( By Dr Manu L Kothari and Dr Lopa A Mehta )

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Death: Design and Definition

Dost thou ask some boon, O Kunti’s Son,
I will grant it.
Except immortality alone, tell me
as to the desire that is in thy heart.

Lord Krishna to Arjuna
In the Mahabharata, Vana Parva

‘Ask, and it shall be given,’ - having said so, the Lord hastens to add ‘except immortality alone’, for to so ask and so grant would be against the nature of things. The Mahabharatian mandate has survived the passage of 2,500 years and the marvels of modern medicine.

In one way or another, the scriptures have striven to drive home this lesson of death’s inevitability, and indispensability. Lord Buddha’s way of consoling the mother who lost her only son was to ask her to go into the town and bring him ‘a little mustard seed from any house where no man hath yet died.’ Achilles, the greatest and the ablest Greek hero, was left with a vulnerable heel; Duryodhan, the Kaurava prince in the Mahabharata, was blessed with head-to-foot invulnerability, save an area on the upper thigh. Lord Krishna himself was fatally wounded by a hunter’s arrow piercing his foot. A patient survived a heart transplant to die of stomach cancer.

A Bengali proverb puts it rather tartly: When the snake has bitten on the head, where should one tie the tourniquet? The understanding of death as an integral design within us is to accord to death the long-denied status of a physiological process. It is to discover the Achilles heel in Everyman.

Death: life’s invention

Robert Ardrey, the noted anthropologist, has described death as life’s most startling invention. Before a certain moment in the history of living things, Ardrey observes, death did not exist. And then, it arrived on the biological stage, as an invention of life to give meaning to life.

Jacob, the French biologist and Nobel prize winner, ends his classic The Logic of Living Systems with a generalization that but for death, evolution could not have been: ‘Not death from without, as the result of some accident: but death imposed from within, as a necessity prescribed from the egg onward by the genetic programme itself.’

This essay on evolution argues that the forces of life have fashioned the forces of death, making death integral to life, as physiologically mediated as life, and in terms of the individual’s growth and maturation, a designed denouement that climaxes a series of timed events. It is significant that death as a function has been found to be independent of the presence or the absence of disease.

Death as a physiological process

The science of physiology (from physik’e = the science of nature ) has been defined as ‘the philosophy of function in living matter, encompassed in this philosophy being the study of factors responsible for the origin, development and progression of life.’ In this definition, the bias towards living and life is clear; no wonder death as a subject does not enjoy a place in physiology texts, and an authoritative medical encyclopaedia accords it no mention at all. It needs to be realized that living and dying, and life and death are but the two sides of the same coin, what the Zen scholar Alan Watts calls, The Two Hands of God.

Living is dying

Granted that living starts at conception, so does the countdown in the organism’s march towards the ultimate event of death. Science’s acceptance that the scriptural idea of the finite number of heartbeats or breaths that a person or an animal is allotted in his or her lifetime may be right, reveals as a direct consequence that a heartbeat or a single act of breathing, while demonstrating the process of living is at the same time an act irretrievably lost towards the process of dying.

Should there be an insistence that dying is equivalent only to diseasing, let it be realized that, integral to man’s biological trajectory, diabetes actually begins at conception, vascular disease - ‘a song that is first sung in the cradle’, responsible for heart attack, stroke or kidney failure - begins in childhood, and a cancer occurring at the age of 56 is a part of the individual’s programme from the very beginning. The sophisticated medical check-ups that lay claims to early diagnoses are examples of ill- founded medical optimism. The infinite mercy of the process of dying rests in its discreet silence. All of us die with far more diseases than we die of, and all these including the presumably lethal diseases, remain discreetly silent for almost the whole lifespan.

Cellular bases of disease and death

The nearly 6000 billion cells that comprise a human being may be broadly classified into two groups: the short-lived dividing cells, and the perennial or immortal non-dividing cells. To the former group belong the blood cells, blood vessel cells, skin cells, kidney cells and so on, which together form the supporting complex mediating the respiratory, circulatory, nutritive, excretory and reproductive functions. The ‘immortal’ group perennial complex comprises the sensory receptors, nerve cells and the muscle cells which in concert constitute the essence of an individual, being the seat of his affective, cognitive, and conative faculties.

