Death: Cessation of brain activity

Death: Cessation of brain activity

Author at Lake Zurich near Dignitas

Author at Lake Zurich near Dignitas

On December 9 2010, a 42-year old British man, Andrew Cogan, a former marine biologist died at the Dignitas clinic in Zurich. He had suffered with Multiple Sclerosis (MS) for the previous 10 years. MS causes patches of inflammation in parts of the brain and spinal cord. Its cause is unknown. It is incurable and progressive. Patients in the beginning have stabbing pains in the muscles and some visual impairment, but end up with difficulty in speaking, paralysis of the lower legs and inability to urinate.

The Dignitas (To die with dignity) Clinic was founded on May 17 1998 in Forch near Zurich, by Ludwig A Minelli, a Swiss lawyer. So far more than 800 people have died there. The assisted suicide market is largely German, as of October 2008, but100 British citizens have travelled to Switzerland todie at Dignitas. Assisted suicide is illegal in England and Wales. In Scotland, a bill aiming to give terminally ill people the right to die has recently been published in the ScottishParliament.

A Scottish MP Margo Macdonald, who has Parkinson’s disease,brought the Bill to make it legal. The first assisted suicide for a Swiss person took place on October 27 1998, and the first non-Swiss resident, a German, took place in September 1999. Dignitas says it has something to do with the last Human Right: the ability to decide how andwhen somebody would like to end one’s own life.

The Right to Die is in fact the very last Human Right. Though there is no law saying that accompaniment to suicide is legal, and no law saying how assisted suicide should be done, Switzerland is simply a liberal country which has allowed such mode of death since 1940, provided it is done for altruistic reasons.

It can bedoctor-hastened death, or non-doctor. It is always reported to the police, and there are fees involved. Travel and hotels are of course, the responsibility of the person asking for help. As of May 4 2010, police found 300 urns of human ashes dumped in Lake Zurich near the DignitasClinic. Only the states of Oregon and Washington (USA), Holland, and Belgium permitphysician- assisted suicide for terminally ill and competent adults, but it is for residents only, and there are strict rules.

There is a protocol in the Dignitas clinic. On the last day, in the presence of a relative or relatives, the dying person is again asked twice whether he/she has finally decided to end his/her life. If affirmative, he/she has to drink an oral dose of an anti-emetic drug (to prevent vomiting after swallowing the poison) is given, followed approximately 30 minutes later by a lethal dose of Nembutal 5 grams (usual hypnotic dose is 200 milligram) dissolved in a glass of water or fruit juice.

Death is caused by respiratory arrest, which occurs within 30 minutes of ingesting Nembutal.

The charges per patient is 4,000 Euro (240,574 rupees) for preparation and suicide assistance, or Euro 7,000 in case of taking over family duties – for funeral, medical costs and official fees.

Research published in the Journal of Medical Ethics (August 27 2010) suggests that atheist or agnostic doctors are almost twice as willing to take decisions that they think will hasten the end of a very sick patient’s life as doctors who are deeply religious.

The data show some religious faith is held only by almost half of the medical population and approximately two-fifths of the general population.” However, according to the author, Professor Clive, University of London – “though doctors do vary according to religious beliefs (Hindus and Muslims pay higher values on human life) there was no evidence of a ‘slippery slope’ that deaths of the most vulnerable are being hastened more than others.”

Though I am not a religious man my view is that human life is of inestimatable value and needs to be preserved. Once a society accepts assisted suicide as a just method to die, it will remove the incentive to give proper care to those who need it and want to live, such as those in a ‘hospice’ (Rest homes for the terminally ill in the West, run by charitable institutions) dying from cancer, or other diseases for which there is no treatment left that might prolong their lives.

Here in the UK where medical care is free, I try to make patients as comfortable as possible while prolonging their lives, by giving adequate morphine-based analgesics, if necessary by automatic syringe drivers and by providing palliative care by specially trained nurses at patients’ homes.

The ‘Right to Die’ will become a ‘Duty to Die’. It will pressurise the elderly and the sick to feel they are a burden to the family, especially in the East, and the society in the West as it will be viewed as an easy low cost alternative to palliative care. It is an attack on the Dignity of Life. Besides, it will turn doctors into killers, as the law will force them to cause the death of patients. It should be left to individuals to decide how they want to end their lives.

The topic brings me to the feared subject of death – what is death? Death is the cessation of the connection between our mind and body. It is an instance of a person or an animal dying. We all know that one day we shall die, but this is a subject we try to avoid discussing; quite rightly so, until one gets old.

As one gets old the dreary subject crops up in one’s mind quite often, preparing for death, arranging for funeral expenses, re-checking the will and so on.

Death, says Socrates, is the separation of the soul from the body. Scientifically, death is the termination of the biological functions that sustain a living organism and the cessation of our consciousness that will never return.

