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Summary
Summary
Important and provocative, The Undead examines why even with the tools of advanced technology, what we think of as life and death, consciousness and nonconsciousness, is not exactly clear and how this problem has been further complicated by the business of organ harvesting.
Dick Teresi, a science writer with a dark sense of humor, manages to make this story entertaining, informative, and accessible as he shows how death determination has become more complicated than ever. Teresi introduces us to brain-death experts, hospice workers, undertakers, coma specialists and those who have recovered from coma, organ transplant surgeons and organ procurers, anesthesiologists who study pain in legally dead patients, doctors who have saved living patients from organ harvests, nurses who care for beating-heart cadavers, ICU doctors who feel subtly pressured to declare patients dead rather than save them, and many others. Much of what they have to say is shocking. Teresi also provides a brief history of how death has been determined from the times of the ancient Egyptians and the Incas through the twenty-first century. And he draws on the writings and theories of celebrated scientists, doctors, and researchers--Jacques-B#65533;nigne Winslow, Sherwin Nuland, Harvey Cushing, and Lynn Margulis, among others--to reveal how theories about dying and death have changed. With The Undead, Teresi makes us think twice about how the medical community decides when someone is dead.
Author Notes
Dick Teresi is the coauthor of The God Particle and the author of Lost Discoveries: The Ancient Roots of Modern Science, both selected as New York Times Book Review Notable Books. He has been the editor in chief of Science Digest, Longevity, VQ, and Omni, and has written for The New York Times, The Wall Street Journal, and The Atlantic, among other publications.
Reviews (6)
Publisher's Weekly Review
Suddenly, death doesn't seem so certain after all. In this brutally honest look at how doctors determine the moment of death, skeptical science writer and Omni magazine cofounder Teresi (The God Particle) relishes ripping into the 1968 Harvard team that formulated new criteria for determining death: "loss of personhood," or brain death. Doctors, Teresi says, can now "declare a person dead in less time than it takes to get a decent eye exam" by testing reflexes: "a flashlight in the eyes, ice water in the ears, and then an attempt to gasp for air" when the respirator is disconnected. Teresi interviews scientists who question the finality of brain death when the heart is still beating, and even the concept that personhood is located solely in the brain. More alarming, Teresi charges that the brain-death revolution is driven by the $20 billion-a-year organ transplant business. Teresi will scare readers to death with examples of how undependable brain-death criteria can be-one organ donor began to breathe spontaneously just as the surgeon removed his liver. But the more powerful effect of this scathing report should be the start of an uncomfortable but necessary conversation between doctors and potential organ donors. Agent: Janklow and Nesbit. (Mar.) (c) Copyright PWxyz, LLC. All rights reserved.
Booklist Review
*Starred Review* The Undead presents chilling, controversial, and, at times, comical commentary on physical death. The determination of death is fuzzier than you might imagine. There are cardiopulmonary death and brain-stem death, necrosis and apoptosis. There are those who straddle the divide between life and death beating-heart cadavers, individuals who've had near-death experiences, and even brain-dead pregnant women who carry fetuses to term. Physical signs of demise and clinical tests (EEG, apnea test, cerebral blood-flow studies) assist in establishing death, but the ultimate authority rests with medical opinion: You're dead when the doctor says you're dead. Teresi frets that physicians may be making moral judgments, not medical verdicts, when it comes to declarations of death. His other gripe involves the organ-transplantation industry (purportedly, a $20-billion-a-year business), which, understandably, revolves around recipients but arguably shortchanges donors and their next of kin. All sorts of experts on coma, animal euthanasia, and execution as well as undertakers, organ-transplant staff, neurologists, ethicists, and lawyers weigh in on the death debate. It is Miracle Max, a character in The Princess Bride, who sums things up best: There's a big difference between mostly dead and all dead. Mostly dead is slightly alive.--Miksanek, Tony Copyright 2010 Booklist
New York Review of Books Review
