0:05

How do you know when a person is

0:07

dead? I mean, it seems like a straightforward

0:09

problem, but this is often a

0:11

very complex issue, both medically

0:14

and legally, because, as we'll

0:16

see in this episode, death is

0:18

not an event but a process.

0:22

So where do the medical and legal systems

0:24

face off against one another in this question?

0:27

Can a person be declared

0:29

legally dead even though he's very much alive.

0:32

Why in twenty eleven did an

0:35

enormous number of families choose

0:37

to pull their loved ones off life support

0:40

just before the new year? And what does

0:42

this have to do with getting buried alive

0:45

or with your family's religious beliefs,

0:47

or whether someone's head stays alive

0:50

after the guillotine. Welcome

0:55

to Inner Cosmos with me David Eagleman.

0:57

I'm a neuroscientist and author at Stance,

1:00

and in these episodes we sail deeply

1:02

into our three pound universe to understand

1:05

why and how our lives

1:07

look the way they do. Today's

1:19

episode is about the science,

1:21

the ethics, and the questions

1:24

about the end of life, What

1:26

qualifies as death, who

1:28

gets to say that

1:30

you are dead? And what is the future

1:32

of this? Okay,

1:34

so let's start with something that's perhaps

1:37

macabre and unexpected. But

1:39

if you're a modern adult and you die

1:42

suddenly, you have all these bill

1:44

pay and credit card payments and automatic

1:47

withdrawals that are scheduled, and

1:49

your finances might keep on trucking

1:51

for a while. You may even receive

1:53

some auto deposits into your bank account,

1:55

And with all the comings and goings,

1:58

it would look to someone who didn't know that

2:00

you're still making transactions. And

2:02

if you happened to have some pre

2:05

scheduled emails that you'd previously

2:07

written, those might go out, and various

2:09

legal things get triggered at different points,

2:11

and it will probably look for a little while

2:14

like you're still making stuff happen

2:16

in the world. And I was thinking

2:18

about this the other day as an analogy

2:21

to what happens with your biology.

2:24

Generally speaking, death is declared

2:27

when a heart stops beating and

2:30

or someone stops breathing. But

2:32

even though we think about death like a binary

2:35

event, there's no central

2:37

command center in the body that says,

2:40

okay, now we're done. Everyone stop

2:42

working. Because the body is made

2:44

of literally trillions of cells,

2:47

and all of their chemical signals

2:50

are connected and intricate cascades

2:52

and loops and when something stops

2:55

running, these nested feedback

2:57

loops tend to bump things

2:59

back to the normal range. We have this compensation.

3:03

Now, at some point the whole show

3:06

grinds to a halt. The compensatory

3:08

mechanisms can't keep up

3:11

with the catastrophic failure of

3:14

loop after loop that stops working,

3:16

and eventually the whole system stops.

3:18

But death is not a moment

3:20

in time. It is a process. In

3:23

other words, the individual cells

3:26

don't necessarily know that the heart

3:28

has stopped or the brain has

3:30

stopped its cognitive whirlwind

3:32

of activity, so they just keep trucking

3:35

along for as long as they can. So

3:38

here's an analogy so we can think about this.

3:40

Imagine you are a space

3:42

alien that's looking down on the Earth and

3:47

you see a large blobby

3:49

organism moving towards some

3:51

fortress. And then the

3:54

blobby organism extends two

3:56

arms around the fortress and starts

3:58

to squeeze it. But then some explosions

4:01

go off and the organism stops moving.

4:03

It seems to die. But then

4:05

you use your alien telescope

4:08

to zoom in more closely, and for the first time,

4:11

you notice a single warrior

4:13

running up the hill, turning back swinging

4:16

his sword, falling to his knees

4:18

in lamentations, and regaining his

4:20

footing and running towards the fortress again.

4:23

So you start panning your telescope round

4:25

and you notice a dozen of these

4:28

rogue swordsmen in different locations

4:30

around the battlefield. And that's when you realize

4:33

that the blobby organism who

4:35

came upon the fortress was actually

4:37

composed of lots of little

4:40

individual agents, all of

4:42

whom worked in concert

4:44

and maybe had hierarchies and rules

4:46

of engagement and backup plans such

4:48

that even when most of the army

4:51

was killed, that didn't necessitate

4:53

that every part stopped the

4:56

survival of individual

4:58

warriors. Suddenly, rev feels that

5:00

the blob was made of these little

5:02

swordsmen all along, even though that was

5:04

difficult to see. And this

5:06

is what happens biologically.

5:09

We are made up of cells that

5:11

operate together. This is

5:13

what makes a person or any animal.

5:16

Trillions of cells collaborating

5:19

to make this giant creature that

5:21

moves around and finds other

5:23

collections of cells to eat and take

5:25

their energy. And researchers

5:28

have made recent discoveries about cells

5:30

that stay alive and actually get more

5:33

active well after

5:35

the rest of the body has been declared

5:37

dead. In other words, these little swordsmen

5:40

warriors that are still running around

5:42

even after the blob has

5:44

stopped. For example, some

5:47

researchers at University of Illinois Chicago

5:49

looked at little pieces of fresh

5:52

brain that get removed during

5:54

brain surgery, and they looked at these either

5:57

right when the tissue was removed or

5:59

at different times after the removal.

6:02

So they called this a simulated

6:04

death experiment, and their point was to think about

6:06

what happens when tissue gets

6:09

separated and dies. And

6:11

what they found after the tissue is removed

6:14

is that some brain cells actually

6:16

increase their activity. These cells will

6:18

often grow really large and they sprout

6:21

long finger like processes for

6:23

several hours after death. Now,

6:26

in some sense this is not too surprising, because

6:28

these are glial cells in

6:30

the brain whose job is to take

6:32

care of inflammation. But

6:35

the researchers pointed out that most

6:37

people don't even look at the brain after

6:39

death because they assume that everything

6:41

dies. But in fact, eighty

6:43

percent of the genes being expressed

6:46

kept on being expressed at their normal

6:48

levels. Twenty four hours later.

6:51

A few genes had their expression levels

6:53

go down, but there was a third group

6:55

of genes, which they called zombie

6:57

genes, whose activity went up,

7:00

and as a result, you have all these cells

7:03

still running around and doing stuff.