The nature of death has been conjectures for millennia – a great concern for theologians and philosophers, who believed in some kind of afterlife and the soul. In modern scientific enquiry, the origin and nature of consciousness or, the existence and non-existence of consciousness after death remain speculative.

We all die from senescence, accidents, intentional activity eg murder, suicide, and war. Indeed all animals die with the exception of jelly fish Turritopsis nutricula, thought to be immortal. Roughly 150,000 people die around the world each day.

In modern days, physiological death is seen as less an event than a process. Conditions once considered indicative of death are now reversible as doctors have begun to play God. In general, clinical death as occurring in Dignitas is neither necessary nor sufficient for a determination of legal death as defined in America.

A person with working heart and lungs but determined to be brain dead can be pronounced legally dead without clinical death occurring. Precise medical definition of death, paradoxically, has become more problematic as scientific knowledge and medicine advance. All the same, people die and we all know when they are irreversibly dead.

In order to die one must lose life. So we need to define life. What is life? One of the challenges in defining death is in distinguishing it from life. There is little consensus over how to define life. At a point of time, death would seem to refer to the moment at which life ends. In a way it is possible to define life in terms of consciousness.

The notable flaw in this approach is that there are many organisms that are alive but probably not conscious eg single-celled organisms such as amoeba. The second problem is in defining consciousness, which has many different definitions given by modern scientists, psychologists and philosophers.

The general problem of defining death now, applies to the particular challenge of defining death in the context of modern medicine. Death describes merely the state where something has ceased to exist ie life. Thus, the definition of “life” simultaneously defines “death”.

Death was once defined as the cessation of heartbeats and of breathing, but the development of cardio-pulmonary resuscitation (CPR) and prompt defibrillation (correcting sudden irregular rapid heart beats) have rendered that definition inadequate because breathing and heartbeat can sometimes be started and life can sometimes be sustained with a combination of life support machines and artificial pacemakers.

Today, where a definition of the moment of death is required, doctors and coroners usually turn to “brain death” or “biological death” to define a person as being clinically dead. A person is considered dead when the electrical activity in their brain ceases, as recorded by the electro encephalogram (EEG). This means suspension of consciousness, which must be permanent, and not transient, as occurs during certain sleep stages, and especially in a coma.

The definition of “brain death” has now run into problems. EEGs can detect spurious electrical impulses, while certain drugs, hypoglycaemia, hypoxia, or hypothermia can suppress or even stop brain activity on a temporal basis. Because of this, hospitals have protocols for determining brain death involving electroencephalograms (EEG) at widely separated intervals under defined conditions.

As medical technologies advance, ideas about when somebody dies may have to be re-evaluated in light of the ability to restore a person to vitality after long periods of apparent death. For example, in cases of electric shock, CPR for an hour or longer can allow stunned nerves to recover, allowing an apparently dead person to survive.

As the lack of electrical brain activity may not be enough to consider someone scientifically dead, the concept of information of theoretical death such as “Thonghangba” meaning, observation of the relaxation of the anus as practised in Manipur by the Maibas (traditional quacks), has been suggested as a better means of defining when true death occurs.

Why do people die at all? Can’t they live for ever? No. It’s not scientifically possible. People die because the mechanical life span of their organs runs out. Human beings are programmed with some exceptions that prove the rule, to longevity of 70-80 years. Anything above 80 is a bonus. In the same way Nature has programmed the life span of lower animals differently. The life span of an elephant is similar to that of a human, while the life span of a mouse is about 1 year.

Like any machinery, human organs suffer wear and tear due to constant use and exposure to the elements. Recurrent episodes of illness, poor diet and misuse of drugs and alcohol take their toll. Ultimately they stop working. However, modern advances in science and medical care have helped prevent people from dying younger with replacement spare parts such as heart valves, kidney, liver, heart and others.

A timely death is a necessary end to human existence. It is a good thing. We all know the suffering of the old and infirm people. Anyone, who has read the story of the medieval Christian mythology of the Wandering Jew will appreciate that it is good to die when one’s time is up.

Immortality is not a nice thing to have. The Biblical legend began to spread to Europe in the 13th century. This Jew named Ahasversus was given the curse of immortality by Jesus Christ. As Christ was carrying his heavy cross from Pilate’s Hall towards the place of crucifixion, Ahasversus, then, a porter or shoemaker, struck Christ, and mocked him for walking so slowly. Because of the curse he was forced to wander in misery with his only hope of rest in death on the second coming of Christ.

Earth is slowing down; the sun and stars are burning up and they also will die. When we die we die all over. From dust we come and to dust we return. “All the world’s a stage, and all the men and women merely players; they have their exits and their entrances” (Shakespeare).

March 7 2011