N"illard Gaylin

flARVESTINGTHE DEAD"he potential for recycling human bodies

::---

Redefining death

~.T0THING IN LIFE is simple any-., more, not even the leaving of it.\.t one time there was no medicalleed for the physician to considerhe concept of death; the fact of deathas sufficient. The difference between

ife and death was an infinite chasmreached in an infinitesimal moment.ife and death were ultimate, self-vident opposites.

With the advent of new techniquesmedicine, those opposites have be-

;un to converge. We are now capablef maintaining visceral functionsithout any semblance of the higher

unctions that define a person. Were, therefore, faced with the task ofleciding whether that which we havetept alive is still a human being, or,o put it another way, whether that

human being that we are maintainingshould be considered "alive."

Until now we have avoided theproblems of definition and reachedthe solutions in silence and secret.When the life sustained was unre-warding-by the standards of thephysician in charge-it was discon-tinued. Over the years, physicianshave practiced euthanasia on an adhoc, casual, and perhaps irrespon-sible basis. They have withheld anti-biotics or other simple treatmentswhen it was felt that a life did notwarrant sustaining, or pulled the plugon the respirator when they wereconvinced that what was being sus-tained no longer warranted the def-Willard Gaylin, M.D., a psychiatrist, is presi-dent of the Institute of Society, Ethics andthe Life Sciences in Hastings-on-Hudson,New York. He is the author of Partial Jus-tice: A Study of Bias in Sentencing, to bepublished by Alfred A. Knopf in October.

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inition of life. Some of these acts areillegal and, if one wished to pros-ecute, could constitute a form ofmanslaughter, even though it is un-likely that any jury would convict.We prefer to handle all problemsconnected with death by denying theirexistence. But death and its dilemmaspersist.

New urgencies for recognition ofthe problem arise from two condi-tions: the continuing march of tech-nology, making the sustaining of vi-tal processes possible for longer peri-ods of time; and the increasing useof parts of the newly dead to sustainlife for the truly living. The problemis well on its way to being resolvedby what must have seemed a rela-tively simple and ingenious method.As it turned out, the difficult issuesof euthanasia could be evaded byredefining death.

23

HARVESTING THE DEAD

INAN EARLIER TIME, death was de- scientific and, theological, groups.fined as the' cessation of breathing. The movement toward redefining

Any movie buff recalls at least one death received considerable impetusscene in which a mirror is held to with the publication of a report spon-the mouth of a dying man. The lack sored by the Ad Hoc Committee ofof fogging indicated that indeed he the Harvard Medical School in 1968.was dead. The spirit of man resided ,The committee offered an alternativein his spiritus (breath). With in- definition of death based on the func-creased knowledge of human phys- tioning of the brain. Its criteria stated'iology and the potential for reviving that if an individual is unreceptivea nonbreathing man, the circulation, and ,unresponsive, i.e., in a state ofthe pulsating heart, became the focus irreversible coma; ,if he has no move-of the definition of life. This is the ' ments or breathing when the mechan-tradition with which most of us have, .ical respirator is turned off; if hebeen' raised; ,demons~rates no reflexes; and if he has

There is of course a relationship a flat electroencephalogram for at.between circulation and, respiration, least twenty-four hours, indicating noand the linkage, not' irrelevantly, is electrical brain activity '(assuming,thebrain. AU body parts require the that he has not been subjected to hy-nourishment, including oxygen, car- pothermia or central nervous systemried hytlie circulating blood. Lack depressants), he may then be de"of blood supply leads to the death of clared dead.an organ; the higherfunctions of the What was originally offered as anbrain are particularly vulnerable. But optional definition of death is, how-if there is no respiration, there is no ever, progressively becoming the def-adequate exchange of oxygen, and inition of death. In most states therethis essential ingredient of the blood is no specific legislation definingis no longer available for distribu- death; ". the ultimate responsibilitytion. If a part of the heart loses its here is assumed to reside in the gen-vascular supply, we may lose that eral medical community. Recently,part and still survive. If a part of the however, there has been a series ofbrain is deprived of oxygen, we may, legal cases which seem to be estab-depending on itslocation, lose it and lishing brain death as a judicial stan-survive. But here we pay a special dard. In California in May of thisprice, for the functions lost are those year an ingenious lawyer, Johnwe identify with the self, the soul, or Cruikshank, offered as a defense ofhumanness, i.e., memory, 'knowledge, his client, Andrew D. Lyons, who hadfeeling, thinking, perceiving, sensing, shot a man in the head, the argumentknowing •.learnil}~, andloving. that the cause of death was not the