HOW dead would you like to be before your organs are harvested for donation? According to Dick Teresi in "The Undead," "pretty dead" is good enough for transplant surgeons. "If you wait for everything to be a hundred percent," a physician tells him, "you'd never have organ donation." In days of yore, the absence of a heartbeat was the gold standard for determining death, but even that wasn't foolproof. "People declared dead come back to life with some frequency," Teresi writes. They recover from drowning, coma, asphyxia and lightning strikes. Rigor mortis doesn't always occur in the dead, and it can occur in the living. Even experienced practitioners could misdiagnose stiffness or coldness, a lack of breath or pulse. An 18th-century Frenchman recorded "more than 150 pages of accounts of premature burial and mistaken death" between ancient times and the mid-1700s. To avoid such errors, Greeks cut off a finger; Romans called out the dead's name; Slavs rubbed bodies with warm water for an hour; Hebrews considered putrefaction the only fail-safe indicator. As science learned more about suspended animation and hibernation in other creatures, the dying were given another chance - subjected to smelling salts, electric shock, sharp pricks to the fingers, yanks to legs and the application of caustic chemicals to the skin, to see if it blistered. And so it went for 5,000 years, with the criteria for death becoming ever more stringent. Then, in 1968, 13 men on a Harvard University committee devised a protocol that privileged a "loss of personhood" over cardiopulmonary death, allowing doctors "to declare a person dead in less time than it takes to get a decent eye exam." Teresi lays the turnabout to the invention of ventilators and advances in organ transplants. By declaring patients with beating hearts brain-dead following two rounds of tests with a Q-tip, a flashlight, ice water, a rubber hammer and the removal of the ventilator, doctors created a vast pool of potential organ donors. The bar for being dead had dropped, and the bar for being considered alive had risen. Adopted in 1981, the Uniform Determination of Death Act states that in order to pronounce brain death, "the entire brain must cease to function, irreversibly." But the act is silent on how this function is measured (in one study, 65 percent of physicians and nurses couldn't identify the established criteria for brain death). Most physicians look at the brain stem, which controls heart and lung functions, but not the cortex, which coordinates consciousness. Teresi reports on an apparently unconscious patient who "could have been calculating the cross section of the bottom quark using Heisenberg's matrices, and no amount of ice water squirted into her ear would have detected it." The patient was unplugged, her organs harvested. The Harvard criteria assume that the brain-dead will quickly move to conventional heart-lung death. But Teresi learns that the brain-dead can maintain a long list of bodily functions, including some sexual responses, stress responses to surgery and the ability to gestate a fetus. After making a case that brain death is easily misdiagnosed and that death can be a construct of convenience, Teresi next places his body between the transplant team and patients who exist in a sort of "death lite" netherworld, with a nonresponsive cortex but a functioning brain stem. And now things get really creepy. A tiny minority of patients in minimally conscious or persistent vegetative states have been known to sit up and speak. And one "locked in" patient (with a brain stem irreparably damaged but a healthy cortex) even wrote a best-selling book about his condition, "The Diving Bell and the Butterfly." But the onus is on patients to prove they are aware or in pain. "We would all sleep better at night if we could believe that patients in unendurable situations were unaware, but that does not make it so," Teresi writes. Off they go to be harvested, despite the potential for surgeons to be distracted by their "screaming during organ retrieval." This is strong stuff, and Teresi - the author of "Lost Discoveries" and the former editor of Science Digest and Omni - never backs off. He circles, probes and pokes. He needles physicians and bioethicists, and he provokes organ banks by agreeing to donate only if he can be guaranteed an anesthetic during the procedure. (When the organizations refuse, he considers commissioning two operations: the organ donation and then a face-lift. "I'd get my anesthetic, and I'd hold the face-lift.") Teresi consorts with death in many places: mortuaries, execution chambers, hospices, intensive-care units and a meeting room filled with people who've had near-death experiences. But he steers a wide berth around two important groups: grateful organ recipients and those who tend the persistently vegetative for years on end. If I'm reading Teresi right, no one who shows any sign of consciousness, and hasn't clearly indicated he or she wants to die, should be unplugged. Where there's life, there's hope. But he gives extremely short shrift to quality-of-life issues. And while a resuscitated donor headed for the transplant table may receive "the best medical care of his life," a vast majority of acutely ill patients on chronic ventilation units don't improve. Their skin gradually breaks down, and their circulatory and renal systems are propped up until an infection finishes them off. Teresi prides himself on his just-the-facts approach, but he hasn't told the entire story. Like the author, I don't want to suffer when my organs are harvested, nor do I want them harvested if I can consciously make use of them myself. This disturbing, often hilarious book raises many critical questions about deadness. But it doesn't, by a long shot, answer them. Elizabeth Royte's books include "Garbage Land" and, most recently, "Bottlemania."