7:06

And if we zoom out our camera, we find

7:08

that different organs keep functioning

7:10

for different amounts of time. So, for example,

7:13

at some point we would say the brain

7:15

is dead. That's followed a little

7:18

later by the heart. Then the liver

7:20

dies next, then the kidneys

7:22

and pancreas can last another hour past

7:24

that before they die, and other

7:26

parts of your body like your heart

7:29

valves, and the corneas of your eyes

7:31

and your tendons and your skin that's

7:34

still alive after about a day.

7:36

So the idea that everything stops

7:39

when you die is not correct.

7:41

Returning to the space alien analogy, imagine

7:44

that the medics come in to take care of the

7:46

fallen warriors, and so there's still lots

7:49

of activity even after the main

7:51

army has fallen. But

7:53

it gets even weirder when we talk about

7:55

things that the larger level

7:57

of the creature. And there's been a history

8:00

of asking these questions. For example,

8:03

you might think that death

8:05

is really clear if say

8:07

a person has had their head cut off

8:09

with a guillotine, I'm going to dive

8:11

into that issue in a future episode because

8:13

the whole thing is so wacky

8:16

and fascinating. But I'll just mention now

8:18

that in the eighteen hundreds, when the guillotine

8:21

was very popular, people got

8:23

interested in this question of whether the head

8:25

can stay conscious after

8:27

separation from the body, and what they

8:29

would do is pick up the freshly

8:32

severed head and try to get it

8:34

to talk or at least blink its eyes

8:37

on command. And at

8:39

that time, other scientists were trying

8:41

things like taking a decapitated

8:44

head from a German shepherd dog

8:46

and reattaching it to the blood supply

8:48

of another dog to see if simply

8:51

restoring blood flow through the brain was

8:54

enough to restore its function. So

8:57

stay tuned for that episode. But what these experiment

9:00

it's highlight is that this question of

9:02

where to draw the line between

9:04

life and death has been with us a

9:06

long time, and in modern

9:08

times we have things like the field

9:10

of cryogenics, which is the art

9:13

of freezing a body

9:15

after death, so it has a chance

9:18

of being revived by future

9:20

scientists who might know how to do

9:22

that, even though we don't know now. In

9:24

the field of cryogenics, it's popular

9:27

to sometimes just save the head

9:29

and get rid of the body, and the assumption

9:31

or the hope really is that that can

9:34

be sufficient, and that if you

9:36

are maintained at ninety six

9:38

degrees below freezing, then you're not actually

9:41

dead, but you're in a state of suspended

9:43

animation and can eventually

9:46

be rebooted. So

9:49

why does all this matter, this question of where

9:51

to draw the line between life and

9:53

death. Well, first of all, it matters

9:55

for the medical system, and

9:57

we see cases come up all the time in hot

10:00

hospitals where there is confusion

10:02

or disagreement about how to make

10:05

the call. There was a case

10:07

in Texas where the doctors told

10:09

a man that his son, who had

10:11

been in a coma, would never return

10:14

back to consciousness, and so the doctors

10:16

wanted to make the call to remove

10:18

the young man from life support, and

10:20

the father was so distraught

10:23

that he pulled a gun on the doctors

10:25

and medical staff and wouldn't let

10:27

them near his son in the hospital bed,

10:29

And so the police were immediately dispatched

10:32

and this man was arrested and put in jail

10:34

for eleven months. But incredibly,

10:37

the son enjoyed a full recovery

10:40

and once the father was released from

10:42

jail. The two of them were happily

10:45

reunited. All of this points

10:47

to the difficulty in determining

10:49

when a body has died irreversibly,

10:53

and the question of life and death matters

10:56

enormously for legal systems

10:58

because so much pivots on whether

11:00

a person is considered alive or

11:03

dead in the eyes of the law.

11:05

How do we know when that line has

11:07

been crossed? So there

11:09

are so many fascinating medical

11:12

and legal and ethical issues around deciding

11:15

when a person has died, and those

11:17

viewpoints don't always align,

11:20

and perhaps surprisingly they often conflict

11:22

badly. And add to this particular

11:26

religious practices that people have and

11:29

business issues like tax implications,

11:31

and what you have is a fascinating set

11:34

of questions that arise. So

11:36

that's what I want to talk about today. How

11:38

we as a society make that

11:40

call and how should we so

11:43

To dig into this, I called up my

11:45

friend and colleague, Jacob Appel. Now,

11:48

Jacob is a very accomplished thinker and

11:50

writer and man of many talents.

11:52

He has seven graduate degrees,

11:55

but for today's episode, the two

11:57

most salient are his law

11:59

degree from Harvard and his medical

12:02

degree from Columbia. Jacob

12:04

works as an emergency room psychiatrist

12:06

in the Mount Sinai Health System, and

12:08

he also serves as the director of Ethics

12:11

Education. So I called

12:13

him up to talk with him about the question

12:16

of how we as a society should

12:18

think about making the tough calls

12:21

about whether a person should be declared

12:23

dead or not, and the complexities

12:26

that lurk inside that seemingly

12:28

simple question, complexities

12:31

that are scientific and legal

12:33

and cultural. How

12:38

do the medical and the legal systems decide

12:41

when you are dead?

12:44

Well, it's interesting because the medical and legal systems

12:46

have very different histories and very different

12:48

approaches. As a legal concept,

12:51

being dead has significant implications

12:53

not just for you, but for your loved ones and

12:56

for society. So, for example, if you're

12:58

dead, your spouse can re marry,

13:01

your heirrors can inherit, You

13:03

stop getting social Security. So,

13:05

whatever your biological status, if you're declared

13:08

dead, it can have significant implications for the.

13:10

World and for you as well.

13:11

I'm reminded several years ago

13:14

a man from Romania had gone to work

13:16

in Turkey, and he'd been gone

13:18

for a long time.

13:19

His wife couldn't find him.