Most peop1e are prepared to say bullet but the removal of his heartthat when all of the brain is destroyed by a transplant surgeon, Dr. Normanthe "person" no longer exists; with Shumway. Cruikshank's argument not-all due respect for the complexities withstanding, the jury found his clientof the mind/brain debate, the "per- guilty of voluntary manslaughter. Inson" (and personhood) is generally the course of that trial, Dr. Shumwayassociated with the functioning part said: "The brain in the 19705 and inof the head-the brain. The higher the light of modern day medical tech-functions of the brain that have been nology is the sine qua non-the cri-described are placed, for the most terion for death. I'm saying anyonepart, in the cortex. The brain stem whose brain is dead is dead. It is the(in many ways more closely allied to one determinant that would he uni-the spinal cord) controls primarily versally applicable, because the brainvisceral functions. When the total is the one organ that can't be trans-brain is damaged, death in all forms planted."will ensue because the lower braincenters that control the circulationand respiration are destroyed. Withthe development of modern respira-tors, however, it is possible to artifi-cially maintain respiration and withit, often, the circulation with whichit is linked. It is this situation thathas allowed for the redefinition ofdeath-a redefinition that is being

24 precipitously embraced by both

THIS NEW DEFINITION, independentI of the desire for transplant, now per-mits the physician to "pull the plug"without even committing an act ofpassive euthanasia. The patient willfirst be defined as dead; pulling the

* Kansas and Maryland have recentlylegislated approval for a brain definitionof death.

HARVESTING THE DEAD

plug will merely be the harmless act It soon becomes apparent, howev-of halting useless treatment ona ca- er , that there is a limitation to thisdaver. But while the new definition procedure. The person in want doesof death avoids one complex problem, not always have a second-best sub-euthanasia, it may create others stitute. He may then be forced toequally difficult which have never borrow from a person with a surplus.been fully defined or visualized. For The prototype, of course, is bloodif it grants the right to pull the plug, donation. Blood may be seen as ait also implicitly grants the privilege regeneratable organ, and we have anot to pull the plug, and the poten- long-standing tradition of blood do-tial and meaning of this has not at all nation. What may be more important,been adequately exami~ed. and perhaps dangerous, ~e have es-

These cadavers would have the le tablished the precedent in blood ofgal status of the dead with none of commercialization-not only are wethe qualities one now associates with free to borrow, we are forced to buy

-. death. They would be warm, respir- and, indeed, in our country at least,.ing, pulsating, evacuating, and excret- . 'permitted to sell. Similarly, we allowing bodies requiring nursing, dietary , the buying or selling, of sperm forand general grooming attention-and artificial insemination. It is most like-could probably be maintained so [or ly that in the near future we will allowa period oj years. If we chose to, we the buying and selling of ripened ovacould, with the technology already at so that a sterile woman may conceive

'. hand, legally avail ourselves of these her baby if she has a functioningnew cadavers to serve science and uterus. Of course, once in vitro fer-mankind in dramatically useful ways. tilization becomes a reality (an im-The autopsy, that most respectable of minent possibility), we may even per·medical traditions, that last gift of mit the rental of womb space forthe dying person to the living future, gestation for a woman who does man-could be extended in principle be- ufacture her own ova but has noxond our current recognition. To save uterus.lives and relieve suffering-tradition. Getting closer to our current prob-al motives for violating tradition- lem, there is the relatively long-stand-we could develop hospitals (an inap- ing tradition of banking body partspropriate word because it suggests the (arteries, eyes, skin) for short peri-presence of living human beings), ods of time for future transplants.banks, or farms of cadavers which Controversy has arisen with recentrequire feeding and maintenance, in progress in the transplanting of majororder to be harvested. To the unini- organs. Kidney transplants from atiated the "new cadavers" in their near relative or distant donor are be-rows of respirators would seem in- coming more common. As heartdistinguishable from comatose pa- transplants become more successful,tients now residing in wards of chron- the issue will certainly be heightened,ic neurological hospitals. for while the heart may have been reo

duced by the new definition of deathto merely another organ, it will al-ways have a core position in the pop'ular thinking about life and death. It

THE IDEA OF wholesale and sys- has the capacity to generate the pas-t tematic salvage of useful body sion that transforms medical deci-

parts may seem startling, but it is not sions into political issues.without precedent. It is simply mag· The ability to use organs from ca-nified .by the. technology of modern davers has been severely limited ininedi~i'ne:Wiihiil the confines of one the past by the reluctance of heirs toindividual, we have always felt free to donate the body of an individual fortransfer body parts to places where distribution. One might well havethey are needed more urgently, felt willed one's body for scientific pur-free to reorder the priorities of the poses, but such legacies had no legalnaturally endowed structure., We will standing. Until recently, the individ-borrow skin from the less visible parts" ualIost control over his -body' once;of the body to salvage a face. If a he died. This has been changed bymuscle is paralyzed, we will often the Uniform Anatomical Gift Act.substitute a muscle that sub serves a This model piece of legislation, adopt-less crucial function. This was com- ed by all fifty states in an incrediblymon surgery at the.time that paralyt- short period of time, grants anyoneic polio was more prevalent. over eighteen (twenty-one in some

Precedents

26

states) the right to donate en masseall "necessary organs and tissues"simply by filling out and mailing asmall card.

