Well into the 18th century, death was understood as a critical moment of the embodied life of a person, insofar as it was the gateway to another, far more important form of life, after the Resurrection and Final Judgment. This is why one always had to remember one’s impending death and act accordingly, always mindful of one’s spiritual life.
Death was such a culturally and socially important event that cemeteries were built well in view of, if not in fact inside, towns and villages: the piety of the individual spoke directly to the piety of the community.
This situation shaped medical understanding of disease as being interrupted by death. From this perspective, anatomical lesions found in a dead body were understood not as signs of disease during life, but of the corruption of the body brought about by death’s intervention. It is on these grounds that medical teaching insisted that dead bodies could tell preciously little about disease. In sum, in both lay and medical understanding, life and death were ontologically distinct figures and forces.
As both Georges Canguilhem and Michel Foucault have noted, during the late 18th and early 19th century, anatomists such as Xavier Bichat dramatically transformed this understanding of death. Death became a limit, marked by the cessation of all vital functions, so that understanding how an organism reached this limit illuminated the nature and ordering of these same vital functions. Death now was the great analyst of life.
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Socially and culturally, this transformation led to both the medicalisation of death (transformation of the coroner) and the disappearance of death from the public sphere (privatisation of funerary ritual). While, as Philippe Ariés has noted, the figure of the living dead captured public anxieties about this double transformation, the more important point is that this is precisely why, throughout the course, we have in fact spoken very little about death (see also Zygmunt Bauman, Mortality, Immortality& Other Life Strategies, 1992).
Paradoxes of progress
One of the most striking features of the contemporary coroner’s practice is the disappearance of the diagnosis of death by natural causes. This is the outcome of the historical construction of death as the cessation of vital functions due to particular and specific physiological malfunctions, which medicine should be able to redress (literal, forensic translation of Bichat’s understanding of the relationship between life and death). During the 19th and 20th centuries, this construction of death has proved immensely powerful in sustaining embodied life.
During the second half of the 20th century, public confidence in the power of medicine to defeat disease grew in an unprecedented manner. Mechanical equipment, such as the respirator and dialysis machine, as well as monitoring technologies such as the electrocardiograph and the electroencephalograph, allowed medical professionals to sustain life beyond previously imagined limits.
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In conjunction with developments in immunology, it was now possible to undertake highly invasive surgical procedures such as organ transplants (procedures that effectively entailed the temporary suspension of the vital functions of the body itself and their removal outside the body).
At the same time, the painful effects of these increasingly invasive procedures, which often only forestalled the advent of death, evoked those growing concerns about the limits of medicine that were captured by films such as ‘Whose Life is it Anyway?’ (1981) (Note the implicit externalisation of life: who or what is it that asks the question?).
These developments lent great impetus to the resurgence of the hospice movement, which had originally been motivated by concern for those suffering from incurable diseases such as cancer, and was then marginalised by the increasing successes in the treatment of this erstwhile incurable disease. Now, however, the motivation was the belief that the life offered by medicine was not worth living, and this it might be better to die as easily as possible (note attempt to reconnect life and the body).
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Between life and death: Euthanasia
During the 1960s and ‘70s, public concern over the limits of medicine and its insistence that life is always preferable to death coincided with the re-emergence of campaigns to legalise euthanasia.
The idea of a life not worth living was first formalised at the beginning of the 20th century, by the German jurist Karl Binding and the German physician Alfred Hoche, in the context of a eugenic understanding of disease, winning widespread support in predominantly Protestant countries (note how life becomes a juridico-legal concept).
Euthanasia was widely discredited, however, when, under National Socialism, it was systematically applied to institutionalised, mentally defective people, on the grounds that the cost of their institutionalisation was unjustifiable (T4 Programme).
This said, from the late 1960s onward, public demand for the legalisation of euthanasia re-emerged, this time in the context of a growing opposition of judaeo-christian notions of the sanctity of life, which are central to the medical profession’s belief that everything possible should be done to forestall the advent of death, and the idea that the latter undermined a person’s quality of life.
In the United States, the legal problems involved in choosing death over life came to a head in the late 1970s, with the case of Karen Ann Quinlan. While Quinlan had been in a coma (no cerebral function) for a number of years, and was kept alive by artificial means, her parents demanded that physicians stop the procedures and allow her to die, thus exposing these physicians to charges of murder. In 1985, the United States Supreme Court ruled in favour of the parents, but the issue has remained enormously controversial. In both Britain and the United States, such cases re-emerge periodically, raising very difficult questions about an increasingly visible zone of indistinction, in which one is neither dead nor alive.
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Brain death
During the race in the 1960s toward ever more radical transplants, one of the principal limitations confronting surgeons was the supply and viability of organs.
It was in this context that, in 1968, the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death sought to clarify the idea first advanced in 1959, by two French neurophysiologists, Pierre Mollaret and Maurice Goulon, that death intervened when the brain waves recorded by an electroencephalograph ceased. From this perspective, a comatose patient was effectively dead and therefore a very useful source of organs for transplants because these organs, unlike the patient, were still functional. Given that, for many patients, a coma is only a temporary situation, however, it was vitally important that some irrefutable criteria be established to identify irreversible coma (which part of the brain must have ceased to function? See the localisation problem). Furthermore, it was equally important to establish to whom the organs of a brain dead patient might belong. Given the huge, modern investment in identifying the person and the body, there arguably no longer was anyone who might claim ownership over these organs (compare Margaret Lock on brain death in Japan).
This situation again proved hugely controversial, fuelling intense suspicions of the medical profession, which were best captured in the film ‘Coma’ (1978).
The legitimacy of the concept of brain death continues to be controversial to this day, although those who refuse to donate organs after death are increasingly constructed as the exception rather than the norm (see arguments over ‘presumed consent’ during consultations over the Human Tissue Act (2004), a fundamental revision of the Anatomy Act (1832)).
Conclusion
What sense are we to make of this transformation of death, in which vital functions are definitively detached from the person?
Firstly, as the philosopher Giorgio Agamben has put it, in this novel context, whether one is dead or alive becomes a matter of juridico-medical discrimination over something for which we really do not have a name, something that is beyond bodies and souls (see Homo Sacer: Sovereign Power and Bare Life, 1998).
Secondly and finally, there is something deeply paradoxical about choosing death over life, insofar as death is supposed to be absolutely meaningless, and yet something so meaningful that it might become one’s object of desire. Lest there should be some confusion, it is important to note in this regard that, wherever euthanasia is permitted, tiredness of life is not a legitimate ground for choosing death. Such a choice must instead be understood as the positive and informed choice between life and death.
Could it be that the bearer of this right to choose is precisely that something for which we really do not have a name, something that is beyond bodies and souls?
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Giacomo Savini (2006)
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