What’s Wrong with the World

Zach's case really is one that calls into question these diagnostic procedures, including some of the more sophisticated ones.

Here is a post on the trouble with brain death diagnosis that fits well with your post, Bill:

http://whatswrongwiththeworld.net/2008/06/serious_questions_about_brain.html

Bill, I agree with you completely about the horrors foisted on us with the theory of "brain death".

Nevertheless, I have a question that is perhaps more philosophical than practical: If the ultimate test of true "death" has to be a state that a person cannot "come back from" or be resuscitated from, then don't ALL incidents of miraculously coming back to life incidents that simply muddy the waters of what is naturally possible versus naturally impossible? Are there (at least theoretically ) possible cases where a person has indeed died, and God restored them to life by direct intervention, but the physical condition of their body during death was (to our limited capacity and knowledge) no worse off than some people who can in fact be resuscitated through natural efforts? We could not know enough to say with certainty that divine intervention took place, so we might not call it a miracle properly speaking, but divine intervention can still be real in such cases.

And are there cases where we are on the borderline gray area of thinking that nature cannot reverse this state, and God steps in and brings them back to life. How could we ever sort out for sure what is really truly "natural powers cannot recover from this state" after such a miracle?

@Tony - Isn't it the point that we can't know for sure, and so folks (especially those with uncertain principles about the sanctity of the person) shouldn't be so quick to act on their "knowledge?"

Are there (at least theoretically ) possible cases where a person has indeed died, and God restored them...etc.

I guess the answer has to be 'yes,' and I guess the answer to your last question is 'we can't.'

I just don't think we ought to assume divine intervention when the evidence is weak, as it is here. It frees the medical folks from having to answer for their actions. Now if Zach had suddenly woke up, bright eyed and bushy tailed, torn out the tubes, hopped out of bed, said, "Hi, mom, hi, dad," then turned to the doctor and growled, "Who you callin' dead, chump?" - then I'd lean more to grandma's point of view.

That was a good thread, Lyida. Your commenter links to an article on Zach's case (which I will read). Your commenter also says: "A human body that cries, and moves, and shrugs, and grimaces may seem like a living person. But if the brain has no function, no metabolism, no blood flow . . . then whatever it was that made that body a person is no more."

You know what I'd say he can do with that.

Sounds misreported or sloppy. Establishing brain death requires at least two examinations several hours apart demonstrating no evidence of cortical activity, no brain stem reflexes and no spontaneous respiration with an "apnea test". Short of meeting these criteria, a determination of brain death (with or without a xenon perfusion scan -- the so-called "black brain" test) would be premature at the least, and verge on negligent.

Two lessons here.

1. Wear a helmet when doing dangerous things.

2. If you are a doctor, follow established protocols.

Al, protocols vary. Even one neurologist who criticizes what was done in this case criticizes it on the basis of what he calls "my personal recommendation" for what the team should have done instead. The team was not being wildly negligent, and there is no indication that they were failing to follow the protocols that they were aware of and that they considered to be standard.

What's interesting about the whole brain death thing is that people always imply that disturbing cases are anomalous, that stricter guidelines or standardized guidelines would eliminate them. The evidence I presented in my other post indicates that this is not plausible and that problems with diagnosing whole brain death are _pervasive_. Pain-like responses in organ donors, for example, are apparently quite common, not anomalous.

A human body that cries, and moves, and shrugs, and grimaces may seem like a living person. But if the brain has no function, no metabolism, no blood flow . . . then whatever it was that made that body a person is no more."

Rubbish. Crying involves brain functioning (this is different from simple lacrimation).

The Chicken

Only brain death? There are also cases of people waking up in morgues, after being declared dead dead.

Two lessons here.

Good old, al, keeping things simple.

But the lesson I took from this is that it's quite likely that a lot of people who weren't really dead have ended up "donating" their organs.

And I thought this was just comedy: http://www.youtube.com/watch?v=aclS1pGHp8o (Warning: gross fake blood & guts)

Interesting post.

One of the main things I took away from my experience as an intern in the Clinical Bioethics Dept. at the N.I.H. some years ago is that we lay-folk have a grossly exaggerated idea of how much doctors know. Medicine is not like chemistry. It's not a (more or less) completed science. Half the time, they seem to be flying by the seat of their pants. That certainly seems to be the case here.