Choice Review
This is a hard-hitting, strongly worded expose of the deep hypocrisy in parts of the medical profession, embodied in the notorious Harvard criteria for so-called brain death. Today, the emphasis is on evidence-based medical practice. However, when collective evidence is applied to the determination of clinical death based on cortical activity but not brain stem functions, the criteria fail. Author/journalist Teresi aptly identifies the real rationale for blurring the line between total lack of competent cardiopulmonary activity (death) and the gray zone that presumes that loss of cerebral cortical function inevitably leads to heart stoppage, viz, the effort to obtain transplantable organs. These endeavors for defining death are sold to the public as laudatory medical advances, ignoring the principle that there is a cost to everything. Many of these practices resulted in revocation of medical licenses and criminal charges of homicide not that long ago. Ironically, this may occur again because just as this book appears, scientific advances show the possibility of creating artificial organs from special cultivation of stem cells. Teresi does not comment on the negative effects of after-death fluid perfusion to maintain organs in preparation for harvest, which often confounds autopsy findings. Overall, a thought-provoking look at a serious medical/ethical issue. Summing Up: Recommended. All levels/libraries. D. R. Shanklin Marine Biological Laboratory
Kirkus Review
Lost Discoveries: The Ancient Roots of Modern Science--From the Babylonians to the Maya, 2002, etc.) claims that the rights of organ donors are being violated by the medical profession. "In 2010," writes the author, "there were an estimated 28,144 transplant operations in the United States"--with 111,530 candidates on the waiting lists as of June 2011. His stated purpose is to call attention to what he sees as a subtle shift in medical emphasis from saving lives to declaring patients dead prematurely in order to preserve their organs for the lucrative organ-transplant business. Like a real-life version of Robin Cook's medical thriller Coma, Teresi paints a grisly picture of organ harvesting and raises uncomfortable questions: Is the donor actually dead rather than at the point of death? Might he or she be revived given time and proper medical attention? Might the donor feel pain during the process of organ extraction even though seemingly brain dead? Citing reports of out-of-body experiences, the locked-in syndrome portrayed in The Diving Bell and the Butterfly and evidence that comatose patients who are apparently unresponsive are sometimes fully aware of conversations held in their presence, Teresi expresses skepticism about the medical definition of brain death. The author searches out experts, including, among others, "undertakers, cell biologists, coma specialists (and those who have recovered from coma), organ transplant surgeons," in an effort to penetrate the boundaries between life and death. "The unborn, fetuses, have plenty of political clout," he writes. "No one speaks for donors," and the press has abdicated its responsibility for investigative journalism. However, some of Teresi's writing verges on sensationalism--e.g., his lurid account of modern executions. A provocative, if one-sided, examination of important ethical issues and the still-unresolved question of what constitutes death.]] Copyright Kirkus Reviews, used with permission.
Library Journal Review
Few if any of the numerous recent books on end-of-life care combine humor, learning, and insight as Teresi (Lost Discoveries: The Ancient Roots of Modern Science) does here. By exploring how death has been determined from ancient times through modern Western medicine, he shows that some tests for death are not always foolproof. He argues that the possibility of organ donation has changed how we define death and shows the sometimes forceful recruitment tactics of procurement agencies. While the book discusses how the 1968 Ad Hoc Committee of Harvard Medical School influentially defined brain death, several other works have covered it in more depth. Teresi also includes sometimes moving personal stories of friends who struggled with end-of-life issues, putting a human face on the debates. VERDICT By combining learning and humor in an accessible format, this book is a good introduction to the medical, biological, and social conditions related to end-of-life care. Teresi will make you laugh, groan, and question what you think you know. An accessible but illuminating introduction to current questions in end-of-life care. [See Prepub Alert, 9/11/11.]-A.W. Klink, Duke Univ., Durham, NC (c) Copyright 2012. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.
