death in technological time

MARGARET LOCK Departments of Social Studies of Medicine and of Anthropology McGill University

Death in Technological Time: Locating the End of Meaningful Life

This article demonstrates how debate about technologically manipulated death is elaborated in radically different forms in the scientifically sophisticated spaces of Japan and North America. Using recent historical materials and contemporary medical, philosophical, and media publications, I argue that the institutionalization and legitimization of “brain death” as the end of life in North America have been justified by a dominant discourse in which it is asserted that i f certain measurable criteria are fulfilled, an individual can be declared scientifically dead. In Japan, by contrast, death is interpreted primarily as a social and not an individual event, and efforts to scientifically define the end of life as a measurable point in time are rejected outright by the majority, including many clinicians. The margins between nature and culture are debated in both cultural spaces, but assigned different moral status in the respective dominant discourses. [death, technology, brain death, cyborg, North America, Japan]

What next, being alive when you’re dead, whatever next?

-Elias Canetti, Auto Da F.4

For some time thoughtful men have been increasingly troubled by the present attitude in the medical profession: “You’re dead when your doctor says you are.”

-Desmond Smith, The Nation, 1968

ichard Selzer, the surgeon who took early retirement in order to write more of his cogitations on Life, died a few years ago but, fortunately for us all, R rose again shortly thereafter. His EKG was flat for four and a half minutes,

and no amount of resuscitation had any effect. The attending nurse wrote the time of death on the chart, and ten minutes later noted the characteristic “settling” of the

Medical Anthropology Quarterly 10(4):575600. Copyright Q 1996 American Anthropological AS= ciation.

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body, “the fixity that is incontrovertible.” Then, unexpectedly, the body shuddered: “A moment later he draws his first breath. It is a deep sigh that might be interpreted as one either of sorrow or of satisfaction, as though one precious thing were being relinquished and another embraced.” Soon, a tracing returns to the electrocardiogram, and the breathing becomes regular. “The room, which had descended into a subaqueous silence emanating from the corpse, is now fiercely active. All the machinery is back in place, chugging, vibrating, clicking, ringing” (Selzer 1993: 4445). Later, at the weekly conference, people question the judgment of death, but the nurses persisted with their claim that the cardiogram was flat, and that there was neither a pulse nor blood pressure.

Selzer’s purpose is not to produce an objective account; he does not strive to tell us what “really” happened. If we are interested only in accuracy we could, perhaps, dismiss this narrative as somewhat fanciful. But surely that would be to avoid the lesson: that we should be left with considerable disquiet. How often are “mistakes” made? And if we can make mistakes with what is, after all, surely a familiar hospital event, how much more so with the recently arrived new death- with brain death? Perhaps some of the accounts we read occasionally, even in respectable newspapers, about people coming “back to life,” are not so bizarre after all.

For example, it was stated in a 1989 article originating from the office of the Canadian Press Associates that doctors in an Ottawa hospital had declared 79-year- old Mr. Cybulski to be brain dead, ten weeks after an emergency operation on his heart. The patient was about to be taken off life support and receive the last rites from a priest when, in response to his two-year-old grandson yelling at him from the door of his room, Mr. Cybulski, it was reported, sat up and stretched out his arms to the child. The patient was described as not only alive but exceedingly well one month after this incident. Apparently the doctors involved cannot account for this case; they c o n f m that the patient’s brain scans showed “almost” no activity, and their assumption was that he had suffered irreparable brain damage. One doctor is reported to have said that “with all our modem technology, it is still difficult to determine when or if a patient will come out of a deep coma” (Montreal Gazette 19892). Deep coma and brain death are not the same diagnosis, and one is left wondering whether it was the newspaper, or the doctors, or both who were confused; but in any event this case, like that of Richard Selzer, is disquieting.

Technoscience and the Reconstruction of Death

Death has become increasingly visible in recent years as a subject for media attention, whether it be a discussion about the moral status of euthanasia or a lament at the increasing number of violent deaths we are confronted with each day. Whatever form death takes, it conjures up that margin between culture and nature that we most fear-the space where mortality must be confronted. The idea of “nature,” including the way in which it is conceptualized in relation to what is understood as culture is, of course, socially produced, and thus meanings attributed to both these concepts change through time and space. Bruno Latour (1993) has discussed the way in which we “moderns” have fragmented our world so that we understand nature as being “out there”-uncontrovertible, scientifically analyz- able, and in a domain distinct from that of society and social relations, both of which

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are in turn different from subjective experience, and also from the discourse that we create to comment on our world. In theory, therefore, nature is conceptualized as a domain entirely independent from the moral order. In practice, however, “nature” continues to serve, as it did prior to the Enlightenment, as a moral touchstone, the effects of which are especially evident when we grapple with assigning the status of life or death to various entities.

After the first artificial respirators were developed in the 1960s, making it possible to sustain brain-dead but otherwise alive human bodies for anything from a number of hours to, very occasionally, several weeks (and recently for much longer periods of time), it became an urgent priority to clarify the concept of death in “technologically advanced” nations. This situation was exacerbated by the simultaneous development of solid-organ transplantation technology in which hearts, livers, lungs, and kidneys could be “harvested” from the brain dead for use in other patients. However, this process of redefining death was not carried out as part of an international endeavor, although at first it was thought that this would be the case, but took place gradually on an ad hoc basis in one interested country after another, with remarkably different outcomes.

In this article, using documents from recent history and contemporary materials from medical, philosophical, and media publications, I will attempt to show how arguments for the institutionalization and legitimization of “brain death” as the end of human life, followed by its routinization across North America and much of Europe, have repeatedly created discussion in which efforts are made to assign the concepts of life and death to scientifically deducible and verifiable categories, and thus to make them indisputable beyond professional medical circles. Thus cases like those of Selzer and Cybulski raise concerns about accuracy and replication but do not usually induce questioning of an ontological kind. This situation will be compared with that of contemporary Japan where I have conducted ethnographic research on this subject for the past ten years (Lock 1996, in press; Lock and Honde 1990, Ohnuki-Tierney 1994). This comparative strategy highlights the ways in which the respective arguments are created out of different dominant sets of assumptions about the relationship between nature and culture. In the case of Japan these assumptions make it difficult to readily construct arguments about death as reducible to questions of scientific accuracy.

Although grounded in different ontologies, the disputes in both locations are fuelled by a perceived need to limit medical authority and professional interests; they reveal concerns about the urgency for society at large to share in, or even take charge of, the technological manipulation of human existence in contemporary society. In both North America and Japan society is, in theory, predominantly secular in orientation and assumed to be driven by principles of rational order and scientific endeavor, principles that are immediately evident in the structure and implementation of the respective health care systems. The existence of “beliefs” and “values” are, of course, acknowledged, but supposedly set aside in the daily round of medical decision making and practice. The dominant argument in North America in connection with technological intrusion into the process of dying has been that if a person can be declared dead using systematic, scientific criteria, a decision based in part on the grounds that the unconscious patient is in an irreversible condition, then it can be assumed that individual interest no longer


exists, and such patients are simply owed the degree of respect that we would normally assign to a cadaver. In other words, organs may be dissected out of their bodies despite the fact that integrated biological activity of various kinds continues in such patients.

In Japan, by contrast, debate about the harvesting of organs from brain-dead patients has opened up the floodgates of concern to the extent that brain death to this day is not legally accepted as death. This reaction reverberates with concerns to such a degree that efforts to assign death scientifically to a measurable point in time are often rejected outright. Death is understood primarily as a social event by the majority, among whom clinicians are included. Both the biological and the cognitive status of the patient is assigned secondary importance. Such a reaction, in which the status of a brain-dead patient is widely discussed among the public and in the media, has been largely absent until very recently in North America, with the exception only of a small circle of interested physicians, lawyers, and intellectuals. This contrast invites comparison of the way in which supposedly secular representations of nature and culture can result in more than one dominant discourse, leading on the one hand to an impasse that has brought the transplant industry to a halt, and on the other to a situation in which organ transplantation has been thoroughly routinized. Routinization has produced a new set of dilemmas, a so-called shortage of human organs, which in turn has caused renewed debate among involved professionals about the care of certain patients other than those diagnosed as brain dead, and whether their continued existence through technological intervention has any meaning for them as individuals. The thrust of the debate is that if their lives can be constructed as without meaning because of irreversible, severe cognitive impairment, even though they are alive by present standards, then organs may be harvested from them (Lock, in press).

