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Speaker 1: How do you know when a person is dead? I mean,

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Speaker 1: it seems like a straightforward problem, but this is often

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Speaker 1: a very complex issue, both medically and legally, because, as

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Speaker 1: we'll see in this episode, death is not an event

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Speaker 1: but a process. So where do the medical and legal

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Speaker 1: systems face off against one another in this question? Can

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Speaker 1: a person be declared legally dead even though he's very

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Speaker 1: much alive. Why in twenty eleven did an enormous number

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Speaker 1: of families choose to pull their loved ones off life

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Speaker 1: support just before the new year? And what does this

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Speaker 1: have to do with getting buried alive or with your

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Speaker 1: family's religious beliefs, or whether someone's head stays alive after

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Speaker 1: the guillotine. Welcome to Inner Cosmos with me David Eagleman.

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Speaker 1: I'm a neuroscientist and author at Stance, and in these

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Speaker 1: episodes we sail deeply into our three pound universe to

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Speaker 1: understand why and how our lives look the way they do.

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Speaker 1: Today's episode is about the science, the ethics, and the

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Speaker 1: questions about the end of life, What qualifies as death,

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Speaker 1: who gets to say that you are dead? And what

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Speaker 1: is the future of this? Okay, so let's start with

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Speaker 1: something that's perhaps macabre and unexpected. But if you're a

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Speaker 1: modern adult and you die suddenly, you have all these

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Speaker 1: bill pay and credit card payments and automatic withdrawals that

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Speaker 1: are scheduled, and your finances might keep on trucking for

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Speaker 1: a while. You may even receive some auto deposits into

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Speaker 1: your bank account, And with all the comings and goings,

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Speaker 1: it would look to someone who didn't know that you're

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Speaker 1: still making transactions. And if you happened to have some

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Speaker 1: pre scheduled emails that you'd previously written, those might go out,

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Speaker 1: and various legal things get triggered at different points, and

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Speaker 1: it will probably look for a little while like you're

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Speaker 1: still making stuff happen in the world. And I was

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Speaker 1: thinking about this the other day as an analogy to

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Speaker 1: what happens with your biology. Generally speaking, death is declared

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Speaker 1: when a heart stops beating and or someone stops breathing.

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Speaker 1: But even though we think about death like a binary event,

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Speaker 1: there's no central command center in the body that says, okay,

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Speaker 1: now we're done. Everyone stop working. Because the body is

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Speaker 1: made of literally trillions of cells, and all of their

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Speaker 1: chemical signals are connected and intricate cascades and loops and

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Speaker 1: when something stops running, these nested feedback loops tend to

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Speaker 1: bump things back to the normal range. We have this compensation. Now,

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Speaker 1: at some point the whole show grinds to a halt.

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Speaker 1: The compensatory mechanisms can't keep up with the catastrophic failure

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Speaker 1: of loop after loop that stops working, and eventually the

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Speaker 1: whole system stops. But death is not a moment in time.

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Speaker 1: It is a process. In other words, the individual cells

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Speaker 1: don't necessarily know that the heart has stopped or the

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Speaker 1: brain has stopped its cognitive whirlwind of activity, so they

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Speaker 1: just keep trucking along for as long as they can.

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Speaker 1: So here's an analogy so we can think about this.

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Speaker 1: Imagine you are a space alien that's looking down on

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Speaker 1: the Earth and you see a large blobby organism moving

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Speaker 1: towards some fortress. And then the blobby organism extends two

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Speaker 1: arms around the fortress and starts to squeeze it. But

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Speaker 1: then some explosions go off and the organism stops moving.

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Speaker 1: It seems to die. But then you use your alien

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Speaker 1: telescope to zoom in more closely, and for the first time,

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Speaker 1: you notice a single warrior running up the hill, turning

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Speaker 1: back swinging his sword, falling to his knees in lamentations,

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Speaker 1: and regaining his footing and running towards the fortress again.

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Speaker 1: So you start panning your telescope round and you notice

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Speaker 1: a dozen of these rogue swordsmen in different locations around

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Speaker 1: the battlefield. And that's when you realize that the blobby

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Speaker 1: organism who came upon the fortress was actually composed of

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Speaker 1: lots of little individual agents, all of whom worked in

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Speaker 1: concert and maybe had hierarchies and rules of engagement and

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Speaker 1: backup plans such that even when most of the army

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Speaker 1: was killed, that didn't necessitate that every part stopped the

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Speaker 1: survival of individual warriors. Suddenly, rev feels that the blob

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Speaker 1: was made of these little swordsmen all along, even though

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Speaker 1: that was difficult to see. And this is what happens biologically.

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Speaker 1: We are made up of cells that operate together. This

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Speaker 1: is what makes a person or any animal. Trillions of

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Speaker 1: cells collaborating to make this giant creature that moves around

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Speaker 1: and finds other collections of cells to eat and take

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Speaker 1: their energy. And researchers have made recent discoveries about cells

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Speaker 1: that stay alive and actually get more active well after

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Speaker 1: the rest of the body has been declared dead. In

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Speaker 1: other words, these little swordsmen warriors that are still running

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Speaker 1: around even after the blob has stopped. For example, some

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Speaker 1: researchers at University of Illinois Chicago looked at little pieces

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Speaker 1: of fresh brain that get removed during brain surgery, and

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Speaker 1: they looked at these either right when the tissue was

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Speaker 1: removed or at different times after the removal. So they

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Speaker 1: called this a simulated death experiment, and their point was

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Speaker 1: to think about what happens when tissue gets separated and dies.

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Speaker 1: And what they found after the tissue is removed is

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Speaker 1: that some brain cells actually increase their activity. These cells

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Speaker 1: will often grow really large and they sprout long finger

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Speaker 1: like processes for several hours after death. Now, in some

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Speaker 1: sense this is not too surprising, because these are glial

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Speaker 1: cells in the brain whose job is to take care

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Speaker 1: of inflammation. But the researchers pointed out that most people

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Speaker 1: don't even look at the brain after death because they

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Speaker 1: assume that everything dies. But in fact, eighty percent of

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Speaker 1: the genes being expressed kept on being expressed at their

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Speaker 1: normal levels. Twenty four hours later. A few genes had

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Speaker 1: their expression levels go down, but there was a third

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Speaker 1: group of genes, which they called zombie genes, whose activity

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Speaker 1: went up, and as a result, you have all these

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Speaker 1: cells still running around and doing stuff. And if we

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Speaker 1: zoom out our camera, we find that different organs keep

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Speaker 1: functioning for different amounts of time. So, for example, at

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Speaker 1: some point we would say the brain is dead. That's

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Speaker 1: followed a little later by the heart. Then the liver

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Speaker 1: dies next, then the kidneys and pancreas can last another

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Speaker 1: hour past that before they die, and other parts of

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Speaker 1: your body like your heart valves, and the corneas of

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Speaker 1: your eyes and your tendons and your skin that's still

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Speaker 1: alive after about a day. So the idea that everything

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Speaker 1: stops when you die is not correct. Returning to the

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Speaker 1: space alien analogy, imagine that the medics come in to

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Speaker 1: take care of the fallen warriors, and so there's still

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Speaker 1: lots of activity even after the main army has fallen.

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Speaker 1: But it gets even weirder when we talk about things

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Speaker 1: that the larger level of the creature. And there's been

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Speaker 1: a history of asking these questions. For example, you might

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Speaker 1: think that death is really clear if say a person

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Speaker 1: has had their head cut off with a guillotine, I'm

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Speaker 1: going to dive into that issue in a future episode

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Speaker 1: because the whole thing is so wacky and fascinating. But

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Speaker 1: I'll just mention now that in the eighteen hundreds, when

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Speaker 1: the guillotine was very popular, people got interested in this

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Speaker 1: question of whether the head can stay conscious after separation

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Speaker 1: from the body, and what they would do is pick

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Speaker 1: up the freshly severed head and try to get it

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Speaker 1: to talk or at least blink its eyes on command.

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Speaker 1: And at that time, other scientists were trying things like

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Speaker 1: taking a decapitated head from a German shepherd dog and

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Speaker 1: reattaching it to the blood supply of another dog to

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Speaker 1: see if simply restoring blood flow through the brain was

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Speaker 1: enough to restore its function. So stay tuned for that episode.

