/deth/, n.1. the act of dying; the end of life; the total and permanent cessation of all the vital functions of an organism. Cf. brain death.2. an instance of this: a death in the family; letters published after his death.3. the state of being dead: to lie still in death.4. extinction; destruction: It will mean the death of our hopes.5. manner of dying: a hero's death.6. (usually cap.) the agent of death personified, usually represented as a man or a skeleton carrying a scythe. Cf. Grim Reaper.7. Also called spiritual death. loss or absence of spiritual life.8. Christian Science. the false belief that life comes to an end.9. bloodshed or murder: Hitler was responsible for the death of millions.10. a cause or occasion of death: You'll be the death of me yet!11. Archaic. pestilence; plague. Cf. Black Death.12. at death's door, in serious danger of death; gravely ill: Two survivors of the crash are still at death's door.13. be death on, Informal.a. to be excessively strict about: That publisher is death on sloppily typed manuscripts.b. to be snobbish about or toward.c. to be able to cope with easily and successfully: The third baseman is death on pop flies.14. do to death,a. to kill, esp. to murder.b. to repeat too often, to the point of becoming monotonous and boring: That theme has been done to death.15. in at the death,a. Fox Hunting. present at the kill.b. present at the climax or conclusion of a situation.16. put to death, to kill; execute.17. to death, to an extreme degree; thoroughly: sick to death of the heat.Syn. 1. decease, demise, passing, departure.Ant. 1. birth, life.
* * *(as used in expressions)programmed cell deathnear death experience
* * *Introductionthe total cessation of life processes that eventually occurs in all living organisms. The state of human (human being) death has always been obscured by mystery and superstition, and its precise definition remains controversial, differing according to culture and legal systems.During the latter half of the 20th century, death has become a strangely popular subject. Before that time, perhaps rather surprisingly, it was a theme largely eschewed in serious scientific, and to a lesser extent, philosophical speculations. It was neglected in biological research and, being beyond the physician's ministrations, was deemed largely irrelevant by medical practice. In modern times, however, the study of death has become a central concern in all these disciplines and in many others.“So many more people seem to die nowadays,” an elderly lady is alleged to have said, scanning the obituary columns of a famous daily. This was not just a comment on the documented passing of a cohort. Various journals now not only list the dead but also describe what they died of, at times in some detail. They openly discuss subjects considered too delicate or personal less than a generation ago. Television interviewers question relatives of the dying—or even the dying themselves—and films depict murders or executions in gruesome and often quite accurate detail. Death is no longer enshrined in taboos. Popular readiness to approach these matters and a general desire to be better informed about them reflect a change in cultural attitudes perhaps as great as that which accompanied the more open discussion of sex after World War I.thanatology—the study of death—delves into matters as diverse as the cultural anthropology of the notion of soul, the burial rites and practices of early civilizations, the location of cemeteries in the Middle Ages, and the conceptual difficulties involved in defining death in an individual whose brain is irreversibly dead but whose respiration and heartbeat are kept going by artificial means. It encompasses the biological study of programmed cell death, the understanding care of the dying, and the creation of an informed public opinion as to how the law should cope with the stream of problems generated by intensive-care technology. Legal and medical quandaries regarding the definition of death and the rights of the terminally ill (or their families) to refuse life-prolonging treatments force physicians to think like lawyers, lawyers like physicians, and both like philosophers. In his Historia Naturalis (Natural History), the Roman author Pliny the Elder wrote that “so uncertain is men's judgment that they cannot determine even death itself.” The challenge remains, but if humans now fail to provide some answers it will not be for lack of trying.The meaning of deathThis subject can be approached from a variety of perspectives. It can, for example, be viewed historically, in terms of how popular perceptions of death have been reflected in poetry, literature, legend, or pictorial art. Illustrations of those killed (mortality) in battle and of their severed parts find particular prominence in ancient Egyptian art (art and architecture, Egyptian). The campaign of the 13th-century-BC Egyptian king Ramses II against the Hittites, in particular the Battle of Kadesh, is recorded in gruesome detail on the battle reliefs of 19th- and 20th-dynasty temples in Upper Egypt. Assyrian art, too, made great play of illustrating cadavers. Those slaughtered by the king Ashurbanipal (flourished 7th century BC) in his campaign against the Arabian king Uate are shown having their eyes plucked out by vultures. These very concrete depictions of the meaning of death seem to have had mainly propagandistic value, boosting the self-confidence of the victors and inspiring fear among the defeated. Deities of the dead were features of many early cultures, but apart from ancient Egypt neither such deities nor those over whom they held dominion were the subject of any significant artistic representation. In Egypt, sepulchral iconography was to reach truly impressive heights, particularly after the democratization of the Osirian cult with its promise of an afterlife for everyone. Well-known sculptors produced some striking individual tombstones in both ancient Greece and Rome, but it was medieval Christianity that gave real impetus to this practice, which can be thought of as an attempt to perpetuate among the living a vivid memory of the dead. The representation of death itself, usually personified in the form of a skeleton, seems to have developed on a large scale only in medieval Christian art.An alternative approach is to look at the meaning of death in terms of various eschatologies (eschatology) (beliefs regarding death and the end of the world). Human beings have been the only species to bury their dead in a systematic way, often with implements to be used in a further existence. The study of death rites and customs illustrates impressively the relation between religious belief and popular practice in the presence of the dead. Such an approach starts from the meaning of death in those cultures (such as Phoenician, early Judaic, Homeric, Epicurean, and Stoic) in which only a shadowy afterlife or no afterlife at all was envisaged; it analyzes other traditions (such as Sumero-Akkadian) in which ambiguities and contradictions abounded; and it finally searches for death's meaning in those cultures (such as ancient Egyptian, Zoroastrian, Hindu, Orphic, Platonic, Christian, Pharisaic Judaic, and Islāmic) in which a very “physical” afterlife, or the presence of an eternal soul, played central roles.Both the historical and the eschatological approaches share a common advantage: they need not be preceded by a definition of death. They accept death as an easily determined empirical fact, not requiring discussion or further elaboration. But a conceptual crisis has arisen in modern medicine (medicine, history of) and biology, a crisis that stems precisely from the realization that the definition of death—taken for granted for millennia—requires reexamination. To approach the subject of death from the biological angle, which is perhaps the most difficult and arguably the most challenging perspective, certainly reflects some of the most pressing needs of modern times.Many dictionaries define death as “the extinction or cessation of life” or as “ceasing to be.” As life itself is notoriously difficult to define—and as everyone tends to think of things in terms of what is known—the problems in defining death are immediately apparent. The most useful definitions of life are those that stress function, whether at the level of physiology, of molecular biology and biochemistry, or of genetic potential. Death should be thought of as the irreversible loss of such functions.The remainder of this article first explores the recurrent problems involved in seeking a biological definition of death. It then examines the implications of these problems in relation to human death. In this context, the article raises two major points: (1) death of the brain (brain death) is the necessary and sufficient condition for death of the individual; and (2) the physiological core of brain death is the death of the brain stem (brainstem). Finally, the article surveys notions about the meaning of human death that have prevailed throughout history in a wide variety of cultural contexts. By so doing, it attempts to show that brain-stem death, far from being a radically new idea, turns out to have always provided both an ultimate mechanism of death and a satisfactory anatomical basis for a wide range of philosophical concepts relating to death.The biological problemsWhether one considers the death of individual cells, the death of small multicellular organisms, or the death of a human being, certain problems are repeatedly met. The physicist may encounter difficulties in trying to define death in terms of entropy change and the second law of thermodynamics. So may the histologist looking at the ultrastructure of dying tissue through an electron microscope. Pope Pius XII, speaking to an International Congress of Anesthesiologists in 1957, raised the question of when, in the intensive care unit, the soul actually left the body. More secularly inclined philosophers have meanwhile pondered what it was that was so essential to the nature of man that its loss should be called death. The questions of what may or may not be legitimately demanded of a “beating-heart cadaver” (in terms of supplying donor organs for transplants or of serving as a subject for physiological experimentation) has given new poignancy to the quip made by the English author Sir Thomas Browne (Browne, Sir Thomas) in 1643: “With what strife and pains we come into the world we know not, but 'tis commonly no easy matter to get out of it.” Common conceptual difficulties underlie many of these questions.Death: process or eventThe American physician and writer Oliver Wendell Holmes (Holmes, Oliver Wendell) said “to live is to function” and “that is all there is in living.” But who or what is the subject who lives because it functions? Is death the irreversible loss of function of the whole organism (or cell); that is, of every one of its component parts? Or is it the irreversible loss of function of the organism (or cell) as a whole; that is, as a meaningful and independent biological unit? To perceive the difference between the two questions is to understand many modern controversies about death. The described dichotomy is clearly part of a much wider one: civilizations fall apart yet their component societies live on; societies disintegrate but their citizens survive; individuals die while their cells, perversely, still metabolize; finally, cells can be disrupted yet the enzymes they release may, for a while, remain active.Such problems would not arise if nature were tidier. In nearly all circumstances human death is a process rather than an event. Unless caught up in nuclear explosions people do not die suddenly, like the bursting of a bubble. A quiet, “classical” death provides perhaps the best illustration of death as a process. Several minutes after the heart has stopped beating, a mini-electrocardiogram may be recorded, if one probes for signals from within the cardiac cavity. Three hours later, the pupils still respond to pilocarpine drops by contracting, and muscles repeatedly tapped may still mechanically shorten. A viable skin graft may be obtained from the deceased 24 hours after the heart has stopped, a viable bone graft 48 hours later, and a viable arterial graft as late as 72 hours after the onset of irreversible asystole (cardiac stoppage). Cells clearly differ widely in their ability to withstand the deprivation of oxygen supply that follows arrest of the circulation.Similar problems arise, but on a vastly larger scale, when the brain is dead but the heart (and other organs) are kept going artificially. Under such circumstances, it can be argued, the organism as a whole may be deemed dead, although the majority of its cells are still alive.The “point of no return”To claim that death is a process does not imply that this process unfurls at an even rate, or that within it there are not “points of no return.” The challenge is to identify such points with greater precision for various biological systems. At the clinical level, the irreversible cessation of circulation has for centuries been considered a point of no return. It has provided (and still provides) a practical and valid criterion of irreversible loss of function of the organism as a whole. What is new is the dawning awareness that circulatory arrest is a mechanism of death and not in itself a philosophical concept of death; that cessation of the heartbeat is only lethal if it lasts long enough to cause critical centres in the brain stem to die; and that this is so because the brain stem is irreplaceable in a way the cardiac pump is not. These are not so much new facts as new ways of looking at old ones.Failure to establish beyond all doubt that