I am a medical student who is (at least now) very interested in neurosurgery, and it is no secret to my friends and people around me. I was asked by some of them, pretty frequently, “why neurosurgery?’, they asked. I have no quick answer or response to that question. I, after thinking for like 30 seconds, answered like “because it is interesting”, “it interests me very much”, or something similar with that. I realized that the question must be one of the most common questions asked in an interview for residency. That means, I have to come up with a better answer than that.
After thinking for some time, I have no better answer. The answer which came up every time I was asked the question, is the honest answer. The nervous system, especially the brain, the magnum opus of evolution, if I might say, fascinates me. It is a mystery, an enigma. It is what defines what we are, who we are. It is the producer of our consciousness. In other word, our essence. Should we have a soul (I doubt it), the brain must be where it lies.
The mystery of the brain is obvious from the moment we asked ourselves questions like: how does it work?. Neuroscientists have researched about how the brain works for a long time, and managed to come up with many interesting answers. They concluded that some part/ location of our brain specializes in certain task. The motor cortex, for example, is the part of the brain which commands what muscle to move. The signal is transmitted by a chemical substance called neurotransmitter, which generates electrical activity in the target muscle (or other nerves), the electrical activity then makes our muscle contracts. Damage of the cortex causes our muscles to become paralyzed, because the muscles can receive no command from our brain. Some parts of our brain, is responsible for our senses’ perception. Signals are received by peripheral nerves, and transmitted (again by neurotransmitter) to our brain to be perceived (either as sound, visual, touch, or other stimuli). Until here, it is pretty simple. But from now on, this gets ridiculously complicated. A part of our brain, called the frontal lobe, is where our ability to plan and to predict something might happen in the future, come from. The neuroscientists can only conclude this by observing that the frontal lobe is the part where our brain is most active (by generating electrical activity with the help of neurotransmitter) when we plan to do something in the future. But in what form exactly our ability to plan and predict is stored? When the frontal lobe is damaged, people may lose the ability to plan or to think ahead, and they lost their ability to think what might be the consequences of their actions, hence they also lose their ability to act in appropriate way. That is just one example. Then, our mind. How can something as physical as our brain, creates something like our mind? How about our memory? In what form is it stored? And our consciousness? I will not explain further as it will be a very long explanation and it might fail to satisfy. The neuroscientists have come up with some interesting ideas, and theories, and evidence, but still, most of the answers to the questions are still mysteries. I am going to explain how does a heart work, for the sake of comparison. The heart is, basically, a set of muscle which work together. It works by rhythmical contraction which generates blood pressure so that it may deliver blood throughout the body. The contraction itself is controlled by an autonomous nervous system, so our heart contracts without us voluntarily controlling it. Explaining how the heart works is simple in comparison with explaining how the brain works. I do not discredit the heart (or any other organ) or any other people interested in studying the heart at all. In fact, it is still a fascinating organ, and not even our brain can work without a functioning heart. I am just saying that the heart (or any other organ in our body) is not a mystery box, as the brain is. So, there is my point. Our brain, is an enigma.
Like I said earlier, the brain must be the essence (if there is an essence) of a human. Let me try to convince you. First, I will explain the definition of essence to avoid confusion. In philosophy, essence is the attribute or set of attributes that make an object or substance what it fundamentally is, without which it loses its identity. There was a paradox about whether anything has an essence or not called the Theseus’ ship paradox. The paradox asked whether a ship which was restored by replacing all its wooden parts remained the same ship. If it is not, when did it become a different ship? Which part defines the identity of the ship? And what if all the replaced wooden parts are assembled again into another ship at another place? Which is the original Theseus’ ship? The answer to these questions are difficult, even philosophers from ancient times argued about them. It can be asked in various ways, and the object is not limited to ship. It can be applied to a sock (there is a hole in the sock, then a patch is applied to it, overtime the whole sock is made of patch; is it still the same sock?), or a car, or a computer, or anything. But such confusion do not apply if the object in question is a human (not necessarily a human, but anything which happen to have a brain) body. A friend asked me whether it had been possible or not to do a brain transplant. I said that it would have been technically impossible with current medical technology and science. After I gave myself sometime to think about it, it is not just technically impossible. It would also be an incorrect term. Rather than a brain transplant, it would be called body transplant. Why? Let us imagine two persons. Let us call her Lucy and Peter. Let us say that the medical technology is already so advanced that it is easy to harvest an organ from someone’s body and to assemble them into another body. What if Lucy’s body parts are exchanged, one by one, with Peter’s body part. Lucy’s body parts are harvested to be transplanted into Peter’s body, and vice versa. So that Lucy’s hands were Peter’s hands and Peter hands were Lucy’s, and Lucy’s heart was Peter’s and Peter’s was Lucy’s, and so on. Which is Lucy? Which is Peter? When did Lucy stop being Lucy and become Peter? Do you see where I am going? I think, the most logical answer is Lucy stop being Lucy exactly when her brain is transplanted into Peter’s body. And Peter stop being Peter when his brain is transplanted into Lucy’s body. So Lucy is having a body transplant, rather than Peter getting a brain (of Lucy) transplant. Our brain is our identity, our essence.