13:20

She had him legally declared dead, and then

13:22

he came back as a surprise,

13:25

and he couldn't run an apartment or get a job his

13:27

casement all the way to the Romanian Supreme

13:29

Court because he was legally dead and nobody,

13:31

even though he was standing in front of him, would overrule

13:34

us. And I will mention also legally

13:36

there are these gray areas. So for example,

13:38

if you were lost to see historically, how

13:41

did we know how long you had it be gone before

13:43

you were dead? And there were different rules

13:45

for how much time had it passed before they could

13:47

give away your property versus not

13:50

having rights over your children.

13:51

So you can be dead for one purpose and alive for another.

13:54

Wasn't there some sixteenth century French

13:57

soldier that this happened to last

13:59

name Gear?

14:01

Yeah, there's a great movie, The Return

14:03

of Martin Gear, which is a classic

14:05

case of this, where someone allegedly

14:08

I believe it was in one hundred Years War, came

14:11

back after being lost in battle. It turned out

14:13

he actually wasn't the person who claimed he

14:15

was. But there were a number of famous cases

14:17

like this over the years, and as a famous

14:19

poem by Tennyson about

14:22

Enoch Arden, hence the term that

14:24

has come into the English language Enoch Arden laws

14:26

which the laws would refer to how long you have

14:28

to be missing before you're dead.

14:30

Wow. Okay, So from

14:33

the legal point of view, there are all these

14:35

things to be considered, including, for example,

14:38

tax laws. Can you just

14:40

mention what happened between the two nine and

14:42

twenty eleven?

14:44

Oh?

14:44

Absolutely, So the Bush

14:46

administration had enacted tax laws

14:49

that gave people a significant tax break on

14:51

their inheritance, and they were going to

14:53

expire at some point, and people's inheritance taxes

14:56

would go up substantially as a

14:58

result of which many people who were at the end of life life

15:00

on life support or their families want

15:02

at their life support terminated before

15:04

January first, when their taxes would double.

15:07

At an entire boutique corner

15:09

of a major New.

15:10

York City law firm is actually devoted specifically

15:12

to this practice.

15:14

Right, So, somebody was on life support

15:17

and the adult children would

15:19

say, look, it's December, let's

15:22

go ahead and pull this now so

15:24

that he dies before January first.

15:27

Yeah, they would say, Grandpa would much

15:29

rather die on December thirtieth and

15:31

leave one hundred billion dollars to his

15:33

grandkids than die on January

15:35

second. Still unloose it. Two days

15:37

later, and leave them nothing. And honestly,

15:39

I can't argue with that.

15:41

Yeah, So how do hospital

15:44

ethics boards deal with questions

15:46

like that? Sure?

15:48

Are so most decisions in hospitals or

15:50

recommendations, you're done by committee. So

15:52

you have an ethics committee, You have a consultant who

15:54

actually gathers the information and presents it to

15:56

the committee, which consist of experts

15:58

in a range of different fields, so not

16:01

just medicine, surgery, pediatrics, but social

16:03

work, nursing, the hospital chaplain.

16:06

They sort of build a consensus and then

16:08

obviously, if you can't build a consensus

16:10

or can't get the family on board, then cases

16:13

end up going to court, and ultimately, in cases

16:15

like this, the court usually will decide looking

16:17

at all the evidence brought before them.

16:19

Okay, and so there are all these legal

16:21

considerations, what are the medical considerations

16:24

when we think about what is death?

16:26

Sure, and the medical considerations are actually

16:29

just as complex. In

16:31

an earlier era, you probably

16:33

have seen movies like The Cursed

16:35

Living Dead, where people are believed dead and then they

16:38

come back to life suddenly, and people who are afraid of

16:40

being buried alive.

16:41

It was actually a fairly.

16:44

Ineffective diagnostic tool to be certain

16:47

someone was dead, they would do things like hold

16:49

up a mirror to your mouth and see if there was

16:51

actually vapor on it, to see if you were breathing.

16:53

So they made mistakes.

16:56

So actually this actually happened

16:58

where people were buried alive.

17:00

Yes, I mean it wasn't a common occurrence,

17:02

but it did happen. I will add,

17:05

as strangers who may sound it still

17:07

happens occasionally. Today you hear these

17:09

stories about people who show up in the morgue

17:11

or show up in a funeral home and

17:14

suddenly they wake up. Usually, I

17:16

will add, by the way, those people are still in a very bad

17:18

shape and they don't make it in the long run. I

17:20

don't know of any case to people who have actually been

17:23

to the morgue and then got home and good health.

17:25

But people have gone and they started breathing and ended

17:27

up backing the ice you before, So that

17:29

should give us pause.

17:31

How does that happen currently? Is it in

17:33

areas where there's not good medical

17:36

diagnosis of what has happened?

17:40

I wouldn't be that critical.

17:41

I would say it's a very hard There are a whole bunch of different

17:43

tests for determining whether someone is dead. Now

17:46

and different diagnostic tools and doctors

17:48

do their best. And sometimes if you're barely

17:51

breathing, and if your pulses very sporadic

17:53

and they catch you a couple of times at the wrong moment,

17:56

maybe you get unlucky.

17:57

I will add often this.

17:58

Does occur in the developing world, where maybe

18:00

their diagnostic tools are not as strong. I

18:03

don't know of any cases in New York City with my luck,

18:05

I'll be the first.

18:08

Okay, So back to a few decades

18:10

ago or a century ago. So you hold

18:12

a mirror to the mouth and you see if there's

18:14

fog on the mirror, and then

18:16

what happened.

18:18

So eventually we did no enough about anatomy

18:20

to recognize cardiac and pulmonary death. Cardiopulmonary

18:23

death, you stop breathing and you

18:25

don't get a pulse for a propracted period

18:27

of time, we accept that you're dead.

18:29

Like how long? What's a protracted period?

18:32

That depended on the doctor.

18:35

Honestly, if you're not breathing or

18:37

you know, a pulse for a good ten to fifteen minutes,

18:39

the odds of you reviving naturally on your own get

18:41

pretty darn low. When you get much

18:43

past that, your odds for surviving

18:46

in a way that is meaningfully cognitive or

18:48

very low and most people stop at some point,

18:50

stop crying. But that was the diagnostic tool

18:53

back then. I will add, by the way,

18:55

that most people historically back then

18:57

were in very bad shape by the time they reached that pointing.