Human life starts as a single cell, the zygote formed by the union of the sperm and the ovum. By dint of very rapid cellular multiplication accompanied by the mysterious process of cell differentiation, the zygote transforms itself into a fully formed human being by the end of the 8th week after conception.Thereafter, throughout the fetal life and the total adult life span, the cells of the supporting complex and those of the perennial complex behave as polar opposites.

The cells of the supporting complex are small cells - a typical mammalian cell measures about 10 microns in diameter. This complex increases its bulk by cell multiplication. Some of the types of cells falling into this category continue to multiply at rates faster than the fastest growing cancer. Yet, the cell number remains constant everywhere by a corresponding rate of elimination of the cells by surface loss or destruction. The faculty of cellular multiplication enables the supporting complex to regenerate, repair, migrate from one site to another like blood cells, and be grafted by the surgeon from one site to another as in transplantation. The ability of the cells to multiply is the most outstanding feature of the supporting complex.

The inability of the cells to multiply beyond the 8th week of life in the womb, is the cardinal feature of the perennial complex. Its constituent cells are formed - in trillions - once and for ever, aligned to each other by very precise, point-to-point connections.

The cells of the perennial complex are incapable of regeneration, i.e. replacement of damaged cells or those lost due to disease or injury. The perennial complex increases its size to keep pace with the growth of the individual not by an increase in cell number (unlike the supporting complex) but by an increase in cell size. In a man 6 feet in height, some of the nerve cells are 6 feet 6 inches long, and some of the muscle cells are over a foot in length. The whole complex is an incredible computer with infinite intercellular connections. Because the cells of this complex do not divide, the connections are not disturbed and hence the precision and accuracy of this computer are assured throughout life.

The supporting complex is our Achilles heel, for senescence and for death, being the target area for the 10,000 shocks that flesh is heir to. The ability of the cells of the supporting complex to divide normally makes them prone to divide abnormally to form tumors, benign or malignant. The cells of the perennial complex cannot divide normally or abnormally. The tumors of the brain and the spinal cord arise from the neuroglial cells, a part of the supporting complex. There are as many as ten neuroglial cells providing support and nutrition to one nerve cell. The cell of the supporting complex, because of their multiplicability, are highly sensitive to damage and death by radiation whereas the cells of the perennial complex by their freedom from multiplicability, are immune to radiation damage.

The collagenous network and the intercellular ‘cement’ that form the general matrix for cells and organs, make integral part of the supporting complex and senesce at parallel rates. This means that there is much more to the frailty and fragility of the supporting complex than we suspect. Its universal network of blood vessels is prone to thickening, stiffening, encrustation and occlusion. (Some researchers hold that the so-called atheromatous process, or artherosclerosis, is a variant of tumor formation from multiplication of cells lining the blood vessels). The blockage of an artery from the heart spells heart attack, of the brain-stroke, of the kidney - high blood pressure and kidney failure, of the limbs or intestine- gangrene. It is not the heart that primarily fails or infarcts, for its muscle cells belong to the immortal perennial complex. In fact, the heart’s blood vessels - the coronaries - are the ones that let it down. The coronary arteries form the recipient part of our Achilles heel, an area that the death-arrow strikes conclusively.

The other sundry maladies - graying of hair, loss of teeth, wrinkling of skin, diabetes, arthritis, metabolic disorders, diseases of immunity - are all in the realm of the supporting complex. The perennial complex is largely exempt even from the ubiquitous microbial infections. Nature in its infinite wisdom has so designed us that ageing, senescence and disease leave our better self - our mind, our brain, our senses - essentially unmolested so that Pablo Picasso could creatively paint in his 80’s, and Voltaire could write Irene late in life. Above all, for these exceptional and for us ordinary mortals, the continuing vigor of the perennial complex allows us to feel the bliss of being, perceive the mercy of God, have possibly the most sublime mental composure in the house of our death, and to welcome death, like Rabindranath Tagore or St. Francis of Assisi, with arms wide open.

What is true of man is true of all vertebrates. Animals too have a perennial complex that is immortal, and a supporting complex that by its programmed fragility, its timed mortality, determines the lifespan of the species in general and of an animal in particular. Beyond the differences in the time-scale,. diseases in animals bear a striking similarity to diseases in man, be it diseased coronaries or a cancerous stomach. The cancer of the breast, or of the blood in a god, or Hodgkins’s disease in a pig, can be passed off as corresponding cancer of a human being if the identity of the source is not revealed.