The opportunity to treat the diseases and the pathology of the brain and the rest of the nervous system (from congenital anomalies to tumors) by manipulating them, is certainly intriguing. The delicate, complex technique to manipulate the nervous system, interests me very much. The only profession in the world who can (and legally) manipulate the brain and other nervous system, is the neurosurgeon. That is why I want to become one.
So, there you are. Those are some reasons why I am interested in neurosurgery. I hope I can explain it to the interviewer should I be asked this question someday. And last of all (maybe the least, maybe not), let’s face it, neurosurgery and neurosurgeon, are cool. Period. There is an old neurosurgery joke: most people will know that the difference between God and a neurosurgeon is that God does not think he is a neurosurgeon although I suggest that many neurosurgeons would ‘see that as one of God’s failings’. And another: “How many neurosurgeons does it take to change a light bulb?” “One: they hold it still while the world revolves around them!” How cool is that? :D
Yesterday I visited my girlfriend’s aunt in a hospital. I saw her lying in an ICU supported by a ventilator to assist her breathing because she would stop breathing once the ventilator stop pushing oxygen into her lungs. Her lungs function was replaced by the machine.
3 days earlier, in the morning, out of nowhere, she suddenly complained of a severe headache. Minutes later, she was unconscious, then was carried hurriedly to the nearest hospital. After being examined by a doctor on duty and being CT scanned, she was diagnosed to suffer from a cerebrovascular accident, which is more commonly known as stroke. The stroke is a hemorrhagic one, rather than an ischemic one, which means that there was some blood vessels that ruptured inside her brain. The ruptured blood vessels then leaked blood into the brain tissue. The blood, which accumulated inside her skull, formed a hematoma compressing other brain structures. Those compressed brain structures then became damaged, and finally the brain stem was also involved. The brainstem, which contains many nerve cells controlling our basic physiological function such as breathing and heart contraction, and also regulates our consciousness, stop functioning. The consciousness level, which was measured semi-objectively in medical world by using a Glasgow Coma Scale (GCS), was very poor, 3 out of 15. 3 is the lowest possible score for GCS, and that means she was in a coma state. The doctor then examined any presence of brain stem function by examining brain stem reflexes and concluded that her brain stem was already injured. My girlfriend and me being members of the medical world makes us know too much for our own good and realize that in any other country other than the country we live in, the doctor could very easily have called her time of death. We know that in such condition, although the heart was still beating and the body was still warm, the brain damage was irreversible, and the expectation for the brain to function again was beyond our hope. I got an impression that some of the family, reluctant to let go, still believed that the hope was there. Then a ventilator was asked for help to assist her breath, although very possible the breathing reflex was there no more. That was what has happened to put her family and also the doctor in a dilemma.
What I want to write on this occasion is not about that event. But the event elicited a question in me which I have thought since a long time ago about life and death, practically and philosophically. What defines life? What defines death? What condition is life? What condition can be called death? Is it permissible to stop the ventilator assisting her breathing? In this condition of brain stem death, is it also called passive euthanasia? How sure is the medical world in the decision to declare that a patient was dead in such condition?
To answer how we could define whether someone/ or something is dead or alive, we should determine first their definition. The problem is, it is not an easy task to determine what their definition is. It is very difficult to define life, this has been debated by the earliest philosopher, yet still to this day, no man can define what life is with confidence. Though we can, in some way, describe its characteristics and its condition. Life is a characteristic that distinguishes objects that have signaling and self sustaining processes from those that do not, either because such function has ceased or because they lack such function (inanimate). Biologists agreed that something can be called alive if it exhibits all or most of these phenomena: has the capability to regulate its own internal condition (homeostasis), composed of cell/ cells, maintains a metabolism process, growth, can adapt to its environment and responses to stimuli, and could reproduce. Should something has such function, it is called alive. The definition is a broad one and is not a practical one. It also presents many problems. If something lack one, or two, or three of those conditions, is it still called alive? Nobody can argue that a single celled organism is also alive, since it fulfills conditions stated above, but what about those which do not fulfill like one or two criteria? Are those people who are sterile, who does not have capability to reproduce, not alive? And to what extent is response to stimuli? This very problem of the definition of life is also the cause of dispute between the pro life and the pro choice point of view about abortion. Which separates abortion from murder? Is embryo, which composed of some living cells, a separate living organism from its mother? Or is it a part of the woman’s body? The pro life’s point of view is the former, while the pro choice’s is the latter. Some also said that the embryo is not yet alive before it has (some) consciousness. I will not discuss consciousness this time since it will deserve another post dedicated entirely to it, which I might come to later, but this consciousness is somewhat related to our discussion later about death, which also mentions brain death.