Excerpts
Excerpts
Prologue "B" Pod of the intensive care unit (ICU) at Baystate Medical Center is very bright: intense lights, everything painted in primary colors. Cabinets, counters, and chairs are a sparkling blue, obviously intended to be cheery, not sepulchral. A blue central stripe on the grayish linoleum floor leads us from room to room. There are three ICU pods at this Springfield, Massachusetts, hospital, each with three rooms arranged like spokes around a central station filled with computer terminals. Doctors and nurses come and go. The patients in their separate rooms, like sickly fish in glass tanks arranged for observation, are largely slack-mouthed and gray or pale yellow in color. Most are fitted with clear plastic tubes the diameter of vacuum-cleaner hoses attached to their mouths. Most are old and gnarled, with sallow, sickly complex-ions. Sometimes one can see a bare concave chest or a yellowed foot sticking out from beneath a sheet. None is conversing. We are not here to see them. We have come for the star of "B" Pod. We will call her Fernanda, a fifty-seven-year-old woman of Portuguese descent, who looks as though she might have just come back from a day at the mall. Her dark olive skin appears healthy against the sheets. Her features do not show the ravages of suffering or pain. Her eyes are closed beneath the heavy arched eyebrows. She has thick black eyelashes. Her wiry black hair with strands of gray is arranged neatly on the pillow. She has delicate legs and exquisite feet. Her face is serene; her chest rises and falls with the familiar rhythm of normal human breathing. She looks as if she had been put to sleep by a wicked queen in a fairy tale and needs only to be reanimated. Her vital signs, displayed on a monitor in squiggles the bright green of coloring books, are normal. She looks better than I do. We are all there, including a group of medical students and interns, to watch Dr. Thomas Higgins pronounce Fernanda brain dead. She had been at work when coworkers found her on the fl oor and threw water on her face, a tactic that doesn't work well against ischemic stroke. She probably had a brief headache, says Higgins, then fell unconscious. The ICU doctors at Baystate feel she will not recover. The brain-death team is about to make it official. Those expecting space-age equipment, sophisticated brain scans, and the like, won't find it. The exam is conducted mostly with tools you could find around your home: a flashlight, a Q-tip, some ice water. Her reflexes are tested. A light is shined in her eyes. Her head is turned from side to side. Cold water is squirted into an ear. She is disconnected from her ventilator to make sure she can't breathe on her own. In less time than my ophthalmologist took to prescribe my last pair of bifocals, Fernanda is declared brain dead. That means she is legally dead, just as dead under the law as if her heart had stopped beating. Fernanda is then hooked back up to her ventilator to keep her organs fresh for transplant. Her heart continues to beat; her lungs continue to breathe. Though dead, she remains the best-looking patient in the ICU. The declaration of her death was more philosophical than physiological. A nurse says, "Whatever it was that made her her isn't there anymore." ONE Death Is Here to Stay For all the accomplishments of molecular biology, we still can't tell a live cat from a dead cat. --Lynn Margulis ARE YOU dead or alive? A dumb question, it would seem. If you're reading this book, you are most likely alive. You know it, but do those in control know it? Will they acknowledge it? These are no longer stupid questions. The bar for being dead has been lowered. The bar for being considered alive has been raised. The old standards for life--Are you breathing? Is your heart beating? Are your cells still intact, not putrifying?--have been abandoned by the medical community in favor of a more demanding standard. Are you a person? Is what makes you you still intact? Can you prove it? Such concepts were previously the domain of philosophers and priests, but today it is doctors who determine our legal humanity. The dead are also not immune from judgment. A presidential council on bioethics recently determined that some dead people are less "healthy" than others. It is a different world. This is a book about physical death. It began as a simple magazine article more than a decade ago, a report on the state of the art of death determination. I assumed I would find hightech medical equipment and techniques that would tell us when a human being had stopped living, that would pinpoint the moment that "what made her her " was gone. I eventually abandoned this goal and the article itself. Humans have long lived in denial about their own deaths, but I discovered that this denial has spread to the medical establishment, even to our beliefs about who is dead and who is alive. Our technology has not illuminated death; it has only expanded the breadth of our ignorance. Technology indicates that many of our assumptions about life and death, consciousness and unconsciousness, are wrong. Technology is telling us a great deal about our ignorance, but we are ignoring the information. My focus is scientific information about physiological death, but science and cultural factors often compete in an unproductive manner, canceling each other out. Though we have made technological advances, they often remain unused when it comes to dealing with the dying and dead, so cultural factors--philosophy, ethics, economics, religion--cannot be ignored. Death, for most people, is not a comforting topic, and thus in the great mass of nonfiction literature devoted to the topic, death is treated as something that happens to someone else. My temptation is to write this as if I were narrating a dirigible explosion ("Oh, the humanity!"). Someone far away, perhaps in New Jersey, is dying. You, the audience, and I, the announcer, are merely witnesses. Let us reject that fiction. You, the reader, will die. If it is any consolation, keep in mind that I will also die. At my age, sooner rather than later. ### During my research, I have spoken about death before groups of people on several occasions: to classes of college students, to groups of senior citizens, to people at dinner parties and other social gatherings. For the most part, those discussions have been disastrous. When I was talking at a dinner about the vagaries of brain death and the fact that our technology cannot ascertain the condition of most of the