I think that's quite true, Steve.

I also think that there is a strong motivation never to consider certain possibilities that would shut down therapeutic options such as vital organ transplant. It's interesting to see how medically the profession is willing ethically to consider some previously "unthinkable" things--PAS, for example--but not willing to consider that we cannot reliably detect whole brain death and that _therefore_ heart transplants are going to have to stop.

Oh, and about miracles and divine intervention...

Here's a very elementary question about such things that's been buzzing around in my head lately, as I prepare to teach some of the basics of Thomism, with the help of Ed Feser's Aquinas: A Beginner's Guide:

The very idea of a miracle, or of divine intervention, seems to picture God as a being who, like us, experiences time. Things are chugging along, according to the laws that He set in motion, when something happens that He doesn't want. Or maybe somebody asks Him, through prayer, for a favor that wasn't on the schedule of material reality, left to itself. So He looks, or listens, and then he decides, and then he says "let it be done," and it is done.

But, setting aside the unique and temporary case of the incarnation, isn't God, strictly speaking, wholly independent of time & space - being, indeed, the very *foundation* for the *possibility* of time and space, and therefore in some deep sense prior to both?

OK, sorry, I'm getting into some serious thread-jacking here. But it's been bugging me.

I don't see how a Boethian view of time (the "outside time and space" view) is incompatible with miracles. The idea that they are in conflict puzzles me. Couldn't God, seeing all things timelessly, also see that person's prayer for a miracle (for example) timelessly and choose, timelessly, to perform a miracle in response to that prayer? (That was C.S. Lewis's view, as I understand it.) The prayer would then "come in," in history, at a particular time, but would have been willed by God from all eternity in line with His knowledge of all of time. Rather as a composer plans and inserts a note as part of a complete piece of music, though the listeners at the concert _hear_ the note only when it comes up as they experience the music sequentially. (Perhaps that's not a good analogy, but it seems okay to me right now.)

I believe that Richard Swinburne, by the way, rejects the Boethian view of the timelessness of God, but at the moment I forget his argument. I just remember that I found it unconvincing. :-)

It just so happens that your friend Zachary Dunlap is only MOSTLY dead. There's a big difference between mostly dead and all dead. Mostly dead is slightly alive. With all dead, well, with all dead there's usually only one thing you can do. . . . Go through his thoracic and abdominal cavities and look for loose organs.

Badum ching. Nice allusion, Miracle Max. I can hear the Billy Crystal accent now.

I believe that Richard Swinburne, by the way, rejects the Boethian view of the timelessness of God

So does Duns Scotus. He thinks the Boethian explanation is tantamount to conflating eternity with time, implying that time exists only "for us" and not in reality (some modern physicists think this is really the case). So that if every moment is always present to God's eternity, then the sequential nature of time is merely phenomenal, since every moment always has some reality. But (the argument goes) time is real, the past does not actually exist in eternity, ergo etc. Consequently Scotus explains God's foreknowledge in a different way than Boethius.

Hmm...Unfortunately due to my job I have seen hundreds of brain dead ventilated patients. I hate to the nay-sayer, but this situation is really, really, really rare. Everyone who who works with families and patients like this wishes it wasn't, but it is. I've waited for months for patients to show some signs of life, at the expence of resources that could save thousands of lives. I've seen dozens of families agonize over what to do only to have those patients eventually die of complications, over and over and over again.

This whole hanging on highly, highly improbable hope at any cost is just another mortality denying artificial construct of a weak, wealthy and thoughtless culture.

I can't speak for others, but I've been doing this for a long time and the idea that healthcare professionals are just waiting around after each trauma hoping for organs is laughable. It's the last thing on anyones mind when it comes to making clinical decisions. Some people watch way to much TV. A lot more thought went into the concept of brain death than simply manufacturing and end point to start organ doning from.

And then there's the unpleasant practical side. We could never staff, equip, house or pay for perment life support for every patient like the one in the story even if we wanted to. Wait until Obamacare tacks that onto the bill.

only to have those patients eventually die of complications

Um, what? The whole point was supposed to be that the person already is dead. Physically dead. Interesting Freudian slip there, though.