the point of no return had been reached has, throughout the ages, had interesting effects on medical practice. The Thracians, according to the ancient Greek historian Herodotus, kept their dead for three days before burial. The Romans (ancient Rome) kept the corpse considerably longer; the Roman author Servius, in his commentary on Virgil, records that “on the eighth day they burned the body and on the ninth put its ashes in the grave.” The practice of cutting off a finger, to see whether the stump bled, was often resorted to. Even the most eminent proved liable to diagnostic error. The 16th-century Flemish physician Andreas Vesalius (Vesalius, Andreas), probably the greatest anatomist of all time, professor of surgery in Padua for three years and later physician to the Holy Roman emperor Charles V, had to leave Spain in a hurry in 1564. He was performing a postmortem when the subject, a nobleman he had been attending, showed signs of life. This was at the height of the Spanish Inquisition and Vesalius was pardoned only on the condition that he undertake a pilgrimage to the Holy Sepulchre in Jerusalem.Fears of being buried (burial) alive have long haunted humankind. During the 19th century, for example, accounts of “live sepulture” appeared in medical writing and led to repeated demands that putrefaction—the only sure sign of death of the whole organism—be considered an essential prerequisite to a diagnosis of death. Anxieties had become so widespread following the publication of some of U.S. author Edgar Allan Poe's macabre short stories that Count Karnice-Karnicke, a Russian nobleman, patented a coffin of particular type. If the “corpse” regained consciousness after burial, it could summon help from the surface by activating a system of flags and bells. Advertisements described the price of the apparatus as “exceedingly reasonable, only about twelve shillings.”At the turn of the century, a sensation-mongering press alleged that there were “many ugly secrets locked up underground.” There may have been some basis for these claims: instances of collapse and apparent death were not uncommon during epidemics of plague, cholera, and smallpox; hospitals and mortuaries were overcrowded, and there was great fear of the spread of infection. This agitation resulted in stricter rules concerning death certification. In the United Kingdom, statutory obligations to register deaths date only from 1874, and at that time it was not even necessary for a doctor to have viewed the corpse.The second half of the 20th century has seen tremendous developments in the field of intensive care and the emergence of new controversies concerning the point of no return. Modern technology now makes it possible to maintain ventilation (by respirators), cardiac function (by various pumping devices), feeding (by the intravenous route), and the elimination of the waste products of metabolism (by dialysis) in a body whose brain is irreversibly dead. In these macabre by-products of modern technology, a dissociation has taken place between the various components of death so that the most important—the death of the brain—occurs before, rather than after, the cessation of other functions, such as circulation. Such cases have presented both practical and conceptual problems, but the latter need not have arisen had what happens during decapitation been better appreciated.“Beating-heart cadavers” were of course familiar to the observant long before the days of intensive care units. A photograph of a public decapitation (beheading) in a Bangkok square in the mid-1930s illustrates such a case. The victim is tied to a stake and the head has been severed, but jets of blood from the carotid and vertebral arteries in the neck show that the heart is still beating. It is doubtful that anyone would describe the executed man—as distinct from some of his organs—as still alive. This gruesome example stresses three points: it reiterates the fact, admittedly from an unusual angle, that death is a process rather than an event; it emphasizes the fact that in this process there is a point of no return; and it graphically illustrates the difference between the death of the organism as a whole and the death of the whole organism. In thinking the implications through, one takes the first steps toward understanding brain death. The executed man has undergone anatomical decapitation. Brain death is physiological decapitation: it arises when intracranial pressure exceeds arterial pressure, thereby depriving the brain of its blood supply as efficiently as if the head had been cut off. The example serves as an introduction to the proposition that the death of the brain is the necessary and sufficient condition for the death of the individual.These issues were authoritatively discussed in 1968, at the 22nd World Medical Assembly in Sydney, Australia. The assembly stated that “clinical interest lies not in the state of preservation of isolated cells but in the fate of a person. The point of death of the different cells and organs is not as important as the certainty that the process has become irreversible.” The statement had a profound effect on modern medical thinking. “Irreversible loss of function of the organism as a whole” became an accepted clinical criterion of death.Semantic confusion may underlie some of the controversies outlined in this section. In many languages, including English, the word death may be used in various ways. The Concise Oxford Dictionary for instance defines death both as “dying” (a process) and as “being dead” (a state). Expressions such as “a painful death” and “a lingering death” show how often the word is used in the former sense. Many people are afraid of dying yet can face the prospect of being dead with equanimity. Another source of confusion that bedevils discussions about death is what the great English mathematician and philosopher Alfred North Whitehead called the “fallacy of misplaced concreteness.” This occurs when one treats an abstraction (however useful it may be to denote the behaviour or properties of objects under specific circumstances) as if it were itself a material thing. “O death, where is thy sting?” may be a searching metaphorical question, but such queries can only confuse the biologist. When the poet John Milton wrote of “the pain of death denounced, whatever thing death be,” the conceptual problem was of his own making.The next two sections of this article illustrate these general principles concerning death from each end of the spectrum of living things: from the level of the cell and from that of the fully developed human being.Cell deathA vast amount of work has been devoted since the late 19th century to discovering how cells multiply. The study of how and why they die is a relatively recent concern: a rubric entitled “cell death” only appeared in the Index Medicus, an index to medical literature, in 1979.What most textbooks of pathology describe as cell death is coagulative necrosis. This is an abnormal morphological appearance, detected in tissue examined under the microscope. The changes, which affect aggregates of adjacent cells or functionally related cohorts of cells, are seen in a variety of contexts produced by accident, injury, or disease. Among the environmental perturbations that may cause cell necrosis are oxygen deprivation (anoxia), hyperthermia, immunological attack, and exposure to various toxins that inhibit crucial intracellular metabolic processes. Coagulative necrosis is the classical form of cell change seen when tissues autolyze (digest themselves) in vitro.But cells may die by design as well as by accident. Research in developmental pathology has stressed the biological importance of this other kind of cell death, which has been referred to as programmed cell death. In vertebrates it has been called apoptosis and in invertebrates, cell deletion. Programmed cell death plays an important role in vertebrate ontogeny (embryological development) and teratogenesis (the production of malformations), as well as in the spectacular metamorphoses (metamorphosis) that affect tadpoles or caterpillars. Such programmed events are essential if the organism as a whole is to develop its normal final form. Waves of genetically driven cell death are critical to the proper modeling of organs and systems. The inflections (curvatures) of the developing mammalian brain and spinal cord, for instance, or the achievement of a proper numerical balance between functionally related cell groups, cannot be understood without an appreciation of how the death of some (or many) cells is necessary for others to reach maturity. Localized cell death, occurring at precise moments during normal ontogeny, explains phenomena as varied as the fashioning of the digits or the involution of phylogenetic vestiges. Several congenital abnormalities can be attributed to disorders of programmed cell death. Cell death occurs spontaneously in normally involuting tissues such as the thymus. It can be initiated or inhibited by a variety of environmental stimuli, both physiological and pathological. Cell death even occurs in some of the cells of untreated malignant tumours, and it is seen during tumour regression induced by X rays or radiomimetic cytotoxic agents. Programmed cell death may also play a part in the process of aging, cells being designed to die after a certain number of mitotic divisions. Groups of cells responsible for the colour of human hair, for instance, may cease to function years before the hair itself loses the capacity to grow: the result is the “uncoloured” white hair of old age.The two types of cell death—imposed from without or programmed from within—have different morphological features. Furthermore, different intracellular mechanisms have been incriminated in their production.Necrosis is characterized by early swelling of the cytoplasm and of the mitochondria (mitochondrion) (energy-releasing organelles) within it. Later changes include the appearance of localized densities, possibly related to calcium deposition, in the matrix (ground substance) of the mitochondria. This is followed by the dissolution of other cytoplasmic organelles and the separation of affected cells from their neighbours through shearing of intercellular junctions. Nuclear alterations occur late and are relatively unremarkable. The nucleus swells, becomes darker (pyknosis), and ruptures (karyolysis) at about the same time as does the plasma membrane, the outer envelope of the cell. The basic mechanism of necrosis is thought to be a loss of control over cell volume, related to changes in the permeability of the cell membrane. These changes form the basis of several of the tests used to diagnose a necrotic cell in the laboratory. The affected membrane rapidly loses its ion-pumping capacity, and there are dramatic increases in the intracellular concentrations of sodium and calcium ions. This is followed by osmotic shock and the development of intracellular acidosis. The early injury to the mitochondria has profound repercussions on intracellular oxidative metabolism. The point of no return is reached with irreversible damage to mitochondrial structure and function. Later still, the lysosomes (lysosome) (membranous bags of hydrolytic enzymes found in most cells) rupture, releasing their acid enzymes into the cytoplasm of the cell. All this produces an ionic milieu unsuitable to the survival of the nucleus. Loss of the cell's capacity to synthesize protein is the ultimate proof that it is functionally dead.Programmed cell death usually affects scattered single cells. Early ultrastructural features are the disintegration of cell junctions and condensations of the cytoplasm. The cells shrivel up instead of swelling. Lumps of chromatin aggregate at the surface of the nucleus. The nuclear membrane develops folds, and the nucleus splits into a number of membrane-bound, ultrastructurally well-preserved fragments, which are shed and promptly taken up by specialized scavenger cells or even by ordinary cells in the neighbourhood. Energy-producing mitochondria are preserved until quite late. The nuclear changes seem to be energy-dependent; they may reflect the fact that genes in the nucleus are beginning to express themselves in new ways, in response to unknown stimuli. One of these responses seems to be the activation of endogenous endonucleases, enzymes in the cell nucleus that “suicidally” disrupt its cardinal functions.Time alone will tell whether the distinctions between the two types of cell death are valid or spurious, and whether the concept of apoptosis will gain wide acceptance. Reality will probably turn out to be a great deal more complex. Meanwhile, one should retain, without overemphasis, the twin visions of cell death—one in which death approaches the cell from the outside and the other in which death starts from within the living core of the cell itself.Clinical deathAt the opposite end of the spectrum from cell death lies the death of a human being. It is obvious that the problems of defining human death cannot be resolved in purely biological terms, divorced from all ethical or cultural considerations. This is because there will be repercussions (burial, mourning, inheritance, etc.) from any decisions made, and because the decisions themselves will have to be socially acceptable in a way that does not apply to the fate of cells in tissue culture.Unless death is defined at least in outline, the decision that a person is “dead” cannot be verified by any amount of scientific investigation. Technical data can never answer purely conceptual questions. Earlier in this article it was suggested that the death of the brain was the necessary and sufficient condition for the death of the individual, but