Beyond the, postmortem, there hasbeen a longer-range use of humanbodies that is accepted procedure-the exploitation of cadavers as teach-ing material in medical schools. Thisis a long step removed from the ra-tionale of the transplant-a dramaticgift of life from the dying to the near-dead; while it is true that medicaleducation will inevitably save lives,the clear and immediate purpose ofthe donation is to facilitate training .

, It is not unnatural for a personfacing death to want his usefulness toextend beyond his mortality; thesame biases and values that influenceour life persist in our leaving of it.It has been reported that the HarvardMedical School has no difficulty in re-ceiving as many donations of cadav-ers as they need, while Tufts andBoston Universities are usually inshort supply. In Boston, evidently,the cachet of getting into Harvard ex-tends even to the dissecting table.

The way is now clear for an ever-increasing pool of usable body parts,but the current practice minimizesefficiency and maximizes waste. Onlya short period exists between thetime of death of the patient and thetime of death of his major parts.

Uses of the neomort

INTHE ENSUING discussion, the wordcadaver will retain its usual mean-

ing, as opposed to the new cadaver,which will be referred to as a neo-mort. The "ward" or "hospital" inwhich it is maintained will be calleca bioemporium (purists may prefeibioemporion) .

Whatever is possible with the 01embalmed cadaver is extended to arincredible degree with the neomortWhat follows, therefore, is not a definitive list but merely the briefest 0

suggestions as to the spectrum 0

possibilities.TRAINING: Uneasy medical student:could practice routine physical examinations-auscultation, percussion O'

. the chest; examination of the retinarectal and vaginal examinations, ecetera-indeed, everything excepneurological examinations, since thtneomort by definition has no functioning central nervous system.

Both the student and his patien

could he spared the pain, fumbling,and embarrassment of the "firsttime."

Interns also could practice stan-dard and more difficult diagnosticprocedures, from spinal taps to' pneu-moencephalography and the makingof arteriograms, and residents couldpractice almost all of their surgicalskills-in other words, most of theprocedures that are now normallytaught with the indigent in wards ofmajor city hospitals could be taughtwith neornorts. Further, studentscould practice more exotic proceduresoften not available in a typical resi-dency-eye operations, skin grafts,plastic facial surgery, amputation ofuseless limbs, coronary surgery, etc.;they could also practice the actualremoval of organs, whether they bekidneys, testicles, or what have you,for delivery to the transplant teams.TESTING: The neomort could be usedfor much of the testing of drugs andsurgical procedures that we now nor-mally perform on prisoners, mentallyretarded children, and volunteers.The efficacy of a drug as well as itstoxicity could be determined beyondlimits we might not have dared ap-proach when we were concernedabout permanent damage to the test-ing vehicle, a living person. For ex-ample, operations for increased vas-cularization of the heart could betested to determine whether theytruly do reduce the incidence of fu-ture heart attack before we performthem on patients. Experimental pro-cedures that proved useless or harm-ful could be avoided; those that suc-ceed could be available years beforethey might otherwise have been. Sim-ilarly, we could avoid the massive de-lays that keep some drugs from themarketplace while the dying clamorfor them.

Neomorts would give us access toother forms of testing that are incon-ceivable with the living human being.We might test diagnostic instrumentssuch as sophisticated electrocardio-graphy by selectively damaging vari-ous parts of the heart to see how orwhether the instrument could detectthe damage.EXPERIMENTATION: Every new med-ical procedure demands a leap offaith. It is often referred to as an "actof courage," which Seems to me aninappropriate terminology now thatorganized medicine rarely uses itselfas the experimental body. Whenever asurgeon attempts a procedure for the

27

HARVESTING THE DEADfirst time, he is at best generalizingfrom experimentation with lower ani-mals. Now we can protect the patientfrom too large a leap by using theneomort as an experimental bridge.

Obvious forms of experimentationwould be cures for illnesses whichwould first be induced in the neo-mort. We could test antidotes byinjecting poison, induce cancer orvirus infections to validate and com-pare developing therapies.