There's also the small point that eventually taking a person off of a ventilator isn't the same thing as cutting his heart out.

Lydia, you're being unnecessarily obtuse, knowing full well that "brain death = death" is a construct defined as equivalent to but not constituted by whole organism failure (ie. James's description of eventually "dying of complications.)

But consider James' observations (ones I probably can corroborate) a little further. There is a way to sort all this out. Perform clinical trials. Establish "brain death" according to the most rigorous criteria available. The recently updated AAN Guidelines are a probably as good a place to start as any (and were, by the way, not followed in the case described in this post). Continue supportive treatment and document recovery or not of any higher level of function, or any level of function. But we probably don't need to repeat this, since it's already been done. In a British study in 1981 (BMJ 1981;282(14)533-539), 609 people diagnosed with brain death according to the Minnesota criteria that essentially match the current AAN guidelines were observed for recovery and provided sustained respiratory and hemodynamic support. Not one recovered, and most had cardiorespiratory failure within 3-5 days. We can quibble the quiddities of whether there is some retention of hypothalamic function (ability to lactate or regulate homeostasis) or higher-than-cervical-cord reflex movements (Karakatsanis' observations come to mind) following establishment of "brain death" by rigorous criteria, but the fact remains that, regardless of these putatively concerning discrepancies, the definition of brain death, as established by carefully followed criteria, remains reliably, and in short order, predictive of immanent whole-body, somatic death by heart and lung criteria. No patient declared brain-dead by properly performed and interpreted tests has ever survived. When you can find a case of recovery from rigorously-defined brain death, then there will be a practical dilemma.

I think what we should be really concerned about, and what the case of Mr. Dunlap illuminates, is the variability in practice and application of guidelines from state to state (Greer et al. Variability of brain death determination guidelines in leading US neurologic institutions. Neurology 2008;70(4):284-9.) The most definitive take-home message we can glean from his story: don't bang your head hard in Oklahoma, unless you've really got an urge to lighten up by an organ or two.

Regards

CH

Steve,

First, Jimmy Akin has a section on his blog called "Theological Connections", which goes into a number of subjects relating to your question of time and eternity.

As for divine intervention, I think I sort of understand what is bothering you. A perfect, eternal God cannot contradict Himself. God created all the universe, laid out the principles of matter and energy, and is meticulously mindful of every particle in the mind-shatteringly enormous universe from beginning to end, and then upsets it all with a miracle. I suppose that is because that this creation, though skillfully rendered, is a work of art, not a machine.

This is sad to read:

We didn't want him as a vegetable

Didn't want him as a vegetable?
Pretty selfish to want only the physically best version of your child.
I have to wonder how much they love this adopted son of theirs.
When my mom had an aneurism I would have done anything to keep her alive.
My only concern at that point was not losing her. Any condition of life is still life.
And I don't care how sick you are or how diminished your condition of life is - the true/pure love of another person makes life all worth it.

Physical abilities and physical conditions might decrease over time - but humans have spiritual needs as well.

Craig Henry,

I don't consider hard evidence of function of portions of the brain to be a mere "quibble." Whole brain death was supposed to be just that--whole brain death. It was supposed to tell us that the person was _physically dead_. It wasn't supposed to be some sort of subjective thing, nor was it supposed to be what Karakatsanis wishes to rename it--apneic coma. A coma without the ability to breathe on one's own could still involve brain function. Brain death was supposed to be the cessation of the functioning of all parts of the brain, period. (That's it's legal definition, as you know.) Hence the analogy I often have made to an oxygenated but decapitated corpse. That wasn't supposed to be just an analogy. The brain stem and the whole works were supposed to be _non-functional_.

Moreover, you and James cannot have it both ways. You wish to tell us that all or most (!) patients properly diagnosed will not be able to be kept going beyond 3-5 days, even with life support, while James wishes to scare us with the prospect of large numbers of patients, diagnosable as brain dead, warehoused for long periods of time on life support. Which is it?

