Neomorts and the Sociocultural Implications of Modern Life Extending Technologies

In recent decades, nations have begun turning to science as a new means by which to biologically extend life beyond traditional death, in much the same way as cultures in the past constructed complex rituals to extend life beyond death through spiritual means. However, while many view such endeavors and the philosophical debates they raise as purely hypothetical and only relevant to discussions of the distant future, the fact remains that modern advances in medicine and life-supporting technologies are already extending the limits of human life and forcing both scientists and policymakers alike to grapple with death in ways never seen before. Hence, while extreme efforts to extend the human lifespan indefinitely may be unachievable in the short run, by examining how boundaries between life and are already being challenged today, society can more fully understand the possible scientific, cultural, and ethical implications of ongoing efforts to extend the human lifespan in the future.

Nowhere are transformative effects of modern advances in life-extending medicine more apparent than in modern debates over the status of the brain dead. Often referred to as “neomorts”, a term first coined in 1974 by Clinical Professor of Psychiatry at Columbia College of Physicians and Surgeons, Willard Gaylin, the brain dead exist in a biological grey area between life and death only recently made possible by the advent of life support technologies [1]. Defined in the U.S. as patients exhibiting no brain activity, but whose cardiopulmonary function are  maintained via ventilators, vasopressors, and other forms life-extending medical technology, neomorts have raised a number of heated scientific, ethical, and religious debates over the nature of their existence, the ethics of keeping them on life support and using them for medical purposes, and the broader cultural implications of their existence [2]. Thus, by investigating how advances in modern medicine have created neomorts and how this development has begun shifting modern views of life and death, we aim to explore the fascinatingly complex ethical, cultural, and scientific implications of life-extending technologies.

In order to fully grasp the cultural and ethical ramifications of life-extending technologies as they pertain to neomorts, it is first important to more thoroughly understand the modern medical advancements that are making such artificial extension life possible and the challenges that remain in diagnosing and caring for brain dead patients. Indeed, technical debates over the scientific nature of brain death itself and the legitimacy of brain death as a scientific term are often the basis for more all-encompassing discussions about the effects of humanity’s ever-increasing power over life and death on societal values. Thus, by understanding how neomorts have come to be scientifically, one can better understand their significance in broader sociocultural contexts.

Historically speaking, the existence of brain death as a medical or legal term is a fairly recent development, only enabled by the advent of mechanical ventilators in the mid 1950s and the subsequent ability of life support to keep patients breathing even without any electrical activity in the medulla, part of the brain stem commonly associated with such autonomous functions as breathing [3]. Indeed, the definition of brain death itself was not publicly introduced until 1968 when an ad hoc committee at Harvard Medical School defined brain death as “unresponsiveness and lack of receptivity, the absence of movement and breathing, the absence of brainstem reflexes, and coma whose cause has been identified”, and since then, all 50 states have gradually come to recognize brain death on varying levels [4].

Current brain death standards in the U.S require complete lack of electrical activity in all parts of the brain, including the brainstem and cerebral cortex. As such, once higher brain function is ruled out via EEG, lack of voluntary movements and loss of consciousness, a long battery of brain stem reflex tests currently constitute the main way in which physicians asses for brainstem death Source: http://fromnewtoicu.com/blog/2016/4/6/brain-death-testing