Normalizing Boundary Transgressions

A postmodern analysis suggests that a brain-dead patient should be thought of as a cyborg, a “coupling between organism and machine, each conceived of as coded devices” (Haraway 1990 196). The boundary transgressions exhibited by cyborgs present “dangerous possibilities” because their development is related to an authoritarian need for control and for universal domination. On the other hand, cyborgs also offer a possibility of criticizing and reconstructing that which is assumed to be natural and inevitable, and thus they permit us to reconsider our relationship with the worlds of the natural and the mechanical (Haraway 1990: 196).

A comparative ethnography of technoscience (and I increasingly think comparison is a fruitful way to take on this daunting subject) must immediately confront the question of why in specific locales certain cyborgs raise little concern while in others they create havoc. In North America we have been forced to confront what it is about the fetus and the embryo that triggers violence and fury, whereas in many other sites these particular hybrids remain dormant and safely obscure, and in yet other situations, although recognized as entities, they cause little debate. Similarly, a brain- dead entity clearly lurks on the margins of life and death, culture and nature, and person and machine. Nevertheless in North America, as I suggested above, we have stayed remarkably silent about this particular technology, whereas turmoil has

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erupted in Japan over the past twenty-five years around this particular domain of technoscience.

So here we are, back in anthropology’s favorite stamping ground of difference, seeking to understand why the compliant Japanese-as our stereotype has it-technologically sophisticated as they are, find themselves unable to recognize brain death as the end of life; why brain death and that other technology inextricably tied up with it, organ transplants, signals for them danger, loud and clear. This danger is perceived to be so potentially destructive that the result has been an exhaustive, as yet unresolved, public self-reflection in which discussion of the relationship of Japan to the West, tradition to modernity, and culture to technology all loom large. This self-reflection reveals the ambivalence many Japanese have in connection with technologies that radically intrude into what is taken as the “natural order” of society together with a concern about the mixing of what is understood as self and other. Yet other issues that arise include reaffirmation of the equality of all citizens, concerns about the integrity of the medical profession, and debate about the status of the body and its position in society, all of which radiate out from the centrifugal trigger of the brain-dead body.

Of even more interest, I think, is to ask why we in North America apparently sense no danger emanating from this deathly cyborg? Quite the contrary, why have we focused almost exclusively on the heroics of organ transplants and the gift of life while apparently deleting virtually all anxiety from our minds about the source of those organs? We have selectively lighted on the second part of the equation only, that other selfhonself hybrid that, it seems, is sufficiently seductive that we are blinded to its origins.

Locating the Moment of Death

Doubts about false declaration of death and premature burial have no doubt always been present in societies that practice burial of the dead. Pernik, in an article entitled “Back from the Grave,” has shown that a concern about ascertaining the time of death correctly has been revived repeatedly throughout history, most often in the wake of new medical discoveries in connection with experimental physiology, resuscitation, and suspended animation (1988:17). As late as 1940 an article in Scienrific American stated that “frequent” errors in diagnosing death remained the cause of cases of premature burial (Newman 1940). Despite this concern, pronouncing death did not usually pose a problem; dying usually took place rather gradually, and whether in hospital or at home, the final moments were often unremarkable except for the fact that breathing stopped. Until the late 1960s the precise time of death was of little consequence, unless foul play was suspected.

Matters became complicated with the introduction in the late 1950s of the artificial respirator or ventilator, by means of which patients who were no longer breathing independently could be kept alive. Many patients are “weaned” off the ventilator to a partial or full recovery, but others never regain consciousness or the ability to breathe for themselves and become, in Willard Gaylin’s heavy-handed neologism, “neomorts”-no longer living by the standards we have come to accept in North America, but sustained as though alive by artificial means (1974). The existence of braindead patients did not initially produce much of a stir in the medical community, no doubt because a body that has sustained massive brain


damage, even when kept functioning artificially, nevertheless degenerates badly, usually in the space of a few days or weeks, and the ventilator is then unplugged (but see Shrader 1986). However, from 1968 on, when transplant surgeons started to make use of patients who had what they determined was irreversible brain damage as a source of human organs, the situation changed drastically. It became imperative for the first time to agree upon a diagnosis of death that could be clearly pinpointed in time, and as an event, rather than as an indeterminate process. Such a death had to be recognized as expediently as possible so that vital organs could be removed while in good condition. This diagnosis was based, moreover, on a lack of brain function rather than on the condition of the heart and lungs as had been the case since the 19th century. Prior to that time many experts claimed that putrefaction was the only reliable sign of death (Alexander 1980).

When the necessity of remaking death was brought up for discussion, from the start it was a fear of repercussions from an anxious public who would refuse to cooperate with organ donation that was uppermost in the minds of many transplant surgeons (Paton 1971:163; Schmeck 1969; Shapiro 196950). Above all, it was agreed, the public had to understand that potential donors would be protected from an untimely death-from “a snatch”of their organs, as it was graphically described at the time (Reeves 1969406).

Dealing with Brain Death “Boldly”

Animal experimentation, the usual testing ground for developing therapies suitable for human use, has been carried out throughout this century in connection with vital organ transplants. Nevertheless, when human kidney transplants were introduced in the 1950s. followed by liver and then heart transplants in the late 196Os, a debate was still raging as to whether these procedures were experimental or therapeutic (Fox and Swazey 1974). Contrary to popular knowledge, physicians at a Mississippi hospital claim that they, and not Christiaan Bamard in South Africa, were the first to conduct a human heart transplant. In 1964 these physicians sacrificed a chimpanzee and placed its heart into a 68-year-old man with severe myocardial disease, in a state of “preterminal” shock at the time of the surgery, and who was expected to die during the course of the next day or two. In the publication that followed this experiment we are given a graphic account of the removal of the primate heart, its care after removal, its treatment once placed inside the recipient, and also of the state of the diseased heart removed from the recipient. Readers are not informed that the patient died, but simply told that the transplanted heart “ceased to function two hours after stabilization in the recipient.” The experiment was described as having “far reaching significance” because it enabled the researchers to establish that a heart could be kept functioning by perfusion alone for at least an hour independently of either primate or human body. The physicians lamented that the human donor they had hoped to make use of had not died speedily enough, and therefore they were forced to use a primate heart that was not sufficiently large, and secondly that the recipient was so sick that he was “perhaps the major factor in eventual failure of the transplant” (Hardy and Chavez 1968:777).

In 1967 Christiaan Barnard carried out what is officially recognized as the first human heart transplant. The recipient experienced acute rejection of the transplant and lived only for 18 days after surgery. On the same day that Bamard was operating

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in South Africa another heart transplant, described as an “unequivocal failure,” took place at Maimonedes Medical Center in Brooklyn involving an anencephalic donor and a 19-month-old recipient. Despite these failures many others rapidly followed suit. Fifteen months later 1 18 heart transplants had been performed in 18 different countries, with a surgical mortality rate of 50 percent (that is, 50 percent of the patients died up to 30 days after surgery) and a cumulative six-month mortality rate of 88 percent (Cooper and Mitchell 1%9).

Although Barnard’s first heart transplant was initially acclaimed triumphantly in the media, doubts and criticism followed hard on its heels. There was a call from some quarters for Barnard to be disbarred permanently from medical practice (Schmeck 1969). Furthermore, although considerable critical attention was given to possible mistreatment of organ recipients, equal concern was initially expressed about the fate of the donor. One American senator apparently believed that all dying patients on ventilators were now vulnerable to having their lives peremptorily extinguished in order to retrieve their organs (Schmeck 1969672). The Nation published an article entitled “The Heart Market,” in which they asked rhetorically if someone was playing God and asserted that a “shocking international heart transplant race” was under way. This article also reminded its readers about the forgotten half of the transplant equation: the donor, and added, “contrary to the general impression, few doctors can predict the so-called ‘moment of death’ with certainty” (Smith 1968:720). The article went on to point out that of a group of 120 head-injury patients at Cambridge University Hospital in England who were unconscious for more than a month, 63 survived. “As the need for donors grows larger, the definition of death must be carefully redefined. When are you dead enough to be deprived of your heart?” asked The Nation (Smith 1968:721). Time (1967) and Saturday Review (Lear 1968) were equally scathing, particularly of Christiaan Barnard himself, while Ebony cautioned, “It is doubtful . . . that the transplant of a Colored heart into a white man will have any positive effect upon the rigidly segregated life of South Africa” (1968).