You know as well as I do that it is not by any means uniformly expected that patients diagnosed as brain dead will be unable to be kept going with respiratory support beyond 3-5 days, as witness cases in which doctors _plan_ to continue to support pregnant female patients thus diagnosed in order to sustain the pregnancy until the unborn child is viable. That's a lot more than 3-5 days! It is possible that the women in these cases were not diagnosed using your recommended procedures, but a) as you yourself grant, this would mean that, had they not been pregnant, they would have been candidates for organ donation, which should disturb you if you consider them to have been improperly diagnosed, and b) the doctors in these cases obviously thought that the women simply _were_ brain dead and presumably would have expected even the most rigorous procedures to confirm this diagnosis, so you cannot _assume_ that the women's diagnosis would not have stood up to your recommended procedures. My point is that it is taken as _not very surprising_ that patients diagnosed as brain dead should be able to be sustained on life support for more than 3-5 days, which should give you some pause.

Your and James's continual references to _recovery_ are missing the point. Zach Dunlap's recovery was a dramatic indication that something was wrong in the diagnosis, but that does not mean that the only thing we are concerned about is patients who might recover! The question, rather, is whether organs are being surgically removed from people who are physically alive. Plenty of people could be physically alive but unlikely to recover. For that matter, plenty of people could be physically alive but likely to die within 3-5 days! The question is whether they are physically alive and whether, therefore, they are being killed by the removal of vital organs. Some of us care about that aside from prognosis. The medical profession is far too quick these days to treat a patient in this or that way based on prognosis. When it comes to actually cutting out a patient's heart and justifying this on the grounds that he isn't expected to recover, we have a major problem, Houston.

But, setting aside the unique and temporary case of the incarnation, isn't God, strictly speaking, wholly independent of time & space - being, indeed, the very *foundation* for the *possibility* of time and space, and therefore in some deep sense prior to both?

Since God keeps everything in existence he has a connection to time. In fact, he has a connection to all times all at once. When God performs a miracle, he can do so, if he choses, in such a way that the miracle is both from nothing (ex nihil) and from no time (ex non tempore). In other words, there need be no time difference from when God conceives of doing a miracle and when the miracle has to be done (although he may use secondary events that take time). Since there is no time change involved, there is no problem with quantum mechanics, because quantum mechanics cannot define what happens in a zero interval of time.

Literally, now you don't see it, now you do.

The Chicken

Lydia, in neither James' nor Mr. Henry's remarks do I see a denial of the possibility that quite a few living people have been made organ donors. But maybe they are not bothered by that.

Steve Burton - I'm not quite clear on your difficulty. When you say "...when something happens that He doesn't want. Or maybe somebody asks Him, through prayer, for a favor that wasn't on the schedule of material reality, left to itself..," you seem to circumscribe God's omniscience, as if something could transpire he didn't know about. Since time is his creation, he knows everything that's in it, including his own interventions. I don't see how his independence from time translates into "can't mess with it." If he made it, he can certainly mess with it, and knew what the messing would be from all eternity.

Neither do I see why the Incarnation should be set aside as a "unique and temporary" instance. I guess because the 2nd Person himself is supposed to have entered history, but I doubt that he was contained by it, like a vapor in a corked bottle.

I think the idea was that Jesus as God Incarnate experienced temporal sequence but that God aside from the Incarnation doesn't experience temporal sequence. Which may be true as far as it goes, but creates no particular problems for miracles. After all, once one grants the Incarnation one _has_ to grant the possibility of miracles, because the Incarnation was a miracle itself--virgin conception.

Actually, I think Steve's point is pretty good, if I understand it correctly. If God is author of reality, and preordains everything that comes to pass, why should He need to step in and "fix" things brought to pass by His own laws, rather than simply making it so that His preferred outcome comes to pass on its own by His own laws in the reality He has set up in the first place?

In my opinion, the answer is at least two-fold. First, part of the reason for most (all?) of the Biblical miracles was God demonstrating His authority over and authorship of reality to human beings. Another reason for God to do miracles would be to accomplish things that *can't* come to pass by physical laws (as opposed to just being unlikely). In this case, it's not a matter of "fixing" the outcome, since no possible outcome of physical law would accomplish the goal. The Incarnation certainly falls into this category, at least.