18:59

It's been other death bed for hours or

19:01

days or weeks.

19:03

So what happened next?

19:05

So there were technological developments

19:07

in medical science that allowed

19:09

us to check for cardiopulmonary

19:11

death basically to figure out whether or not

19:13

your heart was still beating, whether your lungs

19:16

were still breathing, And that was the test

19:18

for many, many years until the nineteen sixties.

19:20

And if you stop breathing and if your

19:22

heartstep beating, you were dead. And

19:24

that, I will add, by the way, is the test still

19:27

used in some religious communities, in some cultural

19:29

traditions. Starting

19:31

in the late nineteen sixties with the

19:34

advent of organ transplant,

19:37

which meant there was a need to harvest organs

19:39

or procure organs from the individuals

19:42

as quickly as possible, and the

19:44

rise of artificial ventilation and

19:47

later artificial heart support, which

19:49

meant that people could be kept alive for months

19:52

or even a year or two on a respirat or

19:54

on a ventilator. That

19:56

created the challenge of how did we know when these individuals

19:58

were dead? And there was a debate

20:00

over whether brain death should be acceptable,

20:03

and the ultimate decision was made by a

20:05

committee of experts at Harvard that has been

20:07

adopted widely that whole

20:09

brain death would be the standard. So, if

20:11

you have two flat EEGs, your

20:14

brain stops functioning entirely, you

20:16

are now legally dead in every state. I

20:19

will add New Jersey, and

20:22

to a lesser degree under some circumstances.

20:24

New York allows people with a religious

20:26

belief only in cardiopulmonary death to opt

20:28

out of that standard, but other states do

20:30

not.

20:31

So give me an example of having

20:33

a religious belief and how that might change

20:36

the decision that a family makes.

20:38

Sure.

20:39

So let us say that my grandfather

20:41

is on a ventilator

20:44

which is artificial. One support and intet

20:46

to buy that which is a machimee that for a

20:48

short period of time to fairly

20:50

late the period of time. Now with new technology can

20:53

replace the heart, so it's entirely artificial.

20:55

And yet he has two flat

20:57

egs. His brain

21:00

is showing no function at all. In

21:02

New Jersey. If I have a religious tradition

21:05

that says that only cardiopulmonary

21:07

depth is alive. In theory, I could

21:10

raise the funds to bring that individual

21:12

home to my living room and keep them on

21:14

ventilator support and buy bad support until

21:16

they can no longer support their

21:19

cart and lungs with those machines, which could

21:21

be a year.

21:23

And this happens sometimes right where someone takes

21:25

a person home.

21:28

It is rare, but it has happened.

21:31

I believe there was a famous case in Utah, a

21:33

Jesse Kutchin case where it has happened. In

21:35

addition to which there have been cases where people

21:38

the Johi McMath case may be the most known,

21:40

who were what was presumed to be a

21:43

state of brain depth for

21:45

families who do not accept that definition, who

21:47

brought their relatives to New Jersey to

21:49

then replace the facilities that keep people who are

21:52

alive in a cardiopulmonary manner but

21:54

is ceased by the brain death standard alive.

21:57

And what's the reason that people do this. It's because

22:00

their religioustration tells them

22:03

even though they're on a bivalve

22:05

and there on a ventilator, they

22:08

do they think the person could come back, or they have other

22:10

issues. I know you wrote once about somebody's

22:14

belief in reincarnation and how that affected.

22:17

So there are two different categories of people, and

22:19

we might treat the cases the same way or

22:21

differently.

22:22

There are those.

22:23

Individuals who truly

22:25

believe that their relative is going to revive themselves,

22:28

even though the data, overwhelmingly

22:30

from past practice says that's not going to happen,

22:33

and they're hoping for a miracle.

22:34

So to speak.

22:35

There are other individuals who may say,

22:38

you know, I understand that my grandfather

22:40

isn't really going to wake up again, but either

22:43

I, or more appropriately,

22:45

he had a deep religious belief that it was

22:47

important to die of quote unquote natural

22:49

causes or if you believe in reincarnation,

22:52

to die at a certain time, and I

22:54

want to fulfill his wish, even though

22:56

I understand that by your standard he's dead. By

22:58

a religious standard of our book, our

23:00

Bible, or tradition, he's not dead, and

23:02

I want to wait the process out.

23:04

I'll add one more thought on that it's okay,

23:06

which.

23:07

Is you also might want to ask the question, does it matter

23:09

whether if someone's been declared brain dead

23:12

you're willing to pay for it when you take them home,

23:14

whether you're asking the taxpayers to put the bill for

23:16

it, because then the vast majority

23:19

of us would say, the taxpayers are paying to

23:21

keep a dead person on a life

23:23

support system in your living room. And the other

23:25

thing to think about is there's something inappropriate

23:27

or grotesque about it. If

23:29

I were to want to bring my grandmother home embalmed

23:32

like Lenin on display in his tomb and prop

23:35

work in my living room, our society would not let

23:37

me do that, not just for public health reasons,

23:39

but probably for reasons of what we would call

23:41

common decency or horem or appropriateness.

23:44

Some would argue, this is not that different.

23:46

And how does this work in terms of making decisions

23:49

for somebody else. Let's say that somebody

23:51

is in critical condition. It doesn't look likely they'll

23:53

recover, but maybe there's some extreme measures

23:56

you can take that involve amputations

23:58

and other things, and a decision

24:01

has to be made about whether that person

24:03

would want that kind of heroic

24:06

medical treatment with the possible

24:08

consequences. How

24:11

does a hospital make the decision about

24:13

that?

24:14

So, while there is some variation among

24:17

state laws, the general accepted

24:19

principle in this country is that we use a substituted

24:21

judgment or vicarious judgment standard,

24:24

which if we asked, what would this person would

24:26

have wanted if they were still awake

24:28

and lucid and able to express an opinion. The

24:31

only two groups of people we don't use that approach

24:33

for are children, where

24:36

parents can decide based on what they perceive

24:38

to be the best interest within certain societal

24:40

parameters, and people who've never

24:42

had the capacity or ability to make that decision.

24:45

We view it as too far elite to say you

24:47

were born with a such a significant cognitive impairment

24:49

that you could never understand his question. But

24:51

if you hadn't been bored in that way, what would

24:53

you want to have had done.