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Speaker 1: But what these experiment it's highlight is that this question

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Speaker 1: of where to draw the line between life and death

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Speaker 1: has been with us a long time, and in modern

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Speaker 1: times we have things like the field of cryogenics, which

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Speaker 1: is the art of freezing a body after death, so

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Speaker 1: it has a chance of being revived by future scientists

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Speaker 1: who might know how to do that, even though we

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Speaker 1: don't know now. In the field of cryogenics, it's popular

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Speaker 1: to sometimes just save the head and get rid of

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Speaker 1: the body, and the assumption or the hope really is

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Speaker 1: that that can be sufficient, and that if you are

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Speaker 1: maintained at ninety six degrees below freezing, then you're not

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Speaker 1: actually dead, but you're in a state of suspended animation

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Speaker 1: and can eventually be rebooted. So why does all this matter,

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Speaker 1: this question of where to draw the line between life

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Speaker 1: and death. Well, first of all, it matters for the

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Speaker 1: medical system, and we see cases come up all the

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Speaker 1: time in hot hospitals where there is confusion or disagreement

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Speaker 1: about how to make the call. There was a case

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Speaker 1: in Texas where the doctors told a man that his son,

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Speaker 1: who had been in a coma, would never return back

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Speaker 1: to consciousness, and so the doctors wanted to make the

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Speaker 1: call to remove the young man from life support, and

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Speaker 1: the father was so distraught that he pulled a gun

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Speaker 1: on the doctors and medical staff and wouldn't let them

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Speaker 1: near his son in the hospital bed, And so the

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Speaker 1: police were immediately dispatched and this man was arrested and

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Speaker 1: put in jail for eleven months. But incredibly, the son

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Speaker 1: enjoyed a full recovery and once the father was released

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Speaker 1: from jail. The two of them were happily reunited. All

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Speaker 1: of this points to the difficulty in determining when a

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Speaker 1: body has died irreversibly, and the question of life and

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Speaker 1: death matters enormously for legal systems because so much pivots

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Speaker 1: on whether a person is considered alive or dead in

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Speaker 1: the eyes of the law. How do we know when

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Speaker 1: that line has been crossed? So there are so many

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Speaker 1: fascinating medical and legal and ethical issues around deciding when

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Speaker 1: a person has died, and those viewpoints don't always align,

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Speaker 1: and perhaps surprisingly they often conflict badly. And add to

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Speaker 1: this particular religious practices that people have and business issues

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Speaker 1: like tax implications, and what you have is a fascinating

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Speaker 1: set of questions that arise. So that's what I want

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Speaker 1: to talk about today. How we as a society make

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Speaker 1: that call and how should we so To dig into this,

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Speaker 1: I called up my friend and colleague, Jacob Appel. Now,

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Speaker 1: Jacob is a very accomplished thinker and writer and man

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Speaker 1: of many talents. He has seven graduate degrees, but for

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Speaker 1: today's episode, the two most salient are his law degree

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Speaker 1: from Harvard and his medical degree from Columbia. Jacob works

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Speaker 1: as an emergency room psychiatrist in the Mount Sinai Health System,

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Speaker 1: and he also serves as the director of Ethics Education.

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Speaker 1: So I called him up to talk with him about

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Speaker 1: the question of how we as a society should think

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Speaker 1: about making the tough calls about whether a person should

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Speaker 1: be declared dead or not, and the complexities that lurk

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Speaker 1: inside that seemingly simple question, complexities that are scientific and

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Speaker 1: legal and cultural. How do the medical and the legal

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Speaker 1: systems decide when you are dead?

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Speaker 2: Well, it's interesting because the medical and legal systems have

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Speaker 2: very different histories and very different approaches. As a legal concept,

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Speaker 2: being dead has significant implications not just for you, but

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Speaker 2: for your loved ones and for society. So, for example,

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Speaker 2: if you're dead, your spouse can re marry, your heirrors

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Speaker 2: can inherit, You stop getting social Security. So, whatever your

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Speaker 2: biological status, if you're declared dead, it can have significant

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Speaker 2: implications for the.

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Speaker 3: World and for you as well.

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Speaker 2: I'm reminded several years ago a man from Romania had

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Speaker 2: gone to work in Turkey, and he'd been gone for

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Speaker 2: a long time.

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Speaker 3: His wife couldn't find him.

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Speaker 2: She had him legally declared dead, and then he came

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Speaker 2: back as a surprise, and he couldn't run an apartment

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Speaker 2: or get a job his casement all the way to

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Speaker 2: the Romanian Supreme Court because he was legally dead and nobody,

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Speaker 2: even though he was standing in front of him, would

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Speaker 2: overrule us. And I will mention also legally there are

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Speaker 2: these gray areas. So for example, if you were lost

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Speaker 2: to see historically, how did we know how long you

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Speaker 2: had it be gone before you were dead? And there

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Speaker 2: were different rules for how much time had it passed

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Speaker 2: before they could give away your property versus not having

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Speaker 2: rights over your children.

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Speaker 3: So you can be dead for one purpose and alive

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Speaker 3: for another.

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Speaker 1: Wasn't there some sixteenth century French soldier that this happened

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Speaker 1: to last name Gear?

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Speaker 2: Yeah, there's a great movie, The Return of Martin Gear,

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Speaker 2: which is a classic case of this, where someone allegedly

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Speaker 2: I believe it was in one hundred Years War, came

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Speaker 2: back after being lost in battle. It turned out he

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Speaker 2: actually wasn't the person who claimed he was. But there

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Speaker 2: were a number of famous cases like this over the years,

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Speaker 2: and as a famous poem by Tennyson about Enoch Arden,

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Speaker 2: hence the term that has come into the English language

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Speaker 2: Enoch Arden laws which the laws would refer to how

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Speaker 2: long you have to be missing before you're dead.

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Speaker 1: Wow. Okay, So from the legal point of view, there

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Speaker 1: are all these things to be considered, including, for example,

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Speaker 1: tax laws. Can you just mention what happened between the

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Speaker 1: two nine and twenty eleven?

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Speaker 3: Oh?

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Speaker 2: Absolutely, So the Bush administration had enacted tax laws that

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Speaker 2: gave people a significant tax break on their inheritance, and

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Speaker 2: they were going to expire at some point, and people's

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Speaker 2: inheritance taxes would go up substantially as a result of

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Speaker 2: which many people who were at the end of life

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Speaker 2: life on life support or their families want at their

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Speaker 2: life support terminated before January first, when their taxes would double.

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Speaker 3: At an entire boutique corner of a major New.

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Speaker 2: York City law firm is actually devoted specifically to this practice.

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Speaker 1: Right, So, somebody was on life support and the adult

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Speaker 1: children would say, look, it's December, let's go ahead and

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Speaker 1: pull this now so that he dies before January first.

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Speaker 2: Yeah, they would say, Grandpa would much rather die on

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Speaker 2: December thirtieth and leave one hundred billion dollars to his

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Speaker 2: grandkids than die on January second. Still unloose it. Two

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Speaker 2: days later, and leave them nothing. And honestly, I can't

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Speaker 2: argue with that.

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Speaker 1: Yeah, So how do hospital ethics boards deal with questions

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Speaker 1: like that? Sure?

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Speaker 2: Are so most decisions in hospitals or recommendations, you're done

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Speaker 2: by committee. So you have an ethics committee, You have

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Speaker 2: a consultant who actually gathers the information and presents it

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Speaker 2: to the committee, which consist of experts in a range

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Speaker 2: of different fields, so not just medicine, surgery, pediatrics, but

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Speaker 2: social work, nursing, the hospital chaplain. They sort of build

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Speaker 2: a consensus and then obviously, if you can't build a

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Speaker 2: consensus or can't get the family on board, then cases

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Speaker 2: end up going to court, and ultimately, in cases like this,

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Speaker 2: the court usually will decide looking at all the evidence

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Speaker 2: brought before them.

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Speaker 1: Okay, and so there are all these legal considerations, what

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Speaker 1: are the medical considerations when we think about what is death?

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Speaker 2: Sure, and the medical considerations are actually just as complex.

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Speaker 2: In an earlier era, you probably have seen movies like

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Speaker 2: The Cursed Living Dead, where people are believed dead and

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Speaker 2: then they come back to life suddenly, and people who

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Speaker 2: are afraid of being buried alive.

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Speaker 3: It was actually a fairly.

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Speaker 2: Ineffective diagnostic tool to be certain someone was dead, they

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Speaker 2: would do things like hold up a mirror to your

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Speaker 2: mouth and see if there was actually vapor on it,

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Speaker 2: to see if you were breathing.

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Speaker 3: So they made mistakes.

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Speaker 1: So actually this actually happened where people were buried alive.

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Speaker 2: Yes, I mean it wasn't a common occurrence, but it

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Speaker 2: did happen. I will add, as strangers who may sound

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Speaker 2: it still happens occasionally. Today you hear these stories about

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Speaker 2: people who show up in the morgue or show up

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Speaker 2: in a funeral home and suddenly they wake up. Usually,

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Speaker 2: I will add, by the way, those people are still

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Speaker 2: in a very bad shape and they don't make it

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Speaker 2: in the long run. I don't know of any case

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Speaker 2: to people who have actually been to the morgue and

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Speaker 2: then got home and good health. But people have gone

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Speaker 2: and they started breathing and ended up backing the ice

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Speaker 2: you before, So that should give us pause.

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Speaker 1: How does that happen currently? Is it in areas where

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Speaker 1: there's not good medical diagnosis of what has happened?

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Speaker 3: I wouldn't be that critical.

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Speaker 2: I would say it's a very hard There are a

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Speaker 2: whole bunch of different tests for determining whether someone is dead.

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Speaker 2: Now and different diagnostic tools and doctors do their best.

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Speaker 2: And sometimes if you're barely breathing, and if your pulses

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Speaker 2: very sporadic and they catch you a couple of times

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Speaker 2: at the wrong moment, maybe you get unlucky.

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Speaker 3: I will add often this.

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Speaker 2: Does occur in the developing world, where maybe their diagnostic

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Speaker 2: tools are not as strong. I don't know of any

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Speaker 2: cases in New York City with my luck, I'll be

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Speaker 2: the first.

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Speaker 1: Okay, So back to a few decades ago or a

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Speaker 1: century ago. So you hold a mirror to the mouth

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Speaker 1: and you see if there's fog on the mirror, and

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Speaker 1: then what happened.

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Speaker 2: So eventually we did no enough about anatomy to recognize

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Speaker 2: cardiac and pulmonary death. Cardiopulmonary death, you stop breathing and

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Speaker 2: you don't get a pulse for a propracted period of time,

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Speaker 2: we accept that you're dead.

