops working? Who decides when you’re dead?

Can you be dead in body, but not in mind? Vice versa?

Cogito ergo sum?

A new study just published in the New England Journal of Medicine adds intriguing neuroscientific fuel to the fires already ablaze around these questions.

Typically, when a severely head-injured patient is checked for consciousness soon after his or her accident, the physician might look for the ability to track a moving item with the eyes or say “lift a finger if you can hear me,” and then if answered in the affirmative, maybe “lift two fingers for yes, one for no.” At some point over time, if there’s no response and apparent unconsciousness continues, the patient is considered to be in a ‘persistent vegetative state.’ Doesn’t sound too good, nobody’s happy. What to do?

Challenging enough question. But, now along comes Martin Monti and his colleagues in Belgium. They add a new test for consciousness, applied to fifty-plus folks in a proclaimed vegetative state. Monti et al., using an MRI machine (which monitors for active neurons in the brain), watch these folks’ brains when they are asked a question. And, amazingly a handful of the patients’ brains light up ‘Yes’ or ‘No’ just like your brain or mine would if we were asked a question. These folks are thinking—they are responding to a specific question. They are not vegetables after all! Or at least I don’t think so.

Think of the implications for: my life (now I can communicate with my family, my health care providers); my care (now I can respond to questions about my health care and comfort); health care in general (do we now spend the time and money to do an MRI on every person thought to be in a vegetative state?); understanding of the conscious and the unconscious (in what kind of thinking-space am I living?). As is often the case, in the scientific paper explaining this new MRI-thinking, most of these issues are either ignored or barely brushed up against (although, to the journal’s credit, the article is accompanied by an editorial that begins to explore some of these issues).

But you can get an idea of the complexity of this research’s ethical implications from the reactions of students in two very different courses I happened to be teaching in a single day. In one class—of physicians discussing research ethics—a neurologist was very upset. She thought these research findings would be just as likely to make it even more difficult for her and families to decide what to do with those in a vegetative or near-vegetative state. The families might demand the new test, and then, if there is some intentional brain activity, they might be excited or even more frustrated and upset, depending on how they interpreted the results in their own consciousnesses.

As if confirming this, in my other course—this time a class of undergraduates exploring why we believe the things we do—we happened to be exploring the question of what constitutes a person. We had just read Descartes’ famous treatise (in which he proclaims “I think, therefore I am”) and the neuroscientist Antonio Damasio’s Descartes’ Error. Based on this new MRI research, we asked the question: If your Dad can only communicate through ‘thought MRI’ like patients in this study, would you consider him alive?

A student answered: I’d rather pull the plug, let him die. From personal experience, I’d rather just pull the plug. Tears formed in the student’s eyes, she broke down, and ran from the room.

Does religion help us here? Yes and no, as we heard in the (in)famous Terry Schiavo case. There are diverse responses to such cases even within particular religions, because the factual and conceptual lines are so blurry. A Catholic or a Jew might say: in Genesis we learn that we are all made in the image of God, we all have an inherent dignity, and to take that away is wrong.

But what constitutes dignity here? another Catholic or Jew (or my student who ran from the room) might ask. A Muslim might say: to kill one person is to kill all people, to help one is to help all—but another might ask: how are we defining life?

One Buddhist says, we must hold on and wait for a miracle—but another responds: we must let this person and her soul go peacefully or else we are negatively impacting its next life.

Once again, science sneaks in on (invades?) the way we live and die—and makes it easier, and harder, to do so.

But here at least is one good thing: palliative medicine—a new official branch of care, complete with certification, association, and peer-reviewed journals—has emerged. The goal of palliative care is to help relieve people who are dying or have a chronic condition from suffering by engaging their physical, mental, and spiritual health. Palliative medicine won’t easily solve problems like those posed here, but at least we are beginning to develop a framework that will allow us to better prepare for death, to more effectively explore the complexities, and, I hope, to reach richer conclusions.