the word death was not given much content beyond the very general definition of “irreversible loss of function.” If one seeks to marry conceptions of death prevalent in the oldest cultures with the most up-to-date observations from intensive care units, one might think of human death as the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe (respiration, human). The anatomical basis for such a concept of human death resides in the loss of brain-stem function.Functions of the brain stem (brainstem)The brain stem is the area at the base of the brain that includes the mesencephalon (midbrain), the pons, and the medulla. It contains the respiratory and vasomotor centres, which are responsible, respectively, for breathing and the maintenance of blood pressure. Most importantly, it also contains the ascending reticular activating system, which plays a crucial role in maintaining alertness (i.e., in generating the capacity for consciousness); small, strategically situated lesions in the medial tegmental portions of the midbrain and rostral pons cause permanent coma. All of the motor outputs from the cerebral hemispheres—for example, those that mediate movement or speech—are routed through the brain stem, as are the sympathetic and parasympathetic efferent nerve fibres responsible for the integrated functioning of the organism as a whole. Most sensory inputs also travel through the brain stem. This part of the brain is, in fact, so tightly packed with important structures that small lesions there often have devastating effects. By testing various brain-stem reflexes, moreover, the functions of the brain stem can be assessed clinically with an ease, thoroughness, and degree of detail not possible for any other part of the central nervous system.It must be stressed that the capacity for consciousness (an upper brain-stem function) is not the same as the content of consciousness (a function of the cerebral hemispheres); it is, rather, an essential precondition of the latter. If there is no functioning brain stem, there can be no meaningful or integrated activity of the cerebral hemispheres, no cognitive or affective life, no thoughts or feelings, no social interaction with the environment, nothing that might legitimize adding the adjective sapiens (“wise”) to the noun Homo (“man”). The “capacity for consciousness” is perhaps the nearest one can get to giving a biological flavour to the notion of “ soul.”The capacity to breathe is also a brain-stem function, and apnea (respiratory paralysis) is a crucial manifestation of a nonfunctioning lower brain stem. Alone, of course, it does not imply death; patients with bulbar poliomyelitis, who may have apnea of brain-stem origin, are clearly not dead. Although irreversible apnea has no strictly philosophical dimension, it is useful to include it in any concept of death. This is because of its obvious relation to cardiac function—if spontaneous breathing is lost the heart cannot long continue to function—and perhaps because of its cultural associations with the “breath of life.” These aspects are addressed in the later discussion of how death has been envisaged in various cultures.Mechanisms of brain-stem deathFrom as far back as medical records have been kept, it has been known that patients with severe head injuries or massive intracranial hemorrhage often die as a result of apnea: breathing stops before the heart does. In such cases, the pressure in the main (supratentorial) compartment of the skull becomes so great that brain tissue herniates through the tentorial opening, a bony and fibrous ring in the membrane that separates the spaces containing the cerebral hemispheres and the cerebellum. The brain stem runs through this opening, and a pressure cone formed by the herniated brain tissue may dislocate the brain stem downward and cause irreversible damage by squeezing it from each side. An early manifestation of such an event is a disturbance of consciousness; a late feature is permanent apnea. This was previously nature's way out.With the widespread development of intensive care facilities in the 1950s and '60s, more and more such moribund patients were rushed to specialized units and put on ventilators just before spontaneous breathing ceased. In some cases the effect was dramatic. When a blood clot could be evacuated, the primary brain damage and the pressure cone it had caused might prove reversible. Spontaneous breathing would return. In many cases, however, the massive, structural intracranial pathology was irremediable. The ventilator, which had taken over the functions of the paralyzed respiratory centre, enabled oxygenated blood to be delivered to the heart, which went on beating. Physicians were caught up in a therapeutic dilemma partly of their own making: the heart was pumping blood to a dead brain. Sometimes the intracranial pressure was so high that the blood could not even enter the head. Modern technology was exacting a very high price: the beating-heart (heart attack) cadaver.Brain-stem death may also arise as an intracranial consequence of extracranial events. The main cause (cardiovascular disease) in such cases is circulatory (circulation) arrest. The usual context is delayed or inadequate cardiopulmonary resuscitation following a heart attack. The intracranial repercussions depend on the duration and severity of impaired blood flow to the head. In the 1930s the British physiologist John Scott Haldane had emphasized that oxygen deprivation “not only stopped the machine, but wrecked the machinery.” Circulatory arrest lasting two or three minutes can cause widespread and irreversible damage to the cerebral hemispheres while sparing the brain stem, which is more resistant to anoxia. Such patients remain in a “persistent vegetative state.” They breathe and swallow spontaneously, grimace in response to pain, and are clinically and electrophysiologically awake, but they show no behavioral evidence of awareness. Their eyes are episodically open (so that the term coma is inappropriate to describe them), but their retained capacity for consciousness is not endowed with any content. Some patients have remained like this for many years. Such patients are not dead, and their prognosis depends in large part on the quality of the care they receive. The discussion of their management occasionally abuts onto controversies about euthanasia and the “right to die.” These issues are quite different from that of the “determination of death,” and failure to distinguish these matters has been the source of great confusion.If circulatory arrest lasts for more than a few minutes, thebrain stem—including its respiratory centre—will be as severely damaged as the cerebral hemispheres. Both the capacity for consciousness and the capacity to breathe will be irreversibly lost. The individual will then show all the clinical features of a dead brain, even if the heart can be restarted.Evolution of the concept of brain-stem deathIt was against this sort of background that French neurologists, in 1958, described a condition they called coma dépassé (literally, “a state beyond coma”). Their patients all had primary, irremediable, structural brain lesions; were deeply comatose; and were incapable of spontaneous breathing. They had not only lost their ability to react to the external world, but they also could no longer control their own internal environment. They became poikilothermic (i.e., they could not control their body temperature, which varied with that of the environment). They could not control their blood pressure or vary their heart rate in response to appropriate stimuli. They could not even retain body water and would pass great volumes of urine. The organism as a whole had clearly ceased to function. Coma dépassé was considered a “frontier state” between life and death. Ventilation was continued in the vast majority of such cases until the heartbeat ceased, usually a few days later.In 1968 the Ad Hoc Committee of the Harvard Medical School published a report entitled “A Definition of Irreversible Coma” in The Journal of the American Medical Association. This watershed article listed criteria for the recognition of the “brain-death syndrome.” It stated that the persistence of a state of apneic coma with no evidence of brain-stem and spinal reflexes and a flat electroencephalogram over a period of 24 hours implied brain death, provided the cause of the coma was known and provided reversible causes of brain dysfunction (such as hypothermia or drug intoxication) had been excluded. The report explicitly identified brain death with death (without seeking to define death) and endorsed the withdrawal of respiratory support in such cases. No evidence was published to legitimize the contention that the coma was irreversible; i.e., that if artificial ventilation was continued no such patient ever recovered consciousness, and that all invariably developed asystole. There was wide medical experience among the members of the committee, however, and its contentions have since been massively validated. Not a single exception has come to light.The next few years witnessed increasing sophistication in the techniques used to diagnose brain death, none of which, however, surpassed basic clinical assessment. In 1973 two neurosurgeons in Minneapolis, Minn., identified the death of the brain stem as the point of no return in the diagnosis of brain death. In 1976 and 1979, the Conference of Royal Colleges and Faculties of the United Kingdom published important memoranda on the subject. The first described the clinical features of a dead brain stem, the second identified brain-stem death with death. In 1981 in the United States, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research published a report (“Defining Death”) and a list of guidelines very similar to the British ones. The commission also proposed a model statute, called the Uniform Determination of Death Act, which was subsequently endorsed by the American Medical Association, the American Bar Association, and the National Conference of Commissioners on Uniform State Laws and became law in many states. International opinion and practice has moved along similar lines in accepting the concept of brain-stem death.diagnosis of brain-stem deathThe diagnosis is not technically difficult. In more and more countries, it is made on purely clinical grounds. The aim of the clinical tests is not to probe every neuron within the intracranial cavity to see if it is dead—an impossible task—but to establish irreversible loss of brain-stem function. This is the necessary and sufficient condition for irreversible unconsciousness and irreversible apnea, which together spell a dead patient. Experience has shown that instrumental procedures (such as electroencephalography and studies of cerebral blood flow) that seek to establish widespread loss of cortical function contribute nothing of relevance concerning the cardiac prognosis. Such tests yield answers of dubious reliability to what are widely felt to be the wrong questions. As the concept of brain-stem death is relatively new, most countries rightly insist that the relevant examinations be carried out by physicians of appropriate seniority. These doctors (usually neurologists, anesthetists, or specialists in intensive care) must be entirely separate from any who might be involved in using the patient's organs for subsequent transplants.The diagnosis of brain-stem death involves three stages. First, the cause of the coma must be ascertained, and it must be established that the patient (who will always have been in apneic coma and on a ventilator for several hours) is suffering from irremediable, structural brain damage. Damage is judged “irremediable” based on its context, the passage of time, and the failure of all attempts to remedy it. Second, all possible causes of reversible brain-stem dysfunction, such as hypothermia, drug intoxication, or severe metabolic upset, must be excluded. Finally, the absence of all brain-stem reflexes must be demonstrated, and the fact that the patient cannot breathe, however strong the stimulus, must be confirmed.It may take up to 48 hours to establish that the preconditions and exclusions have been met; the testing of brain-stem function takes less than half an hour. When testing the brain-stem reflexes, doctors check for the following normal responses: (1) constriction of the pupils in response to light, (2) blinking in response to stimulation of the cornea, (3) grimacing in response to firm pressure applied just above the eye socket, (4) movements of the eyes in response to the ears being flushed with ice water, and (5) coughing or gagging in response to a suction catheter being passed down the airway. All responses have to be absent on at least two occasions. Apnea, which also must be confirmed twice, is assessed by disconnecting the patient from the ventilator. (Prior to this test, the patient is fully oxygenated by being made to breathe 100 percent oxygen for several minutes, and diffusion oxygenation into the trachea is maintained throughout the procedure. These precautions ensure that the patient will not suffer serious oxygen deprivation while disconnected from the ventilator.) The purpose of this test is to establish the total absence of any inspiratory effort as the carbon dioxide concentration in the blood (the normal stimulus to breathing) reaches levels more than sufficient to drive any respiratory centre cells that may still be alive.The patient thus passes through a tight double filter of preconditions and exclusions before he is even tested for the presence of a dead brain stem. This emphasis on strict preconditions and exclusions has been a major contribution to the subject of brain-stem