Deuce, if somebody really has the Spinoza Bug badly enough (and that bit about "fixing" is straight out of the Spinoza playbook), the person will just back up to demanding that God front-load everything by laws *and initial conditions*. Somehow that's supposed to be better, though I must say to me it always just seemed that the "better" in that case was merely from the perspective of a _distaste_ for intervention rather than as a matter of argument.

Of course, you're quite right concerning demonstrating authority. The point (or one major point) of a miracle is communication from outside the realm of the natural world. If the whole thing appears to men to be natural, no such communication takes place.

But actually, I didn't take Steve to be asking the Spinozistic question. I took him to be assuming that God performs miracles in response to things (such as prayers requesting a miracle) that somehow "come up for Him," which would make miracles contrary to Divine timelessness. But that isn't at all necessarily true, as we've said.

In effect, _this_ question about timelessness is closely related to questions that interest open theists. It would equally well apply to the forgiveness of sins: How can God forgive my sins "in response to" my prayers if He is timeless and my sins and prayers for forgiveness occur in time? The answer, of course, is the same--God eternally knows both the sin and the prayer for forgiveness and grants the forgiveness in response to the prayer He eternally sees.

Actually, I am fully aware that misdiagnosis takes place, and I believe that establishing with true curtainty what will happen to a "brain dead" patient with is an impossibility. In every human endevore there is this terrible element of inperfection even when we do our very best. Everything, from space shuttles to declaring war, to making clinical decisions about life and death is tainted with unintended consquences.

An arguement could be made that it is always best to err on the side of life. And believe it or not I agree, I have known families that have kept "vegetative" patients alive for years; that doesn't offend or bother me, I'm good with it. But for almost everyone who has to work on a daily basis with real patients and families a certain guilt eventually creeps in about offering false hope to desperate families. Most of us never see the highly advertised, televised miracle. We and the families just to develope coping mechanisms because almost all of the patients are young and had a full life ahead of them.

So we go home and have a big glass of scotch, turn on the TV and hear the 'World Vision' guy tell us that for just a dollar a day we can save a childs life....Then the crazy math starts...A dollar a day!!??? $%#&#* I just spent 9000$ to keep someones someone "alive" who didn't even want life support to begin with, who as nearly as my imperfect and finite mind can possibly tell, will never ever draw another unassisted breath in their life. The whole idea of life support and organ donation takes on surreal quality. It feel like the indulgences of the royal court before the French Revolution. I've been to places where these questions were not even a consideration because resources where so limited; this is the story of most of human history, if you where dumb or unfortunate enough to get such a catastophic injury you died. Extended life support etc. is just denial...usually. I often wonder what will happen to this debate when we can no longer afford it.

Of course this all boils down to the "lifeboat scenerio", who's life is more valuable than anothers, but as nearly as I can tell the same delemma is in place if you deside not to harvest organs.

Personally the idea of having someone elses organs in my body to stay alive is repulsive and I honestly hope God will never ask me to do it, I'm pretty sure I'd ather die. I know lots of people feel differently about it, and I would never presume to tell other what to do, or condemn their past choices, but as a Christian it intuitively feels wrong to me.

Thanks to otherts for challenging my views;

Pax Christos,

James

Okay, James, pax.

James, please understand that I am _not_ suggesting indefinite ventilator use.(Food and fluids are a different matter, by the way.) That's not my concern. I'm simply suggesting that "err on the side of life" means "don't take organs from people who could plausibly be alive." If the diagnosis problem is as severe as I have come to suspect it is, then this principle alone would mean the end of vital organ donation. I suspect you wouldn't have a problem with that, as long as you understand that what I'm _not_ suggesting is holding out hopes of anything to anybody.

Of course this all boils down to the "lifeboat scenerio", who's life is more valuable than anothers,

It's very important to realize that this is not true. There is no lifeboat containing both the person on life support and the little children served by World Vision. Nobody is, and nobody should be, in a situation of responsibility to look down from a Godlike perspective and allocate some gigantic pile of "the world's resources," deciding "whose life is more valuable" as between these two groups. That sort of collective view is an extremely dangerous one. There are people--we may not know who they are--who have a primary responsibility for the person on life support. And there are people who have a primary responsibility for each of the third world children. In neither case should this responsibility be given to someone who views such widely disparate people as all being in the same lifeboat together and who has some sort of agonizing decision of ditching the one in favor of the other. Such situations should not be created or conceived in this way.