24:55

I've actually been critical of that latter approach.

24:57

Because in that situation we use a societal

25:00

best interest standard, what society would

25:02

think is in your best interests. I have argued

25:04

that for certain communities, let's say you're

25:06

an Amish, Mennonite or a Casidic

25:09

Jew, it might be more appropriate to ask

25:11

what would be the best interest standard in your community,

25:14

because it doesn't seem too far a bridge

25:16

for me to say, if you were born a Mennonite,

25:18

you would want what a Menonite tradition speaks to not

25:21

be overall societal standard.

25:24

Tell me about what happened during Hurricane

25:26

Katrina with the ventilators and what

25:28

that means.

25:30

Sure, so, I think during Hurricane Katrina

25:33

there was a medical

25:35

crisis where they had patients who were ventilators

25:38

who needed them to stay alive, and

25:41

a number of questions around end of life arose. One

25:43

the medical teams for safety had

25:45

to leave some of these patients. Some of them could not be evacuated,

25:48

and they had to decide whether or not to

25:51

continue them on life support, whether or

25:53

not to use morphine

25:55

or other techniques to ease their suffering that

25:57

could have the risk of death. Into

26:00

trial, there was a doctor Poe was actually put on trial

26:02

and eventually acquitted for her role in this.

26:04

These were not easy.

26:05

Questions, right, because

26:07

the decision she made was, you know, if

26:09

we are going to run out of power, then

26:12

people will suffer if they don't have the

26:14

ventilator on anymore, and so

26:17

do we pull the plug

26:19

before we run out of power? Was

26:21

that the issue?

26:23

I mean, that was what she was accused

26:25

of doing. As she describes it.

26:28

I believe she would say she was giving people

26:30

morphine or other medication with a dual

26:32

intent that might have ended their

26:34

life as a result, but the primary goal was

26:36

to ease their suffering. And in palliative

26:39

care and end of life decision making, we often do

26:41

recognize this concept of dual intent.

26:43

We may intend to do one thing that inadvertently

26:46

is a different consequence, but intending

26:48

to relieve suffering that leads to death,

26:50

we view conceptually is very different from intending

26:52

to cause death.

27:10

Okay, so the way we make decisions about

27:12

death now has to do in

27:15

part with this concept of irreversibility.

27:18

And my question to you is how

27:20

do you think about this in terms of the new

27:22

technologies that are coming along and

27:26

change that definition of irreversibility.

27:31

I mean, this comes up not just with defining

27:33

death, but an all end of life decision

27:35

making. So people

27:38

may be toward the end of life

27:40

and have what we call it terminal prognosis, but

27:43

there's no way to be certain that a new technology

27:45

will develop that can cure their illness. And there have been

27:47

cases now of people with rare

27:49

cancers that seemed to one hundred percent fatal

27:52

they always had been before, where new immunotherapies

27:55

suddenly appear in the market or emerge

27:57

as experimental treatments that then save their lives.

28:00

And who are we to.

28:01

Take away someone's hope, which is why we generally

28:03

defer to what the patient's wishes are. And

28:06

that also creates an economic challenge,

28:08

because we may know society that

28:10

almost everyone in this situation dies, or

28:12

even that so far everybody has. But who

28:14

are we to take away hope from the veryous one number

28:17

of people who want to be the teals,

28:19

so to speak, and not the bell.

28:21

I can give you a very concrete example of this.

28:23

I don't know if it's still true, but there was a time

28:26

when if you went on the internet, let's say you were diagnosed

28:28

with ALS blue garage disease and

28:30

typed in prognosis ALS

28:33

blue garage disease on Google, the first

28:35

picture that came up was not lou Garage.

28:37

It was Stephen Hawking.

28:39

The physicists who lived I'm guessing

28:41

thirty forty years with the illness, even

28:44

though the vast majority of people died.

28:46

Within a few years.

28:47

And once you see that, it's hard to make any

28:49

meaning out of statements like a certain percentage

28:51

of Medicare or Medicaid dollars are spent in

28:53

a certain period toward the end of life, because

28:56

as I always ask the medical students after I explain

28:59

that, I say, if if you're in the last six months of

29:01

life, raise your hand now.

29:03

And obviously we don't know.

29:05

So Jacob, when you think about the question

29:07

of irreversibility, what do you think about cryogenics?

29:11

So I'm not one who can say that cryogenics

29:14

will never work, though my guess is there will

29:16

be other technologies that will be developed beforehand

29:19

that may be far more effective at

29:21

life lengthening, or life preserving, or

29:23

even reversibility. I can say

29:26

that nothing I have seen suggests that criogenics

29:28

as it works now is very effective.

29:30

I would not suggest having your head caught off

29:32

now in storage somewhere.

29:34

What else are you seeing that seems like it could

29:37

be more effective?

29:39

I mean, I think at some point, and this is

29:41

obviously in a far fetched way, many

29:43

many years in the future, we may be

29:45

able to download people's personality,

29:48

download their brands into some kind of system

29:51

A computer might be too simplistical word,

29:53

but some kind of extra intelligence

29:55

system that can then reprogram individualism

29:58

in a way That is not something I would say that

30:00

you should bank on in your lifetime or mind. I

30:02

think we're far better off focusing on technologies

30:05

that can extend human life as it exists

30:07

now. And I will add

30:09

even beyond that, we may ultimately have

30:11

that technology to transfer heads

30:14

from one individual or a brand from individual

30:16

into bodies of another, but again we are nowhere

30:18

near prime time on that. I know there's an

30:20

Italian sturage, and thinking about doing that, I

30:23

would be very reluctant to try that procedure

30:25

because not only the possibility will work, which

30:27

the possibility, what would suffer immensely during

30:29

the process.

30:31

I think maybe it was Paul Broca.

30:34

Somebody actually did this with German shepherd

30:36

dogs, where they cut off one head and attached

30:38

to the vasculature to the heart

30:41

of another dog and kept the

30:43

head alive that way.