death, and it has obviated the need for ancillary investigations. Thousands of patients who have met criteria of this kind have had ventilation maintained: all have developed asystole within a few hours or a few days, and none has ever regained consciousness. There have been no exceptions. The relevant tests for brain-stem death are carried out systematically and without haste. There is no pressure from the transplant team.The developments in the idea and diagnosis of brain-stem death came as a response to a conceptual challenge. Intensive-care technology had saved many lives, but it had also created many brain-dead patients. To grasp the implications of this situation, society in general—and the medical profession in particular—was forced to rethink accepted notions about death itself. The emphasis had to shift from the most common mechanism of death (i.e., irreversible cessation of the circulation) to the results that ensued when that mechanism came into operation: irreversible loss of the capacity for consciousness, combined with irreversible apnea. These results, which can also be produced by primary intracranial catastrophes, provide philosophically sound, ethically acceptable, and clinically applicable secular equivalents to the concepts of “departure of the soul” and “loss of the ‘breath of life,' ” which were so important to some earlier cultures.The cultural backgroundThroughout history, specific cultural contexts have always played a crucial role in how people perceived death. Different societies have held widely diverging views on the “breath of life” and on “how the soul left the body” at the time of death. Such ideas are worth reviewing (1) because of the light they throw on important residual elements of popular belief; (2) because they illustrate the distance traveled (or not traveled) between early beliefs and current ones; and (3) because of the relevance of certain old ideas to contemporary debates about brain-stem death and about the philosophical legitimacy of organ transplantation. The following discussion therefore focuses on how certain cultural ideas about death compare or contrast with the modern concept. For an overview of various eschatologies from a cross-cultural perspective, see death rite: Death rites and customs (death rite).Ancient Egypt (Egyptian religion)Two ideas that prevailed in ancient Egypt came to exert great influence on the concept of death in other cultures. The first was the notion, epitomized in the Osirian (Osiris) myth, of a dying and rising saviour god who could confer on devotees the gift of immortality; this afterlife was first sought by the pharaohs and then by millions of ordinary people. The second was the concept of a postmortem judgment, in which the quality of the deceased's life would influence his ultimate fate. Egyptian society, it has been said, consisted of the dead, the gods, and the living. During all periods of their history, the ancient Egyptians seem to have spent much of their time thinking of death and making provisions for their afterlife. The vast size, awe-inspiring character, and the ubiquity of their funerary monuments bear testimony to this obsession.The physical preservation (mummy) of the body was central to all concerns about an afterlife; the Egyptians were a practical people, and the notion of a disembodied existence would have been totally unacceptable to them. The components of the person were viewed as many, subtle, and complex; moreover, they were thought to suffer different fates at the time of death. The physical body was a person's khat, a term that implied inherent decay. The ka was the individual's doppelgänger, or double; it was endowed with all the person's qualities and faults. It is uncertain where the ka resided during life, but “to go to one's ka” was a euphemism for death. The ka denoted power and prosperity. After death it could eat, drink, and “enjoy the odour of incense.” It had to be fed, and this task was to devolve on a specific group of priests. The ka gave comfort and protection to the deceased: its hieroglyphic sign showed two arms outstretched upward, in an attitude of embrace.The ba (often translated as “the soul”) conveyed notions of “the noble” and “the sublime.” It could enter the body or become incorporeal at will. It was represented as a human-headed falcon, presumably to emphasize its mobility. The ba remained sentimentally attached to the dead body, for whose well-being it was somehow responsible. It is often depicted flying about the portal of the tomb or perched on a nearby tree. Although its anatomical substratum was ill-defined, it could not survive without the preserved body.Other important attributes were an individual's khu (“spiritual intelligence”), sekhem (“power”), khaibit (“shadow”), and ren (“name”). In the pyramid of King Pepi I, who ruled during the 6th dynasty (c. 2345–c. 2182 BC), it is recorded how the dead king had “walked through the iron which is the ceiling of heaven. With his panther skin upon him, Pepi passeth with his flesh, he is happy with his name, and he liveth with his double.” The depictions of the dead were blueprints for immortality. Conversely, to blot out a person's name was to destroy that individual for all eternity, to eliminate him from the historical record. The Stalinist and Maoist regimes in the Soviet Union and China were later to resort to the same means, with the same end in mind. They also, however, invented the concept of “posthumous rehabilitation.”The heart played a central part in how the Egyptians thought about the functioning of the body. Political and religious considerations probably lay behind the major role attributed to the heart. Many of the so-called facts reported in the Ebers papyrus (a kind of medical encyclopaedia dating from the early part of the 18th dynasty; i.e., from about 1550 BC) are really just speculations. This is surprising in view of how often bodies were opened during embalmment. A tubular system was rightly said to go from the heart “to all members” and the heart was said “to speak out of the vessels of every limb.” But the vessels were thought to convey a mixture of air, blood, tears, urine, saliva, nasal mucus, semen, and at times even feces. During the process of embalming, the heart was always left in situ or replaced in the thorax. According to the renowned Orientalist Sir Wallis Budge (Budge, Sir Wallis), the Egyptians saw the heart as the “source of life and being,” and any damage to it would have resulted in a “second death” in which everything (ka, ba, khu, and ren) would be destroyed. In some sarcophagi one can still read the pathetic plea “spare us a second death.”The anatomical heart was the haty, the word ib referring to the heart as a metaphysical entity embodying not only thought, intelligence, memory, and wisdom, but also bravery, sadness, and love. It was the heart in its sense of ib that was weighed in the famous judgment scene depicted in the Ani papyrus and elsewhere. After the deceased had enumerated the many sins he had not committed (the so-called negative confession), the heart was weighed against the feather of Maʿat (i.e., against what was deemed right and true). It had to prove itself capable of achieving balance with the symbol of the law. The deceased who was judged pure was introduced to Osiris (in fact, became an Osiris). The deceased who failed was devoured by the monster Am-mit, the “eater of the dead.” It was never the physical body on earth that was resurrected, but a new entity (the Sahu) that “germinated” from it and into which the soul would slip.The Egyptians were concerned that the dead should be able to breathe again. The Pyramid Texts describe the ceremony of the “opening of the mouth,” by which this was achieved. Immediately before the mummy was consigned to the sepulchral chamber, specially qualified priests placed it upright, touched the face with an adz, and proclaimed “thy mouth is opened by Horus with his little finger, with which he also opened the mouth of his father Osiris.” It has proved difficult to relate this ritual, in any meaningful way, to specific beliefs about the ka or ba.The brain is not mentioned much in any of the extant medical papyruses from ancient Egypt. It is occasionally described as an organ producing mucus, which drained out through the nose; or it is referred to by a generic term applicable to the viscera as a whole. Life and death were matters of the heart, although the suggested relationships were at times bizarre—for example, it was said that the “mind passed away” when the vessels of the heart were contaminated with feces. The only reference that might relate death to the brain stem is the strange statement in the Ebers papyrus (gloss 854f) to the effect that “life entered the body through the left ear, and departed through the right one.”It is clear why the Egyptians never cremated their dead: to do so would have destroyed for the deceased all prospects of an afterlife. Fortunately, there was no question of organ transplantation; in the prevailing cultural context, it would never have been tolerated. Whether the pharaohs would have been powerful enough—or rash enough—to transgress accepted norms had transplantation been feasible is quite another matter.MesopotamiaThe Mesopotamian (Mesopotamian religion) (Sumerian (Sumer), Babylonian (Babylonia), and Assyrian (Assyria)) attitudes to death differed widely from those of the Egyptians. They were grim and stark: sickness and death were the wages of sin. This view was to percolate, with pitiless logic and simplicity, through Judaism into Christianity. Although the dead were buried in Mesopotamia, no attempts were made to preserve their bodies.According to Mesopotamian mythology, the gods had made humans of clay, but to the clay had been added the flesh and blood of a god specially slaughtered for the occasion. God was, therefore, present in all people. The sole purpose of humanity's creation was to serve the gods, to carry the yoke and labour for them. Offended gods withdrew their support, thereby opening the door to demons, whose activities the malevolent could invoke.The main strands of Sumero-Akkadian (Akkad) thought held no prospect of an afterlife, at any rate of a kind that anyone might look forward to. In the Gilgamesh epic, the aging folk hero, haunted by the prospect of his own death, sets off to visit Utnapishtim, who, with his wife, was the only mortal to have achieved immortality. He meets Siduri, the wine maiden, who exhorts him to make the most of the present for “the life which thou seekest thou wilt not find.” There was no judgment after death, a common fate awaiting the good and the bad alike. Death was conceived of in terms of appalling grimness, unrelieved by any hope of salvation through human effort or divine compassion. The dead were, in fact, among the most dreaded beings in early Mesopotamian demonology. In a myth called “The Descent of Ishtar to the Underworld,” the fertility goddess decides to visit kur-nu-gi-a (“the land of no return”), where the dead “live in darkness, eat clay, and are clothed like birds with wings.” She threatens the doorkeeper: “If thou openest not that I may enter I will smash the doorpost and unhinge the gate. I will lead up the dead, that they may eat the living.” Given this background, it is not surprising that offerings to the dead were made in a spirit of fear; if not propitiated they would return and cause all kinds of damage.The Babylonians did not dissect bodies, and their approach to disease and death was spiritual rather than anatomical or physiological. They did not speculate about the functions of organs but considered them the seat of emotions and mental faculties in general. The heart was believed to be the seat of the intellect, the liver of affectivity, the stomach of cunning, the uterus of compassion, and the ears and the eyes of attention. Breathing and life were thought of in the same terms. The Akkadian word napistu was used indifferently to mean “the throat,” “to breathe,” and “life” itself.The canonical writings of biblical Judaism record the relations between certain outstanding individuals and their god. The events described are perceived as landmarks in the unfurling of a national destiny, designed and guided by that god. Jewish eschatology is in this sense unique: its main concern is the fate of a nation, not what happens to an individual at death or thereafter.In classical Judaism death closes the book. As the anonymous author of Ecclesiastes bluntly put it: “For the living know that they will die, but the dead know nothing, and they have no more reward” (Eccles. 9:5). The death of human beings was like that of animals: “As one dies, so dies the other. They all have the same breath, and man has no advantage over the beasts . . . all are from the dust, and all turn to dust again” (Eccles. 3:19–20). Life alone mattered: “A living dog is better than a dead lion” (Eccles. 