Disease doesn’t cause death

The formidable array of pathological processes to which one’s supporting complex is prey fails to help medical men to comprehend the genesis of death. Diseased, very diseased, persons survive; healthy, ‘too good to die’ persons collapse and die. A person with manifest disease of the coronary arteries outlives his fellow with ‘normal’ arteries; a treated or exercised cancer fails to guarantee survival; the presence of untreated cancer, even advanced cancer, fails to guarantee death. Diseasing is the time-bound temperament of our tissues; death is a timed event that is largely independent of the nature or the extent of the disease process.

Over the past 200 years, from the time that the autopsy (the postmortem) became routine practice, medicine has tried to study diseases to understand the genesis of death, but has failed. Medicine’s pathological approach assumes that the presence of pathology must lead to disease on the one hand, and death on the other. On both counts, medicine has been proved wrong. Most pathological processes remain discreetly silent and as experience shows, beg to be left untouched. The idea that death is caused by a particular disease or diseases has proved so unreliable that an American researcher-writer, Mack Lipkin, in The New England Journal of Medicine has rightly described the charade of an autopsy and the related clinicopathologic conference, as anachronistic.

What kind of death for whom?

To cite but one example, let us consider the occurrence of death in a cancer patient. The patient has advanced cancer, and the patient, physician, and the next of kin are virtually waiting for the cancerous axe to snap the cord of the patient’s life. But cancer fails, for heart attack or stroke overtakes and beats cancer to the final post. Patients do not necessarily die of the disease from which they have suffered for so long. To the question concerning what kind of death for what kind of patient, the most scientific reply would be to express admission of medical ignorance. The lay and the learned are interested in knowing how death would come, and which disease would cause it. One can be wiser only after the event.

Defining death

While at death, we may define it. A clear definition of death (until recently, no great problem) has now become a pressing need, in academia, hospitals and courts, because of the emergence of organ transplantation. The transplant surgeon is plagued by a clinical paradox with regard to the organ-donor: he or she should give a live functioning organ from a live, active body although such a donor, to be a donor, should be assumed dead. The transplant paradox has been resolved by the invention of the concept of brain-death, ‘which declares a person dead when the brain is not functioning even though the heart beats on.’

This intellectual compromise, the definition of convenience labelled ‘brain-death’, is made in the face of the facts that (a) except for the surface areas of the cerebral hemispheres, the rest of the brain is neither inactive nor dead; (b) the major systems of circulation, respiration, digestion, excretion and even reproduction are alive and actively functioning, and (c) because of (b) all the vital signs are present. The unmistakable imprints of individuality - the physiognomy, the finger prints, the immune system actively opposed to any foreign protein in the form of microbes or a graft - are all untouched in brain-death. Death as we have known it, aims at disincarnation, a dissolution of the body by enzymatic and microbial forces released from within the body. No such thing happens after brain-death. No wonder it has been alleged that, in the absence of an unquestionable definition of death in the world of transplantation, the overweening enthusiasm of the transplant surgeon has meant assuming that organ-donors are dead when they are far from being so.

A way of defining death is to define life; from the womb to the tomb. The human body is an assemblage of different, highly specialized systems that are reciprocally connected to one another and to the external world by the universal network of blood vessels that derive their life-giving throb from a vigorous central pump called the heart. Even the nascent human embryo, which starts as an amorphous mass of cells in no way recognizable then as a human form, presages this need: the very first functioning system it fashions is the heart and its blood vessels that are present by the 4th week after fertilization, at a time when no other system is anywhere around. Students of the chick embryo can see, by the forth-fourth hour of the development of a chick, the tiny, bright, red heart with its blood vessels as the island throbbing with life in the otherwise absolutely featureless egg. The cell-to-cell universality of the circulatory system - heart and blood vessels - provides it with the pristine primacy of enlivening and interconnecting all other systems, giving each of them a meaning, a purpose, be it in a fully healthy individual, a deeply comatose patient, or a crusader fasting to death. We can generalize that the heartbeat - as felt over the heart or the peripheral pulse - representing active circulation of blood is the lowest common, debate-free denominator of life. The heartbeat is life. Its absence is death. Human life, in a manner of speaking is a brief spell of existence between two heartbeats, man’s first and man’s last.