30:46

I'm not sure if it always broke up, but a number

30:48

of different people have done this over the years,

30:50

with more or less suctatistic with various

30:52

animals, So the theoretical

30:55

concept is there. There obviously are

30:57

both a number of logistical premises

31:00

is in terms of attaching neurop tissue, and

31:02

also a large number of ethical dilemmas.

31:05

It's very I don't want to say easy, but

31:07

it's much more easy to get decided to accept killing

31:09

a German shepherd to say of another German shepherd.

31:12

They get used to kill one person to say of another

31:14

person.

31:15

That's right, Although as I as I understand

31:17

it, it's the idea is taking

31:20

somebody who is brain dead

31:22

but their body is still functioning, and

31:24

then taking somebody else who has

31:26

a functioning brain. But let's say they're quadriplegic

31:29

and their body is degrading. So it's

31:31

somebody who is already judged

31:33

to be dead by brain dead standards.

31:36

Is the first body?

31:39

Absolutely, I mean that that is the

31:41

theoretical approach. The

31:43

obviously both logistical

31:45

challenges in terms of what if you have a mismatch

31:48

of heads and bodies, and the

31:50

ethical questions of who this person legally

31:52

is going forward and how they relate to their

31:55

one family versus the other inheritance

31:58

whose fingerprints to the have in a legal sense

32:01

becomes very very complicated, very very

32:03

quickly. I'm not saying this issue can't be solved.

32:06

I would say we want to solve these questions

32:08

before we start using the technology, or

32:10

we're going to find yourself painted into a very unpleasant

32:12

quarter.

32:14

Yes, So let me come back to that question about

32:17

how committees at

32:19

hospitals, how ethics committees make this decision.

32:21

You pointed out that ethics committees are

32:23

made up of many different points of view.

32:27

What have you seen is the most contentious

32:31

argument that you have come across.

32:34

I can tell you that speaking more broadly,

32:36

because I don't want to reveal now Sini's confidential

32:38

epics debates, but historically the

32:41

most controversial issue in epics committees

32:44

has related to a very specific scenario that

32:46

occurred over and over again throughout this country

32:48

from nineteen seventies through the nineteen nineties, and

32:51

how to do with patients who were

32:53

in accidents with C three S force

32:55

bibal fractures so they would never be

32:58

able to breathe again on their own, never be able to

33:00

to move below their neck on their own, and they would

33:02

wake up from his accidents and say, I

33:04

don't want to live like this, turn my life support

33:06

off, and palliative care

33:08

would say we need to respect their autonomous

33:11

wishes. They don't want to suffer. And psychiatry

33:13

would say, but we know that

33:16

a certain percentage of people, approximately half

33:19

who we do talk into staying alive

33:21

and do therapy with after a year are

33:23

actually glad they stayed

33:26

alive and take meaningful value in their life. And they point

33:28

out, for example, the Superman actor Christopher

33:30

Reeve and Pallid of Care would cut back and

33:32

say, yes, but we know that the other half or

33:34

not, and the interest to the other half

33:36

to not suffer existentially outweigh

33:38

those of the first half to have a

33:40

meaningful life in the long run. And this was a deeply

33:43

heated debate which there's no conceptually

33:45

correct answer. You can't reduce

33:48

it to any level where there's a right answer. I

33:50

can tell you in practice, palliad of care

33:52

has won misbattle.

33:54

Ah And what was it with Christopher

33:56

Reeve? Which way did

33:58

he go on that he was happy that he had stay

34:00

alive.

34:01

After a year?

34:01

Even I think before a year he'd was very grateful to have

34:04

stayed live and he brought great meaning to his life

34:06

and helped others. But I will add, if

34:08

you're Superman and you have a loving

34:10

family and a great deal of financials

34:13

for it and amazing doctors, it may be

34:15

easier to find that comfort zone than

34:17

if you're indigent. If you don't have social

34:19

support if you don't have good medical care, if you're

34:22

in a back room somewhere in a nursing facility.

34:24

So I think the other major issue that is

34:26

the end of life, which we've only touched

34:28

on the iceberg tip of the iceberg up

34:31

so far. He is medical aid and dying,

34:33

which has become a national debate over

34:35

when, if ever, people can choose to end their own lives.

34:38

And there's a slow consensus building that

34:40

people with terminal illness, terminal physical

34:42

illness should be able to end their own lives

34:45

if they have a diagnosis of als

34:48

or cancer and they're not going to survive a prolonged period

34:50

of time. And we've seen from one state,

34:52

Oregon in the nineteen nineties to I believe it's now

34:54

ten jurisdictions to legalize this, and

34:56

the trend going forward is to expand this. However,

34:59

we have really not come to terms with

35:01

a question of people who are not suffering

35:04

physically but suffering psychiatrically

35:07

or existentially. And

35:10

for example, we've seen this heated debate in Colorado

35:12

over patients with anarettia who have

35:14

not responded to treatment over a very long period of

35:16

time should be able to turn down refeeding

35:19

or turn down nutritional

35:22

support, even if it means the end of their life, and the

35:24

way we would let a patient with a kidney

35:26

problem turn down dialysis let themselves

35:28

die.

35:29

And we're going to see this question more and more.

35:31

Obviously, if you show up in the emergency room and

35:34

you've broken up with your prom date and you take

35:36

it over as a tile and all, I don't think any Risgilble

35:38

person would say, well, you've had a long, meaningful life,

35:40

you should be able to make this decision. On the other

35:42

head, if you've had depression for

35:44

forty years and you've suffered and no

35:47

treatment is worked after every intervention and

35:49

you say, if you could help me, I want

35:51

that, But since you can't, please let me in my life.

35:54

It's a harder question.

35:56

And why do you see these questions coming

35:58

up more and more?

36:00

Well, I think they've come up in part because

36:02

patients are raising these issues and the clinical

36:04

practice. Patients often will say, doctor,

36:07

I've done everything you've asked me to do. I'm

36:09

in that very small percentage of people who simply

36:11

don't respond to treatment, whether it's for psychosis

36:15

or for depression or for anxiety. I

36:17

wish I did but I've waited you out

36:20

for forty years and there hasn't been a new technology.

36:22

I don't want to wait any longer. And

36:25

you've actually seen a handful of countries, Canada

36:27

most recently, adopt legalization.