9:4). Even Job (Job, The Book of), whose questioning at times verges on subverting Yahwist doctrine, ends up endorsing the official creed: “Man dies, and is laid low . . . . As waters fail from a lake, and a river wastes away and dries up, So man lies down and rises not again; till the heavens are no more he will not awake, or be roused out of his sleep” (Job 14:10–12).Yet such views were far from universal. The archaeological record suggests that the various racial elements assimilated to form the Jewish nation each had brought to the new community its own tribal customs, often based on beliefs in an afterlife. Both Moses (Deut. 14:1) and Jeremiah (Jer. 16:6) denounced mortuary practices taken to imply such beliefs. Necromancy, although officially forbidden, was widely practiced, even in high places. Saul's request to the witch of Endor to “bring up” the dead prophet Samuel for him (I Sam. 28:3–20) implied that the dead, or at least some of them, still existed somewhere or other, probably in Sheol, “the land of gloom and deep darkness” (Job 10:21). In Sheol, the good and the wicked shared a common fate, much as they had in the Babylonian underworld. The place did not conjure up images of an afterlife, for nothing happened there. It was literally inconceivable, and this is what made it frightening: death was utterly definitive, even if rather ill-defined.Many were unsatisfied by the idea that individual lives only had meaning inasmuch as they influenced the nation's destiny for good or ill. There was only one life, they were told, yet their everyday experience challenged the view that it was on earth that Yahweh rewarded the pious and punished the wicked. The Book of Job offered little solace: it was irrelevant that the good suffered and that the wicked prospered. One did not pray to improve one's prospects. The worship of God was an end in itself; it was what gave meaning to life. Against this backdrop of beliefs, the longing for personal significance was widespread.It is difficult to determine when the notion of soul first emerged in Jewish writings. The problem is partly philological. The word nefesh originally meant “neck” or “throat,” and later came to imply the “vital spirit,” or anima in the Latin sense. The word ruach had at all times meant “wind” but later came to refer to the whole range of a person's emotional, intellectual, and volitional life. It even designated ghosts. Both terms were widely used and conveyed a wide variety of meanings at different times, and both were often translated as “soul.”The notion of a resurrection of the dead has a more concrete evolution. It seems to have originated during Judaism's Hellenistic period (4th century BC–2nd century AD). Isaiah announced that the “dead shall live, their bodies shall rise,” and the “dwellers in the dust” would be enjoined to “awake and sing” (Isa. 26:19). Both the good and the wicked would be resurrected. According to their deserts, some would be granted “everlasting life,” others consigned to an existence of “shame and everlasting contempt” (Dan. 12:2). The idea that a person's future would be determined by conduct on earth was to have profound repercussions. The first beneficiaries seem to have been those killed in battle on behalf of Israel. Judas Maccabeus (Maccabeus, Judas), the 2nd-century-BC Jewish patriot who led a struggle against Seleucid domination and Greek cultural penetration, found that his own supporters had infringed the law. He collected money and sent it to Jerusalem to expiate their sins, acting thereby “very well and honorably, taking account of the resurrection. For if he were not expecting that those who had fallen would rise again, it would have been superfluous and foolish to pray for the dead” (II Macc. 12:43–45).Sheol itself became departmentalized. According to the First Book of Enoch (Enoch, First Book of), a noncanonical work believed to have been written between the 2nd century BC and the 2nd century AD, Sheol was composed of three divisions, to which the dead would be assigned according to their moral deserts. The real Ge Hinnom (“Valley of Hinnom”), where the early Israelites were said to have sacrificed their children to Moloch (and in which later biblical generations incinerated Jerusalem's municipal rubbish), was transmuted into the notion of Gehenna, a vast camp designed for torturing the wicked by fire. This was a clear precursor of things to come—the Christian and Islāmic versions of hell.Orphic and Platonic ideas also came to exert a profound influence on the Judaic concept of death. These were perhaps expressed most clearly in the apocryphal text known as the Wisdom of Solomon (Solomon, Wisdom of), written during the 1st century BC and reflecting the views of a cultured Jew of the Diaspora. The author stressed that a “perishable body weighs down the soul” (Wisd. Sol. 9:15) and stated that “being good” he had “entered an undefiled body” (Wisd. Sol. 8:20), a viewpoint that was quintessentially Platonic in its vision of a soul that predated the body. Flavius Josephus (Josephus, Flavius), the Jewish historian of the 1st century AD, recorded in Bellum Judaicum (History of the Jewish War) how doctrinal disputes about death, the existence of an afterlife, and the “fate of the soul” were embodied in the views of various factions. The Sadducees (who spoke for a conservative, sacerdotal aristocracy) were still talking in terms of the old Yahwist doctrines, while the Pharisees (who reflected the views of a more liberal middle class) spoke of immortal souls, some doomed to eternal torment, others promised passage into another body). The Essenes held views close to those of the early Christians.Following the destruction of the Temple (AD 70) and, more particularly, after the collapse of the last resistance to the Romans (c. 135), rabbinic teaching and exegesis slowly got under way. These flowered under Judah ha-Nasi (“Judah the Prince”), who, during his reign (c. 175–c. 220) as patriarch of the Jewish community in Palestine, compiled the collection of rabbinic law known as the Mishna. During the next 400 years or so, rabbinic teaching flourished, resulting in the production and repeated reelaboration first of the Palestinian (Jerusalem) and then of the Babylonian Talmuds (Babylonian Talmud). These codes of civil and religious practice sought to determine every aspect of life, including attitudes toward the dead. The concepts of immortality and resurrection had become so well established that in the Eighteen Benedictions (recited daily in synagogues and homes) God was repeatedly addressed as “the One who resurrects the dead.” Talmudic sources warned that “anyone who said there was no resurrection” would have no share in the world to come (tractate Sanhedrin 10:1). Over the centuries, a radical doctrinal shift had occurred. One would have to await the great political volte-faces of the 20th century to witness again such dramatic gyrations of decreed perspective.One of the strangest notions to be advanced by rabbinic Judaism—and of relevance to the evolution of the concept of death—was that of the “bone called Luz” (or Judenknöchlein, as it was to be called by early German anatomists). In his Glossa magna in Pentateuchum (AD 210), Rabbi Oshaia had affirmed that there was a bone in the human body, just below the 18th vertebra, that never died. It could not be destroyed by fire, water, or any other element, nor could it be broken or bruised by any force. In his exceeding wisdom, God would use this bone in the act of resurrection, other bones coalescing with it to form the new body that, duly breathed upon by the divine spirit, would be raised from the dead. The name of the bone was derived from lus, an old Aramaic word meaning “almond.” The emperor Hadrian had apparently once asked Rabbi Joshua, son of Chanin, how God would resurrect people in the world to come. The rabbi had answered “from the bone Luz in the spinal column.” He had then produced a specimen of such a bone, which could not be softened in water or destroyed by fire. When struck with a hammer, the bone had remained intact while the anvil upon which it lay had been shattered. The bone had apparently been called Aldabaran by the Arabs. In some of the most interesting writings of polemical anatomy, Vesalius showed, in 1543, that the bone did not exist.Orthodox (Orthodox Judaism) Jewish responses to current medical controversies concerning death are based on biblical and Talmudic ethical imperatives. First, nothing must be done that might conceivably hasten death. Life being of infinite worth, a few seconds of it are likewise infinitely valuable. Causing accidental death is seen as only one step removed from murder. When a patient is in the pangs of death the bed should not be shaken, as even this might prove to be the last straw. Such invasive diagnostic procedures as four-vessel angiography (to assess cerebral blood flow) would almost certainly be frowned upon. Even a venipuncture (say, for tissue typing) could be conceived of as shpikhut damim, a spilling of blood with nefarious intent. In secular medical practice, however, problems of this sort are unlikely to arise. Much more important is the conceptual challenge presented by the beating-heart cadaver. Here it must be stressed that absence of a heartbeat was never considered a cardinal factor in the determination of death (Bab. Talmud, tractate Yoma 85A). Talmudic texts, moreover, clearly recognized that death was a process and not an event: “the death throes of a decapitated man are not signs of life any more than are the twitchings of a lizard's amputated tail” (Bab. Talmud, tractate Chullin 21A; Mishna, Oholoth 1:6). The decapitated state itself defined death (Maimonides: Tumath Meth 1:15). Brain-stem death, which is physiological decapitation, can readily be equated with death in this particular perspective.What mattered, in early Jewish sources, was the capacity to breathe spontaneously, which was seen as an indicator of the living state. The Babylonian Talmud (tractate Yoma 85A) explained that when a building collapsed, all lifesaving activities could legitimately cease on determination that the victim was no longer breathing. The instructions were quite explicit: “As soon as the nose is uncovered no further examination need be made, for the Tanach (Bible) refers to ‘all living things who have the breath of life in their nostrils.' ”Apnea alone, of course, does not constitute death; it is a necessary but not a sufficient condition for such a diagnosis. But if apnea is conjoined to all that is implied in the notion of the decapitated state (in terms of the irreversible loss of the capacity for consciousness, for instance), one finds that the concepts of death in the Talmud and in the most modern intensive care unit are virtually identical.The issue of transplantation (transplant) is more complex. The Talmud forbids the mutilation of a corpse or the deriving of any benefit from a dead body, but these considerations can be overridden by the prescriptions of pikuakh nefesh (“the preservation of life”). The Chief Rabbi of Israel has even argued that, as a successful graft ultimately becomes part of the recipient, prohibitions related to deriving benefit from the dead do not, in the long run, apply.Among the collected hymns of the Rigveda (which may date from 1500 BC and probably constitute the earliest known book in the world), there is a “Song of Creation.” “Death was not there,” it states, “nor was there aught immortal.” The world was a total void, except for “one thing, breathless, yet breathed by its own nature.” This is the first recorded insight into the importance of respiration to potential life.Later, by about 600 BC, the Upaniṣad (Upanishad)s (a collection of searching, intellectually stimulating Indo-Aryan texts) record the quest for a coordinating principle that might underlie such diverse functions of the individual as speech, hearing, and intellect. An essential attribute of the living was their ability to breathe (an). Their praṇa (“breath”) was so vital that on its cessation the body and its faculties became lifeless and still. The word for “soul,” ātman (atman), is derived from an, thus placing the concept of breath at the very core of the individual self or soul.The Hindu concept of the soul is central to an understanding of most Hindu practices related to death. In The Discovery of India, Jawaharlal Nehru described Hinduism as a faith that was “vague, amorphous, many-sided and all things to all men.” The practices that the religion inspires do indeed entail acts that appear contradictory. What is unique to Hinduism, however, is that these are not perceived as contradictions. A common thread unites the most abstract philosophical speculations and childish beliefs in ghosts; a deep respect for nonviolence and the bloodiness of certain sacrificial rites; extreme asceticism and the sexual aspects of Tantric worship. At very different levels of sophistication, these all represent attempts to expand human perception of the truth and to achieve a cosmic consciousness. To the intellectually inclined Hindu, the eternal, infinite, and all-pervasive principle of Brahman (brahma) alone is real, and the acquisition of cosmic consciousness allows humans to become one with it. The individual soul (ātman) is merely a particle of this cosmic principle, the relationship being likened to that between air, temporarily trapped in an earthen jar, and the endless space without; or to that between a particular wave and the ocean as a whole.Death practices are probably more important in Hinduism than in any other religion. At one level they derive from explicit religious premises. Each being is predestined to innumerable rebirths (saṃsāra (samsara)), and one's aggregate moral balance sheet (karman (karma)) determines both the length of each life and the specific form of each rebirth. Moral attributes are minutely quantifiable causal agents: every grain sown in this existence is reaped in the next. The prospect of innumerable lives is therefore envisaged with dismay. To escape the dreaded rebirths is to achieve final emancipation (mokṣa (moksha)). “Life everlasting” (at least of the type already sampled) is the last thing a Hindu would aspire to. Mokṣa can be achieved only by the saintly, or perhaps by those who have died in Vārānasi and had their ashes strewed on the Ganges River. For others, the wages of worldliness is inevitable reincarnation.Hindu death practices, however, also reflect popular beliefs and fears, as well as local customs. They