Today under the 1981 Uniform Determination of Death Act (UDDA), the US adheres to the “total brain” definition of brain death, meaning that for a person to be considered a neomort both medically and legally  they must have irreversible loss of all functions of the brain, including the brain stem” [5]. To examine patients for this total loss of brain function, physicians look for a number of telling symptoms, overarchingly summarized by “absence of brainstem reflexes, etiologically explained coma, and apnea” [6]. Requiring at least two physicians to observe these symptoms, and tests to be repeated again after 6 hours, current legal provisions in the U.S. aim to prevent patients being declared brain dead preemptively or exploited while in a compromised position [7]. However, the validity of brain death as a term and the means by which brain death is diagnosed remain contentious topics medically, legally, and culturally given that the great variability in brain-death policy across states and nations, and the reality of neomorts maintaining many of the basic functions humans viscerally associate with life. Indeed, while the total brain death definition  seems somewhat straightforward, the lack of consensus on how to tests for total brain death, the limitations of current medical technology, and the vast diversity of perceptions of death between different cultures has lead to much controversy both within the international medical community and within local medical and legal systems regarding the status of neomorts. Thus highlighting the ontological ambiguity that has arisen surrounding life and death as a result of modern life-extending technologies, such scientific, legal, ethical, and sociocultural debates surrounding this topic raises further questions as to how medical advances in life-extending technology will reshape and be shaped by traditional notions of life and death in the future.

One of the most central debates in modern discourse regarding neomorts is if and to what extent they can be considered alive. Ironically, given how their very existence has been facilitated by modern life-extending technologies, neomorts are legally and medically defined as dead under current policy [8]. However, despite their status, with the help of modern technology, neomorts retain many of the biological functions that have been traditionally associated with life, extending from cellular respiration and some hormone production on the microscopic level to cardiac output and organ functions on a macroscopic scale [9]. As a result of these retained biological functions, some argue that neomort’s are not, in fact, dead in a biological sense, and that brain death is simply a term fabricated to force organ donation from neomorts to fit the dead donor criteria [10]. Such rejections of brain death as a biological term are only further bolstered by the lack of uniformity in the specific procedures used to test for the neurological markers of brain death, with one 2017 database study finding only a 38.5% adherence of physicians to the American Academy of Neurology’s guidelines for brain death diagnosis [11]. That being said, legal systems in many states have taken measure towards making brain death diagnosis more uniform. Moreover, ongoing research aimed at finding more accurate ways to directly assess brain function, such as measuring blood flow to the brain, glucose consumption, and electrical activity through fMRI, PET, and EEG techniques, promises to make the diagnosis of brain death much more accurate in the future [12]. Thus, at least from a medical perspective, the differentiation between brain death and other forms of brain injury and loss of consciousness will likely soon reach the level of accuracy necessary to stem some of the ethical concerns regarding misdiagnosis. Nonetheless, a great deal of ambiguity remains regarding whether or not brain death should be equated to biological death, and whether such reformulations of traditional notions of life and death are ethically and culturally acceptable.

This PET image reflects differences in brain glucose metabolism between a healthy brain the brain of a neomort, and that of a person with Unresponsive Wakefulness Syndrome. With the brain dead patient showing the classic “hollow skull” sign, reflected by the lack of glucose metabolism within the brain, this image thus illustrates how modern advances in brain imaging technology are improving the accuracy of brain death diagnosis.

In addition to scientific controversy regarding the legitimacy of brain death as a diagnosis, differences in sociocultural views of death across various demographics and cultures further complicate modern views of brain death and highlight how advances in modern medicine and life-extending technologies are challenging traditional conceptions of life and death. For instance, Israel, Denmark, and Japan remain resistant to the implementation of new “high technology” such as artificial life support and transplants despite its normalization in Western medical practices. In these countries, much of this resistance stems from the threat such life-extending technologies pose to cultural tradition.

In Japan, for example, medical officials are reluctant to accept brain death and perform the medical operations using the brain dead not due to economic or technological capabilities, but rather because such procedures defy traditional Japanese emphasis on the natural. Indeed, in part, for this reason, Japan has not yet passed legislation declaring brain death to equate to the death of a person. Such qualms have been further fueled by skepticism among the Japanese as to whether brain death can medically be determined with certainty and as to whether or not current brain death diagnostic criteria guarantee permanent nonfunction of the individual’s brain. Such concerns are emphasized by the fact that in Japanese culture, an inactive brain is viewed as a prolongation of life rather than the Western view of it being a prolongation of dying [13]. To them, organ donation by neomorts is ethically questionable because they believe a neomort is not truly dead and thus dies through the removal of organs. With transplantation of organs being seen as culturally unacceptable, the use of neomorts in Japanese medical practice is thus almost unfathomable given their view of neomorts as compromised, but still living beings [14]. Thus, as is demonstrated by this particular culture’s reluctance to accept brain death as a medical reality and to use the brain dead for life saving procedures, efforts to extend life beyond traditional death cannot be made independent of sociocultural influence, with advances in medical technology and cultural views of life and death constantly reshaping each other.