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Speaker 1: Like how long? What's a protracted period?

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Speaker 3: That depended on the doctor.

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Speaker 2: Honestly, if you're not breathing or you know, a pulse

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Speaker 2: for a good ten to fifteen minutes, the odds of

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Speaker 2: you reviving naturally on your own get pretty darn low.

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Speaker 2: When you get much past that, your odds for surviving

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Speaker 2: in a way that is meaningfully cognitive or very low

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Speaker 2: and most people stop at some point, stop crying. But

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Speaker 2: that was the diagnostic tool back then. I will add,

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Speaker 2: by the way, that most people historically back then were

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Speaker 2: in very bad shape by the time they reached that pointing.

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Speaker 2: It's been other death bed for hours or days or weeks.

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Speaker 1: So what happened next?

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Speaker 2: So there were technological developments in medical science that allowed

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Speaker 2: us to check for cardiopulmonary death basically to figure out

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Speaker 2: whether or not your heart was still beating, whether your

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Speaker 2: lungs were still breathing, And that was the test for many,

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Speaker 2: many years until the nineteen sixties. And if you stop

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Speaker 2: breathing and if your heartstep beating, you were dead. And that,

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Speaker 2: I will add, by the way, is the test still

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Speaker 2: used in some religious communities, in some cultural traditions. Starting

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Speaker 2: in the late nineteen sixties with the advent of organ transplant,

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Speaker 2: which meant there was a need to harvest organs or

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Speaker 2: procure organs from the individuals as quickly as possible, and

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Speaker 2: the rise of artificial ventilation and later artificial heart support,

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Speaker 2: which meant that people could be kept alive for months

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Speaker 2: or even a year or two on a respirat or

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Speaker 2: on a ventilator. That created the challenge of how did

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Speaker 2: we know when these individuals were dead? And there was

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Speaker 2: a debate over whether brain death should be acceptable, and

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Speaker 2: the ultimate decision was made by a committee of experts

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Speaker 2: at Harvard that has been adopted widely that whole brain

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Speaker 2: death would be the standard. So, if you have two

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Speaker 2: flat EEGs, your brain stops functioning entirely, you are now

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Speaker 2: legally dead in every state. I will add New Jersey,

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Speaker 2: and to a lesser degree under some circumstances. New York

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Speaker 2: allows people with a religious belief only in cardiopulmonary death

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Speaker 2: to opt out of that standard, but other states do not.

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Speaker 1: So give me an example of having a religious belief

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Speaker 1: and how that might change the decision that a family makes.

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Speaker 3: Sure.

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Speaker 2: So let us say that my grandfather is on a

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Speaker 2: ventilator which is artificial. One support and intet to buy

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Speaker 2: that which is a machimee that for a short period

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Speaker 2: of time to fairly late the period of time. Now

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Speaker 2: with new technology can replace the heart, so it's entirely artificial.

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Speaker 2: And yet he has two flat egs. His brain is

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Speaker 2: showing no function at all. In New Jersey. If I

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Speaker 2: have a religious tradition that says that only cardiopulmonary depth

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Speaker 2: is alive. In theory, I could raise the funds to

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Speaker 2: bring that individual home to my living room and keep

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Speaker 2: them on ventilator support and buy bad support until they

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Speaker 2: can no longer support their cart and lungs with those machines,

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Speaker 2: which could be a year.

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Speaker 1: And this happens sometimes right where someone takes a person home.

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Speaker 3: It is rare, but it has happened.

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Speaker 2: I believe there was a famous case in Utah, a

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Speaker 2: Jesse Kutchin case where it has happened. In addition to

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Speaker 2: which there have been cases where people the Johi McMath

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Speaker 2: case may be the most known, who were what was

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Speaker 2: presumed to be a state of brain depth for families

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Speaker 2: who do not accept that definition, who brought their relatives

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Speaker 2: to New Jersey to then replace the facilities that keep

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Speaker 2: people who are alive in a cardiopulmonary manner but is

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Speaker 2: ceased by the brain death standard alive.

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Speaker 1: And what's the reason that people do this. It's because

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Speaker 1: their religioustration tells them even though they're on a bivalve

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Speaker 1: and there on a ventilator, they do they think the

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Speaker 1: person could come back, or they have other issues. I

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Speaker 1: know you wrote once about somebody's belief in reincarnation and

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Speaker 1: how that affected.

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Speaker 2: So there are two different categories of people, and we

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Speaker 2: might treat the cases the same way or differently.

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Speaker 3: There are those.

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Speaker 2: Individuals who truly believe that their relative is going to

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Speaker 2: revive themselves, even though the data, overwhelmingly from past practice

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Speaker 2: says that's not going to happen, and they're hoping for

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Speaker 2: a miracle.

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Speaker 3: So to speak.

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Speaker 2: There are other individuals who may say, you know, I

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Speaker 2: understand that my grandfather isn't really going to wake up again,

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Speaker 2: but either I, or more appropriately, he had a deep

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Speaker 2: religious belief that it was important to die of quote

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Speaker 2: unquote natural causes or if you believe in reincarnation, to

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Speaker 2: die at a certain time, and I want to fulfill

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Speaker 2: his wish, even though I understand that by your standard

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Speaker 2: he's dead. By a religious standard of our book, our Bible,

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Speaker 2: or tradition, he's not dead, and I want to wait

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Speaker 2: the process out.

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Speaker 3: I'll add one more thought on that it's okay, which.

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Speaker 2: Is you also might want to ask the question, does

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Speaker 2: it matter whether if someone's been declared brain dead you're

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Speaker 2: willing to pay for it when you take them home,

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Speaker 2: whether you're asking the taxpayers to put the bill for it,

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Speaker 2: because then the vast majority of us would say, the

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Speaker 2: taxpayers are paying to keep a dead person on a

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Speaker 2: life support system in your living room. And the other

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Speaker 2: thing to think about is there's something inappropriate or grotesque

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Speaker 2: about it. If I were to want to bring my

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Speaker 2: grandmother home embalmed like Lenin on display in his tomb

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Speaker 2: and prop work in my living room, our society would

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Speaker 2: not let me do that, not just for public health reasons,

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Speaker 2: but probably for reasons of what we would call common

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Speaker 2: decency or horem or appropriateness.

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Speaker 3: Some would argue, this is not that different.

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Speaker 1: And how does this work in terms of making decisions

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Speaker 1: for somebody else. Let's say that somebody is in critical condition.

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Speaker 1: It doesn't look likely they'll recover, but maybe there's some

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Speaker 1: extreme measures you can take that involve amputations and other things,

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Speaker 1: and a decision has to be made about whether that

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Speaker 1: person would want that kind of heroic medical treatment with

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Speaker 1: the possible consequences. How does a hospital make the decision

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Speaker 1: about that?

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Speaker 2: So, while there is some variation among state laws, the

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Speaker 2: general accepted principle in this country is that we use

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Speaker 2: a substituted judgment or vicarious judgment standard, which if we asked,

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Speaker 2: what would this person would have wanted if they were

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Speaker 2: still awake and lucid and able to express an opinion.

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Speaker 2: The only two groups of people we don't use that

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Speaker 2: approach for are children, where parents can decide based on

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Speaker 2: what they perceive to be the best interest within certain

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Speaker 2: societal parameters, and people who've never had the capacity or

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Speaker 2: ability to make that decision. We view it as too

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Speaker 2: far elite to say you were born with a such

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Speaker 2: a significant cognitive impairment that you could never understand his question.

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Speaker 2: But if you hadn't been bored in that way, what

440
00:24:53,600 --> 00:24:54,920
Speaker 2: would you want to have had done.

441
00:24:55,280 --> 00:24:57,639
Speaker 3: I've actually been critical of that latter approach.

442
00:24:57,560 --> 00:25:00,919
Speaker 2: Because in that situation we use a societal best interest standard,

443
00:25:01,400 --> 00:25:04,000
Speaker 2: what society would think is in your best interests. I

444
00:25:04,040 --> 00:25:07,520
Speaker 2: have argued that for certain communities, let's say you're an Amish,

445
00:25:07,560 --> 00:25:10,840
Speaker 2: Mennonite or a Casidic Jew, it might be more appropriate

446
00:25:10,840 --> 00:25:13,000
Speaker 2: to ask what would be the best interest standard in

447
00:25:13,040 --> 00:25:16,480
Speaker 2: your community, because it doesn't seem too far a bridge

448
00:25:16,480 --> 00:25:18,560
Speaker 2: for me to say, if you were born a Mennonite,

449
00:25:18,600 --> 00:25:20,879
Speaker 2: you would want what a Menonite tradition speaks to not

450
00:25:21,000 --> 00:25:22,440
Speaker 2: be overall societal standard.

451
00:25:24,000 --> 00:25:27,359
Speaker 1: Tell me about what happened during Hurricane Katrina with the

452
00:25:27,440 --> 00:25:29,119
Speaker 1: ventilators and what that means.