thus may vary considerably from region to region or from sect to sect, bearing a rather variable relation to religious doctrine. Many practices are derived from the Dharma-śastra (dharmashastra) of Manu, the most authoritative of the books of Hindu sacred law. The alleged author of the book is the mythical sage Manu, who combined flood-surviving attributes (like Noah of Jews and Christians, and Utnapishtim of the Mesopotamians) with law-giving propensities (like Moses and Hammurabi). The book, which grew by repeated additions over many centuries, reflects the evolving interests of a male Brahman priesthood: its prescriptions are overwhelmingly recorded in terms of what is appropriate for men. Women are seldom referred to, and then often in derogatory terms.Death practicesHindus hold that a span of 120 years has been allotted to human life, a strange notion in a country where the average life expectancy was under 30 into the 20th century. They have no difficulty with the concept of death as a process. Mythological beliefs involving early Vedic gods held that the god reigning over the ears departed early, as did the gods of the eyes, hands, and mind.When devout Hindus sense death approaching, they begin repeating the monosyllable Om. (This word refers to Brahman and is widely used in religious observance to help concentrate the mind on what matters.) If it is the last word on a person's lips, it guarantees a direct passage to mokṣa. When the dying are judged to have only an hour or so left, they are moved from their bed to a mattress on the floor and their heads are shaved. The space between ground and the ceiling is thought to symbolize the troubled area between earth and sky, and those dying there may return after death as evil spirits. A space on the ground is sanctified with Ganges water and various other ingredients, including cow dung, barley, and sesame seeds. A Hindu should never die in bed, but lying on the ground. As they take their last breaths, the dying are moved from the mattress to ground. Experienced members of the family are usually present to help decide the opportune moment. Water taken from the confluence of the rivers Ganges and Yamuna (at Allahābād) is poured into the mouth, into which is also placed a leaf of the tulsi plant (Ocimum sanctum). The forehead is smeared with white clay (gopi candana). A woman whose death precedes her husband's is considered so fortunate that her face, and especially her forehead, may be smeared with red. Sometimes, if there is doubt as to whether death has occurred, a lump of ghee (clarified butter) is placed on the forehead; if it does not melt, it is taken as a sign that life is extinct—an interesting but potentially misleading practice in the light of modern awareness of how hypothermia can mimic death. The dead body is wrapped in clean cloth of varying colours that indicate age. In the home the relatives walk clockwise around the body; they will walk around the funeral pyre in the opposite direction.The body is looked upon as an offering to Agni, god of fire. According to the Vedas, the Indo-Aryans used to bury their dead. Why the Hindus and Buddhists burn (cremation) theirs has been the subject of much controversy. It has been variously interpreted as a gesture of purification, as the most efficient means of releasing the soul from the corrupted body, as a public health measure with important ecological benefits in a crowded country, or as a symbol of the transitory nature of any particular life and the desire that it should end in permanent anonymity. Fire taken from the deceased's home is transported to the cremation ground in a black earthen pot; this is carried immediately in front of the deceased, and nothing must come between them. For many years women were not allowed to follow the cortege, and only the wives of Brahmans could walk around the pyre. At the cremation site, a lighted torch is handed to the eldest son or grandson, who ignites the pyre, near the feet of the dead woman, at the head of the dead man. While the body is burning the soul is thought to seek refuge within the head. The intense heat usually explodes the skull, liberating the soul; when this does not happen spontaneously, the skull is deliberately shattered by blows from a cudgel. Other traditions hold that the soul passes out through the nose, eyes, and mouth. Some believe it is better still if it leaves through the anterior fontanel, an opening in the skull that normally closes during early childhood. Such theorists hold that if the deceased has practiced yoga or intense meditation, this opening will reopen, allowing free passage to the soul. In some parts of India it is believed that the souls of the really wicked depart through the rectum, and in so doing acquire such defilement that endless purification is necessary.Children under the age of two are not cremated but buried. When dying, they are not placed on the ground; instead they are allowed to expire in their mothers' arms. There are no special death rites; it is felt the child must have been a monster of iniquity in its previous life to have incurred such a terrible karman. Infant mortality is clearly attributed to the child's own wickedness and carries a load of 84 lakhs of rebirths (i.e., the child has to be reborn 8,400,000 times). The ceremonial defilement of relatives is short, lasting only three days. Among the very high-caste Nagaras, when a pregnant woman dies the fetus is removed and buried, while the mother is cremated.Ascetics, too, are buried rather than burnt, usually in an upright posture with the body surrounded with salt. Lepers and smallpox victims used to be buried in a recumbent position. Smallpox has been eradicated, and leprosy victims are usually cremated. If a Hindu “breaks caste” by becoming either a Muslim or a Christian, a death ceremony is conducted, the relatives bathe to purge their defilement, and the person's name is never mentioned again. The concept of death clearly influences what is deemed appropriate death behaviour, as was argued earlier in this article.The fate of the soulWhat happens between death and reincarnation is seldom discussed in articles about Hinduism. This is regrettable, for the perception of these events helps explain some of the rites of the religion and provides unique insights into the human preference, when thinking about death, to conceptualize metaphysical developments in very concrete terms.Immediately after death, the soul is not clothed in a physical body but in a vaporous thumb-sized structure (linga) (linga ṡarīra). This is immediately seized by two servants of Yama, the god of death, who carry it to their master for a preliminary identity check. Afterward, the soul is promptly returned to the abode of the deceased, where it hovers around the doorstep. It is important that the cremation be completed by the time of the soul's return, to prevent it from reentering the body. By the 10th day, the near relatives have purged some of the defilement (mṛitaka sutaka) they incurred from the death, and the chief mourner and a priest are ready to carry out the first śrāddha (sraddha) (ritual of respect). This is a step toward the reconstitution of a more substantial physical body (yatana ṡarīra) around the disembodied soul (preta) of the deceased. A tiny trench is dug in a ritually purified piece of land by a river, and the presence of Vishnu is invoked. Ten balls of barley flour mixed with sugar, honey, milk, curds, ghee, and sesame seeds are then placed, one by one, in the soil. As the first ball is offered, the priest says (and the son repeats after him), “May this create a head”; with the second ball, “May this create neck and shoulders”; with the third, “May this create heart and chest”; and so on. The 10th request is for the ball to create the capacity to digest, thereby satisfying the hunger and thirst of the newly created body. Bungled ceremonies can have catastrophic effects. Prayers are offered to Vishnu to help deliver the new entity (now perceived as some 18 inches [46 centimetres] long) into the power of Yama. The balls of barley are picked up from the trench and thrown into the river. Further śrāddhas are performed at prescribed times, varying according to caste; one of these rituals makes the soul an ancestral spirit, or pitṛi (pitṛ). With the completion of these rituals, the soul of the deceased leaves this world for its yearlong and perilous journey to Yama's kingdom. The family is now formally cleansed. The men shave their heads, and the women wash their hair. The family's tutelary god (removed by a friend at the time of the death) can be returned to its home. A feast is offered to Brahmans, neighbours, and beggars—even the local cows are given fresh grass. There is a sense of general relief: if the śrāddhas had not been performed, the preta could have become a bhūta (bhut) (malignant spirit), repeatedly turning up to frighten the living. For the deceased, things would have been worse: the preta would have been left errant. (A similar fate befalls the soul of a person who commits suicide.) The horror of dying unshriven that haunted people in medieval Europe resembles the despair of the devout Hindu at the prospect of having no son to perform the śrāddhas.The soul, in its substantial envelope, is meanwhile proceeding on its journey, holding onto a cow's tail to cross the Vaitarani, a horrible river of blood and filth that marks the boundary of Yama's kingdom. Throughout, it is sustained by further śrāddhas, during which friends on earth seek to provide it with shoes, umbrellas, clothing, and money. These they give to a Brahman, in the hope that the deceased will benefit. During such rituals relatives have to avoid all sewing, which might occlude the pitṛi's throat, rendering it incapable of ever breathing or drinking again. After a year, the pitṛi in its yatana ṡarīra reaches Yama's seat of judgment, where it is sentenced to a strictly limited term in heaven (svarga) or hell (naraka) according to its deserts. This completed, it moves into another body (the karaṇa ṡarīra), whose form depends on the individual's karman. It could be a plant, a cockroach, a canine intestinal parasite, a mouse, or a human being. Unlike Jains, Hindus believe that whatever body the soul eventually moves into, it inhabits as sole tenant, not as a tenement lodger.IslāmProbably no religion deals in such graphic detail as does Islām with the creation, death, “life in the tomb,” and ultimate fate of humankind. Yet the Qurʿān (Qurʾān), the holy book of Islām, itself provides no uniform or systematic approach to these problems. It is only in its later parts (which date from the period when the small Muslim community in Medina had come into contact with other religious influences) that problems such as the relation of sleep to death, the significance of breathing, and the question of when and how the soul leaves the body are addressed in any detail. Popular Muslim beliefs are based on still later traditions. These are recorded in the Kitāb al-rūḥ (“Book of the Soul”) written in the 14th century by the Ḥanbalī theologian Muḥammad ibn Abī-Bakr ibn Qayyīm al-Jawzīyah.The basic premise of all Qurʿānic teaching concerning death is Allāh's (Allāh) omnipotence: he creates human beings, determines (predestination) their life span, and causes them to die. The Qurʿān states: “Some will die early, while others are made to live to a miserable old age, when all that they once knew they shall know no more (22:5; i.e., sūrah [chapter] 22, verse 5). Damnation and salvation are equally predetermined: “Allāh leaves to stray whom he willeth, and guideth whom he willeth” (35:8). As for those whom Allāh leaves astray, the Qurʿān states that “for them there will be no helpers” (30:29). Allāh has decided many will fail: “If We had so willed We could certainly cause proper guidance to come to every soul, but true is My saying ‘assuredly I shall fill Jihannam' ” (32:13).In this perspective the individual's fate (including the mode and time of death) appears inescapably predetermined. The very term Islām, Arabic for “surrender,” implies an absolute submission to the will of God. But what freedom does this allow those predestined to continue in the path of error, or to reject God's will? And if there is no such freedom, what sense was there in the mission of the Prophet Muḥammad (Islām's founder) and his appeal to people to alter their ways? It is hardly surprising that arguments about free will and predestination broke out soon after the Prophet's death. The ensuing tensions dominated theological (and other) controversies within Islām during many centuries.Questions concerning the meaning of life and the nature of the soul are dealt with patchily in both the Qurʿān and the Ḥadīth (the record of the sayings attributed to the Prophet). The Qurʿān records that, when asked about these matters by local leaders of the Jewish faith, the Prophet answered that “the spirit cometh by command of God” and that “only a little knowledge was communicated to man” (17:85). Humanity was created from “potter's clay, from mud molded into shape” into which Allāh has “breathed his spirit” (15:28–29). A vital spirit or soul (nafs) is within each human being. It is associated, if not actually identified, with individuality and also with the seat of rational consciousness. It is interesting to speculate on the possible relation of the term nafs to such Arabic words as nafas (“breath”) and nafīs (“precious”), particularly in a language where there are no written vowels.Death is repeatedly compared with sleep, which is at times described as “the little death.” God takes away people's souls “during their sleep” and “upon their death.” He “retains those against whom he has decreed