Award-winning science journalist Robin Marantz Henig and podcast host Steve Mirsky discuss her article in the September issue about organ donation and definitions of death. Plus, we test your knowledge about some recent science in the news. Web sites related to this episode include When Does Life Belong To The Living?; How Time Flies
Steve: Welcome to Science Talk, the weekly podcast of Scientific American, posted on September 23rd, 2010. I'm Steve Mirsky. In this episode we'll look at the increasingly important question of when exactly a person dies, because if affects whether somebody else might be able to benefit from their organs. Science journalist Robin Marantz Henig tackled the question in her article in the September issue of Scientific American titled "When Does Life Belong to the Living?". Robin is one of the country's best known science writers. She is the author of Pandora's Baby, a history of in vitro fertilization, and of The Monk in the Garden, a look at Gregor Mendel's world changing 19th-century genetics research. Robin and I spoke at Scientific American's offices.
Steve: So Robin, there's this it's almost a game that—and I don't mean to trivialize it because it's the most serious thing there; [it's] life and death—but there is the this kind of a game that the medical profession is straightjacketed into [regarding] time of death and organ donations.
Robin: Right. I think more of it like a little dance that they've had to do.
Steve: Right. You do describe it that way in the article in fact.
Robin: Right. I don't think that we even would have wondered when the moment of the death is, where it not for the fact that we need those organs for donations, you know. [So] even the first time that anybody defined death back in the '60s, it was because of the complexities of donating organs.
Steve: [Defined] an exact time of the death. You know that if somebody was, you know, well let me be gross—if they were decaying they were obviously dead. You know, history is rife with incidences with somebody who is about to be buried, who pops up in the coffin during a wake because they're not dead. So this reality of organic donation has made time of death down to the second a crucial entity.
Robin: And it also made brain death a crucial entity because, you know, we traditionally think that when we you stop breathing and your heart stops beating, you're dead. But we needed some of those organs. We needed the breathing to go on artificially, if the organs were to be transplantable. So brain death, which you know, I think that it really is a sincere, accurate designation of somebody not existing anymore, but brain death needed to be stated specifically as the equivalent to not breathing and not having your heart beating.
Steve: You have this other expression, which apparently is a term of art that I had never seen before—the heart-beating cadaver.
Robin: Right. That's the kind of cadaver, the kind of organ donor, who's heart is kept beating artificially. He's not literally brain dead. Brain death is defined as "no function in the brain cortex or in the brain stem" which controls all the autonomic functions. So he's not brain dead, but he's going to die. He's kept alive by these, you know, heroics and you have, to sort, wait until his heart stops when, you know, you remove from the life-support systems, and when his heart does stop, you have to wait a little while to see if it's going to start up again.
Robin: Right. Which, you know, even if that did happen, it doesn't mean that he's not gonna die soon, but it's one of these other dances that surgeons go through to make sure that what they're taking an organ from is a dead donor. The question though becomes then should the dead donor rule be the thing that we reconsider that we, you know, are we really even taking organs from people who are actually dead? Or are we doing that dance, you know, are we pretending that we've waited those two minutes to make sure the heart doesn't start up again and so this is really somebody who's actually dead, who we can take the organs from. Maybe it's more truthful to just say, "Well we'll take these organs and that will be the cause of the death in this terminally ill patient."
Steve: And that would really define a new, but legally, morally and ethically acceptable official cause of death [would be] cause of death by organ donation.
Robin: Right. I mean, there's already cause of death by removal of life support, if you think about it. The death certificate doesn't say that, it says that whatever was the underlying cause, the need for being put on life support to begin with; but the proximate cause actually is that you've taken the machinery away. The same thing—in one way of thinking about this—the same thing could be done for organ donation. But it's very creepy, you know, I think that's what's keeping anybody from really suggesting this seriously.
Steve: It brings to mind, you know the Monty Python sketch, the organ donation sketch.
Robin: I don't know that one.
Steve: These two guys show up at a house and knock on the door, and they say "We're here for your liver." And [the guy in the house say, "What do you mean, you're here for my liver? I'm alive." [And they say, "Well you signed your card." And they proceed to remove his liver while he's still alive.