36:31

And so what do hospital ethics committees

36:33

decide on these or is it just

36:36

a very contentious issue or people disagree?

36:39

Well, it's not yet a contentious issue in the United States,

36:41

because no American state lets you make this

36:43

choice yet. But I imagine now that Canada

36:46

and several European countries have changed their rules

36:48

in the last year or two, we're going to see

36:51

at least debate over this coming forward.

36:52

In the United States.

36:53

I were to hear colleges discussing this and

36:55

this widespread disagreement.

36:58

So what's going on in the United States? Is

37:01

medical assistant suicide for someone

37:03

who is physically ill,

37:05

right, but not mentally exactly? Okay?

37:07

Yeah, and I will add in all the cases in

37:09

the United States, we do not have a

37:11

euphenagia program. We do not end

37:13

someone's life if they can't make the choice on their own. We

37:16

only have a program where we will prescribe your medication

37:18

to let you choose death. When the time comes. In

37:21

my own experience, having talked to many patients,

37:24

and this may surprise people, be people who benefit

37:26

from this option the most are people who never

37:29

use it and people who know that if

37:31

things got bad enough, they could

37:33

make this choice, which actually gives them

37:35

hope to keep on fighting their illness. It's

37:37

paradoxical, but it's really a stunning

37:40

phenomena, fascinating.

37:43

How does it work? Sorry, so they're prescribed

37:46

the medication that are actually given them, medication

37:48

where they can pull the ripcord if they want

37:51

to. Is that the idea?

37:53

Yeah, So a doctor will write you a prescription and

37:55

you fill the prescription after a number

37:57

of safeguards, an interview with a psychiatrist. I

37:59

mean, you can choose whether to take this medication

38:01

that will end your life in a very peaceful way. In

38:03

some states people actually have going away parties,

38:05

so to speak, where they bring their friends and family,

38:08

which is not that different from how death was

38:10

in the nineteenth century, when people often

38:13

had diseases that were terminal, where they would

38:15

be on a deathbed and their friends and family would come to

38:17

say goodbye. Now we've sanitized

38:19

death in a way. People die in hospitals.

38:22

I think as a medical resident, the most

38:24

disconcerting experience ever was

38:27

showing up in a hospital room at five in the morning,

38:29

six in the morning to see a patient you've seen the night before,

38:32

and finding the room empty, which the patient

38:34

had passed away overnight and completely sanitized

38:36

and stripped down, like a hotel room where sometimes

38:39

even they already brought the next patient into the bed,

38:41

which are very different and in some ways dehumanizing

38:44

process. I understand why that

38:46

may be necessary with the economic forces in

38:48

medicine right now, better than having

38:50

the living person waiting on a gurning

38:52

and a foyer, but it's still unsettling.

38:57

Give me a sense of how people did used to die.

39:01

So often if you had a terminal

39:03

illness by cancer or heart disease,

39:06

there were far fewer treatments in there are today,

39:09

So you're running time, so to speak,

39:11

between when you got ill and when you would die and

39:13

when you would make lucidity before you die would actually

39:15

be longer, so people would have a sense

39:18

they were dying, and they could call their family together.

39:20

They could call the priests for the last rites, or the

39:22

minister to say a blessing or of a rabbi to

39:25

say farewell.

39:26

They could rewrite their will.

39:28

There are all sorts of both cases in mystery

39:30

novels in the nineteenth and early twentieth century

39:32

about rewriting wills. And that's because

39:34

people have this window that we really don't

39:36

have today, because people live

39:39

until their bodies essence shut down.

39:41

I think a related question.

39:44

Is so George

39:46

Church, who's a biologist

39:49

at Guganticist d at Harvard, talked

39:51

about the prospect of bringing

39:53

back not just people who've been deceased, bringing

39:55

back species that have been deceased, and specifically

39:58

human species. I made

40:00

species like Neanderthal man, and

40:02

that raises a whole set of complex related

40:04

questions of its own, of what rights Neanderthals

40:07

would have in the context of human

40:09

society, whether bringing the back would cause them

40:11

existential suffering, whether they would have

40:13

the same rights as Homo sapiens.

40:15

But in the relation to this context, it also

40:18

risk the possibility of bringing back Neanderthals

40:20

who are not Homo sapiens

40:23

and using bare bodies to transplant

40:25

human heads into which might plausibly

40:28

be doable at

40:30

some point in the future, and raise really

40:32

complex ethical questions.

40:51

Let me ask you this you're a psychiatrist, among

40:53

other things, what would you do if you were

40:55

assigned the revivification

40:58

of a Neanderthal man and you

41:00

were the first person in the room when

41:02

he wakes up. Now, obviously you wouldn't share the same language,

41:05

So what would you try to do to

41:08

reduce existential suffering

41:10

on his part?

41:13

I think first I would try to reduce existential suffering

41:15

on my part by standing behind something

41:17

very large, because my

41:20

census Neanderthals waking up

41:22

in this situation might not.

41:23

Be very friendly.

41:25

But beyond that, I think the real answers

41:27

we don't know in the same way we don't

41:29

know how to communicate with dolphins, so they may have

41:31

a very sophisticated language of their own. We

41:34

may have any idea how to communicate

41:36

or appreciate the emotional response of a Neanderthal

41:39

man. It's taken us many, many

41:41

years to understand in a most rudimentary

41:43

way the relationships human beings have with

41:46

other high word er apes like a relige, chimpanzees

41:48

or arangutans. Neanderthals

41:51

will be intellectually far more sophisticated.

41:53

Are going to be a puzzile we first made them. If we first

41:55

made them.

41:56

So what would you actually do if you were assigned

41:59

that.

42:00

Job as a psychiatrist.

42:02

I would probably wait. I would probably

42:04

do nothing until I first see how

42:08

this revived creature responds to me and

42:10

take cues from them in the same way I would do

42:12

seeing any other patient in the emergency room. And

42:14

I I am not comparing any of my patients

42:17

to Neanderthal men, though they may compare me to

42:19

one. But I

42:21

do think it's important first take cues from your

42:23

patients, to take cues from

42:25

other individuals what they expect from

42:27

you. And that's what I think the wisest course of

42:30

action would be.