death, but returns the others to their bodies for an appointed term” (39:42–43). During death, the soul “rises into the throat” (56:83) before leaving the body. These are interesting passages in the light of modern medical knowledge. The study of sleep has identified the episodic occurrence of short periods during which the limbs are totally flaccid and without reflexes, as would be the limbs of the recently dead. Modern neurophysiology, moreover, stresses the role of structures in the upper part of the brain stem in the maintenance of the waking state. Lesions just a little higher (in the hypothalamus) cause excessively long episodes of sleep. Irreversible damage at these sites is part of the modern concept of death. Finally, various types of breathing disturbance are characteristic of brain-stem lesions and could have been attributed, in former times, to occurrences in the throat. Nothing in these passages outrages the insights of modern neurology. The absence of any cardiological dimension is striking.It is orthodox Muslim belief that when someone dies the Angel of Death (malāk al-mawt) arrives, sits at the head of the deceased, and addresses each soul according to its known status. According to the Kitāb al-rūh, wicked souls are instructed “to depart to the wrath of God.” Fearing what awaits them, they seek refuge throughout the body and have to be extracted “like the dragging of an iron skewer through moist wool, tearing the veins and sinews.” Angels place the soul in a hair cloth and “the odour from it is like the stench of a decomposing carcass.” A full record is made, and the soul is then returned to the body in the grave. “Good and contented souls” are instructed “to depart to the mercy of God.” They leave the body, “flowing as easily as a drop from a waterskin”; are wrapped by angels in a perfumed shroud, and are taken to the “seventh heaven,” where the record is kept. These souls, too, are then returned to their bodies.Two angels coloured blue and black, known as Munkar (Munkar and Nakīr) and Nakīr, then question the deceased about basic doctrinal tenets. In a sense this trial at the grave (fitnat al-Qabr) is a show trial, the verdict having already been decided. Believers hear it proclaimed by a herald, and in anticipation of the comforts of al-jannah (the Garden, or “paradise”) their graves expand “as far as the eye can reach.” Unbelievers fail the test. The herald proclaims that they are to be tormented in the grave; a door opens in their tomb to let in heat and smoke from jihannam (“hell”), and the tomb itself contracts “so that their ribs are piled up upon one another.” The period between burial and the final judgment is known as al-barzakh. At the final judgment (yaum al-Hisāb), unbelievers and the god-fearing are alike resurrected. Both are endowed with physical bodies, with which to suffer or enjoy whatever lies in store for them. The justified enter Gardens of Delight, which are described in the Qurʿān in terms of prevalent, but essentially masculine, tastes (37:42–48). At the reception feast on the Day of Judgment unbelievers fill their bellies with bitter fruit, and “drink down upon it hot water, drinking as drinks the camel crazed with thirst” (56:52–55). They then proceed to hell, where they don “garments of fire” (22:19) and have boiling water poured over their heads. Allāh has made provision against the annihilation of the body of the damned, promising that “whenever their skins are cooked to a turn, We shall substitute new skins for them, that they may feel the punishment” (4:56). Pleas for annihilation are disregarded. Although this is sometimes referred to as the “second death,” the Qurʾān is explicit that in this state the damned “neither live nor die” (87:13).A special fate is reserved for the martyrs (martyr) of Islām; i.e., for those who fall in a jihād (jihad) (“holy war”). Their evil deeds are instantly expiated and the formalities of judgment are waived; they enter the Garden immediately. Similar dispensations are promised to “those who had left their homes, or been driven therefrom, or who had suffered harm” in the divine cause (3:195). For the Shīʾites (Shīʿite), followers of the smaller of Islām's two major branches, the prospects for martyrdom are even wider. A major event of the origin of Shīʾism, moreover, was the slaughter of the Prophet's grandson, Ḥusayn, in 680; this heritage has imbued Shīʾism with a zeal for martyrdom. Some of the behaviour of Islāmic fundamentalists is explicable from this perspective.A gentler strand in Islāmic eschatology produced, over the centuries, a series of reinterpretations or adaptations of the original doctrine, some of whose tenets were even claimed to have been only metaphorical. These tendencies, which stressed individual responsibility, were often influenced by the Ṣūfīs (Islāmic mystics).Muslims accord a great respect to dead bodies, which have to be disposed of very promptly. The mere suggestion of cremation, however, is viewed with abhorrence. The philosophical basis, if any, of this attitude is not clear. It is not stated, for instance, that an intact body will be required at the time of resurrection. It is unlikely, moreover, that the abhorrence—which Orthodox Jews share—arose out of a desire to differentiate Islāmic practices from those of other “people of the Book” (i.e., Jews and Christians). The attitude toward dead bodies has had practical consequences; for instance, in relation to medical education. It is almost impossible to carry out postmortem examinations in many Islāmic countries. Medical students in Saudi Arabia, for example, study anatomy on corpses imported from non-Islāmic countries. They learn pathology only from textbooks; many complete their medical training never having seen a real brain destroyed by a real cerebral hemorrhage.In 1982 organ donation (transplant) after death was declared ḥallāl (“permissible”) by the Senior ʾUlamāʿ Commission, the highest religious authority on such matters in Saudi Arabia (and hence throughout the Islāmic world). Tales inculcated in childhood continue, however, to influence public attitudes in Islāmic nations. The widely told story of how the Prophet's uncle Ḥamzah was murdered by the heathen Hind, who then opened the murdered man's belly and chewed up his liver, has slowed public acceptance of liver transplantation. Kidney transplantation is more acceptable, perhaps because the Ḥadīth explicitly states that those entering the Garden will never more urinate.The Christian legacyThe spread of rationalistic and scientific ideas since the 18th century has undermined many aspects of religion, including many Christian beliefs. The church, moreover, although still seeking to exert its influence, has ceased to dominate civil life in the way it once did. Religion is no longer the pivot of all social relations as it once was in ancient Egypt and still is in some Islāmic countries. The decline of the church is epitomized by the fact that, while it is still prepared to speak of the symbolic significance of the death of Jesus Christ (and of human death in general), it has ceased to emphasize many aspects of its initial eschatology and to concern itself, as in the past, with the particular details of individual death. In the age of Hiroshima and Nagasaki, the elaborate descriptions of heaven, purgatory, and hell in Dante's Divine Comedy, while remaining beautiful literature, at best raise a smile if thought of as outlines for humanity's future.Death is at the very core of the Christian religion. Not only is the cross to be found in cemeteries and places of worship alike, but the premise of the religion is that, by their own action, humans have forfeited immortality. Through abuse of the freedom granted in the Garden of Eden, Adam and Eve not only sinned and fell from grace, but they also transmitted sin to their descendants: the sins of the fathers are visited on the children. And as “the wages of sin is death” (Rom. 6:23), death became the universal fate: “Therefore as sin came into the world through one man and death through sin, and so death spread to all men” (Rom. 5:12). Christian theologians spent the best part of two millennia sorting out these implications and devising ways out of the dire prognosis implicit in the concept of original sin. The main salvation was to be baptism into the death of Jesus Christ (Rom. 6:3–4).Among early Christians delay in the promised Second Coming of Christ led to an increasing preoccupation with what happened to the dead as they awaited the resurrection and the Last Judgment. One view was that there would be an immediate individual judgment and that instant justice would follow: the deceased would be dispatched forthwith to hell or paradise. This notion demeaned the impact of the great prophecy of a collective mass resurrection, followed by a public mass trial on a gigantic scale. Moreover, it deprived the dead of any chance of a postmortem (i.e., very belated) expiation of their misdeeds. The Roman Catholic notion of purgatory sought to resolve the latter problem; regulated torture would expiate some of the sins of those not totally beyond redemption.The second view was that the dead just slept, pending the mass resurrection. But as the sleep might last for millennia, it was felt that the heavenly gratification of the just was being arbitrarily, and somewhat unfairly, deferred. As for the wicked, they were obtaining an unwarranted respite. The Carthaginian theologian Tertullian, one of the Church Fathers, outlined the possibility of still further adjustments. In his Adversus Marcionem, written about 207, he described “a spatial concept that may be called Abraham's bosom for receiving the soul of all people.” Although not celestial, it was “above the lower regions and would provide refreshment (refrigerium) to the souls of the just until the consummation of all things in the great resurrection.” The Byzantine Church formally endorsed the concept, which inspired some most interesting art in both eastern and western Europe.During its early years, the Christian Church debated death in largely religious terms. The acerbitas mortis (“bitterness of death”) was very real, and pious deathbeds had to be fortified by the acceptance of pain as an offering to God. Life expectancy fell far short of the promised threescore years and 10. Eastern medicine remained for a long time in advance of that practiced in the West, and the church's interventions were largely spiritual. It was only during the Renaissance and the later age of Enlightenment that an intellectual shift became perceptible.Descartes, the pineal soul, and brain-stem deathThe first attempts to localize the soul go back to classical antiquity. The soul had originally been thought to reside in the liver, an organ to which no other function could, at that time, be attributed. Empedocles, Democritus, Aristotle, the Stoics, and the Epicureans had later held its abode to be the heart. Other Greeks (Pythagoras, Plato, and Galen) had opted for the brain. Herophilus (flourished c. 300 BC), a famous physician of the Greek medical school of Alexandria, had sought to circumscribe its habitat to the fourth ventricle of the brain; that is, to a small area immediately above the brain stem. Controversy persisted to the very end of the 16th century.The departure of the soul from the body had always been central to the Christian concept of death. But the soul had come to mean different things to various classical and medieval thinkers. There was a “vegetative soul,” responsible for what we would now call autonomic function; a “sensitive soul,” responsible for what modern physiologists would describe as reflex responses to environmental stimuli; and, most importantly, a “reasoning soul,” responsible for making a rational entity (res cogitans) of human beings. The reasoning soul was an essentially human attribute and was the basis of thought, judgment, and responsibility for one's actions. Its departure implied death. The Anatome Corporis Humani (1672) of Isbrand van Diemerbroeck, professor at Utrecht, appears to have been the last textbook of anatomy that discussed the soul within a routine description of human parts. Thereafter, the soul disappeared from the scope of anatomy.The modern and entirely secular concept of brain-stem death can, perhaps rather surprisingly, find both a conceptual and a topographical foundation in the writings of René Descartes (Descartes, René) (1596–1650), the great French philosopher and mathematician who sought to bring analytical geometry, physics, physiology, cosmology, and religion into an integrated conceptual framework. Descartes considered the body and the soul to be ontologically separate but interacting entities, each with its own particular attributes. He then sought to specify both their mode and site of interaction; the latter he deduced to be the pineal gland. The pineal was to become, in the words of Geoffrey Jefferson, “the nodal point of Cartesian dualism.”Before Descartes, the prevailing wisdom, largely derived from Greece, had regarded the soul both as the motive force of all human physiological functions and as the conscious agent of volition, cognition, and reason. Descartes succeeded in eliminating the soul's general physiological role altogether and in circumscribing its cognitive role to the human species. Descartes's writings about death show that his concept of the soul clearly implied both mind and the immaterial principle of immortality. It had to mean both things, for no one had ever conceived of survival after death without a mind to verify the fact of continued existence, to enjoy its pleasures, and to suffer its pains.The relation between body and soul had been discussed in patristic literature, and, because