In July 1968 Barnard arranged for an international meeting to be held in Cape Town of those surgeons who had carried out heart transplants to date in order that they might learn from one another. Most of the time was devoted to surgical and postoperative techniques, diagnosis of organ rejection, and pathological findings from dead recipients. The first part of the meeting, however, was given over to the selection and preparation of donors and recipients. Barnard made it clear that his prime interest was in the condition of the donor’s heart rather than in the condition of the donor as an individual, but he nevertheless called on “our Neurosurgeon, Dr. de Villiers,” and asked him to describe when a patient can be thought of as a potential donor. De Villiers pointed out that any patient suffering from an “irrecov- erable cerebral lesion” and who cannot maintain “respiratory and circulatory functions independently” is legally dead. He also voiced concern about the need for redefining what is taken to be a cadaver in light of recent developments in

A discussion then ensued in which it was emphasized that if the “conventional point of death’*-that is, cessation of the heart beat-was the earliest possible moment to declare death, then this made it impossible to carry out the “proper preparation” of a heart for transplant. However, it was also stated that “for social

transplant technology.

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and legal reasons” the introduction of “radically new concepts” with respect to death should be avoided. With these thoughts in mind, the surgeon Rose-Innes proposed what he described as a “deliberately” conservative position. He pointed out that when an “observation” is made that a patient has died on the basis that the heart and lungs have ceased to function, this is simply a clinical test that is applied to a patient who “may still be living.” Death, in fact, occurs “shall we say, 5-15 minutes later in relation to the central nervous system” in a body at normal temperatures (Shapiro 196939). Thus, although the conventional “point of death” is declared with respect to the cessation of a heart beat and independent breathing “by long experience, we are absolutely sure” that the central nervous system will also cease to function a short time later.

Rose-Innes supported the neurosurgeon de Villiers in his suggestion that one could conveniently declare death at an earlier point, namely when “meaningful treatment of patients,” including those with severe brain damage, “comes to an end.” Such a point is “not the death point,” but the point at which a clinical decision is made to stop treatment (Shapiro 196940). Rose-Innes went on to argue that the termination of treatment should be entirely a medical decision: “I don’t believe we can share this responsibility even with relatives. We may not ask consent of the relatives; it is entirely a technical medical decision, nor should we be circumscribed in this decision by legal authority” (Shapiro 1969:40).

Another participant in the discussion suggested that a group of physicians separate from the transplant team should make the decision to end treatment, but Bamard immediately countered that a transplant surgeon simply “might want to call on the neurosurgeon to give [one] a hand” (emphasis added). Kantrowitz, the American surgeon who had attempted to transplant a heart into a 19-month-old baby, reminded the group that it had been shown with canine experiments that there is a much greater success rate with transplants if a beating heart is used, and that if the heart has stopped and has then to be resuscitated, it does not “perform as well.” Kantrowitz went on to emphasize that the “point” when treatment is terminated should be the point when “irreversible brain death” has been established. Dr. Cooley, a transplant surgeon also from the United States, stepped in at this juncture to comment:

neuro-surgical colleagues at times have used terms which should be avoided. In the first place-I think that we should avoid the words ‘alive’ and ‘dead’ as synonymous with brain function or cardiac function. ‘Alive’ and ‘dead’ are such nebulous and vague terms, so ill-defined that they will never be defined, since no one understands either the meaning of ‘life’ or ‘death.’ One should say the heart is contracting, or beating, but not ‘alive’. . . . And I am sure that each of us is honest enough to admit that the heart was still contracting. . . when it was used in the donation or the actual operation. Brain destruction was irreversible in all instances.

In my opinion the clinician can become too pre-occupied with the rights of the dead, namely the donor, at the expense of the recipient. We should not jeopardize the possible survival of the recipient while we are waiting around to made a decision whether the cadaver, as you call it, is dead or not. [Shapiro 1969:45]

Shortly after this speech, Dr. Cooley commented that donors are “difficult to come by in our hospital” and reiterated that the recipient must be uppermost in the doctor’s mind. The discussion then continued with a plea for the need to create a


definition, to “establish some boundaries” about the point of no return so that public criticism about transplants could be averted. It was pointed out that in France and Great Britain guidelines were already in place, and the decision to declare termination of treatment had been taken out of the hands of transplant surgeons and placed in the domain of neurosurgeons. Bamard and Kantrowitz both took excep tion to such guidelines, stating that because the medical profession has always demonstrated that it could be relied upon, people “around the world” have confi- dence in physicians, obviating the need for formalized criteria. Bamard then declared, on the basis of the preceding discussion:

I think we can say we now have a donor, i.e. a potential donor. On the whole, people will agree that there is no need to wait for conventional death. Dr. Rose-Innes said that one should wait until that point, because only at that point can one say with certainty, after a certain period, that the patient will be dead-is that correct? But I can tell you that if you have a patient with or who can fulfill the criteria for becoming a potential donor, once you stop the respirator you can also be certain that the patient will die, so why wait until the heart stops beating when you are sure that the patient is going to die? [Shapiro 1969501

Rose-Innes retorted that the patient must be declared dead before the transplant surgeon could proceed, but Bamard remained unconcerned about precise details, provided one is “sure” the patient is going to die, whereupon another participant chimed in “we don’t even have a definition of death.” At this juncture, Bamard emphatically declared that the group should pass on to more important matters because “we are running rather short of time.” With that, the death of the donor disappeared from view and was not raised again throughout the conference, only to remain as a very shadowy presence to this day in the transplant enterprise.

In May 1968 an editorial appeared in the Journal of the American Medical Association in which the dilemma posed by vital organ transplants was clearly voiced, “It is obvious that if. . . organs [such as the liver and heart] are taken long after death, their chance of survival in another person is minimized. On the other hand, if they are removed before death can be said to have occurred by the strictest criteria that one can employ, murder has been done.” The editorial went on to state that it is therefore “mandatory that the moment of death be defined as precisely as possible” and concluded:

When all is said and done, it seems ironic that the end point of existence, which ought to be as clear and sharp as in a chemical titration, should so defy the power of words to describe it and the power of men to say with certainty, “It is here.” [JAMA 1968:220]

One month later, in August 1968, an ad hoc committee composed primarily of physicians called together by the Harvard Medical School, published the findings of their meetings in the Journal of the American Medical Association. The committee agreed that “ ‘irreversible coma’ must be substituted for ‘cessation of vital functions’ as the criterion for death. Two reasons were given as to why there was a need for this new definition: improvements in resuscitative and supportive measures had led to increased efforts to save those who are desperately injured, sometimes with only partial success, so that someone with irreversible brain damage might continue to have a beating heart. The burden of such patients was


great on families, hospitals, and those in need of beds, it was argued. A second reason given was that “obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation’’ (JAMA 1968:337). The report noted that the first problem for the committee was to determine the “characteristics of a permanently nonfunctioning brain,” which were then described. It was emphasized that a decision to declare irreversible coma must be made only by the physician-in-charge, in consultation with one or more physicians directly involved with the case (implying that transplant surgeons should not be involved). The report continued that “it is unsound and undesirable to force the family to make the decision.”

A legal commentary that followed this statement corroborated that judgment of death was solely a medical issue, and that the patient be declared dead before any effort is made to take “him off a respirator”; otherwise the physicians would be “turning off the respirator on a person who is, under the present strict, technical application of law, still alive” (JAMA 1968:362). The article also noted that Pope Pius XI1 had, in 1957, stated that it is “not within the competence of the Church” to determine death in cases where there is overwhelming brain damage, and that verification of death can be determined, “if at all,” only by a physician (1968:362). In what seems to be, in retrospect, a surprising oversight, the impression is given in this article that from now on all death will be determined by the condition of the brain.

In 1969 Henry Beecher, the physician who had headed up the Harvard Committee, published a commentary in the New England Journul of Medicine in which he lamented the fact that lawyers had not been as enthusiastic as they might about accepting irreversible coma and had contributed to a tentativeness among hospital administrators about cooperating with the new death. Thus, although the legal profession was apparently content to leave the actual determination of death in the hands of the medical profession, it seems that certain lawyers nevertheless retained doubts about what was taking place. Beecher believed that “more social and emotional maturity” was called for in order to handle the question of brain death “boldly,” and that to fail to do so “verges on the unethical” ( 1969 107 1).