brain, one woman, a medical doctor, actually rose from her seat and yelled at me. She said that writing about this topic was "irresponsible," that it would set organ donation back decades. She threatened to "call your editor." In an undergraduate honors class at the University of Massachusetts, a senior premed major became angry with me when I spoke about patients in persistent vegetative state who show signs of consciousness. Her grandmother was in a comatose state, and her family was confused about what to do. The woman's estate was dwindling because of her care, and, I gathered, so were the student's hopes of paying for medical school. The premed student said that her grandmother was no longer "useful." Those were two remarkable cases, but in general I made people uneasy, even angry. They defended their traditional ideas of life and death to me passionately, forcefully. My protestations that I was merely a journalist reporting facts as I found them, not making moral judgments, was of no consolation. I told the angry doctor that she could yank as many organs as she pleased out of people, and I would not stop or condemn her. I told the student that she and her family could pull the plug on Grandmother and I would not say a word. This just made them angrier. Not everyone was upset with the facts I presented. But those who were, were livid. It was years before I figured out my apparent mistake. I assumed the information I was presenting, which threatens traditional views of death, was upsetting them. I now believe that it was something simpler: I was reminding people that they were going to die. Not someone else. Them. In 1973, the cultural anthropologist Ernest Becker put forth an unusual thesis. In The Denial of Death, his Pulitzer Prize--winning book, Becker said that humans are like other animals, with an evolutionary drive to survive. "Live! Live! Live!" our genes are screaming at us. Unlike other animals, however, said Becker, we humans know we cannot ultimately survive, that we will die. This dilemma, he believed, drives us mad. The awareness of our inevitable annihilation combined with our evolutionary program for self-preservation holds the potential for evoking paralyzing terror. Becker stated, "The result was the emergence of man as we know him: a hyperanxious animal who constantly invents reasons for anxiety even where there are none." Becker wrote that man is terrified of death, and deals with this terror by denying death and keeping it unconscious. He felt that this terror directs a "substantial portion of human behavior," according to one researcher. Becker's hypothesis was wide-sweeping. Death terror, he said, was the primary reason that humans created culture. Our religions, our political systems, our art, music, and literature--all this we have constructed "to assure ourselves that we have achieved something of lasting worth." Becker said that "everything that man does in his symbolic world is an attempt to deny and overcome his grotesque fate. He literally drives himself into a blind obliviousness with social games, psychological tricks, personal preoccupations so far removed from the reality of his situation that they are forms of madness--agreed madness, shared madness, disguised and dignified madness, but madness all the same." Those who delude themselves into believing they have achieved something of lasting worth would include, I assume, people who write books. Becker's theory was intriguing, plausible, and explained much of human behavior. Its only fl aw was that Becker had no concrete evidence. As a matter of fact, how would one even go about testing the hypothesis? Terror management was the superstring theory of anthropology--fascinating but not testable. Help came long after Becker had resolved, by dying, his own death terror. In the late 1970s, three graduate students on an intramural bowling team at the University of Kansas began discussing death terror while the pins were being reset. Through the years, Jeff Greenberg, Tom Pyszczynski, and Sheldon Solomon translated Becker's ideas into a formal theory that could be examined empirically. Their work culminated in a series of remarkable "mortality salience" experiments detailed in a 1997 paper. Subjects were not told the true purpose of the experiment. Irrelevant questions and reading passages were included to mislead them. Embedded in an opening questionnaire, however, were these directions: "Please describe the emotions the thought of your own death arouses in you. Jot down, as specifically as you can, what you think will happen to you physically as you die and once you are physically dead." Greenberg, Pyszczynski, and Solomon used this and other techniques in different experiments, such as asking subjects to write their own obituaries or flashing the word "death" intermittently on a computer screen for twenty-eight milliseconds. In another case, the researchers used no verbal signals. They simply interviewed subjects in front of a funeral home. Control groups received no such death signals. At the heart of the experiment were essays, pro-American and anti-American, supposedly written by foreign students studying in the United States but actually written by the psychologists. The pro essays stated that the United States was the greatest country in the world, the land of opportunity and freedom, and so on. The anti essays stated that American ideals were phony and the rich were getting richer, the poor poorer. Those subjects who were subjected to "mortality salience" ranked the pro essayist as extremely likable, and the anti essayist as extremely unlikable. The control group was not nearly so adamant. Greenberg et al. say that those who are made aware of their mortality need to offset their inner terror by defending their worldview and will praise to extremes those who hold the same worldview and denigrate those who hold different values. Excerpted from The Undead: Organ Harvesting, the Ice-Water Test, Beating Heart Cadavers--How Medicine Is Blurring the Line Between Life and Death by Dick Teresi All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
Table of Contents
Acknowledgments | p. vii |
Prologue | p. ix |
1 Death Is Here to Stay | p. 3 |
2 A History of Death | p. 50 |
3 The Brain-Death Revolution | p. 89 |
4 The New Undead | p. 141 |
5 Netherworlds | p. 170 |
6 The Near-Death Experience | p. 198 |
7 Postmodern Death | p. 224 |
8 The Moment of Death and the Search for Self | p. 26 |
Notes | p. 293 |
Selected Bibliography | p. 331 |
Index | p. 335 |