of his Jesuit education, Descartes would have been familiar with these discussions. The church's interest in these matters was strictly nonmedical, seeking only to reconcile earlier Greek theories with its own current doctrines. Descartes was the first to tackle these problems in a physiological way. With one foot still firmly on consecrated ground (and with Galileo's difficulties with the Inquisition very much in mind), he sought to give a materialistic, even mechanistic, dimension to the discussion. In this sense, his De Homine (On Man; published posthumously in 1662) can be thought of as an updating of Plato's Timaeus. His contemporaries viewed Descartes as having delivered the coup de grace to an earlier Greek tradition (dating back to several centuries before Christ) that had claimed that animals, as well as humans, had souls. This had been the subject of much discussion in the early Christian Church. During the 4th century, St. John Chrysostom (Chrysostom, Saint John) (onetime archbishop of Constantinople) had denounced the idea, attributing it to the devil, who had allegedly managed by various maneuvers to deceive people as varied as Pythagoras, Plato, Pliny, and even Zoroaster.Descartes probably was impressed by the central location of the unpaired pineal gland, situated where neural pathways from the retinas converge with those conveying feelings from the limbs. This “general reflector of all sorts of sensation” is, moreover, sited in the immediate proximity of the brain ventricles, from which (according to the wisdom of the day) “animal spirits” flowed into the hollow nerves, carrying instructions to the muscles. In his Excerpta Anatomica, Descartes had even likened the pineal to a penis obturating the passage between the third and fourth ventricles.Descartes proved wrong in his beliefs that all sensory inputs focused on the pineal gland and that the pineal itself was a selective motor organ, suspended in a whirl of “animal spirits,” dancing and jigging “like a balloon captive above a fire,” yet capable in humans of scrutinizing inputs and producing actions “consistent with wisdom.” He was also wrong when he spoke of the “ideas formed on the surface” of the pineal gland, and in his attribution to the pineal of such functions as “volition, cognition, memory, imagination, and reason.” But he was uncannily correct in his insight that a very small part of this deep and central area of the brain was relevant to some of the functions he stressed. We now know that immediately below the pineal gland there lies the mesencephalic tegmentum (the uppermost part of the brain stem), which is crucial to generating alertness (the capacity for consciousness), without which, of course, there can be no volition, cognition, or reason.It is a matter of vocabulary whether one considers the mesencephalic tegmentum either as being involved in generating a “capacity for consciousness” or as preparing the brain for the exercise of what Descartes would have considered the “functions of the soul” (volition, cognition, and reason). In either case, the total and irreversible loss of these functions dramatically alters the ontological status of the subject. Descartes specifically considered the example of death. In “La Description du corps humain” (1664) he wrote that “although movements cease in the body when it is dead and the soul departs, one cannot deduce from these facts that the soul produced the movements.” In a formulation of really modern tenor, he then added “one can only infer that the same single cause (a) renders the body incapable of movement and (b) causes the soul to absent itself.” He did not, of course, say that this “same single cause” was the death of the brain stem. Some 300 years later, in 1968, the Harvard Committee spoke of death in terms of “irreversible coma” (where Descartes had spoken of the “now absent soul”) and stressed, as had Descartes, the immobility of the comatose body. The religious and secular terms seem to describe the same reality.There have been other neurological controversies concerning the locus of the soul. Early in the 18th century Stephen Hales (Hales, Stephen), an English clergyman with a great interest in science, repeated an experiment originally reported by Leonardo da Vinci. Hales tied a ligature around the neck of a frog and cut (beheading) off its head. The heart continued to beat for a while, as it usually does in the brain dead. Thirty hours later, the limbs of the animal still withdrew when stimulated. In fact, the elicited movements only ceased when the spinal cord itself had been destroyed. This observation gave rise to a great controversy. Reflex action at spinal cord level was not then fully understood, and it was argued that the irritability implied sentience, and that sentience suggested that the soul was still present. The “spinal cord soul” became the subject of much debate. It is now known that such purely spinal reflex movements may occur below a dead brain. It was shown during the 19th century that individuals executed on the guillotine might retain the knee jerk reflex for up to 20 minutes after decapitation.The church is still concerned with the diagnosis of death, but the theological argument has, during the last half of the 20th century, moved to an entirely different plane. As mentioned earlier, in 1957 Pope Pius XII raised the question whether, in intensive care units, doctors might be “continuing the resuscitation process, despite the fact that the soul may already have left the body.” He even asked one of the central questions confronting modern medicine, namely whether “death had already occurred after grave trauma to the brain, which has provoked deep unconsciousness and central breathing paralysis, the fatal consequences of which have been retarded by artificial respiration.” The answer, he said, “did not fall within the competence of the Church.”Public attitudesUntil about 100 years ago, people had by and large come to terms with death. They usually died in their homes, among their relatives. In villages, in the 18th or early 19th centuries, passers-by might join the priest bearing the last sacrament on his visit to the dying man or woman. Doctors even stressed the public health hazards this might cause. Numerous pictures attest to the fact that children were not excluded from deathbeds, as they were to be during the 20th century.The general acceptance of death was to be subverted by the advances of modern medicine and by the rapid spread of rationalist thought. This led, during a period of only a few decades, to a striking change of attitudes. In the advanced industrial countries, a large number of people now die in hospitals. The improvement in life expectancy and the advances of modern surgery and medicine have been achieved at a certain price. A mechanistic approach has developed, in which the protraction of dying has become a major by-product of modern technology. The philosophy of modern medicine (medicine, history of) has been diverted from attention to the sick and has begun to reify the sickness. Instead of perceiving death as something natural, modern physicians have come to see it as bad or alien, a defeat of all their therapeutic endeavours, at times almost as a personal defeat. Sickness is treated with all possible weapons, often without sufficient thought for the sick person—at times even without thought as to whether there is still a “person” at all. The capacity to “care” for biological preparations, with no other human attribute than physical form, is part of the context in which the reevaluation of death described earlier has taken place.Parallel developments have taken place at the level of the psyche of the dying person and of the person's relatives. Elisabeth Kübler-Ross, an American psychiatrist, has outlined the stages (denial, anger, bargaining, preparatory grief, and acceptance) through which people, informed of their own approaching death, are said to pass. Her writings are based on a wide but essentially American experience, and their universality has not been tested, particularly in other cultural contexts. They may well prove somewhat ethnocentric.The development of the death industry (satirized in Evelyn Waugh's Loved One and explored in Jessica Mitford's American Way of Death) is also a by-product of the technological revolution and of modern attitudes to death. Undertakers have become “morticians” and coffins “caskets.” Embalming has enjoyed a new vogue. Drive-in cemeteries have appeared, for those seeking to reconcile devotion to the dead with other pressing engagements. Cryogenic storage of the corpse has been offered as a means to preserve the deceased in a form amendable to any future therapies that science may devise. Commercial concerns have entered the scene: nonpayment of maintenance charges may result in threats of thawing and putrefaction. In a contentious environment, the law has even invaded the intensive care unit, influencing the decisions of physicians concerning the withdrawal of treatment or the determination of death. A wit has remarked that in the modern era, the only sure sign that a man is dead is that he is no longer capable of litigation.Additional ReadingBiological aspectsThe concept of apoptosis (programmed cell death) is outlined in A. Glücksman, “Cell Deaths in Normal Vertebrate Ontogeny,” Biological Reviews of the Cambridge Philosophical Society, 26:59–86 (1951); A.H. Wyllie, J.F.R. Kerr, and A.R. Currie, “Cell Death: The Significance of Apoptosis,” International Review of Cytology, 68:251–306 (1980); I.D. Bowen and R.A. Lockshin (eds.), Cell Death in Biology and Pathology (1981); I. Davies and D.C. Sigee (eds.), Cell Ageing and Cell Death (1985). The development of the idea of brain death (and of its evolution into the concept of brain-stem death) can be followed in P. Mollaret and M. Goulon, “Le Coma dépassé,” Revue Neurologique, 101(1):3–15 (July 1959); Ad Hoc Committee Of The Harvard Medical School To Examine The Definition Of Brain Death, “A Definition of Irreversible Coma,” J.A.M.A., 205(6):337–340 (Aug. 5, 1968); Julius Korein (ed.), Brain Death: Interrelated Medical and Social Issues (1978); A. Earl Walker, Cerebral Death, 3rd ed. (1985); President's Commission For The Study Of Ethical Problems In Medicine And Biomedical And Behavioral Research, Defining Death: A Report on the Medical, Legal, and Ethical Issues in the Determination of Death (1981, reprinted 1983); Bryan Jennett, John Gleave, and Peter Wilson, “Brain Death in Three Neurosurgical Units,” Br.Med.J., 282:533–539 (Feb. 14, 1981); Christopher Pallis, ABC of Brain Stem Death (1983), and his “Brain-stem Death: The Evolution of a Concept,” in Peter J. Morris (ed.), Kidney Transplantation: Principles and Practice, 2nd ed., pp. 101–127 (1984); James L. Bernat, “The Definition, Criterion, and Statute of Death,” Seminars in Neurology, 4(1):45–51 (March 1984). Clinical and biological aspects are explored by a physician in Sherwin B. Nuland, How We Die (1994).Philosophical and cultural aspectsE.A. Wallis Budge, Egyptian Ideas of the Future Life: Egyptian Religion (1899, reprinted 1979 as Egyptian Religion: Egyptian Ideas of the Future Life); Ange P. Leca, La Médecine égyptienne au temps des pharaons (1971); Alexandre Piankoff (ed.), Le “Cœur” dans les textes égyptiens depuis l'ancien jusqu' à la fin du nouvel empire (1930); and Henry E. Sigerist, A History of Medicine, 2 vol. (1951–61), are useful reviews of the notion of death in ancient Egypt. Mesopotamian concepts are described in J. Hackin et. al., Asiatic Mythology (1932, reissued 1963); and Samuel George Frederick Brandon, Man and His Destiny in the Great Religions (1962, reprinted 1963). The latter and F.H. Garrison, “The Bone Called ‘Luz,' ” New York Medical Journal, 92(4):149–151 (July 23, 1910), also contain much useful information on Judaic attitudes. Hindu perceptions and practices are detailed in Paul Thomas, Hindu Religion, Customs and Manners, 6th ed. (1975); and Nirad C. Chaudhuri, Hinduism: A Religion to Live By (1979, reprinted 1980). Muḥammad ibn Abī Bakr Ibn Qayyīm al-Jawzīyah, Kitāb al-rūḥ, 2nd ed. (1324); and Frank E. Reynolds and Earle H. Waugh (eds.), Religious Encounters with Death: Insights from the History and Anthropology of Religions (1977), present Islāmic attitudes. More recent developments are discussed in T.S.R. Boase, Death in the Middle Ages: Mortality, Judgment and Remembrance (1972); and Philippe Ariès, Western Attitudes Toward Death: From the Middle Ages to the Present, translated from the French (1974, reprinted 1975), and The Hour of Our Death (1981, reissued 1982; originally published in French, 1977). Information about the “pineal soul” is found in René Descartes, Treatise of Man, translated from the 1664 French edition, by Thomas Steele Hall (1972), originally published in a Latin translation, 1662; and about the “spinal cord soul” in Edward George Tandy Liddell, The Discovery of Reflexes (1960). See also Geoffrey Jefferson, “René Descartes on the Localisation of the Soul,” Irish Journal of Medical Science, 285:691–706 (Sept. 1949); and G. Corner, “Anatomists in Search of the Soul,” Annals of Medical History, 2(1):1–7 (Spring 1919). Modern attitudes on death form the basis of Jessica Mitford, The American Way of Death (1963, reprinted 1978); Elisabeth Kübler-Ross, On Death and Dying (1969, reprinted 1979); and Robert M. Veatch, Death, Dying and the Biological Revolution: Our Last Quest for Responsibility (1976). Herman Feifel (ed.), The Meaning of Death (1959, reissued 1965); and James P. Carse, Death and Existence: A Conceptual History of Human Mortality (1980), both present excellent overviews.Christopher A. Pallis Ed.
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