A Japanese Murder

The first and only heart transplant to be conducted in Japan took place in Sapporo, Hokkaido, in 1968. As in other parts of the world, the Sapporo procedure initially produced an accolade from the Japanese media and was heralded as a dramatic medical triumph. However, several months later, the physician in charge, Dr. Wada, was arrested for murder and only acquitted after six years of wrangling. The majority of Japanese believe in retrospect that the patient whose heart was removed was not brain dead, and that the recipient, who died two-and-a-half months after the operation, was not sufficiently in need of a new heart to have undergone the procedure in the first place (Goto 1992). As part of the current national debate about organ transplants, a debate that has ensued ceaselessly in Japan since the time of the Wada case, the chairman of the Japan Medical Association, testifying before a government committee in 1981, reported that twenty-three years earlier, right after the removal of the supposedly ineffective heart from the recipient, it had been tampered with, indicating that the involved doctors may have tried to exaggerate

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the degree of its deterioration (Muinichi Shinbun 1991). The case is now considered in retrospect as a barbarous piece of medical experimentation carried out by a doctor who, significantly, had received a good portion of his training in America.

Brain death is not recognized as the end of life in Japan to this day, and therefore very few Japanese have received vital organ transplants unless they have gone abroad to obtain them. The one exception to this is those children (more than 150) who have received what is known as a “live liver transplant” in which a section of liver is removed from a parent and transplanted into their dying child.

Among the many arguments against accepting brain death as death has been an outpouring of literature in Japanese that questions whether lack of integrated brain function means that a person is dead. One journalist, very influential among the public, has emphasized that brain cells continue to function even when the brain as a whole has no integrated function as indicated by a flat elector-encephalogram (Tachibana 1991). Other writers are concerned that because brain death can only be established by the medical profession4nxause it is rnienai shi (death which cannot be seen)-it represents a radical departure from a death where the family participates fully in the recognition of the process. On the contrary, making integrated brain function the measure of death ensures that the family is pushed to the sidelines, rendered passive, and placed entirely at the mercy of medical decision making (Nakajima 1985). Numerous television programs, magazine articles, and books have repeatedly cast doubt as to whether death, at least death as it is in theory experienced in Japan, can be understood as a clearly diagnosable event (Hirosawa 1992; Komatsu 1993; Uozumi 1992). It has also been argued in books and the media that irreversibility is hard to establish conclusively, and cases have been referred to (outside of Japan) where mistakes have evidently been made. The media further argues that brain death cannot be easily distinguished from other conditions where the patient is unconscious, notably persistent vegetative state. At least one Japanese hospital where special nursing care is employed to assist in the recovery, sometimes substantial, of certain patients in persistent vegetative state has been filmed extensively by national television.

This barrage of media attention, accompanied by an almost annual polling of the nation as to how it feels about brain death, the results of which are widely publicized and which reveal considerable ambivalence, has ensured that discussion about hospital death has aroused a good deal of anxiety in Japan over the past 25 years. In the meantime Japanese transplant surgeons have argued vociferously for their point of view, but they have been unable, perhaps because of their exposure to a great deal more public scrutiny than transplant surgeons in other parts of the world, to advance their case (Lock 1996).

A close reading of the Bamard transplant reveals that it was not entirely different from the Wada effort. The death of the South African donor was determined by “the absence of reflexes, of spontaneous respiration and of electrical activity on the electrocardiogram for five minutes” (Bamard 1968587, emphasis added)-hardly an adequate confirmation of death, even by the most lax of standards, and apparently resuscitation was not attempted. The donor’s next-of-kin, his wife, did not give consent for the heart to be used because she was too “distraught,” and the donor’s mother was consulted in her place (Lear 196856). The transplant team took over from the donor’s physician to determine death and

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also approached the relatives of the donor directly. This state of affairs was duly recorded in Saturday Review where it was noted that, with the exception only of that magazine, the national newspapers and all other major American magazines, no doubt overwhelmed by the heroics of the surgery, had entirely failed to report on the world’s first heart transplant from the point of view of the donor’s family.

Clearly, tampering with what had been conventionally accepted as death struck a much more sensitive cord in Japan than it did in North America, Europe, or South Africa. The Japan Bar Association continues to this day to be adamantly opposed to accepting brain death as the end of life, as are many doctors and citizen activists. Moreover, in the flood of literature on this topic in Japanese, in contrast to that produced in the West, the plight of potential recipients, until very recently, has been notably absent, while that of donors has taken center stage. Those Japanese who go abroad for transplants have been described in the media as selfish (although this attitude is slowly changing as organ recipients become more active politically), and some have received hate mail on their return home.

Official Japanese guidelines, put out by the Ministry of Health and Welfare, exist for establishing a diagnosis of brain death. However, because no major organ transplants are performed (except for kidneys, for which a cadaver donor can be used-that is, a patient whose heart has stopped beating, or alternatively a living related donor), there is little pressure to diagnose a “moment” of death. The 18 Japanese intensive care specialists I have interviewed all agree that in their estima- tion the criteria for brain death must establish irreversibility, and therefore indicate either the approach of death or that death has already taken place. Moreover, they concur that brain death is distinct from other conditions where the brain is severely traumatized, including a persistent vegetative state. However, these specialists went on to state that they do not usually follow all the recommended guidelines for diagnosing brain death and instead rely in good part on clinical judgment rather than on technologically created evidence when reaching a diagnosis.

Even when they themselves are convinced that the patient is dead, terms such as “almost brain dead” (hobo noshi no jotai) and “damage to the consciousness” (ishiki s&gai) are used when talking to relatives of patients. Over the space of several days, on being told repeatedly that there is no improvement, and that the situation looks “hopeless,” the family usually comes to accept that the patient is dead, and the respirator is then turned off. The possibility of organ transplants is rarely raised by either the family or medical staff, even in tertiary care centers in Tokyo and other large cities. In a few hospitals where transplant surgeons are particularly active, the question is brought up more often, and some families then agree to cooperate in donating kidneys and other body parts.

The Japanese public knows very little about daily clinical practice in connection with the brain dead, except when they read the rather frequent newspaper accounts about possible malpractice on the part of physicians who at times remove organs from brain-dead patients without the informed consent of the involved family (Lock 1996). Doctors are often accused of obtaining agreement only in principle but without the family being fully aware of the circumstances. What the public has also been reminded of in the media is that tampering with dead bodies goes against Japanese tradition, that it is “unnatural,” and, moreover, that for “the Japanese” the center of the body has historically not been located in the brain, as it

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is suggested has been the case throughout the history of the “West.” Nor, it is asserted, has mind/body dualism been a dominant ideology in Japan (Lock 1996).

Plugging Up the Loopholes

The concept of “brain death syndrome” was challenged in the courts during the early 1970s in North America. In one landmark case in Virginia in 1972, the jury ruled against the donor’s family who claimed that the transplant surgeons had been responsible for the death of their relative. Other court cases followed, including several involving homicide victims, but none resulted in the prosecution of a doctor (Simmons et al. 1987). At the same time a debate about medical practice was under way in the medical world itself, in particular as to which tests, if any, could be relied upon to confm an individual doctor’s opinion about brain death, and secondly as to who would act as “gatekeepers” to protect physicians from malpractice suits (Black 1978).

By 198 1 it was recognized that public policy in connection with defining death had become an urgent matter, and accordingly a Uniform Determination of Death Act was proposed after extensive debate among the members of a special Presi- dent’s commission, less than half of whom were physicians. This act was immediately supported by the American Medical Association and the American Bar Association, and subsequently adopted over the years by the majority of state legislatures and in the Canadian provinces.

The President’s Commission, in opposition to the position taken by a good number of individual physicians, philosophers, and theologians, opted to further rationalize and update what they characterized as “obsolete” diagnostic criteria present in the Harvard statement and to enshrine a definition of death in law, something that thus far had not been the case (Annas 1988:621). The Commission Report stated at the outset that their mandate was to produce “clear and principled guidance” for determining whether “bodies” that breathe only through artificial means, and which have no capacity for integration of bodily functions, no consciousness, or capacity for other human experience, are alive or dead (1981:3). The report stressed that it was the death of a human being, “not the ‘death’ of cells tissues and organs” about which they were concerned. Although it was recognized that functional cessation of vital bodily systems can be used as standards to judge whether biological death has occurred, the importance of such findings, it was asserted, are for what they reveal about “the status of the person,” rather than about the body physical. The report was explicit that the “meaning” of death should not be radically changed, and thus its focus was on independent breathing or a lack thereof, and the rapid effects a lack of oxygen has on brain function, together with the relationship of these observations to consciousness and therefore, by implica- tion, to the person as a whole. There was concern, above all, to establish a single set of standards that would be accepted throughout the United States. The difficul- ties of transporting bodies across state lines for the purposes of “treatment” was raised as a major stumbling block unless a clear public policy was set in place. It was also emphasized that physicians must know as early as possible when a mechanically supported patient’s brain ceases to function in order that they could adequately take care of those organs designated for transplant. It was explicitly stated that in a brain-dead patient, even when on a respirator, internal organs


undergo changes that make them less fit for transplants unless they are carefully perfused and certain medications avoided.