Robin: Well that's what everybody is afraid of though, because, you know, you think you signed your card, you have your organ donor card. What are they gonna do now, you know—"If they really, really need my organs are they gonna maybe not take such good care of me? Are they gonna do something that hastens my death because there's somebody waiting in the wings who they think is more valuable?" I think there are enough checks and balances to make sure that that kind of thing doesn't happen, but even proposing, creating a new definition of death as death by organ donation is something that really worries a lot of people.
Steve: And after the death panels arguments of the health care bill, I mean, who really is gonna ever have the political will to propose this kind of a thing?
Robin: You're right. I mean, when you think about what those death panels were, all they were offering [were] alternatives for end of life care. They weren't death panels at all.
Steve: Well they [were] offering insurance coverage [for those] because those happened already [all the time].
Robin: That's right that's right. You know, this would be really easy to mess around with and make political hay with.
Steve: Let's go back. I think we might have been a little vague in our earlier discussion. It literally is two minutes, 120 seconds, that has become the ethical window that you must wait after the heart stops before you begin harvesting organs.
Robin: Well that's become sort of the convention, and it's called the Pittsburgh Convention, in fact, because there's been no recorded case in which the heart spontaneously started up again once it didn't start up after two minutes. You know, there was no reason to wait for two and half minutes because the odds were if it was 120 seconds, the person was really dead. But that's actually been changed recently. I talk about this in the article, about some pediatric surgeons who actually waited 75 seconds in one case because they were pretty sure that that heart wasn't gonna start up again even after a minute plus.
Steve: And we should say, it's not a case that if the heart had started, the kid would've just bounced off the table and said, "Oh! I'm fine now."
Steve: I mean there were other huge problems.
Robin: This child in these cases or this individual is going to die, I mean, that's very clear. And so the question just is, do you orchestrate the moment of death with the availability of a transplant surgeon so that the organs haven't started to lose their oxygen after the heart stops beating and are still usable.
Steve: There was a New England Journal of Medicine article that kind of summed up the current situation and recommended alterations.
Robin: That's not exactly how it happened. The New England Journal of Medicine article described these pediatric surgeons taking hearts from dying infants in less than the typical two minutes of waiting for the heart to stop beating. Once that article came out, the journal kind of figured that this was going to be very controversial, and so they convened a roundtable discussion from some surgeons and some bioethicists talking about this issue, talking about whether the surgeons who had written the article had actually violated any ethical guidelines, and maybe what new guidelines should be. That's where I first came across this one bioethicist who says, "Let's cut the charade of pretending that these people are really dead, because we've done something to the definition of death and let's instead say, We're taking these organs from people who are imminently dead; and who have given really clear consent.'"—which he says is the most important part of that equation, is that they really understand that this is what's happening.
Steve: And that's Truagh.
Robin: Right, I think it's pronounced "Traugh".
Steve: Truagh, okay. But then you have Arthur Caplan, who's a really well known bioethicist and is on the board of advisors for Scientific American, who has; it's not that he completely disagrees but he's worried about the slope, the slippery slope.
Robin: He's worried about the slippery slope, and he's also worried about how it will look to people. You know, this Monty Python sketch you talked about, that is people who are being asked to donate their organs before they're actually dead. And so if we say, "Well forget about the dead donor rule, that just made us come up with tricks to make it sound like these donors are dead, let's not have a dead donor rule." If you say that, then these kind of scary prospects are going to be seen as even more imminent.
Steve: And then there was a presidential bioethics commission. There was a report they issued in 2008, where they were leery of making any kind of changes like this.
Robin: That's right, but what they did do was they endorsed the idea of brain death, what they were calling "the neurological standard of death". And they said that if the brain stem and the frontal cortex are not working, this individual is actually dead. That's actually a very tricky thing for people to understand because especially if that person is hooked up to some life support—actually even calling it life support is confusing, because what it is kind of death support.
Steve: Right, or viability support.
