Think freely. Write freely.

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