Because they have an active hema-topoietic system, neomorts would beparticularly valuable for' studyingdiseases of the blood. Many of theexamples that I draw from that fieldwere offered to me by Dr. John F.Bertles, a hematologist at St. Luke'sHospital Center in New York. Onewhich interests him is the utilizationof marrow transplants. Few human-to-human marrow transplants havebeen successful, since the kind of im-munosuppression techniques that re-quire research could most safely beperformed on neomorts. Even suchresearch as the recent experimenta-tion at Willowbrook-where mentallyretarded children were infected withhepatitis virus (which was not yetculturable outside of the human body)in an attempt to find a cure for thispernicious disease---eould be donewithout risking the health of thesubjects.BANKING: While certain essentialblood antigens are readily storable(e.g., red celts can- now be preservedin a frozen state), others are not, andthere is increasing need for potentialmeans of storage. Research on stor-age of platelets to be used in transfu-sion requires human recipients, andthe data are only slowly and tediouslygathered at great expense. Use ofneomorts would permit intensive test-ing of platelet survival and probablywould lead to a rapid development ofa better storage technique. The samewould be true for white cells.

As has been suggested, there isgreat wastage in the present systemof using kidney donors from cadav-ers. Major organs are difficult tostore. A population of neomorts main-tained with body parts computerizedand catalogued for compatabilitywould yield a much more efficient sys-tem. Just as we now have blood banks,we could have banks for all the majororgans that may someday be trans-plantable-lungs, kidney, heart, ova-ries. Beyond the obvious storage usesof the neomort, there are others not

28

previously thought of because therewas no adequate storage facility. Dr.Marc Lappe of the Hastings Center hassuggested that a neomort whose ownimmunity system had first been se-verely repressed might be an ideal"culture" for growing and storingour lymphoid components. When weare threatened by malignancy or viraldisease, we can go to the "bank" andwithdraw our stored white cells tohelp defend us.HARVESTING: Obviously, a sizablepopulation of neomorts will provide asteady supply of blood, since theycan be drained periodically. Whenwe consider the cost-benefit analysisof this system, we would have to eval-uate it in the same way as the lumberindustry evaluates sawdust-a prod-net which in itself is not commercial-ly feasible but which supplies a prof-itable dividend as a waste from amore useful harvest.

The blood would be a simultaneoussource of platelets, leukocytes, andred cells. By attaching a neomort toan IBM cell separator, we could iso-late cell types at relatively low cost.The neomort could also be tested forthe presence of hepatitis in a waythat would be impossible with com-mercial donors. Hepatitis as a trans-fusion scourge would be virtuallyeliminated.

Beyond the blood are rarer har-vests. Neomorts offer a great poten-tial source of bone marrow for trans-plant procedures, and I am assuredthat a bioemporium of modest sizecould be assembled to fit most trans-plantation antigen requirements. Andskin would, of course, be harvested-similarly bone, corneas, cartilage,and so on.MANUFACTURING: In addition to sup-plying components of the humanbody, some of which will be contin-ually regenerated, the neomort canalso serve as a manufacturing unit.Hormones are one obvious product,but there are others. By the injectionof toxins, we have a source of anti-toxin that does not have the compli-cation of coming from another ani-mal form. Antibodies for most of thernajor diseases can be manufacturedmerely by injecting the neomort withthe viral or bacterial offenders.

Perhaps the most encouraging ex-tension of the manufacturing processemerges from the new cancer re-search, in which immunology is com-ing to the fore. With certain bloodcancers, great hope attaches to the

use of antibodies. To take just oneexample, it is conceivable that leuke-mia could be generated in individualneomorts-e-not just to provide for invivo (so to speak) testing of anti-leukemic modes of therapy but alsoto generate antibody immunity re-sponses which could then be used inthe living.

Cost-benefit analysis

IF SEEN ONLY AS the harvesting ofproducts, the entire feasibility of

such research would depend on intel-ligent cost-benefit analysis. Althoughcertain products would not warrantthe expense of maintaining a com-munity of neomorts, the enormousexpense of other products, such as redcells with unusual antigens, wouldcertainly warrant it. Then, of course,the equation is shifted. As soon asone economically sound reason isfound for the maintenance of the com-munity, all of the other ingredientsbecome gratuitous by-products, a fa-miliar problem in manufacturing.There is no current research to indi-cate the maintenance cost of a bioem-porium or even the potential durationof an average neomort. Since we donot at this point encourage sustaininglife in the brain-dead, we do notknow the limits to which it could beextended. This is the kind of technol-ogy, however, in which we have pre-viously been quite successful.