Robin: Right, right. So if the individual is hooked up to all that, his heart is beating, his lungs are functioning, he is pink, he is warm, he doesn't look dead, but the bioethics commission reviewed all of the scientific evidence and said, "But he really is dead, there's no coming back. You know, this isn't a persistent vegetative state where sometimes there's actually activity in there. This is death." So it was interesting for that group to come up with that decision, because they were very conservative group of bioethicists, and I was surprised and impressed that they had really gone through some of this very carefully and that was their conclusion.
Steve: Right because usually, you can kind of predict how a presidential bioethics commission is gonna behave by looking at the date that, the year of their publication of their opinions.
Robin: Right, like which president was this?
Steve: So this is 2008, so George W. Bush is still president, which means it's probably a conservative and religiously informed bioethics commission.
Robin: Right. And, you know, the history of bioethics commissions has been that they're convened by a particular president. They're asked to review these very tricky questions and they issue their decisions and then generally they disband, and a bioethics commission is formed to answer the same question because the new president wants a different answer.
Steve: Right. There's a really interesting kind [of] ethical situation that we don't really go into too much in the article, but there's a very famous example of, you know, there's a guy on a railroad track, and there's five people on the other railroad track.
Robin: The trolley equation.
Steve: The trolley equation. And if you have the opportunity to change the trolley from going on to the track that's only got one person or the one that has five people, would you do it? And most people would do it and feel kind of comfortable with their ethical decision. But if the same kind of situation comes up where you actively have to kill somebody to achieve the same goal, it's very different in people's emotional reaction to the question, and this kind of situation also exists here because we're for, kind of, implicitly obvious reasons, we're prioritizing here the person we're gonna harvest the organs from rather than the people who maybe in almost as dire a condition who will be saved by those organs.
Steve: But we can never actively kill the person, if there's a chance that they're still in small way alive, just to get those organs and maybe save three other people with two kidneys and a liver.
Robin: You know, I've heard the trolley program taken to its logical extreme. What you suggested was, you know, the first question is, do you flip a switch so that you kill one individual and save the five on the other track? The second question is, do you—actually what I've heard it as—throw a fat man off a bridge so that you stop the train and it doesn't kill the five individuals. And then I've heard it taken to the next level, which is you walk into a room where there are five people in need of five different organs, and there's a healthy person standing there, do you kill him and save those five people?
Robin: And that's what you're reacting to is that, something like this kind of equation that people have to come up with, is whose life is more worthwhile? And the truth is that the donor is going die anyway. The person who is waiting for the new organ is probably not going to die once he gets the organ, is going to die if he doesn't get the organ, and the family of the people whose, you know, loved one is dying and could be an organ donor tend to want the organs to be in good shape and to be able to donate them to make some sense of that person's death. You know, it tends to be a very gratifying experience for the bereaved family to think that the heart and lungs are working in some other individual.
Steve: Some part of the deceased is actually is still alive. Are you an organ donor?
Robin: Yes, I am. I'm also a bone marrow donor. I mean, you know, when you say are you donor, I'm on a registry for bone marrow transplantation if need be, and I have that little thing checked off on my driver's license. And I've spoken to my family about it too, which is really the part that you really need to do
Steve: As have I. I've told them, "Please, should I die, please consider me to be a big pile of harvestable meat for somebody else to use."
Robin: But you have to die in the right circumstance for that to happen, and unfortunately that doesn't happen that often—or fortunately I guess. But you know, if you live to a ripe old age, and die a natural death, you're not gonna be an organ donor.
Steve: Right. And also if you're exposed to some toxin that might make your organs unusable.
Steve: So you wanna die nice and clean and young and healthy if you're gonna be an organ donor. No, we just we want everybody to live a nice, healthy, long life and you know, in the unfortunate case of any accidents then at least some of the organs can be harvestable. I did a column a few months back, people might wanna look at that describes how a guy who was on a scooter riding hands free, while he was texting and had earbuds in from his smart phone—he was texting on the smart phone, and had earbuds—so he couldn't see, he couldn't hear and he was driving hands free. And I had passed him when I saw this, and then he caught up to me at a light, and I rolled down the window and I said, "Hey", and he didn't really hear me, saw me waving at him, and he took the ear buds out. And I said, "Ah! I just hope you signed your donor card." And he looked at me you know, quizzically and he said, "Huh?" And I said, "Well I hope you signed your donor card because your life expectancy is like eight minutes, and at least, you know, somebody might benefit from your imminent demise." So Robin Marantz Henig, are you working on another book right now? What else are you working on?