42:32

Great, God, this is going to be a Hollywood

42:34

screenplay that we should write,

42:36

Okay, any any other thing.

42:39

And I think that covers my end of life

42:41

thinking. I have lots

42:43

of other issues I can always.

42:44

Talk about, but.

42:47

Give me, give me a sense of one.

42:49

Sure. I think one issue that is related but

42:51

distinct.

42:54

Is the situation of conjoined twins

42:57

who wish one twin wishes

42:59

to be separated and the other twin does not wish

43:01

to be separated because of the risk involved in the procedure.

43:04

And you have a situation.

43:05

Where one person's life is at stake

43:07

for the other person, the autonomy and welfare

43:10

of their being is at stake, And there's no

43:12

easy way to resolve that question. And it sort

43:14

of brings to bear all of the different ethical issues

43:16

we have raveled with his society bioethically

43:19

over the last fifty years, and that it's one of

43:21

the only questions in bioethics, by the way, where

43:24

not only do I not have a path to help people move

43:26

forward, I have no visceral sense of what

43:28

the right answer is either. I feel like if I'm not in

43:30

that situation, I can't even think about how to approach

43:32

it.

43:34

Wow, are there other situations

43:36

where one person's

43:38

life would be in danger if something

43:41

happened that would help another person? There must be

43:43

other situations that are analogous.

43:46

Yeah, I mean there's the famous case of Shimp versus

43:48

McFall, where there were two

43:50

cousins and one of them made a bone

43:53

marrow transplant and his cousin was

43:55

the only person in the entire world with

43:57

a bone marrow transplant that could match him that

44:00

he needed to save his life. And he did

44:02

not have a negative relationship with his cousin, but they weren't

44:04

particularly close and he went to his cousin

44:06

and said, please give me the bone marrow transplant,

44:08

and the bone mara trus plant was not high risk,

44:10

but it had some risk in some discomfort. And

44:12

his cousin said, no, I don't owe you that. And

44:15

then he went before the court and said, I'm going to die

44:17

without this bone marrow. It's not that much of an inconvenience

44:20

or risk to my cousin. Please make him do it. And

44:22

the court said no, and

44:24

I believe he died.

44:26

Oh

44:28

do you know anything about what the cousin's reasoning

44:30

was beyond the inconvenience.

44:34

I don't think, and I am not an expert in his case,

44:36

but I don't think the cousin had a great deal of health literacy.

44:38

And the cousin was someone who was a fairly suspicious

44:41

of medicing a baseline. So no matter how

44:43

many times you might tell him he's got a high risk procedure,

44:45

it's not so clear he really believed that.

44:47

Okay, incredible,

44:51

And.

44:51

I will add, by the way, even though that seems

44:54

like a shocking case, every single one of us

44:56

has the ability to save the life of a stranger.

44:59

You can give a a.

45:00

Kidney or part of a liver, and

45:03

some people do altruistically and save someone's

45:05

life, someone who will otherwise die, and

45:08

the vast majority of us, for reasons,

45:10

whether wise or.

45:11

Not wise, choose not to. So in

45:13

some sense we're all mister

45:15

ship.

45:18

Yeah, and we all risk

45:21

being mister McFall too.

45:22

At some point we should not forget right.

45:25

So what do you advise your students on that

45:28

front?

45:30

I mean, I think I advised them in the same way by

45:32

advised students about every ethical issue,

45:35

which is I can't tell you what the right

45:37

answer is. The two things that are important,

45:40

actually, there are three things that are important. The first one is recognized

45:42

and said it is an ethical issue, many of the difficult

45:44

problems that arise in medical ethics, or because no

45:46

one matter how wise or well attention, actually

45:49

recognize this is an ethical challenge. The

45:52

second thing that's really important is

45:54

that when you start with a certain premise, you want

45:56

to logically come to a conclusion based on that premise.

45:58

So at some point between your premise in your conclusion

46:01

a miracle happens here, so to speak, you

46:03

want to.

46:03

Go back to square one.

46:05

And then finally, I say, once you reach

46:08

those two premises, the

46:10

final step is to recognize that very

46:12

well intentioned people with very good values

46:15

come to very different answers about this questions

46:17

from starting with different premises and different

46:20

cultural beliefs and values of their own, and the

46:22

goal is to understand them and respect them even

46:24

if you don't agree with them, because they're

46:26

not fools simply because they disagree with you. And

46:28

I think our society as a whole would be a much better

46:30

place we were able to agree

46:32

to disagree with mutual respect, and we actually would

46:34

be able to find a lot more common ground

46:37

at the corners of a lot of issues where there might be a lot

46:39

of overlap.

46:44

So that was my interview with Jacob Appel,

46:46

one of a very small group of people

46:49

who can equally address both the medical

46:51

and legal and ethical aspects

46:54

of death and the complexities

46:56

at the interface. What I

46:58

hope you've gathered from today's episode

47:00

is that the issue of declaring death is

47:03

not straightforward, and often

47:05

we find the most complex cases

47:07

at the intersection of medical and legal

47:10

systems, and zooming

47:12

out to the beginning, I just want to remind us

47:14

that although we think of death as

47:16

binary, it's often much

47:18

more complex and we are always

47:20

going to be confronted with these problems. As

47:23

technology improves, we're

47:25

going to be able to rescue a life from

47:27

different states that would have been previously

47:30

impossible to reverse or even

47:32

imagine reversing. And

47:34

so as biology marches

47:36

along each year into the future, the

47:38

answer to the question of when

47:41

you are dead is one that will

47:43

change along in lockstep,

47:46

and in two hundred years we

47:48

might find our current answers unpalatable

47:51

and inconceivable. But

47:54

in any case, in each generation, with

47:56

each landscape of new technology,

47:59

we have to con continually revisit

48:01

this question, where do we draw the

48:04

line between life

48:06

and death? Go

48:12

to Eagleman dot com slash podcast

48:14

for more information and to find further

48:16

reading. Send me an

48:18

email at podcasts at eagleman

48:20

dot com with questions or discussions, and

48:22

I'll be making an episode soon in which I address

48:25

those. Until

48:28

next time, I'm David Eagleman, and

48:30

this is Inner Cosmos.