453
00:25:30,560 --> 00:25:35,159
Speaker 2: Sure, so, I think during Hurricane Katrina there was a

454
00:25:35,200 --> 00:25:38,800
Speaker 2: medical crisis where they had patients who were ventilators who

455
00:25:38,840 --> 00:25:41,919
Speaker 2: needed them to stay alive, and a number of questions

456
00:25:41,920 --> 00:25:45,320
Speaker 2: around end of life arose. One the medical teams for

457
00:25:45,400 --> 00:25:47,240
Speaker 2: safety had to leave some of these patients. Some of

458
00:25:47,240 --> 00:25:50,040
Speaker 2: them could not be evacuated, and they had to decide

459
00:25:50,080 --> 00:25:53,280
Speaker 2: whether or not to continue them on life support, whether

460
00:25:53,400 --> 00:25:57,000
Speaker 2: or not to use morphine or other techniques to ease

461
00:25:57,040 --> 00:26:00,600
Speaker 2: their suffering that could have the risk of death. Into trial,

462
00:26:00,600 --> 00:26:02,440
Speaker 2: there was a doctor Poe was actually put on trial

463
00:26:02,480 --> 00:26:04,000
Speaker 2: and eventually acquitted for her role in this.

464
00:26:04,440 --> 00:26:05,440
Speaker 3: These were not easy.

465
00:26:05,280 --> 00:26:09,560
Speaker 1: Questions, right, because the decision she made was, you know,

466
00:26:09,600 --> 00:26:12,680
Speaker 1: if we are going to run out of power, then

467
00:26:12,840 --> 00:26:16,200
Speaker 1: people will suffer if they don't have the ventilator on anymore,

468
00:26:16,720 --> 00:26:20,840
Speaker 1: and so do we pull the plug before we run

469
00:26:20,880 --> 00:26:22,600
Speaker 1: out of power? Was that the issue?

470
00:26:23,840 --> 00:26:26,399
Speaker 2: I mean, that was what she was accused of doing.

471
00:26:26,960 --> 00:26:29,280
Speaker 2: As she describes it. I believe she would say she

472
00:26:29,359 --> 00:26:32,639
Speaker 2: was giving people morphine or other medication with a dual

473
00:26:32,640 --> 00:26:35,560
Speaker 2: intent that might have ended their life as a result,

474
00:26:35,600 --> 00:26:38,199
Speaker 2: but the primary goal was to ease their suffering. And

475
00:26:38,400 --> 00:26:40,719
Speaker 2: in palliative care and end of life decision making, we

476
00:26:40,800 --> 00:26:44,120
Speaker 2: often do recognize this concept of dual intent. We may

477
00:26:44,119 --> 00:26:47,080
Speaker 2: intend to do one thing that inadvertently is a different consequence,

478
00:26:47,520 --> 00:26:50,520
Speaker 2: but intending to relieve suffering that leads to death, we

479
00:26:50,640 --> 00:26:53,200
Speaker 2: view conceptually is very different from intending to cause death.

480
00:27:10,320 --> 00:27:13,280
Speaker 1: Okay, so the way we make decisions about death now

481
00:27:13,880 --> 00:27:17,880
Speaker 1: has to do in part with this concept of irreversibility.

482
00:27:18,720 --> 00:27:21,160
Speaker 1: And my question to you is how do you think

483
00:27:21,200 --> 00:27:24,120
Speaker 1: about this in terms of the new technologies that are

484
00:27:24,119 --> 00:27:30,600
Speaker 1: coming along and change that definition of irreversibility.

485
00:27:31,200 --> 00:27:33,720
Speaker 2: I mean, this comes up not just with defining death,

486
00:27:33,760 --> 00:27:38,240
Speaker 2: but an all end of life decision making. So people

487
00:27:38,560 --> 00:27:41,000
Speaker 2: may be toward the end of life and have what

488
00:27:41,040 --> 00:27:43,679
Speaker 2: we call it terminal prognosis, but there's no way to

489
00:27:43,680 --> 00:27:46,120
Speaker 2: be certain that a new technology will develop that can

490
00:27:46,160 --> 00:27:48,800
Speaker 2: cure their illness. And there have been cases now of

491
00:27:48,840 --> 00:27:51,920
Speaker 2: people with rare cancers that seemed to one hundred percent fatal

492
00:27:52,000 --> 00:27:56,000
Speaker 2: they always had been before, where new immunotherapies suddenly appear

493
00:27:56,000 --> 00:27:59,320
Speaker 2: in the market or emerge as experimental treatments that then

494
00:27:59,359 --> 00:28:00,160
Speaker 2: save their lives.

495
00:28:00,480 --> 00:28:01,159
Speaker 3: And who are we to.

496
00:28:01,160 --> 00:28:03,879
Speaker 2: Take away someone's hope, which is why we generally defer

497
00:28:04,119 --> 00:28:06,800
Speaker 2: to what the patient's wishes are. And that also creates

498
00:28:06,840 --> 00:28:11,200
Speaker 2: an economic challenge, because we may know society that almost

499
00:28:11,240 --> 00:28:13,520
Speaker 2: everyone in this situation dies, or even that so far

500
00:28:13,560 --> 00:28:15,960
Speaker 2: everybody has. But who are we to take away hope

501
00:28:16,000 --> 00:28:18,280
Speaker 2: from the veryous one number of people who want to

502
00:28:18,320 --> 00:28:21,000
Speaker 2: be the teals, so to speak, and not the bell.

503
00:28:21,160 --> 00:28:23,119
Speaker 3: I can give you a very concrete example of this.

504
00:28:23,800 --> 00:28:25,639
Speaker 2: I don't know if it's still true, but there was

505
00:28:25,680 --> 00:28:27,840
Speaker 2: a time when if you went on the internet, let's

506
00:28:27,840 --> 00:28:30,879
Speaker 2: say you were diagnosed with ALS blue garage disease and

507
00:28:30,960 --> 00:28:34,960
Speaker 2: typed in prognosis ALS blue garage disease on Google, the

508
00:28:35,000 --> 00:28:37,439
Speaker 2: first picture that came up was not lou Garage.

509
00:28:37,880 --> 00:28:38,800
Speaker 3: It was Stephen Hawking.

510
00:28:39,320 --> 00:28:43,000
Speaker 2: The physicists who lived I'm guessing thirty forty years with

511
00:28:43,080 --> 00:28:46,560
Speaker 2: the illness, even though the vast majority of people died.

512
00:28:46,360 --> 00:28:47,360
Speaker 3: Within a few years.

513
00:28:47,560 --> 00:28:49,600
Speaker 2: And once you see that, it's hard to make any

514
00:28:49,680 --> 00:28:52,320
Speaker 2: meaning out of statements like a certain percentage of Medicare

515
00:28:52,360 --> 00:28:54,960
Speaker 2: or Medicaid dollars are spent in a certain period toward

516
00:28:54,960 --> 00:28:57,400
Speaker 2: the end of life, because as I always ask the

517
00:28:57,400 --> 00:29:00,080
Speaker 2: medical students after I explain that, I say, if if

518
00:29:00,080 --> 00:29:01,959
Speaker 2: you're in the last six months of life, raise your

519
00:29:02,000 --> 00:29:02,560
Speaker 2: hand now.

520
00:29:03,000 --> 00:29:04,280
Speaker 3: And obviously we don't know.

521
00:29:05,440 --> 00:29:08,440
Speaker 1: So Jacob, when you think about the question of irreversibility,

522
00:29:08,440 --> 00:29:10,040
Speaker 1: what do you think about cryogenics?

523
00:29:11,880 --> 00:29:14,920
Speaker 2: So I'm not one who can say that cryogenics will

524
00:29:14,960 --> 00:29:17,080
Speaker 2: never work, though my guess is there will be other

525
00:29:17,160 --> 00:29:19,800
Speaker 2: technologies that will be developed beforehand that may be far

526
00:29:19,880 --> 00:29:25,000
Speaker 2: more effective at life lengthening, or life preserving, or even reversibility.

527
00:29:25,440 --> 00:29:27,720
Speaker 2: I can say that nothing I have seen suggests that

528
00:29:27,800 --> 00:29:30,880
Speaker 2: criogenics as it works now is very effective. I would

529
00:29:30,880 --> 00:29:33,760
Speaker 2: not suggest having your head caught off now in storage somewhere.

530
00:29:34,920 --> 00:29:37,040
Speaker 1: What else are you seeing that seems like it could

531
00:29:37,080 --> 00:29:37,800
Speaker 1: be more effective?

532
00:29:39,320 --> 00:29:41,480
Speaker 2: I mean, I think at some point, and this is

533
00:29:41,600 --> 00:29:44,120
Speaker 2: obviously in a far fetched way, many many years in

534
00:29:44,160 --> 00:29:48,120
Speaker 2: the future, we may be able to download people's personality,

535
00:29:48,200 --> 00:29:52,200
Speaker 2: download their brands into some kind of system A computer

536
00:29:52,320 --> 00:29:55,200
Speaker 2: might be too simplistical word, but some kind of extra

537
00:29:55,280 --> 00:29:58,640
Speaker 2: intelligence system that can then reprogram individualism in a way

538
00:29:58,840 --> 00:30:00,600
Speaker 2: That is not something I would say that you should

539
00:30:00,640 --> 00:30:02,880
Speaker 2: bank on in your lifetime or mind. I think we're

540
00:30:02,920 --> 00:30:06,440
Speaker 2: far better off focusing on technologies that can extend human

541
00:30:06,440 --> 00:30:09,800
Speaker 2: life as it exists now. And I will add even

542
00:30:09,840 --> 00:30:13,360
Speaker 2: beyond that, we may ultimately have that technology to transfer

543
00:30:13,800 --> 00:30:16,760
Speaker 2: heads from one individual or a brand from individual into

544
00:30:16,800 --> 00:30:19,360
Speaker 2: bodies of another, but again we are nowhere near prime

545
00:30:19,440 --> 00:30:21,760
Speaker 2: time on that. I know there's an Italian sturage, and

546
00:30:21,760 --> 00:30:24,360
Speaker 2: thinking about doing that, I would be very reluctant to

547
00:30:24,400 --> 00:30:27,360
Speaker 2: try that procedure because not only the possibility will work,

548
00:30:27,560 --> 00:30:30,760
Speaker 2: which the possibility, what would suffer immensely during the process.

