10) The Reinvention of Death?

Well into the 18th century, death was understood as a critical moment of life as it was the gateway to another, more important life. This is why people had to remember their impending death and act accordingly. It was such an important event that cemeteries were built well in view of, if not within, towns and villages. This shaped medical understanding of disease as being interrupted by death. From this perspective, anatomical lesions found in dead bodies were understood as the corruption of the body brought about by death's intervention. So, medical teaching insisted that dead bodies told little about disease. In both lay and medical understanding, life and death were ontologically distinct figures and forces.

As Canguilhem and Foucault have noted, during the late 18th and early 19th centuries, anatomists like Xavier Bichat dramatically transformed the understanding of death. It became a limit marked by the cessation of all functions, so understanding how an organism reached this limit illuminated the integration of these vital functions. So, death had become the end-point.

Socially and culturally, this transformation led to the medicalisation of death and its disappearance from the public sphere. Philippe Ariés noted that the figure of the living dead captured public anxieties about this transformation. This medicalisation also made the doctor the most important person who could declare what was happening. So, death withdrew from the public sphere (e.g. cemeteries), to the private sphere of the medical room or the home.

One of the most striking features of the contemporary coroners' practice is the disappearance of the diagnosis of death from natural causes. This is because death was now the cessation of vital functions due to specific malfunctions in the body that medicine could treat.

During the second half of the 20th century, public confidence in the power of medicine grew in an unprecedented manner. Mechanical equipment like respirators and dialysis machines, and monitoring technologies like the electocardiograph, allowed medical professionals to sustain life beyond previously imagined limits.

In conjunction with developments in immunology, it was now possible to undertake highly invasive surgical procedures like organ transplants. At the same time, the painful effects of these increasingly invasive surgeries, which only forestalled the advent of death, evoked growing concerns about the limits of medicine.

These developments lent great impetus to the resurgence of the hospice movement. Campaigns for hospices had originally been motivated by concern for those suffering with incurable diseases like cancer, but was then marginalised by the increasing successes in the treatment of this previously uncurable disease. Now, the motivation is the belief that life offered by medicine is not worth living and that it might be better to offer some opportunity to die as early as possible in an attempt to reconnect the person with the body.

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-emerging campaigns to legalise euthanasia. The idea of a life not worth living was formalised at the beginning of the 20th century by Karl Binding and Alfred Hoche, winning widespread support in mainly Protestant countries.

However, euthanasia was widely discredited after the Nazis systematically applied it to institutionalised, mentally ill people, saying that the cost of their institution was unjustifiable. But, from the late 1960s, public demand for legalising euthanasia re-emerged, partly in response to modern medicine and its power to sustain life in unprecedented circumstances.

This development of medicine has led to questioning the Judaeo-Christian notion of the sanctity of life and its role in the evolution of the medical profession's belief that everything possible should be done to keep death away, even at the cost of a person's quality of life. In the US, the legal problems in choosing death over life came to a head in the late 1970s with Karen Ann Quinlan. Following a drug overdose, she was kept alive artificially, but her higher brain functions had ceased. Her parents demanded that physicians allow her to die, but this exposed the physicians to charges of murder. In 1976, the New Jersey Supreme Court ruled in favour of the parents and life support was turned off. She continued to live in a vegetative state until 1986. Such cases re-emerge periodically in both the US and UK raising questions about the indistinction of neither being alive nor dead.

During the race in the 1960s towards more radical transplants, one of the main limitations confronting surgeons was the supply and viability of organs. In 1968, the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death sought to clarify the idea advanced in 1959 by 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. But, as a coma is only a temporary situation for many patients, it was vitally important that some irrefutable criteria was established to identify irreversible coma. It was equally important to establish to whom the organs of a brain-dead patient might belong. There was arguably no longer anyone to claim ownership of the organs. But, this situation proved hugely controversial, fuelling intense suspicions of the medical profession.

The illegitmacy of the concept of brain death continues to be controversial today, although those who refuse to donate organs after death are increasingly constructed as the exception rather than the norm. These discussions continue, in an effort to balance the ethical goods of saving lives, and respecting a particular set of concerns about the link between persons and bodies.