Robin: I don't know yet. I just wrote an article about emerging adults about 20-something-year-old, young people, and I might be turning that into a book, I'm not sure.
Steve: And that was for The New York Times Magazine …
Steve: …where you often contribute. What were some of the reactions to that?
Robin: Well the funny ones were things like "Oh, you're just old and jealous." I don't know how they realized how old I am, but they did, and you know …
Steve: Because no 20-something-year-old could write that article.
Robin: Is that it?
Steve: The article was basically about how this generation of young people doesn't quite seem prepared for reality, right?
Robin: No, it wasn't exactly that, and I think a lot of people saw that kind of judgment in it; and I don't actually, I don't judge young people harshly. Some of my favorite daughters are young people. What the article was about is that that young people now seem to be taking longer to attain some of the traditional markers of adulthood than their predecessors did. You know, they're marrying later, they're having children later, they're settling into their careers later. And so the question is, why is that and is there actually a new developmental stage that's akin to adolescence and not quite adult that we should be thinking of these kids as being in the middle of?
Steve: It's called graduate school. But some of the reactions were …
Robin: Some of the reactions were, "Why are you so critical of us? It's not our fault, it's your fault. You left us a bad world, the economy is so bad." Some of the reactions though, the ones that I really valued were from people in their [twenties] or their parents saying, "This sounds just like me, thank you for making me not feel so odd about it."
Steve: You can visit Robin Marantz Henig's Web site at www.robinhenig.com. Now it's time to play TOTALL……. Y BOGUS. Here are four science stories; only three are true. See if you know, which story is TOTALL……. Y BOGUS.
Story number 1: The first continuous human-powered ornithopter flight finally happened in Canada over five centuries after da Vinci sketched a flapping-wing flying machine.
Story number 2: Also from Canada, a company is developing an electric car, the body of which will be made from hemp.
Story number 3: Over 7 percent of the entire world's population is on Facebook.
And story number 4: Playing football was the most common reason for an emergency room visit because of a concussion in the U.S. even for kids in the eight- to 13-year-old range.
Story 1 is true. An ornithopter piloted by a PhD candidate in Engineering at the University of Toronto flew for over 19 seconds traveling 145 meters, which is longer than the Wright Brothers' first flight.
Story 2 is true. Calgary's Motive Industries is developing the hemp auto or cannabis car, which is really being called the Kestrel, rather than say the [Cheech and Chong mobile]. Henry Ford actually made a hemp car, too, long ago. It's ordinarily illegal to grow hemp in the U.S., but they can grow it in Canada, and the U.S. can import goods made of hemp that's been processed. So you may see a Kestrel on the road sometime in the U.S. soon. Or you may just think you saw one.
And story 3 is true. 7.6 percent of the world's population has a Facebook account according to graphical research published on the Web site, Sociological Images. 43 percent of North Americans and 20 percent of Europeans have an account.
All of which means that story 4, about age 13-year-old kids getting the most concussions from football is TOTALL……. Y BOGUS. But what is true is that in sports-related concussions that caused an emergency room visit, football was the leader for kids from 14 to 19 years old. That's according to research in the journal of the American Academy of Pediatrics, covering the years 2001 to 2005. For kids between eight and 13 years old, more concussions happened in bicycling accidents than were sustained playing football.
That's it for this episode. If you remember the last episode, George Musser and I were talking about how time moves at different rates at even small differences in altitude. For more on that check out the article just posted on our Web site on September 23rd by John Matson titled "How Time Flies: Ultraprecise clock rates vary with tiny differences in speed and elevation". And visit the new-look ScientificAmerican.com for all your science news. And follow us on Twitter, where you'll get a tweet every time a new article hits the Web site. Our Twitter name is @SciAm. For Science Talk, the podcast of Scientific American, I'm Steve Mirsky. Thanks for clicking on us.