 

Above is an example of the ankh symbol commonly found in Egyptian and Asante artwork. Symbolic of life, death, and spiritual eternity, this shape highlights the uniquely continuous way these cultures view life and death, thus lending insight into their rejection scientific advancements that change traditional definitions of biological death.
Source: https://c8.alamy.com/comp/A5J5GP/carving-of-the-ankh-key-of-life-at-luxor-in-egypt-A5J5GP.jpg

Modern rejection of brain death in many African cultures provides yet another example of how the future of life-extending technologies cannot be discussed in full without taking into account how various cultures will react to such scientific advancements. In the view of many Africans, for instance, brain death is not an acceptable definition of death because it complicates, and even disrupts, the cycle of life and death. More specifically, according to African folklore, there was a time when people experiencing death petitioned God to stop death. The request was granted, and for the next 3 years no one died and no children were born. The people again petitioned God to have children even if it also meant accepting death. This ancient African folklore illustrates the African worldview that life and death are complementary—a view of life and death as cyclical with death viewed as a part of this cycle. Given this view of life and death, African cultures are often far more accepting of death as inevitable part of nature, a trend that is often highlighted by the artwork of many African societies and tribes, in which the symbol of the circle often appears as a metaphor for the unity between life and death. For instance, among the Asante, the symbol of the Ankh, a circle with a small cross, symbolizes life, fertility, and the renewal of life, but also has culturally implicated associations with death as death is viewed as a part of life. Thus, many African cultures do not accept that the brain dead should be kept artificially alive because it disrupts the natural cycle of life and death. This rejection of brain death is further supported by the fact that many African cultures believe in an afterlife of joining the community of ancestors and reuniting with loved ones, funerals are referenced as “homegoing services” and celebrates the passing of the individual from the material world to the spirit world [15]. Thus, keeping a person artificially trapped in a state of liminality between life and death appears particularly abhorrent to many Africans as it prevents the transition of the individual’s spirits from the world of the living to the world of the dead. Given these traditional beliefs, it is unsurprising that a majority of African Countries lack institutional brain death guidelines, unlike in the U.S and other westernized countries were brain-death provisions and organized transplantation networks abound. Organ transplantation is not even legal yet in many Sub Saharan African countries because medical and social consensus on the definition of brain death is needed for the development of brain death legislation [16]. It follows that, as medical advancements progress and more extreme life-extending technologies become available, such cultural reluctance to accept life-extending technologies will continue to shape how these technologies are developed and made available. With many nations, such as Japan and countries in Africa, not accepting life-sustaining measures for fear of disrupting nature and being held back from their inevitable death and ultimate transition to the spirit world, it is unlikely that these nations will accept other forms of death-redefining technology in the future [17].

Regardless of whether or not societies accept brain death, the biological reality of neomorts retaining many of the basic functions of life despite being legally defined as dead in the U.S. attests to how modern technology is blurring definitions of biological life, a trend which will only proliferate as medicine and other life extend technologies advance in the future. Ironically, neomorts, who are themselves held in existence by modern life support technologies including ventilators, blood pressure maintaining medications, and artificial hormones, may contribute to further scientific means by which to extend human lives [18]. For instance, some have proposed to use neomorts as test subjects for experiments aimed at finding ways to regenerate lost neurons in the brain which could help lead to breakthroughs in treating deadly diseases such as Alzheimer’s and ALS [19]. Still others, like Willard Gaylin in his controversial 1978 paper “Harvesting Organs”, have provocatively proposed creating “neomortoriums” in which neomorts are used for such purposes as to store organs for donation, produce blood for transfusions, train medical students, and test new drugs [20][21].