With these points in mind, the commission recommended that a concept of “whole-brain death,” equated with an “irreversible loss of all brain function,” be adopted. This condition was carefully distinguished in the report from a “persistent vegetative state,” as exemplified by patients such as Karen Ann Quinlan and Nancy Beth Cruzan, whose brain stems continued to function despite an irreversible loss of higher brain function. The earlier definition of “irreversible coma” left room for doubt as to whether patients such as these could be taken for dead, and the concept of whole brain death sought specifically to clarify this point.

Despite this effort to establish uniformity, a good number of publications appeared shortly after the act was passed in which medical professionals, philosophers, and social scientists pointed out the numerous ways in which the wording of the act remained ambiguous, particularly so because two criteria were recognized as acceptable in the determination of death: irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem.

The philosopher Lamb, in summarizing this controversy, argued that ambiguity arose because the commission (as did the surgeons in South Africa more than a decade earlier), wished to avoid producing a statement that appeared to be a radical departure, a “paradigm shift” from what, until the invention of the artificial ventilator, everybody had informally recognized as death. It was assumed that most members of the public would be unlikely to cooperate with the transplant enterprise if they understood that death itself was being tinkered with, especially since brain death is not intuitively recognizable, even to a trained observer. A patient who is brain dead usually appears as though sleeping, the body is warm, skin color is normal, hair and nails continue to grow, babies have been delivered from brain dead pregnant women and respiration takes place, albeit with the aid of a ventilator (observations that are well versed in the media in Japan). Relatives must be willing to accept professional interpretations of readings produced by machines as indica- tors of death-something about which the Japanese public clearly feels considerable ambivalence.

The commission, committed to vital organs transplants, was willing to take a risk that involved families would not resist. Thus they strove to make it legally possible to remove organs before their condition had deteriorated by creating criteria for a new death in which the nonfunctioning state of the brain would be of overriding importance. At the same time they emphasized, in contrast to the Harvard Report, that in most cases the former definition of death, based on cardiac and respiratory criteria, remained effective (Lamb 198523).

As with the physician-dominated groups who had met earlier, one of the most difficult problems the commission faced was to transform the process of dying into an event that could be established scientifically, while at the same time striving to make it appear that nothing had been radically altered. Byrne and Nilges had noted just prior to the establishment of the commission that “dying must never be confused with death,” indicating that in their minds, at least, death is the endpoint of a recognizable process (1993:3). Their interest in the state of potential organs for transplant ensured that the commission sought to establish as early as possible

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along a continuum that death was indeed taking place-in other words, that an irreversible situation had set in. If it could be agreed that the brain was no longer functioning in an integrated fashion, and that this situation could only get worse, then it would “naturally” follow that the “person” no longer existed since all capacity for cognitive function would have ceased. Even though many of the cells of the body were still active, it was assumed that few people would argue against this concept of whole brain death, because the brain and therefore the person was clearly damaged beyond hope of recovery.

Among the tests to establish a diagnosis of brain death, one had to be included to demonstrate conclusively that the patient had not regained the ability to breathe independently. Hence the apnea test, in which the patient is unhooked from the respirator for at least ten minutes, was included as a diagnostic tool in order to establish conclusively that without continued medical intervention “conventional” death would set in at once. Since, while undergoing the apnea test, the vital organs of the body are at risk for becoming deoxygenated, which would therefore make them less than perfect for transplantation, oxygen must be “passively” piped into the patient’s body through a tube inserted into the trachea for the duration of the test. Thus, at this stage of establishing a diagnosis, if the patient is a potential donor, the condition of the respective organs rather than of the person are uppermost in the minds of at least some, if not all, of the attending medical staff. Some involved medical personnel I have interviewed have stated that the apnea test is very stressful. When asked for whom, the patient or the person doing the test, the answer has most usually been “for both.” Clearly there is some concern that the “near” brain-dead or brain-dead patient may remain sensitive to what is happening to them.

Fifty-two physicians and one Ph.D., many of whom are well-known neurosurgeons and neurologists, wrote the “Guidelines for the Determination of Death,” which appears at the end of the Commission Report. In addition to a description of the necessary diagnostic tests, warnings are sounded about reversible and compli- cating conditions that may make it appear as though a patient is brain dead when this is not in fact the case. Depending upon what caused the patient’s condition, and on what confirmatory tests are used, it is recommended that physicians wait for either 6.12, or 24 hours before finally confirming brain death, but the guidelines also state that duration of observation is a matter of “clinical judgment and that some physicians suggest shorter or longer periods” than those recommended in the report (1981:161).

The report states that “successful use” of the guidelines requires a “competent and judicious” physician, experienced in clinical examinations. Consultations are recommended when appropriate. Given the urgency that transplant surgeons inevitably experience once they have been notified that a potential donor is available, it is evident that they should not be involved in making the diagnosis about death, a recommendation that everyone whom I have talked to in six major hospitals claims to follow today without exception.

Despite this concerted effort to routinize whole brain death as a diagnosis, and to create uniformity in the determination of death, preliminary interviews I have conducted with physicians and nurses working in intensive care units make it clear that there is some variation in clinical practice. Indeed, the guidelines left room for such variation. There is also considerable concern among some specialists who

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have produced evidence to show that time pressure, working conditions, and human fallibility must inevitably lead to misdiagnosis at times (Byme and Nilges 1993). Moreover, doubt and debate continue to this day as to whether or not we are on an ethical slippery slope and as to what actually constitutes death (Arnold and Youngner 1993a; Veatch 1993). In some segments of the intellectual and medical worlds we clearly remain, in Kuhn’s terms, in a paradigm crisis, striving for commensurability but unable to achieve it. There has been only a partial rupture with the past, a situation exacerbated by the need to convey the idea to the public that in practice no change has taken place.

Ironically, in contrast to Japan, the North American public is largely unaware that any professional dilemmas have been associated with the creation of brain death because this debate so rarely spills over into the media and popular press. Moreover, the majority of tertiary-care hospitals in North America have now routinized these procedures, and most of the public and involved medical professionals apparently have no difficulty with this state of affairs (but see Caplan 1988; Childress 1989; Sanner 1994; Youngner et al. 1989). The dominant position, made clear through interviews and at conferences, is that brain death is a “robust” diagnosis, one that is rather readily determined, making disconnection of the ventilator a relatively uncomplicated decision.

At the end of March 1993 there were 30,000 potential recipients waiting for organs, and it was reported that on average six to seven of them died each day. The transplant world is suffering from what they describe as a “chronic shortage” of organs, and potential donors have actually decreased in recent years due to im- proved safety standards on the roads (Amold and Youngner 1993b). Ways to increase the donor pool are continually on the minds of transplant surgeons. Two more sources of organs have recently crept into usage in the United States and in parts of Europe: (1) from patients whose heart stops beating close enough to a hospital so that intravascular catheters can be rapidly inserted to cool the organs in order to preserve their condition until permission for removal can be established; and (2 ) from patients who have requested removal of life support and are expected to die a very short time afterwards. Organs are removed from these latter patients with their prior approval. A recent issue of the Kennedy Institute of Ethics Journal devoted to what have come to be called “Non-Heart-Beating Cadavers Donors” (NHBCDs) suggests that it is time that we focus our attention on the treatment of donors.

Locating the Person

The President’s Commission, which culminated in the Uniform Determina- tion of Death Act, stated clearly that for death to be diagnosed, all brain function must have ceased, including the reflexes controlled by the brain stem. At this point a lack of “neurological integration” exists, and what is left is “no longer a functional or organic unity, but merely a mechanical complex” (Bemat et al. 198 1 :391). Zaner, a bioethicist, has pointed out that for whole-brain advocates, “it is the biological organism (or, more specifically, the physiologicaYanatomical nervous system) that is definitive for life and death, not the person whose organism (or nervous system) it is” (1988:7). Zaner believes that the commission put the cart before the horse when it tried to develop a concept of death out of a set of standardized medical tests

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while evading the central issue of just who had died. In order for there to be a uniform statutory definition of human death, there must be first of all, according to Zaner, a general consensus over what constitutes “personhood” or “personal identity” (19883. The commission acknowledged that no such consensus exists, pointed out that the issue has been debated for centuries, and explicitly sought to circumvent the problem by making a biological argument in which rationally conceived operational criteria and medical tests provided the answer, something with which not only the scientists but also the lawyers on the commission were apparently comfortable.