Meantime, a further refinement ofdeath might be proposed; At presentwe use total brain function to definebrain death. The source of electro-encephalogram activity is not knownand cannot be used to distinguishbetween the activity of higher andlower brain centers. If, however, weare prepared to separate the conceptof "aliveness" from "personhood" inthe adult, as we have in the fetus, agood argument can be made thatdeath should be defined not as cessa-tion of total brain function but merelyas cessation of cortical function. Newtests may soon determine when cor-tical function is dead. With this pro-posed extension, one could then main-tain neomorts without even the com-plication and expense of respirators.The entire population of decorticatesresiding in chronic hospitals and nowclassified among the incurably illcould be redefined as dead.

But even if we maintain the morerigid limitations of total brain death

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HARVESTING THE DEADit would seem that a reasonable pop-ulation could be maintained if thepurposes warranted it. It is difficultto assess how many new neomortswould be .available each year to satis-fy the demand. There are roughly 2million deaths a year in the UnitedStates. The most likely sources ofintact bodies with destroyed brainswould be accidents (about 113,000per year), suicides (around 24,000per year), homicides (18,000), andcerebrovascular accidents (some210,000 per year). Obviously, ineach of these categories a great manyof the individuals would be useless-their bodies either shattered or scat-tered beyond value or repair.

AND YET, AFTER all the benefits are~outlined, with the lifesaving po-tential clear, the humanitarian pur-poses obvious, the technology ready,the motives pure, and the materialcosts justified-how are we to rec-oncile our emotions? Where in thisdebit-credit ledger of limbs and liversand kidneys and costs are we to weighand enter the repugnance generatedby the entire philanthropic endeavor?

Cost-benefit analysis is always leastsatisfactory when the costs must bemeasured in one realm and the ben-efits in another. The analysis is par-ticularly skewed when the benefitsare specific, material, apparent, andimmediate, and the price to be paid isgeneral, spiritual, abstract, and of thefuture. It is that which induces peo-ple to abandon freedom for security,pride for comfort, dignity for dollars.

William May, in a perceptive arti-cle, * defended the careful distinctionsthat have traditionally been drawnbetween the newly dead and the longdead. "While the body retains itsrecognizable form, even in death, itcommands a certain respect. Nolonger a human presence, it still re-minds us of that presence which oncewas utterly inseparable from it." Butthose distinctions become obscuredwhen, years later, a neomort will re-tain the appearance of the newlydead, indeed, more the appearanceof that which was formerly describedas living.

Philosophers tend to be particu-larly sensitive to the abstract needsof civilized man; it is they who haveoften been the guardians of values

* "Attitudes Toward the Newly Dead,"The Hastings Center Studies, volume 1,number 1, 1973.

whose abandonment produces painsthat are real, if not always quantifi-able. Hans Jonas, in his PhilosophicalEssays, anticipated some of the pos-sibilities outlined here, and de-fended what he felt to be the sanctityof the human body and the unknow-ability of the borderline between lifeand death when he insisted that"Nothing less than the maximum def-inition of death will do-brain deathplus heart death plus any other indi-cation that may be pertinent-beforefinal violence is allowed to be done."And even then Jonas was only con-templating temporary maintenance oflife for the collection of organs.

The argument can be made on bothsides. The unquestionable benefits tobe gained are the promise of cures.for leukemia and other diseases, thereduction of suffering, and the main-tenance of life. The proponents ofthis view will be mobilized with aforce that may seem irresistible.

They will interpret our revulsionat the thought. of a bioemporium as abias of our education and experience,just as earlier societies were probablyrevolted by the startling notion ofabdominal surgery, which we nowtake for granted. The proponents willargue that the revulsion, not the tech-nology, is inappropriate.

Still there will be those, like May,who will defend that revulsion as aquintessentially human factor whoseremoval would diminish us all, andextract a price we cannot anticipatein ways yet unknown and times notyet determined. May feels that thereis "a tinge of the inhuman in the hu-manitarianism of those who believethat the perception of social needeasily overrides all other considera-tions and reduces the acts of imple-mentation to the everyday, routine,and casual."

This is the kind of weighing ofvalues for which the computer offerslittle help. Is the revulsion to the newtechnology simply the fear and hor-ror of the ignorant in the face of thenew, or is it one of those componentsof humanness that barely sustain usat the limited level of civility anddecency that now exists, and whoseremoval is one more step in erasingthe distinction between man and thelesser creatures-beyond that, thedistinction between man and matter?

Sustaining life is an urgent argu-ment for any measure, but not if thatmeasure destroys those very qualitiesthat make life worth sustaining. 0