Despite the many possible medical uses of neomorts, attempts at employing neomorts for such purposes have generally been rejected by ethics committees at various research centers due to concerns over the ethics of keeping neomorts in an artificially induced liminality between life and death. Indeed, while Gaylin himself argued that experimentation on heart-beating cadavers is just as ethical as experimentation on traditionally dead cadavers,  such assertions hinge upon the notion that brain death is truly equal to biological death [22][23].  With this overly simplistic view of neomorts and their status as either living or dead often failing to mesh with the complex ways in which various cultures view death and the true biological reality of neomorts not being physically dead in a traditional sense, upholding such arguments for using brain dead for experimentation is often difficult. Thus, while from a utilitarian perspective using neomorts for experimentation appears ethical, the ambiguity of neomorts’ physical and symbolic status in society continues to complicate efforts to do so.  Moreover, apart from such ontological debates over the status of neomorts, questions of autonomy also play a major part in modern discourse over the ethics of keeping the brain dead alive for medical purposes. Indeed, at least in the U.S. where issues of autonomy are central to political discourse, many argue that for such “neomortoriums” to be ethical,  informed consent by the patient is necessary, much as how consent is needed for experimentation on living patients [24]. However, given how brain death is often caused by acute ailments that are not easily predicted, such as anoxia, cerebrovascular injuries(such as strokes or aneurysms), and other forms of traumatic brain injury, getting such consent would prove difficult in many cases [25].  Ultimately, this highlights how, despite the brain dead medically and legally being diagnosed with dead, they are often ethically treated as living beings in modern debates over what can and cannot be done with them. Thus, underscoring how modern life supporting and life-extending technologies create new ethical and cultural dilemmas as society tries to reconcile evolving definitions of death with traditional sociocultural beliefs and moral codes, such ethical quandaries over the use of neomorts illustrate the immense societal impacts the further advancement of life extended technologies could have. Indeed, if modern policymakers cannot even come to an ontological consensus on the status of neomorts or agree on the ethics of using them for medical purposes, it unlikely similar ethical debates in the future over the status of those whose lives have been extended artificially will be solved without marked shifts in the ways in which various cultures and societies treat life and death both on a physical and symbolic level.

Ultimately, modern controversies surrounding the biological status of the brain dead, the cultural implications of their existence, and the ethics of keeping them “alive” highlight the complex ways in which advances in life-extending technologies are already challenging and reshaping traditional views of life and death. If the diversity of ways in which different cultures and individuals have reacted to the rise of neomorts is anything to go by, future medical advances that similarly redefine biological life will have even more pronounced sociocultural impacts as various societies move to reconcile their traditions and beliefs with scientific reality. Thus, in the end, the complex ways in which modern discourse regarding brain death has shaped and been shaped by societal values provides valuable insight into the ways in which further advances in medical technology will impact society in the future.

 

Elizabeth Switzer

Taylor Baldwin

Alina Taing

 

[1] Hull, Richard T. “Neomort.” In Encyclopedia of Death and the Human Experience, edited by Clifton D. Bryant and Dennis L. Peck, 781. Thousand Oaks, CA: SAGE Publications, Inc., 2009. doi: 10.4135/9781412972031.n255.

[2] Wicclair, Mark R. “Informed Consent and Research Involving the Newly Dead.” Kennedy Institute of Ethics Journal 12, no. 4 (2002): 351-372. https://muse.jhu.edu/ (accessed April 6, 2019).

[3] Goila, Ajay Kumar, and Mridula Pawar. “The Diagnosis of Brain Death.” Indian Journal of Critical Care Medicine 13, no. 1 (January/February 2009): 7-11. Accessed April 3, 2019. doi:10.4103/0972-5229.53108.