Critics of the findings of the commission argue that neither operational criteria nor valid tests can be created unless an agreed upon working definition is first established-namely a concept of what it means to die (Bartlett and Youngner 1988). Such a definition has to be “societal” and not biological, the philosopher and psychiatrist team of Bartlett and Youngner argued, since it is the permanent loss of personhood that is of central concern, rather than the demise of the body physical (1 988). Definitions of death grounded in the idea of a loss of personhood have been characterized as “ontological” and contrasted with what are taken to be narrowly defined scientific definitions based on the state of brain function (Gervais 1987). Lamb, a philosopher, has expressed grave reservations about ontological definitions of death. He states that those who argue for yet another redefinition of death based on ontological criteria are in actuality appealing to the idea that a loss of higher brain function alone, and not the whole brain, is what ultimately counts. What has come to be known as “neocortical death”+onditions where there is an irreversible loss of consciousness and cognitive function, but an intact brain stem-is simply, according to Lamb, a rewording in scientific terms of a definition based on a loss of personhood.

Lamb cites one of the papers in the Zaner collection where the author, a lawyer, argues that neocortical death has already been recognized legally, since life support has on occasion been removed from patients in a persistent vegetative state, that is, from patients who have undergone “neocortical death.” This author is explicit that medical recognition of neocortical death would be invaluable in the increased procurement of organs for transplants:

A newortical death standard could significantly increase availability and access to transplants because patients.. . declared dead under a neccortical definition could be biologically maintained for years as opposed to a few hours or days, as in the case of whole brain death. Under the present Uniform Anatomical Gift Act, this raises the possibility that neocortically dead bodies or parts could be donated and maintained for long-term research, as organ banks, or for other purposes such as drug testing or manufacturing biological compounds. [Smith 1988: 1291

Lamb points out that arguments such as Smith’s are concerned only with criteria that assist in describing “the minimum necessary qualities for personhood, defined in terms of psychological abilities.”

Gervais has in turn criticized Lamb for placing too much reliance on a biological definition; Lamb, she states, sees death as ‘‘a fact awaiting discovery” (Gervais 1987:155), and characterizes the ontological approach, in contrast, as based in ethical reflection. Lamb has countered this rebuttal by claiming that whole brain death is an “ethically superior formulation” to neocortical death because “in

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matters of life and death, objective testable criteria concerning presence or absence of vital functions, are more reliable than indeterminant assessments concerning the quality of residual life, or speculations regarding personhood, or utilitarian require- ments for transplant organs” (Lamb 1985). Lamb is clearly concerned that overriding interests about the supposed crisis precipitated by an “organ shortage” will seize the day and send us on our way down the slippery slope to redefining death in response to an identified need. Thus he is adamantly opposed to Green and Wikler (1981), for example, who argue for the importance of a “psychological continuity” equated with higher brain function as necessary for the preservation of personal identity and hence life. For psychological advocates such as these authors Lamb states, “personal identity” appears to be “the measure of human life” (199O:G). He adds that the whole brain death formulation does not dispute that all capacity for integrated mental activity is lost, but he believes that the “essence” of personal identity is an elusive concept that in any case resides in a different logical space than the cessation of vital functions, and is certainly not one on which doctors should rely in making decisions about death. Personal identity, after all, does not have any specific anatomical location, claims Lamb, but is a quality akin to “spirit,” “will,” or “soul,” with religious, legal, and political associations.

Lamb has gone on to develop a cogent argument to counter those who distinguish between “having a life” in the biological sense (considered relatively unimportant), and “being alive,” in the social and moral sense (Rachels 1986). He believes that this type of argument too is misguided and suffers, in common with similar arguments about loss of personhood, from a Cartesian dualistic bias in that the “ethical cut-off point is assumed to be when the ‘ghost’ leaves the machine.” Lamb and others who think like him are adamant that definitions based on concepts such as a loss of personhood or moral sense are cultural products, subject to a wide range of interpretation, and open to easy manipulation and abuse where pragmatism and utilitarianism holds sway.

As early as the 1970s Hans Jonas detected the classical “soul-body dualism” of Enlightenment philosophy at work in recent reformulations of death in the West.

[In] its new apparition. . . the dualism of the brain and body. . . holds that the true human person rests in (or is represented by) the brain, of which the rest of the body is a mere subservient tool. Thus when the brain dies, it is as when the soul departed: what is left are ‘mortal remains.’ Now nobody will deny that the cerebral aspect is decisive for the human quality of life of the organism. . . . The position I advance acknowledges just this. . . [but] the extracerebral body [has] its share of the identity of the person. The body is uniquely the body of this brain and no other, as the brain is uniquely the brain of this body and no other. What is under the brain’s central control, the bodily total, is as individual, as much ‘myself,’ as singular to my identity (fingerprints!), as noninterchangeable, as the controlling (and reciprocally controlled) brain itself. My identity is the identity of the whole organism, even if the higher functions of personhood are seated in the brain. [Jonas 1974: 1391

Lamb, in agreement with Jonas, asks, “If patients in a persistent vegetative state are to be considered dead, then how much neocortical damage would be necessary for a patient to be labeled as vegetative?” (199053). He points out that there is no “clinical homogeneity” in vegetative patients since there are no firm criteria for defining just what such a state is. Diagnosis can be difficult (Beresford

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1978), and is particularly so in children; absence of consciousness and self-aware- ness is not at all easy to define or establish, cases of significant recovery from this condition have been reported in reputable journals (Dougherty et al. 1981:997; Rosenberg et al. 1977: 167-8), and several clinics exist that specialize in the care of patients in persistent vegetative state, many of whom make remarkable recoveries.

Given this climate Lamb, together with other supporters of whole brain death, believe it is imperative to search out “precise” measurement of neurological functioning. They are driven to this position because they are both suspicious of a narrow Euro-American, psychologically driven interpretation of life and, at the same time, see less of an opening for abuse of a tightly defined biologically based definition (provided in practice there is an under diagnosis of death whenever doubt exists). Fost has reached a more radical conclusion: that the problem with utilitarian justifications for redefining death, including the Uniform Determination of Death, is that they invite constant redefinition whenever utility requires it, creating “not only instability, but the perception and possibility that unwanted persons can be defined out of existence [whenever] it serves the greater good“ (1988:7).

The Slippery Slope of Truth

As early as 1975 the bioethicist Tristram Engelhardt wrote that a definition of death as irreversible coma is a “conservative definition,” and went on, “it takes more to be a person than reaction to pain, spontaneous respiration, and reflex activity” (1975365). Engelhardt, rigorously following a mindbody dichotomy, believes that an “intellectual decision” has been made by defining death in terms of the brain, namely that “human biological life is not the same as human personal life. An otherwise intact and alive, but brain-dead, person is not a human person. We who have grown up since the development of modem neurology and neurophysiology take for granted the assertion that to be a mind in this world is to ‘have’ an intact functioning brain” (1975365). Engelhardt then pursues the argument to what for him is a logical conclusion: that lack of upper brain function alone signals death, and therefore patients in persistent vegetative state are no longer alive. He then continues, ‘The brain-oriented concept of death offers medicine a way of distinguishing between patients, i.e., the persons to whom medicine has obligations, and the collection of human organs (ie., mere human biological life), which can be used to help persons still alive” (1975366). Since there are no obligations to organs, no ethical quandary exists about the removal of organs from those who are defined as nonpersons.

More recently, the philosopher Veatch has argued that theories of personhood are notoriously controversial. He acknowledges the possibility of errors in diagnosing death, however it is defined, and goes on to claim that the “definition of death debate is actually a debate over the moral status of human beings. It is a debate over when humans should be treated as full members of the human community. When humans are living, full moral and legal rights accrue” (1993:21). Thus, Veatch believes, science cannot solve the problem, nor are we likely to reach an easy agreement in a pluralistic society since the issue is basically one of morals, philosophy, and religion. Veatch claims that diversity of beliefs should be tolerated, and therefore individuals should be free to choose their own definition of death; such choices, however, would have to “avoid violating the rights of others and avoid


creating insurmountable social problems for the rest of society” (1993:22). Veatch then argues that individuals would not be able to pick a definition of death that “required society to treat them as dead even though they retained cardiac, respiratory, mental and neurological integrated functions. Likewise, I assume that people would not be permitted to pick a definition that would insist that they be treated as alive when all these functions were absent” (1993:22). In practice, Veatch con- cludes, one can choose among heart-, whole-brain, and higher-brain oriented definitions, and he would like to see a definition of “irreversible cessation of the capacity for consciousness” written into law as a third option for death. However, Veatch himself believes that a whole-brain orientation to death is “old fashioned” and is becoming less and less plausible: “To me, the principle is that for human life to be present-that is, for the human to be treated as a member in full standing of the human moral community-there must be integrated functioning of mind and body. That means some version of a higher-brain-oriented formulation (1993:24).