549
00:30:31,640 --> 00:30:35,560
Speaker 1: I think maybe it was Paul Broca. Somebody actually did

550
00:30:35,560 --> 00:30:37,959
Speaker 1: this with German shepherd dogs, where they cut off one

551
00:30:38,000 --> 00:30:41,280
Speaker 1: head and attached to the vasculature to the heart of

552
00:30:41,320 --> 00:30:45,680
Speaker 1: another dog and kept the head alive that way.

553
00:30:46,120 --> 00:30:47,880
Speaker 2: I'm not sure if it always broke up, but a

554
00:30:47,960 --> 00:30:50,440
Speaker 2: number of different people have done this over the years,

555
00:30:50,960 --> 00:30:54,600
Speaker 2: with more or less suctatistic with various animals, So the

556
00:30:54,600 --> 00:30:58,600
Speaker 2: theoretical concept is there. There obviously are both a number

557
00:30:58,600 --> 00:31:01,840
Speaker 2: of logistical premises is in terms of attaching neurop tissue,

558
00:31:02,200 --> 00:31:05,920
Speaker 2: and also a large number of ethical dilemmas. It's very

559
00:31:06,160 --> 00:31:08,120
Speaker 2: I don't want to say easy, but it's much more

560
00:31:08,160 --> 00:31:10,600
Speaker 2: easy to get decided to accept killing a German shepherd

561
00:31:10,760 --> 00:31:12,040
Speaker 2: to say of another German shepherd.

562
00:31:12,040 --> 00:31:13,880
Speaker 3: They get used to kill one person to say of

563
00:31:13,920 --> 00:31:14,520
Speaker 3: another person.

564
00:31:15,400 --> 00:31:18,400
Speaker 1: That's right, Although as I as I understand it, it's

565
00:31:19,160 --> 00:31:22,320
Speaker 1: the idea is taking somebody who is brain dead but

566
00:31:22,360 --> 00:31:25,680
Speaker 1: their body is still functioning, and then taking somebody else

567
00:31:25,720 --> 00:31:29,480
Speaker 1: who has a functioning brain. But let's say they're quadriplegic

568
00:31:29,560 --> 00:31:32,200
Speaker 1: and their body is degrading. So it's somebody who is

569
00:31:32,280 --> 00:31:36,920
Speaker 1: already judged to be dead by brain dead standards. Is

570
00:31:36,960 --> 00:31:37,719
Speaker 1: the first body?

571
00:31:39,160 --> 00:31:43,400
Speaker 2: Absolutely, I mean that that is the theoretical approach. The

572
00:31:43,480 --> 00:31:47,400
Speaker 2: obviously both logistical challenges in terms of what if you

573
00:31:47,440 --> 00:31:50,880
Speaker 2: have a mismatch of heads and bodies, and the ethical

574
00:31:50,960 --> 00:31:54,040
Speaker 2: questions of who this person legally is going forward and

575
00:31:54,080 --> 00:31:57,000
Speaker 2: how they relate to their one family versus the other

576
00:31:57,400 --> 00:32:01,120
Speaker 2: inheritance whose fingerprints to the have in a legal sense

577
00:32:01,320 --> 00:32:04,480
Speaker 2: becomes very very complicated, very very quickly. I'm not saying

578
00:32:04,480 --> 00:32:07,000
Speaker 2: this issue can't be solved. I would say we want

579
00:32:07,040 --> 00:32:10,120
Speaker 2: to solve these questions before we start using the technology,

580
00:32:10,400 --> 00:32:12,360
Speaker 2: or we're going to find yourself painted into a very

581
00:32:12,400 --> 00:32:13,120
Speaker 2: unpleasant quarter.

582
00:32:14,280 --> 00:32:17,080
Speaker 1: Yes, So let me come back to that question about

583
00:32:17,520 --> 00:32:21,800
Speaker 1: how committees at hospitals, how ethics committees make this decision.

584
00:32:21,840 --> 00:32:24,479
Speaker 1: You pointed out that ethics committees are made up of

585
00:32:24,800 --> 00:32:28,160
Speaker 1: many different points of view. What have you seen is

586
00:32:28,200 --> 00:32:33,240
Speaker 1: the most contentious argument that you have come across.

587
00:32:34,280 --> 00:32:36,960
Speaker 2: I can tell you that speaking more broadly, because I

588
00:32:37,000 --> 00:32:39,680
Speaker 2: don't want to reveal now Sini's confidential epics debates, but

589
00:32:39,840 --> 00:32:44,560
Speaker 2: historically the most controversial issue in epics committees has related

590
00:32:44,600 --> 00:32:47,320
Speaker 2: to a very specific scenario that occurred over and over

591
00:32:47,360 --> 00:32:50,720
Speaker 2: again throughout this country from nineteen seventies through the nineteen nineties,

592
00:32:51,000 --> 00:32:54,360
Speaker 2: and how to do with patients who were in accidents

593
00:32:54,520 --> 00:32:57,560
Speaker 2: with C three S force bibal fractures so they would

594
00:32:57,640 --> 00:32:59,680
Speaker 2: never be able to breathe again on their own, never

595
00:32:59,680 --> 00:33:01,480
Speaker 2: be able to to move below their neck on their own,

596
00:33:01,800 --> 00:33:03,800
Speaker 2: and they would wake up from his accidents and say,

597
00:33:04,160 --> 00:33:05,920
Speaker 2: I don't want to live like this, turn my life

598
00:33:05,960 --> 00:33:10,000
Speaker 2: support off, and palliative care would say we need to

599
00:33:10,040 --> 00:33:13,080
Speaker 2: respect their autonomous wishes. They don't want to suffer. And

600
00:33:13,120 --> 00:33:17,280
Speaker 2: psychiatry would say, but we know that a certain percentage

601
00:33:17,280 --> 00:33:21,120
Speaker 2: of people, approximately half who we do talk into staying

602
00:33:21,120 --> 00:33:24,160
Speaker 2: alive and do therapy with after a year are actually

603
00:33:25,320 --> 00:33:27,640
Speaker 2: glad they stayed alive and take meaningful value in their life.

604
00:33:27,640 --> 00:33:30,200
Speaker 2: And they point out, for example, the Superman actor Christopher

605
00:33:30,280 --> 00:33:33,040
Speaker 2: Reeve and Pallid of Care would cut back and say, yes,

606
00:33:33,080 --> 00:33:35,360
Speaker 2: but we know that the other half or not, and

607
00:33:35,440 --> 00:33:37,840
Speaker 2: the interest to the other half to not suffer existentially

608
00:33:38,120 --> 00:33:41,000
Speaker 2: outweigh those of the first half to have a meaningful

609
00:33:41,040 --> 00:33:43,080
Speaker 2: life in the long run. And this was a deeply

610
00:33:43,120 --> 00:33:47,520
Speaker 2: heated debate which there's no conceptually correct answer. You can't

611
00:33:48,320 --> 00:33:50,520
Speaker 2: reduce it to any level where there's a right answer.

612
00:33:50,800 --> 00:33:53,040
Speaker 2: I can tell you in practice, palliad of care has

613
00:33:53,040 --> 00:33:53,760
Speaker 2: won misbattle.

614
00:33:54,080 --> 00:33:58,080
Speaker 1: Ah And what was it with Christopher Reeve? Which way

615
00:33:58,080 --> 00:33:59,800
Speaker 1: did he go on that he was happy that he

616
00:33:59,840 --> 00:34:00,920
Speaker 1: had stay alive.

617
00:34:01,360 --> 00:34:01,960
Speaker 3: After a year?

618
00:34:01,960 --> 00:34:03,800
Speaker 2: Even I think before a year he'd was very grateful

619
00:34:03,840 --> 00:34:05,840
Speaker 2: to have stayed live and he brought great meaning to

620
00:34:05,920 --> 00:34:08,600
Speaker 2: his life and helped others. But I will add, if

621
00:34:08,640 --> 00:34:12,000
Speaker 2: you're Superman and you have a loving family and a

622
00:34:12,000 --> 00:34:14,840
Speaker 2: great deal of financials for it and amazing doctors, it

623
00:34:14,920 --> 00:34:17,759
Speaker 2: may be easier to find that comfort zone than if

624
00:34:17,800 --> 00:34:20,640
Speaker 2: you're indigent. If you don't have social support if you

625
00:34:20,640 --> 00:34:22,399
Speaker 2: don't have good medical care, if you're in a back

626
00:34:22,440 --> 00:34:25,319
Speaker 2: room somewhere in a nursing facility. So I think the

627
00:34:25,480 --> 00:34:27,959
Speaker 2: other major issue that is the end of life, which

628
00:34:27,960 --> 00:34:30,760
Speaker 2: we've only touched on the iceberg tip of the iceberg

629
00:34:30,840 --> 00:34:33,520
Speaker 2: up so far. He is medical aid and dying, which

630
00:34:33,520 --> 00:34:36,680
Speaker 2: has become a national debate over when, if ever, people

631
00:34:36,680 --> 00:34:38,799
Speaker 2: can choose to end their own lives. And there's a

632
00:34:38,840 --> 00:34:42,440
Speaker 2: slow consensus building that people with terminal illness, terminal physical