[4] Ibid.

[5] Sarbey, Ben. “Definitions of Death: Brain Death and What Matters in a Person.” Journal of Law and the Biosciences 3, no. 3 (2016): 743-52. doi:10.1093/jlb/lsw054.

[6] Goila, The Diagnosis of Brain Death.

[7] “Update: Determining Brain Death in Adults.” American Academy of Neurology 74 (2010): 1911-918.

[8] Goila, The Diagnosis of Brain Death.

[9] Nair-Collins, Michael, and Franklin G. Miller. “Do the ‘brain Dead’ Merely Appear to Be Alive?” Journal of Medical Ethics. November 2017. Accessed April 04, 2019. https://www.ncbi.nlm.nih.gov/pubmed/28848063.\

[10] Sarbey, Definitions of Death: Brain Death and What Matters in a Person.

[11] Ashutosh Pandey, Pradeep Sahota, Premkumar Nattanmai, and Christopher R. Newey, “Variability in Diagnosing Brain Death at an Academic Medical Center,” Neuroscience Journal, vol. 2017, Article ID 6017958, 7 pages, 2017. https://doi.org/10.1155/2017/6017958.

[12] Young, G. Bryan, Sam D. Shemie, Christopher James Doig, and Jeannie Teitelbaum. “Brief Review: The Role of Ancillary Tests in the Neurological Determination of Death.” Canadian Journal of Anesthesia/Journal Canadien Danesthésie 53, no. 6 (2006): 620-27. doi:10.1007/bf03021855.

[13] Ohnuki-Tierney, Emiko, Michael V. Angrosino, Carl Becker, A. S. Daar, Takeo Funabiki, and Marc I. Lorber. “Brain Death and Organ Transplantation: Cultural Bases of Medical Technology [and Comments and Reply].” Current Anthropology 35, no. 3 (1994): 233-54. http://www.jstor.org/stable/2744197.

[14] Lock, Margaret. “Contesting the Natural in Japan: Moral Dilemma and Technologies of Dying.”

[15] Barrett, Ronald K. “African Beliefs and Traditions.” In Encyclopedia of Death and the Human Experience, edited by Clifton D. Bryant and Dennis L. Peck, 20-22. Thousand Oaks, CA: SAGE Publications, Inc., 2009. doi: 10.4135/9781412972031.n6.

[16] Waweru-Silka, W., M. E. Clement, L. Lukoko, S. Nadal, P. M. Rosoff, V. Naanyu, and P. S. Kussin. “Brain Death Determination: The Imperative for Policy and Legal Initiatives in Sub-Saharan Africa.” Glob Public Health 12, no. 5 (May 2017): 589-600. Accessed April 4, 2019. doi:10.1080/17441692.2015.1094108.

[17] Boland, Torrey, MD. “Worldwide Variations in Brain Death Declaration.” World Neurology. August 5, 2015. Accessed April 08, 2019. https://worldneurologyonline.com/article/worldwide-variations-in-brain-death-declaration/.

[18] Rettner, Rachael. “Life After Brain Death: Is the Body Still ‘Alive’?” LiveScience. January 03, 2014. Accessed April 08, 2019. https://www.livescience.com/42301-brain-death-body-alive.html.

[19] Sheridan, Kate. “A Controversial Trial to Bring the Dead Back to Life Plans a Restart.” STAT. June 13, 2017. Accessed April 08, 2019. https://www.statnews.com/2017/06/01/brain-death-trial-stem-cells/.

[20] Wicclair, Informed Consent and Research Involving the Newly Dead.

[21] Puma, John La. “Discovery and Disquiet: Research on the Brain-Dead.” Annals of Internal Medicine 109, no. 8 (1988): 606. doi:10.7326/0003-4819-109-8-606.

[22] Idib.

[23] Wicclair, Mark R. “Ethics and Research with Deceased Patients.” Cambridge Quarterly of Healthcare Ethics 17, no. 1 (2008): 87–97. doi:10.1017/S0963180108080092.

