Remember those who lost their mothers and fathers
And make sure that every single moment that you have with them
You show them love
You show them love
You’ll see
— Stevie Wonder
I’ll give an example of two cases, both of whom eventually passed on, and then we can get to answering these two questions, if at all there are answers.
The first one fails to erase herself from my memory. I was nearing the end of my shift. The previous day, she was due to have a procedure done to widen her large vessels at the cath lab. She was barely twenty, pregnant, and had travelled to our country from South Sudan to seek assistance.
When you’re expectant and have a heart condition, pushing may be a blunder. The exertion can strain the heart and the lungs, and may lead to death. Furthermore, pregnancy tends to increase the volume of blood mothers typically have, adding an extra strain to the heart. To give her a fighting chance, she came to our facility.
And when she was on the bed, she had a cardiac arrest.
Code blue was signalled. The team arrived. She already had a tube giving oxygen directly to her lungs. We were administering drugs and alternating the chest compressions. The cycles continued for close to 45 minutes. We didn’t want to give up on her. Then the heart came back to life.
We booked a bed in ICU. She was sedated and hooked to a telemetry monitor. The obstetrics and gynecology team were called to assess what we already intuited. The foetus had already passed on. The team lead gave instructions on how to release the products from the womb.
The following day, she was up, fighting the vent. She wanted the tube out. Forcefully, she pulled it out. This typically corrodes the mucosal lining. Once she was able to get her voice back, she apologized profusely to the nurse for her violent actions. We reassured the husband. The family was informed about the passing of the baby. The mother needed blood. They donated. From every assessment, she looked like she would be discharged to the ward the following day.
Half an hour before the end of my shift, the nurse came to me, worried. The lady’s chest was not the best. Coarse crackles, even when she spoke. I gave instructions about her intake, and rushed to collect her blood. When I came back, she was already having a fit, and fluid was pouring from her mouth and nose. She needed to get back to the vent.
It was close to impossible. A flood of fluid collected in her mouth and airway, pool after pool despite several suctions. By the time I had secured a tube into her trachea, all signs were lost. This time around, we were not able to pull her back.
It was tragic. A few hours ago, I was reassuring the family. I didn’t know how I would break it down to them that their loved one was no more. I even imagined one of the brothers pinning me down out of anger, and gouging out my eyes, without having the willpower to fight back. This was the first case.
The second one was a lady who had been in and out of our unit, with a heart condition that pointed towards infective endocarditis. She was also undergoing regular dialysis sessions. She was in her late sixties.
One morning, a code blue was sounded. The team began the routine rescue protocol. It lasted around 40 minutes. However, by the time we had stabilized her, tube intact, central venous catheter inserted, inotropes started, and with all vitals within normal range, a final review showed that her pupils were blown out and unreactive to light.
The words of Pusha T capture such moments:
Sayin’ you was tired but not ready to go
Basically was dying without letting me know
So, I have been…
Trying to answer these two questions
Some experience death and feel numbness
But not me, I felt it all and couldn’t function— Pusha T
I have asked myself the questions that form the title and subtitle of this article because I had written a controversial article a while back. One of the readers wondered why I confidently claimed that we have no clear definition of life. We don’t. It is like consciousness. Most researchers go back to Thomas Nagel’s essay as a guide to intuit what consciousness is, although there is no precise definition. It is agreeable that it is subjective experience, but it has no definition in the sense an atom does.
We can, however, get closer to understanding what life is by trying to define death. The simpler definition is that death is the absence of life. In the ICU, we can detect that from our monitors. No heartbeat. No respiratory effort. No pupillary response after shining light.
Regardless, if there is one thing I have learned from working in the ICU, it’s that the human being is a modular complex adaptive system. The lines between life and death are just as blurry as the definition of life.
Consider a patient who has been brought to the ICU after a surgery. They are completely sedated. The ventilator is supporting the breathing. As far as this goes, the person cannot survive without the machine. We call this person alive with the aid of the ventilator. The ventilator alerts us that they are making 20 breaths every minute in a typical inspiratory-expiratory pattern.
Two days later, the blood pressure sinks. We start inotropic infusions. It picks. This person is still alive, despite the medication being the reason his organs are getting blood supply.
However, because the blood pressure dropped, after 12 hours, we have only seen 40 milliliters of urine. This is a state of acute kidney injury. They may need dialysis. After a nephrologist review, we plan to do just that. Another name for dialysis is kidney replacement therapy. The machine replaces the kidney as it recovers from its insults. The body’s renal system also receives support. Up to this point, the patient is still alive.
After a couple of days, the infusions are stopped. The blood pressure is now within the normal range. The kidney is now doing its role just fine. Dialysis is halted. However, they still need ventilatory support.