633
00:34:42,480 --> 00:34:45,160
Speaker 2: illness should be able to end their own lives if

634
00:34:45,160 --> 00:34:48,799
Speaker 2: they have a diagnosis of als or cancer and they're

635
00:34:48,840 --> 00:34:50,520
Speaker 2: not going to survive a prolonged period of time. And

636
00:34:50,560 --> 00:34:53,520
Speaker 2: we've seen from one state, Oregon in the nineteen nineties

637
00:34:53,520 --> 00:34:56,160
Speaker 2: to I believe it's now ten jurisdictions to legalize this,

638
00:34:56,600 --> 00:34:59,640
Speaker 2: and the trend going forward is to expand this. However,

639
00:34:59,719 --> 00:35:02,320
Speaker 2: we have really not come to terms with a question

640
00:35:02,440 --> 00:35:06,920
Speaker 2: of people who are not suffering physically but suffering psychiatrically

641
00:35:07,440 --> 00:35:11,600
Speaker 2: or existentially. And for example, we've seen this heated debate

642
00:35:11,600 --> 00:35:15,240
Speaker 2: in Colorado over patients with anarettia who have not responded

643
00:35:15,280 --> 00:35:17,640
Speaker 2: to treatment over a very long period of time should

644
00:35:17,640 --> 00:35:22,880
Speaker 2: be able to turn down refeeding or turn down nutritional support,

645
00:35:23,120 --> 00:35:24,400
Speaker 2: even if it means the end of their life, and

646
00:35:24,440 --> 00:35:26,800
Speaker 2: the way we would let a patient with a kidney

647
00:35:26,840 --> 00:35:29,240
Speaker 2: problem turn down dialysis let themselves die.

648
00:35:29,600 --> 00:35:31,440
Speaker 3: And we're going to see this question more and more.

649
00:35:31,800 --> 00:35:34,120
Speaker 2: Obviously, if you show up in the emergency room and

650
00:35:34,160 --> 00:35:36,279
Speaker 2: you've broken up with your prom date and you take

651
00:35:36,280 --> 00:35:37,920
Speaker 2: it over as a tile and all, I don't think

652
00:35:37,960 --> 00:35:39,879
Speaker 2: any Risgilble person would say, well, you've had a long,

653
00:35:39,960 --> 00:35:42,120
Speaker 2: meaningful life, you should be able to make this decision.

654
00:35:42,480 --> 00:35:45,200
Speaker 2: On the other head, if you've had depression for forty

655
00:35:45,239 --> 00:35:48,200
Speaker 2: years and you've suffered and no treatment is worked after

656
00:35:48,239 --> 00:35:51,200
Speaker 2: every intervention and you say, if you could help me,

657
00:35:51,239 --> 00:35:53,239
Speaker 2: I want that, But since you can't, please let me

658
00:35:53,280 --> 00:35:53,880
Speaker 2: in my life.

659
00:35:54,000 --> 00:35:54,880
Speaker 3: It's a harder question.

660
00:35:56,560 --> 00:35:58,799
Speaker 1: And why do you see these questions coming up more

661
00:35:58,800 --> 00:35:59,160
Speaker 1: and more?

662
00:36:00,160 --> 00:36:02,840
Speaker 2: Well, I think they've come up in part because patients

663
00:36:02,880 --> 00:36:06,040
Speaker 2: are raising these issues and the clinical practice. Patients often

664
00:36:06,080 --> 00:36:08,920
Speaker 2: will say, doctor, I've done everything you've asked me to do.

665
00:36:09,280 --> 00:36:11,640
Speaker 2: I'm in that very small percentage of people who simply

666
00:36:11,760 --> 00:36:16,000
Speaker 2: don't respond to treatment, whether it's for psychosis or for

667
00:36:16,120 --> 00:36:19,279
Speaker 2: depression or for anxiety. I wish I did but I've

668
00:36:19,320 --> 00:36:21,440
Speaker 2: waited you out for forty years and there hasn't been

669
00:36:21,440 --> 00:36:23,760
Speaker 2: a new technology. I don't want to wait any longer.

670
00:36:24,960 --> 00:36:28,120
Speaker 2: And you've actually seen a handful of countries, Canada most recently,

671
00:36:28,360 --> 00:36:29,400
Speaker 2: adopt legalization.

672
00:36:31,440 --> 00:36:34,640
Speaker 1: And so what do hospital ethics committees decide on these

673
00:36:35,120 --> 00:36:38,640
Speaker 1: or is it just a very contentious issue or people disagree?

674
00:36:39,239 --> 00:36:41,480
Speaker 2: Well, it's not yet a contentious issue in the United States,

675
00:36:41,520 --> 00:36:44,239
Speaker 2: because no American state lets you make this choice yet.

676
00:36:44,520 --> 00:36:47,280
Speaker 2: But I imagine now that Canada and several European countries

677
00:36:47,320 --> 00:36:49,799
Speaker 2: have changed their rules in the last year or two,

678
00:36:50,160 --> 00:36:52,680
Speaker 2: we're going to see at least debate over this coming forward.

679
00:36:52,680 --> 00:36:53,279
Speaker 3: In the United States.

680
00:36:53,320 --> 00:36:57,160
Speaker 2: I were to hear colleges discussing this and this widespread disagreement.

681
00:36:58,440 --> 00:37:01,680
Speaker 1: So what's going on in the United States? Is medical

682
00:37:01,680 --> 00:37:06,080
Speaker 1: assistant suicide for someone who is physically ill, right, but

683
00:37:06,120 --> 00:37:07,399
Speaker 1: not mentally exactly? Okay?

684
00:37:07,760 --> 00:37:09,759
Speaker 2: Yeah, and I will add in all the cases in

685
00:37:09,760 --> 00:37:13,040
Speaker 2: the United States, we do not have a euphenagia program.

686
00:37:13,160 --> 00:37:14,920
Speaker 2: We do not end someone's life if they can't make

687
00:37:14,920 --> 00:37:16,839
Speaker 2: the choice on their own. We only have a program

688
00:37:16,880 --> 00:37:19,640
Speaker 2: where we will prescribe your medication to let you choose death.

689
00:37:19,680 --> 00:37:23,080
Speaker 2: When the time comes. In my own experience, having talked

690
00:37:23,120 --> 00:37:25,919
Speaker 2: to many patients, and this may surprise people, be people

691
00:37:25,960 --> 00:37:28,640
Speaker 2: who benefit from this option the most are people who

692
00:37:28,680 --> 00:37:31,840
Speaker 2: never use it and people who know that if things

693
00:37:31,880 --> 00:37:35,360
Speaker 2: got bad enough, they could make this choice, which actually

694
00:37:35,400 --> 00:37:38,680
Speaker 2: gives them hope to keep on fighting their illness. It's paradoxical,

695
00:37:38,880 --> 00:37:43,120
Speaker 2: but it's really a stunning phenomena, fascinating.

696
00:37:43,640 --> 00:37:46,520
Speaker 1: How does it work? Sorry, so they're prescribed the medication

697
00:37:46,560 --> 00:37:49,759
Speaker 1: that are actually given them, medication where they can pull

698
00:37:49,800 --> 00:37:52,480
Speaker 1: the ripcord if they want to. Is that the idea?

699
00:37:53,200 --> 00:37:55,200
Speaker 2: Yeah, So a doctor will write you a prescription and

700
00:37:55,200 --> 00:37:58,000
Speaker 2: you fill the prescription after a number of safeguards, an

701
00:37:57,960 --> 00:38:00,319
Speaker 2: interview with a psychiatrist. I mean, you can choose whether

702
00:38:00,360 --> 00:38:02,200
Speaker 2: to take this medication that will end your life in

703
00:38:02,239 --> 00:38:04,880
Speaker 2: a very peaceful way. In some states people actually have

704
00:38:05,000 --> 00:38:07,200
Speaker 2: going away parties, so to speak, where they bring their

705
00:38:07,239 --> 00:38:09,759
Speaker 2: friends and family, which is not that different from how

706
00:38:09,800 --> 00:38:13,279
Speaker 2: death was in the nineteenth century, when people often had

707
00:38:13,320 --> 00:38:15,400
Speaker 2: diseases that were terminal, where they would be on a

708
00:38:15,440 --> 00:38:17,960
Speaker 2: deathbed and their friends and family would come to say goodbye.

709
00:38:18,400 --> 00:38:21,879
Speaker 2: Now we've sanitized death in a way. People die in hospitals.

710
00:38:22,680 --> 00:38:26,080
Speaker 2: I think as a medical resident, the most disconcerting experience

711
00:38:26,239 --> 00:38:28,879
Speaker 2: ever was showing up in a hospital room at five

712
00:38:28,920 --> 00:38:30,360
Speaker 2: in the morning, six in the morning to see a

713
00:38:30,400 --> 00:38:33,520
Speaker 2: patient you've seen the night before, and finding the room empty,

714
00:38:33,560 --> 00:38:36,719
Speaker 2: which the patient had passed away overnight and completely sanitized

715
00:38:36,719 --> 00:38:39,279
Speaker 2: and stripped down, like a hotel room where sometimes even

716
00:38:39,360 --> 00:38:41,640
Speaker 2: they already brought the next patient into the bed, which

717
00:38:41,680 --> 00:38:45,200
Speaker 2: are very different and in some ways dehumanizing process. I

718
00:38:45,280 --> 00:38:48,280
Speaker 2: understand why that may be necessary with the economic forces

719
00:38:48,320 --> 00:38:51,480
Speaker 2: in medicine right now, better than having the living person

720
00:38:51,560 --> 00:38:56,840
Speaker 2: waiting on a gurning and a foyer, but it's still unsettling.