The unrestricted, unconditional and universal applicability of the above definition of life and death based on the presence or absence of a functioning circulatory system may be realized from the fact that (a) the anesthetists who take humans into a deep, reversible coma must keep the circulatory system going, (b) the surgeons who, during surgery, put the heart and / or lungs out of action must maintain the circulatory system by machines, and (c) the resuscitators who bring back to life a person who has had a cardiac arrest or has been buried and frozen in snow, must, above all, revive the circulatory system. If blood is circulating, life if. If not, death is. Needless to say, the above definition of and approach to the ascertainment of life or death is applicable with ease by everyone, everywhere. Brain-dead people are heart-alive, and therefore not dead. The solution to the current acrimonious debate about brain-death is the medical candor that sees a live individual as live, and not as dead just because a part of the brain is not functioning. Such an unconscious patient is a live donor, like any other live donor, and should be respected and treated as such.

Why death is, the moment the heartbeat is not?

Broadly speaking, a human being is comprised of the circulatory, respiratory, nervous, digestive, excretory, reproductive, and locomotor systems. All these systems - each a highly evolved biologic unit - are knitted into an organic whole by the prime unit of heart and blood vessels. Two features of each of these systems - structural and functional reserve on the one hand, and summary dispensability on the other - merit discussion here.

Each one of us has been provided by a generous, almost profligate Nature with a lot of extra liver, extra kidney substance, extra endocrines, extra lungs, extra brain and so on. Even the vulnerable heart and its vulnerable blood vessels are endowed with a surprising structural and functional reserve (The pairing of most of the organs is the body’s survival instinct in action). Hence, although each system decays and diseases with age, life, good active life, goes on. With advancing age, the functional demands on each system decline, so that a degenerate or diseased organ still continues to be compatible with good living. The heart, too, takes a good deal of punishment before giving up. There are persons who get a series of heart attacks over a period of many years and pull through every time to lead to a long life. Even a heart attack, per se is not the cause of death. Hence, in fact, the surprising but certain dissociation between the presence of disease and the occurrence of death.

Experimental physiology and clinical experience have shown that life can continue, every unaided, in the absence of lung function for a few heart beats, in the absence of the liver for a few days, of the gut or the kidneys for a few weeks, of the endocrines for a few months, of the brain - brain-death - for a few years, of the limbs (as in thalidomide children) for a lifetime. The only indispensable unit is the heart and its blood vessels. Without them life ceases to be, even though all other systems may be in perfect condition. When death does occur in states of liver, kidney or endocrine disorders, the final decisive point is the cessation of the heartbeat. Heartbeat, present or absent, is thus the final arbiter of the presence or absence of life.

The question of sudden death

The realization that the cessation of heartbeat is the only incontrovertible element in the genesis and diagnosis of death bears relevance to the problem of sudden death.

Consider the deaths of Mahatma Gandhi felled by an assassin’s bullets, of King George the VI who died in his sleep, of Jawaharlal Nehru long-ailing from a stroke, of Gamal Abdul Nasser long-ailing from diabetes, and of you and me, one in the best of health, dying on the spot from the very first heart attack and the other dying after a series of heart attacks or after a protracted illness of the liver / kidneys / brain etc. When did death occur? Was it sudden or gradual?

Death, in health or in illness, either without any injury or following injury, is always a sudden event, being but the small decisive gap between the presence of heartbeat and the permanent, total absence of the immediate next beat. Bullets tore through Gandhi’s heart, yet he lived for a brief while, and in utter grace, said ‘Hey Rama.’ From the time the bullets were pumped in, to the time his heart beat its last, he was alive, only to die suddenly when the next heart beat did not come. The same for the King of England, for Nehru, for Nasser, for someone in absolute health, and someone in extreme illness.

What people actually mean by ‘sudden death’ is unexpected death, both in health and in sickness. This attitude of not expecting death stems from lay and learned ignorance of the constant proximity of death during any phase of life, and the obsession that only the presence of advanced illness is the harbinger of death. On both counts people and physicians have been proved wrong. The sudden death of a person in good health is a climatic event that the person’s body was preparing for without the knowledge and permission of his or her doctors. On the contrary, when the doctors give up a case as hopeless and as facing imminent death, the body declares that, for individual and herd reasons, its time has not yet ended, and in the teeth of medical opinion, continues to live. The medical arrogance and its misplaced confidence in its ‘objective’ tests is best shown in a cartoon that appeared in the Science Digest 1979. It shows a physician rather overbearingly declaring to the distraught patient seated across the table: ‘

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