As is well known, “souVmind”-the formulation usually attributed to Des- cartes, later reconceptualized as “mind”-was constituted in 18th century Europe as the repository of pure, untrammeled rational thought and set apart from the sinful Christian body. That contemporary Western moral philosophy remains influenced by this formulation seems evident in the examples cited above. The arguments of Englehardt and Veatch are, I believe, extreme. I do not think that most people would comfortably count patients who breathe independently but are unconscious as dead. Nevertheless, I imagine that the majority of people born and raised in North America would probably find it hard to understand the “person” as being located somewhere else than the brain.

The Japanese have not been overly concerned with the Cartesian dichotomy, nor has the concept of unique, clearly bounded individuals in whom rights are unequivocally invested been integral to their recent heritage, although both these topics are extensively debated in Japan today. Among the 50 Japanese I have asked, only one-third clearly locate the “center” of their bodies in the brain; the others, of varying ages, selected kokoro as the center, a very old metaphorical concept that represents a region in the thorax where “true” feelings are located.

The idea of individual rights is currently gaining a serious foothold in Japan but has to battle against the powerful flow of a tradition in which an individual is conceptualized as residing at the center of a network of obligations, so that personhood is constructed out-of-mind, beyond body, in the space of ongoing human relationships. “Person” in Japan remains for, perhaps the majority. a dialogical creation, and what one does with and what is done to one’s body are by no means limited to individual wishes (although contemporary Japanese literature disputes this position). Moreover, individual self-determination is thought by many as essentially selfish. The Japanese have also, perhaps in part as a result of their Buddhist heritage, long invested in the importance of nonverbal communication. Establishing rapport with another individual, especially a close relative, in which a “oneness” is achieved, often through touching rather than language, is highly valued. There is, moreover, plenty of evidence that recently deceased relatives continue to play an important role for many people in daily life in Japan, a cultural attribute that has a powerful influence on behavior around the dying and dead (Lock 1996).


Japanese citizens are as steeped in “modern neurophysiology” as are North Americans, yet, not surprisingly given the particularities of their past, they have chosen to focus their concerns on the donor-on those who are brain dead-rather than on the heroics associated with the “gift of life.” Ironically, activist groups opposing any changes in the definition of death often demand that the “rights” of the brain dead be recognized. It will come as no surprise that when both Englehardt and Veatch spoke at a bioethics conference in Tokyo recently, their talks confirmed what I believe a number of Japanese anticipated: that America is a land of extremes where people have forgotten how to care about one another.

Crossing “Natural” Boundaries

Representing the brain dead as cyborg signals the ambiguity, the presence of polysemic potential. Such a hybrid causes us to ask what is at stake morally and politically in the presence of this new entity, understood by many as dead, by others as past hope for a return to life but not yet dead, or alternatively as close to death but with a possibility of a return to life, or for yet others as clearly alive, while many other people have never considered what to make of it. Responses depend in part upon whether one understands this state as a neurological condition, a“preparation of liver and heart,” a person, or a dying individual virtually inseparable from a family and the larger social order. Accounts will also differ depending upon whether one literally works on the brain dead as object, or simply uses the concept of brain death for the purposes of a philosophical exercise or, alternatively, have lived with and hold dear the person whose brain is damaged-although, of course, certain individuals may fall into more than one of these categories. Many North American medical professionals and some philosophers are probably convinced that their reading is the only correct answer-a fundamental truth-and some may try, on the basis of this conviction, to insist that others with a different viewpoint are misguided. For these protagonists we are in the realms of logic and science, worlds where natural phenomena are subject to measurement and evaluation, from which deductions can be made about “persons,” their worth, and their aliveness or otherwise. For a philosopher like Lamb this is the only safe path to tread in a world driven by utility. These disputants have no truck with culture or with context, but in their discussions about brain death they nevertheless act as moral arbitrators. For the majority, respiring individuals whose minds do not function cognitively have no intrinsic worth and may be used in the service of other individuals.

The dominant Japanese argument, as we have seen, starts out from a different ontological perspective, one in which death remains above all as a social event, and as such is best evaluated intuitively and through social consensus. Curtailing the reaching of this consensus in order to vivisect the dying is unthinkable for many people, including many clinicians. Thus dying remains as a process into which scientific intrusion is often resented and, furthermore, little pressure is exerted to formalize a distinct demarcation between life and death-between the transition from culture to nature. Numerous Japanese intellectuals understand only too well how a bright naturehlture dichotomy is inherent to a scientific enterprise that emerged out of the philosophical tradition of the West and, even at the risk of seeming “old fashioned,” they exhibit clear ambivalence about locating death entirely in the world of technoscience.

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I suspect that the brain dead body has failed to signal “dangerous possibilities” to most North American commentators because, despite its machinehuman coupling, it does not transgress boundaries that cause much concern. There were early warnings in a few media reports, and minority positions continue to exist in which doubts about the criteria for measuring death and about the accuracy of their application in practice are expressed. The possibility of achieving satisfactory informed consent with families has also been questioned ceaselessly. Nevertheless, relegation of the brain dead to a condition beyond meaningful human life has moved relentlessly forward, and we are now on the verge of steamrolling other cognitively impaired persons into oblivion. It would appear that, whether it is the heart or brain that stops functioning, we have not had to reconfigure our dominant positioning about death as a biological event through use of the ventilator; this piece of technology has simply permitted us to manipulate what will signify as the pertinent physical criteria to meet the utilitarian interests of the transplant world. Culture has intruded into nature yet again in the guise of science; a little tinkering has taken place, but, in contrast to Japan, no radical threat is posed to boundary formulations. However, since we consistently deflect debate around death and transform it into the vocabulary of saving lives, it may be that further investigation will reveal a good deal more ambivalence about the new death than is at present apparent.

There is no doubt in my mind that much suffering is relieved through the transplant enterprise, and many thousands of sick Japanese and their families are bitter that they cannot benefit from this technology. On the other hand, well-docu- mented excesses in the transplant world have been the source of much suffering. As technoscience continues its dramatic incursions into what has until now been beyond the pale, we would do well to insist that anthropological investigations into the flexible domain of nature and its availability as moral arbitrator through its cultural construction as science be taken seriously by those who actually tinker at these margins and those whose task it is to pontificate on the outcomes of such tinkering.

NOTES

Research Council of Canada, grant number 410-93-0544.

Social Studies of Medicine, 3655 Jhmmond St., Montreal, Quebec, Canada H3G 1Y6.

Acknowledgments. This research was funded by the Social Sciences and Humanities

Correspondence may be addressed to the author at McGill University, Department of

REFERENCES CITED

Alexander, Marc 1980 The Rigid Embrace of the Narrow House: Premature Burial and the Signs of Death.

Hastings Center Report 1025-3 1. AMCIS, George J.

1988 Brain Death and Organ Donation: You Can Have One without the Other. Hastings Center Report 18:28-30.

Arnold, Robert, and Stuart Youngner 1993a Back to the Future: Obtaining Organs from Non-Heart-Beating Cadavers. Ken-

1993b The Dead Donor Rule: Should We Stretch It, Bend It, or Abandon It? Kennedy nedy Institute of Ethics Journal 3: 103-1 1 1.

Institute of Ethics Journal 3:263-278.


Bamard, Christiaan N. 1968 Human Cardiac Transplantation: An Evaluation of the First Two Operations

Performed at the Groote Schuur Hospital, Cape Town. American Journal of Cardiology 22:584-596.

Bartlett, Edward T., and Stuart J. Youngner 1988 Human Death and the Destruction of the Neocortex. In Death Beyond Whole-

Brain Criteria. R. Zaner, ed. Pp. 199-206. Dordrecht: Kluwer Academic Publishers. Beecher, Henry 1969 After the “Definition of Irreversible Coma.” New England Journal of Medicine 28 1 : 1070-1 072.

Beresford, H. R. 1978 Cognitive Death Differential Problems and Legal Overtones. Annals of the New

York Academy of Sciences 315:339-348. Bernat, James L., Charles M. Culver, and Bernard Gert 1981 On the Definition and Criterion of Death. Annals of Internal Medicine 94389-391.