721
00:38:57,040 --> 00:39:00,000
Speaker 1: Give me a sense of how people did used to die.

722
00:39:01,400 --> 00:39:04,640
Speaker 2: So often if you had a terminal illness by cancer

723
00:39:04,920 --> 00:39:08,160
Speaker 2: or heart disease, there were far fewer treatments in there

724
00:39:08,200 --> 00:39:11,440
Speaker 2: are today, So you're running time, so to speak, between

725
00:39:11,440 --> 00:39:13,600
Speaker 2: when you got ill and when you would die and

726
00:39:13,640 --> 00:39:15,880
Speaker 2: when you would make lucidity before you die would actually

727
00:39:15,880 --> 00:39:18,600
Speaker 2: be longer, so people would have a sense they were dying,

728
00:39:18,640 --> 00:39:20,920
Speaker 2: and they could call their family together. They could call

729
00:39:20,960 --> 00:39:23,080
Speaker 2: the priests for the last rites, or the minister to

730
00:39:23,120 --> 00:39:26,040
Speaker 2: say a blessing or of a rabbi to say farewell.

731
00:39:26,640 --> 00:39:27,759
Speaker 3: They could rewrite their will.

732
00:39:28,000 --> 00:39:30,640
Speaker 2: There are all sorts of both cases in mystery novels

733
00:39:30,640 --> 00:39:33,520
Speaker 2: in the nineteenth and early twentieth century about rewriting wills.

734
00:39:33,840 --> 00:39:36,239
Speaker 2: And that's because people have this window that we really

735
00:39:36,239 --> 00:39:40,560
Speaker 2: don't have today, because people live until their bodies essence

736
00:39:40,560 --> 00:39:41,080
Speaker 2: shut down.

737
00:39:41,360 --> 00:39:43,160
Speaker 3: I think a related question.

738
00:39:44,360 --> 00:39:50,000
Speaker 2: Is so George Church, who's a biologist at Guganticist d

739
00:39:50,000 --> 00:39:54,080
Speaker 2: at Harvard, talked about the prospect of bringing back not

740
00:39:54,200 --> 00:39:56,600
Speaker 2: just people who've been deceased, bringing back species that have

741
00:39:56,640 --> 00:40:00,800
Speaker 2: been deceased, and specifically human species. I made species like

742
00:40:00,880 --> 00:40:04,120
Speaker 2: Neanderthal man, and that raises a whole set of complex

743
00:40:04,200 --> 00:40:07,359
Speaker 2: related questions of its own, of what rights Neanderthals would

744
00:40:07,360 --> 00:40:10,600
Speaker 2: have in the context of human society, whether bringing the

745
00:40:10,640 --> 00:40:13,440
Speaker 2: back would cause them existential suffering, whether they would have

746
00:40:13,440 --> 00:40:16,479
Speaker 2: the same rights as Homo sapiens. But in the relation

747
00:40:16,640 --> 00:40:19,800
Speaker 2: to this context, it also risk the possibility of bringing

748
00:40:19,840 --> 00:40:24,359
Speaker 2: back Neanderthals who are not Homo sapiens and using bare

749
00:40:24,400 --> 00:40:28,600
Speaker 2: bodies to transplant human heads into which might plausibly be

750
00:40:29,760 --> 00:40:32,480
Speaker 2: doable at some point in the future, and raise really

751
00:40:32,480 --> 00:40:48,520
Speaker 2: complex ethical questions.

752
00:40:51,360 --> 00:40:54,120
Speaker 1: Let me ask you this you're a psychiatrist, among other things,

753
00:40:54,360 --> 00:40:57,840
Speaker 1: what would you do if you were assigned the revivification

754
00:40:58,080 --> 00:41:02,040
Speaker 1: of a Neanderthal man and you were the first person

755
00:41:02,040 --> 00:41:03,680
Speaker 1: in the room when he wakes up. Now, obviously you

756
00:41:03,680 --> 00:41:06,799
Speaker 1: wouldn't share the same language, So what would you try

757
00:41:06,840 --> 00:41:11,359
Speaker 1: to do to reduce existential suffering on his part?

758
00:41:13,320 --> 00:41:15,480
Speaker 2: I think first I would try to reduce existential suffering

759
00:41:15,520 --> 00:41:19,520
Speaker 2: on my part by standing behind something very large, because

760
00:41:19,840 --> 00:41:23,160
Speaker 2: my census Neanderthals waking up in this situation might not.

761
00:41:23,040 --> 00:41:23,760
Speaker 3: Be very friendly.

762
00:41:25,040 --> 00:41:27,759
Speaker 2: But beyond that, I think the real answers we don't

763
00:41:27,800 --> 00:41:30,080
Speaker 2: know in the same way we don't know how to

764
00:41:30,080 --> 00:41:32,600
Speaker 2: communicate with dolphins, so they may have a very sophisticated

765
00:41:32,640 --> 00:41:35,960
Speaker 2: language of their own. We may have any idea how

766
00:41:35,960 --> 00:41:39,479
Speaker 2: to communicate or appreciate the emotional response of a Neanderthal man.

767
00:41:40,120 --> 00:41:42,560
Speaker 2: It's taken us many, many years to understand in a

768
00:41:42,600 --> 00:41:46,560
Speaker 2: most rudimentary way the relationships human beings have with other

769
00:41:46,640 --> 00:41:49,440
Speaker 2: high word er apes like a relige, chimpanzees or arangutans.

770
00:41:50,239 --> 00:41:53,600
Speaker 2: Neanderthals will be intellectually far more sophisticated. Are going to

771
00:41:53,600 --> 00:41:55,439
Speaker 2: be a puzzile we first made them. If we first

772
00:41:55,440 --> 00:41:56,080
Speaker 2: made them.

773
00:41:56,600 --> 00:41:59,080
Speaker 1: So what would you actually do if you were assigned that.

774
00:42:00,120 --> 00:42:04,560
Speaker 2: Job as a psychiatrist. I would probably wait. I would

775
00:42:04,600 --> 00:42:08,880
Speaker 2: probably do nothing until I first see how this revived

776
00:42:08,880 --> 00:42:11,840
Speaker 2: creature responds to me and take cues from them in

777
00:42:11,880 --> 00:42:14,000
Speaker 2: the same way I would do seeing any other patient

778
00:42:14,040 --> 00:42:16,160
Speaker 2: in the emergency room. And I I am not comparing

779
00:42:16,200 --> 00:42:18,560
Speaker 2: any of my patients to Neanderthal men, though they may

780
00:42:18,560 --> 00:42:22,280
Speaker 2: compare me to one. But I do think it's important

781
00:42:22,320 --> 00:42:25,640
Speaker 2: first take cues from your patients, to take cues from

782
00:42:25,800 --> 00:42:28,719
Speaker 2: other individuals what they expect from you. And that's what

783
00:42:28,840 --> 00:42:30,560
Speaker 2: I think the wisest course of action would be.

784
00:42:32,080 --> 00:42:34,960
Speaker 1: Great, God, this is going to be a Hollywood screenplay

785
00:42:35,160 --> 00:42:38,359
Speaker 1: that we should write, Okay, any any other thing.

786
00:42:39,680 --> 00:42:42,240
Speaker 2: And I think that covers my end of life thinking.

787
00:42:43,440 --> 00:42:45,239
Speaker 2: I have lots of other issues I can always.

788
00:42:44,960 --> 00:42:45,600
Speaker 3: Talk about, but.

789
00:42:47,440 --> 00:42:48,840
Speaker 1: Give me, give me a sense of one.

790
00:42:49,719 --> 00:42:52,800
Speaker 3: Sure. I think one issue that is related but distinct.

791
00:42:54,280 --> 00:42:58,879
Speaker 2: Is the situation of conjoined twins who wish one twin

792
00:42:58,920 --> 00:43:01,239
Speaker 2: wishes to be separated and the other twin does not

793
00:43:01,280 --> 00:43:03,279
Speaker 2: wish to be separated because of the risk involved in

794
00:43:03,320 --> 00:43:03,880
Speaker 2: the procedure.

795
00:43:04,239 --> 00:43:05,800
Speaker 3: And you have a situation.

796
00:43:05,440 --> 00:43:08,680
Speaker 2: Where one person's life is at stake for the other person,

797
00:43:08,760 --> 00:43:11,320
Speaker 2: the autonomy and welfare of their being is at stake,

798
00:43:11,640 --> 00:43:14,239
Speaker 2: And there's no easy way to resolve that question. And

799
00:43:14,239 --> 00:43:16,000
Speaker 2: it sort of brings to bear all of the different

800
00:43:16,000 --> 00:43:19,759
Speaker 2: ethical issues we have raveled with his society bioethically over

801
00:43:19,800 --> 00:43:21,719
Speaker 2: the last fifty years, and that it's one of the

802
00:43:21,760 --> 00:43:24,399
Speaker 2: only questions in bioethics, by the way, where not only

803
00:43:24,600 --> 00:43:26,640
Speaker 2: do I not have a path to help people move forward,

804
00:43:27,000 --> 00:43:29,000
Speaker 2: I have no visceral sense of what the right answer

805
00:43:29,040 --> 00:43:31,200
Speaker 2: is either. I feel like if I'm not in that situation,

806
00:43:31,320 --> 00:43:32,920
Speaker 2: I can't even think about how to approach it.