Then, one day, the doctor notices that the eyes are no longer responding to light. They order an EEG (electroencephalogram) to assess the brain wave function. The report is not promising. From the ventilator, we see no signs of respiratory effort. The neurophysician performs caloric and apnoeic tests. Nothing. They certify that the person is brain dead.
Yes, they are brain dead, but the heart is beating just fine. The kidney is doing its job. There is a pulse. The lungs are responding to the ventilation. Now, is the patient alive or dead?
At what point do we say they are dead? Is it the brain? For most clinicians, once the brain is gone, so is the person. But is the person only made of the brain? What constitutes being alive? Aren’t the other desiderata satisfied?
If they are female, their ovaries can be harvested. If it’s a male, the sperm can be harvested. This person can still have a baby despite not participating in sexual intercourse. There is a potential for reproduction, a necessary qualification for Darwinian evolution. So, are they alive or dead?
Humans have all forms of support. A blind person has a cane to help them navigate through space. I use a pair of glasses to improve my visual acuity. The one with hearing difficulties has cochlear implants. The cancer patient may get a chemoport. The patient with a femoral fracture may get a titanium plate. Those who can’t walk can get a wheelchair. Humans have all forms of support to account for their shortcomings. Through these machines and devices, humans have a richer life experience. They feel more alive.
In the ICU, we resort to extreme support. For breathing, the ventilator. For cardiovascular support, it could be a pacer and ionotropes. For the kidney, it’s dialysis. The patients may not feel more alive, but from the support offered, they are kept alive.
But at which point do we say that they are completely gone?
Last year, we had one patient who had valiantly gone to help their colleagues from a waste sewer. They all survived except him. The fumes and effluents, it appeared, crept to the brain. He had been intubated since he was wheeled to the unit. His heart and kidneys were functioning normally. His brain, however, was not. There were mixed reactions from the pupils when light was shone on them. Days later, after a battery of tests, he was declared brain dead.
But is this person dead?
In a world where ventilatory support was freely given, they could age on the bed. They are alive. But is being alive the same as living? I don’t think so. But you could be alive, but not dead, and yet, because one does not share the same experiences as the others, there may not be that distant from the dead.
These are the reasons I prefer to think of an organism as that which avoids annihilation. I am not keen on explaining whether they are alive or dead, but that there is a physical system displaying features of organisational closure and thermodynamic openness.
The patient who was brain dead had features of organisational closure. You could see the body. It was distinct from any other person’s body. It also had features of thermodynamic openness. The ventilator provided oxygen and support, and the body used it to continue its processes. The heart continued to beat. The kidney continued to make urine.
By adding these support machines, the person was no longer able to comfortably avoid annihilation without them. Along this spectrum is someone who has a cochlear implant or a pair of contacts. The organism has used its environment to acquire resources that help it navigate its life.
An organism, by my definition, is a physical entity that is organizationally closed and thermodynamically open, and tends to avoid annihilation. If that includes light, as I argued in the article, then it is consistent. The idea that man and living creatures should be superior is the reason Galileo was kept under house arrest. We don’t want to be dethroned from our godly status.
It is easier to bridge ourselves from atoms when we think of physical systems as those having organismal-like properties. If it is not consistent with Darwinian evolution, that does not mean we should exclude them. It means we can have a theory that still captures evolution without necessarily bringing in ideas of genes. And indeed, I have developed such a theory.
How is it that even though one is considered brain dead, their organs can be harvested and transferred to someone in need? Organs are like biological machines. Where a ventilator supported someone’s lungs, another person donated their lungs. This person now lives because of another, with a pair of lungs with cells whose genomes differ from the recipient’s. As with all transplants, they need to find ways of reducing the immune system from attacking the graft, a condition known as graft-versus-host disease.
Are we getting closer to answering the questions on life and death? I don’t think so. If we are, I may be blind. I don’t mind being enlightened.
Does it help to forget the question and rethink the issue from a different perspective? Maybe. It’s not usually a healthy practice to avoid a question that has proven insoluble. Insolubility, nevertheless, could mean we may be asking the wrong questions.
What I’m trying to say is…
I don’t think we can ever know the difference between life and death with sharp lines as we intuit abstraction from reality.
I have explained elsewhere how life-like systems can emerge from abiotic systems in an idea I call the evolutionary singularity hypothesis. The idea bridges the “dead” world from the “alive” one. The distinguishing factor is a will to avoid annihilation.
As long as a system is organizationally closed, thermodynamically open, and tends to avoid annihilation, it behaves like the cell. Or rather, the cell behaves like such a system. Take your pick.
I don’t consider it relevant that we trouble ourselves with the question of what is alive and what isn’t. We can refocus our energy to study systems from the perspective I have shared. It’s richer, broader, and has a potential for generating interesting research frameworks.
This song inspired some of the lines used in this article. Source — YouTube