Black, Peter

Byme, Paul, and Richard Nilges 1978 Brain Death. New England Journal of Medicine 229338-344.

1993 The Brain Stem in Brain Death: A Critical Review. Issues in Law and Medicine 93-21.

Caplan, Arthur L. 1988 Professional Arrogance and Public Misunderstanding. Hastings Center Report 18:3437.

Childress. J. F. 1989 Ethical Criteria for Procuring and Distributing Organs for Transplantation. In

Organ Transplantation Policy: Issues and Prospects. J. F. Blumstein and F. A. Sloan, eds. Pp. 87-1 13. Durham, NC: Duke University Press.

Cooper. Theodore, and Sheila C. Mitchell 1 %9 Cardiac Transplantation: Current Status. Transplantation Proceedings l(2): 755-757.

Dougherty, John, Jr.. F. Rawlinson, David E. Levy, and Fred Plum 1981 Hypoxic-Ischemic Brain Injury and the Vegetative State: Clinical and Neuro-

pathologic Correlation. Neurology 3 I :991-997.

1968 The Telltale Heart. March1 18-1 19.

1975 Defining Death: A Philosophical Problem for Medicine and Law. American Engelhardt, Tristram

Review of Respiratory Disease 112587-590. Fost. Norman 1988 Organs from Anencephalic Infants: An Idea Whose Time Has Not Yet Come.

Hastings Center Report 185-10. Fox, Re&, and Judith Swazey 1974 The Courage to Fail: A Social View of Organ Transplants and Dialysis. Chicago:

University of Chicago Press. Gaylin, Willard

Gervais, Karen G.

Gbto, Masaharu

1974 Harvesting the Dead. Harpers Magazine 52:23-30.

1987 Redefining Death. New Haven: Yale University Press.

1992 Body and Soul: Organ Transplants. Look Japan 38:32-33.


Green, Michael B., and Daniel Wikler 1981 Brain Death and Personal Identity. In Medicine and Moral Philosophy. Marshall

Cohen, Thomas Nagel, and Thomas Scanlon, eds. Pp. 49-77. Princeton, NJ: Princeton University Press.

Haraway, Donna 1990 A Manifesto for Cyborgs: Science Technology and Social Feminism in the 1980s. In FerninismPostmodemism. L. J. Nicholson, ed. Pp. 190-233. London: Routledge.

Hardy, James D., and Carlos M. Chavez 1968 The First Heart Transplant in Man: Developmental Animal Investigations with

Analysis of the 1964 Case in the Light of Current Clinical Experience. American Journal of Cardiology 22772-78 1.

Hirosawa, Kbshichirb 1992 Tachiba kara mita nbshi to shinzb ishoku (Brain death and heart transplants from

the point of view of a circulatory system specialist). In Nbshi to zbki-ishoku (Brain Death and Organ Transplants). Takeshi Umehara, ed. Pp. 62-80. Tokyo: Asahi Shin- bunsha.

JAMA (Journal of the American Medical Association) Editorials 1968 What and When is Death 204(6):219-220.

Jonas, Hans 1974 Philosophical Essays: From Ancient Creed to Technological Man. Englewood

Cliffs, NJ: Prentice Hall. Komatsu, Yoshihiko

1993 Sentaku gijutsu to nbshironsb no shikaku (The blind spot in advanced technology and brain death debates). Gendai Shisb 2 I : 198-2 12.

Lamb, David 1985 Death, Brain Death and Ethics. London: Croom Helm. 1990 Organ Transplants and Ethics. London: Routledge.

Latour, Bruno 1993 We Have Never Been Modern. Cambridge, MA. Harvard University Press.

Lear, John 1968 A Realistic Look at Heart Transplants. Saturday Reviewmesearch. February 3.

Lock, Margaret 1996 Deadly disputes: Ideologies and Brain Death in Japan. In Organ Transplantation:

Meanings and Realities. S. J. Youngner, R. C. Fox, and L. J. O’Connell, eds. 4. 142-167. Madison: University of Wisconsin Press.

In press The Quest for Human Organs and the Violence of Zeal. In Situating Violence. V. Daas, A. Kleinman, M. Ramphele, and P. Reynolds, eds. Berkeley: University of California Press.

Lock, Margaret, and Christina Honde 1990 Reaching Consensus About Death: Heart Transplants and Cultural Identity in

Japan. In Social Science Perspectives on Medical Ethics. G. Weisz, ed. Pp. 99-1 19. Dordrecht: Kluwer Academic Publishers.

Mainichi Shinbun

Montreal Gazette

Nakajima, M.

1991 Cover-up suspected in f i s t heart transplant. March 31.

1989 Two-year-old’s voice woke grandfather from coma. January 22nd.

1985 Mienai shi: Nbshi to zbki ishoku (Invisible Death: Brain Death and Organ Transplants). Tokyo: Bungei Shunju.

Newman, B. M. 1940 What Is Death? Scientific American 162336-337.


Ohnuki-Tiemey , Emiko 1994 Brain Death and Organ Transplantation: Culture Bases of Medical Technology.

Paton, Alec 1971 Life and Death Moral and Ethical Aspects of Transplantation. Seminars in

Pemick, M. 1988 Back from the Grave: Recurring Controversies over Defining and Diagnosing

Death in History. In Death: Beyond Whole-Brain Criteria. R. M. Zaner, ed. 4.17-74. Dordrecht: Kluwer Academic Publishers.

Current Anthropology 35233-254.

Psychiatry 3(1): 161-168.

President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.

1991 Defining Death: Medical, Legal and Ethical Issues in the Determination of Death. Washington, Dc: US. Government Printing Office.

Rachels, James

Reeves, Robert B., Jr. 1986 The End of Life. Oxford Oxford University Press.

1969 The Ethics of Cardiac Transplantation in Man. Bulletin of the New York Academy of Medicine 45:404-411.

Rosenberg, G. A.. S. F. Johnson, and R. P. Brenner 1977 Recovery of Cognition after Prolonged Vegetative State. Annals of Neurology

2:167-168. Sanner, Margareta

1994 A Comparison of Public Attitudes toward Autopsy, Organ Donation and Anatomic Dissection. Joumal of the American Medical Association 27 1 :284-288.

Selzer, Richard

Schmeck, Harold 1993 Mortal Lessons. New Yo&: Touchstone Books.

1969 Transplantation of Organs and Attitudes: The Public’s Attitude toward Clinical Transplantation. Transplantation Proceedings I (1):670-674.

Shapiro, Hillel. ed. 1969 Experience with Human Heart Transplantation. Proceedings of the Cape Town

Symposium July 13-16, 1968. Durban: Butterworths. Shrader, Douglas

Simmons, Roberta G., Susan D. Klein, and Richard L. Simmons 1986 On Dying More Than One Death. Hastings Center Report 16: 12-1 7.

1987 Gift of Life: The Effect of Organ Transplantation on Individual, Family, and Societal Dynamics. New Brunswick, NJ: Transaction Books.

Smith, David Randolph 1988 Legal Issues Leading to the Notion of Neocortical Death. In Death: Beyond

Whole-Brain Criteria. R. M. h e r , ed. Pp. 11 1-144. Dordrecht: Kluwer Academic Publishers.

Smith, Desmond

Tachibana, Takashi

Time

Uozumi, Tbru

1968 Someone Playing God. The Nation, December 30.

1991 Nbshi (Brain Death). Tokyo: Nihon HBs6 Shuppan KyBkai.

1967 Surgery: The Ultimate Operation. December 15.

1992 Nbshi mondai ni kansuru shikkan to teian (My Opinion and Proposals on the Brain Death Issue). In Nbshi to zbki-ishoku (Brain Death and Organ Transplants). Takeshi Umehara, ed. 4.8699. Tokyo: Asahi Shinbunsha.

600 MEDICAL ANTHROPoLoGY QUARTERLY

Veatch, Robert M. 1993 The Impending Collapse of the Whole-Brain Definition of Death. Hastings Center

Report 23(4): 18-24. Youngner, Stuart J., Martha Allen, Edward T. Bartlett, Helmut F. Cascorbi, Toni Hau, David Jackson, Mary B. Mahowald, and Barbara J. Martin

1989 Psychosocial and Ethical Implications of Organ Retrieval. New England Journal of Medicine 313:321-324.

Zaner, Richard M. 1988 Introduction. In Death: Beyond Whole-Brain Criteria. R. M. Zaner, ed. 4. 1-14.

Dordrecht: Kluwer Academic Publishers.

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