807
00:43:34,120 --> 00:43:38,839
Speaker 1: Wow, are there other situations where one person's life would

808
00:43:38,880 --> 00:43:42,880
Speaker 1: be in danger if something happened that would help another person?

809
00:43:42,920 --> 00:43:45,640
Speaker 1: There must be other situations that are analogous.

810
00:43:46,480 --> 00:43:49,160
Speaker 2: Yeah, I mean there's the famous case of Shimp versus McFall,

811
00:43:49,840 --> 00:43:52,439
Speaker 2: where there were two cousins and one of them made

812
00:43:52,480 --> 00:43:55,960
Speaker 2: a bone marrow transplant and his cousin was the only

813
00:43:56,000 --> 00:43:59,120
Speaker 2: person in the entire world with a bone marrow transplant

814
00:43:59,120 --> 00:44:01,320
Speaker 2: that could match him that he needed to save his life.

815
00:44:01,840 --> 00:44:03,879
Speaker 2: And he did not have a negative relationship with his cousin,

816
00:44:03,920 --> 00:44:06,000
Speaker 2: but they weren't particularly close and he went to his

817
00:44:06,040 --> 00:44:08,480
Speaker 2: cousin and said, please give me the bone marrow transplant,

818
00:44:08,640 --> 00:44:10,640
Speaker 2: and the bone mara trus plant was not high risk,

819
00:44:10,680 --> 00:44:13,000
Speaker 2: but it had some risk in some discomfort. And his

820
00:44:13,080 --> 00:44:15,640
Speaker 2: cousin said, no, I don't owe you that. And then

821
00:44:15,640 --> 00:44:17,360
Speaker 2: he went before the court and said, I'm going to

822
00:44:17,440 --> 00:44:19,480
Speaker 2: die without this bone marrow. It's not that much of

823
00:44:19,520 --> 00:44:21,839
Speaker 2: an inconvenience or risk to my cousin. Please make him

824
00:44:21,840 --> 00:44:24,919
Speaker 2: do it. And the court said no, and I believe

825
00:44:24,960 --> 00:44:25,279
Speaker 2: he died.

826
00:44:26,480 --> 00:44:30,800
Speaker 1: Oh do you know anything about what the cousin's reasoning

827
00:44:30,920 --> 00:44:32,520
Speaker 1: was beyond the inconvenience.

828
00:44:34,120 --> 00:44:35,759
Speaker 2: I don't think, and I am not an expert in

829
00:44:35,800 --> 00:44:37,360
Speaker 2: his case, but I don't think the cousin had a

830
00:44:37,360 --> 00:44:39,719
Speaker 2: great deal of health literacy. And the cousin was someone

831
00:44:39,719 --> 00:44:42,680
Speaker 2: who was a fairly suspicious of medicing a baseline. So

832
00:44:42,680 --> 00:44:44,440
Speaker 2: no matter how many times you might tell him he's

833
00:44:44,440 --> 00:44:46,520
Speaker 2: got a high risk procedure, it's not so clear he

834
00:44:46,560 --> 00:44:47,279
Speaker 2: really believed that.

835
00:44:47,880 --> 00:44:51,839
Speaker 1: Okay, incredible, And.

836
00:44:51,880 --> 00:44:54,200
Speaker 2: I will add, by the way, even though that seems

837
00:44:54,360 --> 00:44:56,879
Speaker 2: like a shocking case, every single one of us has

838
00:44:56,880 --> 00:44:58,800
Speaker 2: the ability to save the life of a stranger.

839
00:44:59,120 --> 00:45:00,160
Speaker 3: You can give a a.

840
00:45:00,239 --> 00:45:03,799
Speaker 2: Kidney or part of a liver, and some people do

841
00:45:03,880 --> 00:45:07,040
Speaker 2: altruistically and save someone's life, someone who will otherwise die,

842
00:45:07,400 --> 00:45:11,160
Speaker 2: and the vast majority of us, for reasons, whether wise or.

843
00:45:11,200 --> 00:45:14,879
Speaker 3: Not wise, choose not to. So in some sense we're

844
00:45:14,920 --> 00:45:16,279
Speaker 3: all mister ship.

845
00:45:18,840 --> 00:45:22,080
Speaker 2: Yeah, and we all risk being mister McFall too.

846
00:45:22,080 --> 00:45:25,040
Speaker 3: At some point we should not forget right.

847
00:45:25,880 --> 00:45:28,760
Speaker 1: So what do you advise your students on that front?

848
00:45:30,520 --> 00:45:32,160
Speaker 2: I mean, I think I advised them in the same

849
00:45:32,200 --> 00:45:35,640
Speaker 2: way by advised students about every ethical issue, which is

850
00:45:36,320 --> 00:45:38,400
Speaker 2: I can't tell you what the right answer is. The

851
00:45:38,440 --> 00:45:40,920
Speaker 2: two things that are important, actually, there are three things

852
00:45:40,920 --> 00:45:42,600
Speaker 2: that are important. The first one is recognized and said

853
00:45:42,600 --> 00:45:44,880
Speaker 2: it is an ethical issue, many of the difficult problems

854
00:45:44,880 --> 00:45:47,320
Speaker 2: that arise in medical ethics, or because no one matter

855
00:45:47,320 --> 00:45:50,040
Speaker 2: how wise or well attention, actually recognize this is an

856
00:45:50,040 --> 00:45:54,239
Speaker 2: ethical challenge. The second thing that's really important is that

857
00:45:54,239 --> 00:45:56,400
Speaker 2: when you start with a certain premise, you want to

858
00:45:56,440 --> 00:45:58,719
Speaker 2: logically come to a conclusion based on that premise. So

859
00:45:58,960 --> 00:46:01,480
Speaker 2: at some point between your premise in your conclusion a

860
00:46:01,560 --> 00:46:03,719
Speaker 2: miracle happens here, so to speak, you want to.

861
00:46:03,719 --> 00:46:05,360
Speaker 3: Go back to square one.

862
00:46:05,440 --> 00:46:09,960
Speaker 2: And then finally, I say, once you reach those two premises,

863
00:46:10,440 --> 00:46:13,520
Speaker 2: the final step is to recognize that very well intentioned

864
00:46:13,560 --> 00:46:16,680
Speaker 2: people with very good values come to very different answers

865
00:46:16,719 --> 00:46:20,040
Speaker 2: about this questions from starting with different premises and different

866
00:46:20,080 --> 00:46:22,399
Speaker 2: cultural beliefs and values of their own, and the goal

867
00:46:22,440 --> 00:46:24,520
Speaker 2: is to understand them and respect them even if you

868
00:46:24,560 --> 00:46:27,359
Speaker 2: don't agree with them, because they're not fools simply because

869
00:46:27,360 --> 00:46:29,279
Speaker 2: they disagree with you. And I think our society as

870
00:46:29,280 --> 00:46:31,359
Speaker 2: a whole would be a much better place we were

871
00:46:31,400 --> 00:46:34,040
Speaker 2: able to agree to disagree with mutual respect, and we

872
00:46:34,040 --> 00:46:36,200
Speaker 2: actually would be able to find a lot more common

873
00:46:36,200 --> 00:46:38,560
Speaker 2: ground at the corners of a lot of issues where

874
00:46:38,560 --> 00:46:39,640
Speaker 2: there might be a lot of overlap.

875
00:46:44,360 --> 00:46:46,960
Speaker 1: So that was my interview with Jacob Appel, one of

876
00:46:47,280 --> 00:46:50,360
Speaker 1: a very small group of people who can equally address

877
00:46:50,440 --> 00:46:54,640
Speaker 1: both the medical and legal and ethical aspects of death

878
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Speaker 1: and the complexities at the interface. What I hope you've

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Speaker 1: gathered from today's episode is that the issue of declaring

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00:47:02,560 --> 00:47:05,960
Speaker 1: death is not straightforward, and often we find the most

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Speaker 1: complex cases at the intersection of medical and legal systems,

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Speaker 1: and zooming out to the beginning, I just want to

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Speaker 1: remind us that although we think of death as binary,

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Speaker 1: it's often much more complex and we are always going

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Speaker 1: to be confronted with these problems. As technology improves, we're

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Speaker 1: going to be able to rescue a life from different

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00:47:28,360 --> 00:47:31,840
Speaker 1: states that would have been previously impossible to reverse or

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00:47:31,840 --> 00:47:37,040
Speaker 1: even imagine reversing. And so as biology marches along each

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Speaker 1: year into the future, the answer to the question of

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Speaker 1: when you are dead is one that will change along

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00:47:44,960 --> 00:47:49,320
Speaker 1: in lockstep, and in two hundred years we might find

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00:47:49,400 --> 00:47:54,760
Speaker 1: our current answers unpalatable and inconceivable. But in any case,

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Speaker 1: in each generation, with each landscape of new technology, we

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00:47:59,280 --> 00:48:03,560
Speaker 1: have to con continually revisit this question, where do we

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Speaker 1: draw the line between life and death? Go to Eagleman

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00:48:12,800 --> 00:48:16,000
Speaker 1: dot com slash podcast for more information and to find

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00:48:16,040 --> 00:48:20,600
Speaker 1: further reading. Send me an email at podcasts at eagleman

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00:48:20,680 --> 00:48:23,479
Speaker 1: dot com with questions or discussions, and I'll be making

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Speaker 1: an episode soon in which I address those. Until next time,

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Speaker 1: I'm David Eagleman, and this is Inner Cosmos.