On refection, I regret having spoken too strongly. I'm not without doubts about the clarity and certainty of a clinical test that claims such a definitive determination. I'm not sure some of the outliers are practically relevant (and am certain that Zach's case is a lousy example), but I do see and am troubled by even the chance that a diagnosis with such ethical weight may not actually or fully establish what it's said to represent. I'd be hesitant to categorically give up on the usefulness of the more rigorously applied whole brain death criteria, having seen plenty of cases where there really was nothing left functioning above the neck. Also, despite concerns about its crispness, it's presently the firmest line we have between here and some even more troubling alternatives.

Seems the further we advance control over our bodies, the deeper we trip into territory we didn't adequately pack for.

Regards,

CH

Also, despite concerns about its crispness, it's presently the firmest line we have between here and some even more troubling alternatives.

There we are in full and total agreement, CH. If you read my post in which I raised some questions about the diagnosis of whole brain death, you saw what I said about always arguing on two fronts. It's incredibly important that we make it clear what whole brain death is _supposed_ to be and oppose that idea to the sloppy use (even, horrifyingly, by some medical people) of "brain dead" as a synonym for "persistently unconscious," even sometimes applying it to people who are breathing on their own, etc.

I would only add that we wouldn't have to worry about this if there weren't so many people out there eager to declare people dead while still having recourse to their organs. Certainly it would be much, much worse as a matter of public policy if the dead donor rule were abolished and if, for example, patients diagnosed as PVS could have their organs harvested. One of the most shocking things about articles in which criteria of brain death are questioned for their reliability is that the authors go in the _wrong direction_. Instead of questioning the ethical feasibility of vital organ donation, they instead suggest that we be "honest" and throw out the dead donor rule altogether! What a horrible moral to draw! It reminds me a bit of the situation in which we pro-lifers rightly point out the similarities between abortion and infanticide and the other side responds by endorsing post-birth infanticide.

You know, it's cases like this that confirm everything that Dr. Byrne said at the Pro-life Technology Conference three years ago. I had an organ donation marker (a little heart) on my driver's license back then.

When it was time to renew the license, the organ donation tag was not. Nor will it be.

Steven, just hope your state doesn't start going with "presumed consent." Then we'll need markers on our driver's licenses that say we _definitely are not_ organ donors.

As an additional reference, I think this article is free, and describes the problems Lydia illuminates about "wrong directions" in response to doubts about the reliability of brain death criteria. And for further reading, this review.

Exactly, Mr. Henry, and thanks much. I almost sometimes get the eerie feeling that some people on the opposite side from me on every issue are eager to question the reliability of the criteria of brain death so that they can throw out the dead donor rule. That should certainly make me cautious about accepting their results, but unfortunately the data _look_ very concerning, even if one has no such dreadful agenda.

Good links, but I can access only the abstract of the second one.

Mr. Luce

I sent you a PDF of the full article care of the blog editor address.

Regards,

CH

Thanks much.

Let them shout "miracle" all they want. Like the Springsteen song says, it ain't no sin to be glad you're alive.

I had the priviledge of being present in that ICU waiting room with standing room only when hands were held while prayer was being said for Zach. The Holy Spirit was present among that assembly that day. God answered that prayer and Zach came back from the dead. As for his parents Pam and Doug, they are wonderful parents and love Zach and his adopted sister very much. Some of the above comments make me sick. The bible says that God is the same yesterday, today and forever.Miracles still happen and God chose to perform one that day.

Some of the above comments make me sick.

Maybe this is a bad idea, but I missed out on this discussion the first time and I'm curious: What, exactly, do you take issue with here?

The only comment I can think of that might "make you sick" was this by Manuel Labor:

Pretty selfish to want only the physically best version of your child. I have to wonder how much they love this adopted son of theirs.

But-I agree with Manuel's sentiment, which is that we should do everything we can to keep our loved ones alive through natural means. And honestly I don't think there's an issue with anything anybody else said here-in fact, it all seems to be quite nuanced and carefully written.

Also: Just because it was an answered prayer does not necessarily make it a miracle. And the fact that it wasn't a miracle doesn't mean it wasn't an answered prayer.