Definition of death is less philosophical and is more practical than the definition of life and so it is easier to define, or is it? Once the definition of life becomes clear, a cessation of life might be the easiest definition of death. What defines life also defines death in some way. But since the definition of life itself is not very clear, so is the definition of death stated in simply a cessation of life. Defining death has become a dilemma in the medical world, but the need to make a clear distinction whether someone is dead or alive is not arguable. Doctors should call people dead if and only if they are really dead (true positive) and decide to stop giving valuable resources to treat dead people. The definition of death then becomes a clinical diagnosis, simply because doctors have to decide when exactly death occurs. And the task is not a simple one. The definition of death in medical world in as a clinical diagnosis has changed over time. In a simpler old times, death was defined traditionally as a cessation of cardiopulmonary function. People with asystole (cessation of heart beat, which means heart loses its function) and apnea (absence of breathing) are called dead. But problems with this definition came when health technology and science advanced. In 1954, James Elam together with Peter Safar demonstrated a life saving technique which would eventually be widely known as cardiopulmonary resuscitation/ CPR. CPR makes it possible, although only in some limited cases, but nonetheless, to reverse the cessation of cardiopulmonary function to function again. Invention and widespread use of mechanical ventilators in hospitals around the world makes it possible for people with failed respiration to breath again in hope that they will breath air spontaneously once more after the underlying condition causing the breathing reflex cessation in the first place has been overcome. Those advances make the earlier definition of death stated as a cessation of cardiopulmonary function becomes obsolete. They also propose new problem for doctors, because people with no possible reversibility of consciousness might “survive” as long as they are cardiopulmonarily supported. All those, and also heavy influence by the need of organ transplant, demand a newer definition of death. In 1959, Mollaret and Gouloun proposed a concept of brain death which is stated as a state beyond coma. They believed that there was a definable condition from which recovery was impossible. That condition is called brain stem death. Then they proposed some criteria, although they were not recognized widely. Then an act, the Uniform Determination of Death Act, stated someone is called death if:” … has sustained either irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brain stem …”. After that, many new definitions were defined, and protocols and algorithms were published, but the concept differed little. Nowadays this concept of brain death is widely accepted, but there are still some countries that do not adopt this concept. Even many of those who do, actually have some brain death criteria differences. In some country, someone can be called dead, while in another not called dead yet. This also proposes problems. Someone who fulfills brain death criteria might show some signs of life stated earlier because its body cells are still alive. All organs other than the brain might function properly, which is the reason why the organs can be donated. If we could in any way (such as using ventilators) provide the body cells with enough nutrition and oxygen, the body may still be alive after its brain is dead. This makes death not an absolute condition but rather a consensus. When we are given the situation, as a doctor or as a family, to decide whether to discontinue treatment (especially mechanical ventilator) or not, we will be in a dilemma. Is it right to prolong the life of the body with dead brain while knowing that the body will not become conscious again? Should we discontinue the treatment and let the body die?
I am not trying to conclude this because maybe to the end of time, this controversy about life and death will never be settled. I hope what I write here might give you something to think about and can make you realize, when you are put into situation like that (either as a family or a friend or even as the patient), but I hope none of us are, that there might be no right answer in such situation. And I want you to know that the decision has never been an easy one and whatever the decision that you are making, people will respect you for it, simply because you have made a decision.
Last but not least, I want to say that although we may not know what defines our life and death, and also cannot determine in what way or when we will die someday, but we can choose how to live our life. If not, what are we living for? :D
Many of us thinks that we are not a sexist person. But let me tell you a story which might change your opinion about yourselves.
Once upon a time, on Sunday morning, there were a father and his son walking on a street. Suddenly, there was a car coming from the corner of the street followed by a police car behind it in a very-high-speed car-chase. The son was very unfortunate, he was at the trajectory of the car and then was hit. The father caught a glimpse of the driver’s face, and what he saw was a man with a scar on his left cheek. The father then came hurriedly to his son, which was lying on the street. He screamed: “Help! Help!”. Then he called an ambulance. Came then the ambulance, about 10 minutes later, to take the son to a nearby hospital. Upon arriving at the hospital, the son was received by a surgeon who was on duty at that time. The surgeon was flabbergasted. The surgeon recognized the boy at once and said: “This is my son! What has happened?”, the surgeon asked the father of the son. Then the father explained what happened to the surgeon. The son then underwent an emergency surgery.
How could this happen? The boy was the surgeon’s biological child, and also the father’s biological child.
I will tell you now the answer (to any of you who couldn’t find the answer). To those who still want to take a little more time to think about the answer, please stop reading at this moment.
Did I say that the surgeon was a man? The surgeon was a woman and she was the mother of the son. So sure we are (and the image is so strong) that the surgeon was a man so that it was difficult for us to answer the simple question which actually needs only simple reasoning. If, by any chance, you could answer the question but needed some effort to do so, it doesn’t mean that you are not sexist at all. So, still think that you are not sexist?