[24] Berger, Jeffrey T., Fred Rosner, and Eric J. Cassell. “Ethics of Practicing Medical Procedures on Newly Dead and Nearly Dead Patients.” Journal of General Internal Medicine17, no. 10 (2002): 774-78. doi:10.1046/j.1525-1497.2002.11139.x.

[25] “Understanding Brain Death.” Finger Lakes Donor Recovery Network. Accessed April 04, 2019. http://www.donorrecovery.org/learn/understanding-brain-death/.

5 Comments

  1. This post did a really good job analyzing how cultural differences can make it hard to define death. It’s easy to assume that your own definition of death is the “norm”. Many people in America think of technological advances when it comes to medical life extension are good, and that’s a personal opinion. But some cultures, as stated in this post, don’t feel the same way. Determining death is a very personal thing and that makes it hard to make policies surrounding death. As difficult as it is, I think it is still important to keep humanity in death and medical life-saving technology.

  2. This post did a phenomenal job of introducing the topic in a clear and concise manner and then effectively supporting its claims. I especially liked the sentence in the introduction that talks about how extending human lifespan indefinitely may not be achievable in the short run, but by analyzing the efforts currently taking place, humanity can better understand the pros and cons of continuing to try to find ways to expand the human lifespan. Additionally, I feel that it is crucial to understand why some cultures do not agree with the extension of life. The topic of life, death, and prolonging the inevitable will always come with complications. This post summarizes several perspectives in an eye-opening manner. Well written.

  3. I really enjoyed reading this post! First, I really liked the line about a prolongation of death vs. a prolongation of life. I had never thought about it like that, but it makes a lot of sense that many cultures would attach the in-between state of “brain death” to the living section of someone’s story while we, in many Western cultures, attach brain death to the process of dying. Second, the part about the African cultures was super interesting, especially the story about the people who prayed for no death and, with it, received no births. We don’t always think about how circular life is, relying on death and birth to keep our population here. You can’t have one without the other, which is another thing people should think about when they fear death: without death, there is no forward movement or progress, we must all experience it.

  4. This post was very well-written and informative. The ethical portion was especially interesting to me, as it analyzed the use of neomorts from various ethical principles. Under some ethical principles, such as the utilitarian perspective, the utilization of neomorts is acceptable and would greatly benefit society. Under others, such as autonomy, the use of neomorts enters a gray area. Personally, when I first heard about possibly using neomorts to maintain organs, develop fetuses, or for medical experimentation, I was opposed to the idea. This was not necessarily supported by much reasoning. Instead, my gut reaction was that it is morally wrong. I think it would have been interesting to include the results of a survey on the public opinion of neomorts, and what factors make a person more likely to agree or disagree with the concept. As mentioned in this post, religious beliefs would likely play a role, as well as where a person is from culturally. The point brought up about being in a state of liminality was interesting, and I wonder if a societal consensus on brain death meaning real death would actually help validate the use of neomorts, or if people will still be relatively uncomfortable with the idea?

  5. This article reminded me of “Doctors as End-Of-Life Patients” because of the talk about extending the limits of human life made me recall the claim that “the entire enterprise of medicine is focused on the extension of life, and often prioritizes quantity over quality.” It was very interesting to see the cultural differences that influenced the view and treatments of neomorts. I liked that this article included two cultures with completely different views so that we had a full spectrum of the different views and responses to a neomort. I am curious why Denmark is against the technology of life support and transplants, since I consider it a part of Western civilization, so it is strange why it doesn’t have “Western medical practices.”The discussion of African cultures’ view of death reminded me of our article about mummies. The discussion that death is viewed as a part of life recalled the elaborate rituals that ancient Egyptians go through to ensure a comfortable Afterlife, which showed that they believed that death was like Life 2.0 (ie. death is a continuation of life). I never thought about the difference in controversies between using dead cadavers and brain-dead, so it was a fun article.

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