Sunday, 12 February 2012

Defining death biblically

Modern medicine defines death in several ways. There can be cessation of heart beating, cessation of breathing, or cessation of brain activity. The latter is intended to be defined quite clearly so as to not include people in comas that may potentially wake up.

Heart death is when the heart stops pumping and electrical activity ceases (asystole, flat-lining). A heart may stop beating but the electrical activity continues. This may occur because the heart cannot pump (pulseless electrical activity) such as when there is no blood (bleeding), or nowhere for the blood to go (clot in the lungs), or no space for the heart to contract (blood around the heart). It may also occur when abnormal electrical activity does not cause heart contraction (ventricular fibrillation). Both these situations very rapidly become asystole if not treated, and frequently even if treated, especially when death is expected.

Cessation of breathing, eg. blocked airway or drowning, leads to a rise in carbon dioxide in the blood and decreasing oxygen. Increased carbon dioxide quickly leads to unconscious and acidification of the blood. The heart stops after a few minutes (unless there is severe hypothermia) for various reasons.

Brain death is defined as no electrical activity of the brain, no brain reflexes, no response to a stimulus. The person cannot breathe independently, and sometimes cannot maintain a heart beat; thus such a definition exist because of advances in medicine allowing prolonged mechanical ventilation.

These definitions of death are somewhat reasonable. Nevertheless we need to consider what Scripture may say to the issue and whether that modifies our thinking around physical death.

The Bible has several references to various organs of the body. Kidneys, intestines, eyes, liver, skin, blood, bone, heart. Several of the occurrences are literal when describing sacrifice: what to do with the kidneys or liver when offering sacrifices to God. Several are metaphorical, though different to the metaphors we use in English. Thus translators may use English metaphors, though some have become English metaphors from the Hebrew via the English Bible.

"Kidney" (kilyah) may represent emotion. Consider Jeremiah 17:10a
“I the LORD search the heart (leb)
and test the mind (kilyah), (ESV)

I, the Lord, probe into people’s minds (leb).
I examine people’s hearts (kilyah). (NET)
"Kidney" appears on the second line, translated "mind" in the ESV and "heart" in the NET. "Heart" (leb, lebab) in the Hebrew apears in the first line. The ESV retains heart whereas in the NET it is translated as "mind". The NET's translation of "heart" as "mind" is not without justification as "heart" often carries the connotation of "will" in Hebrew, whereas it tends to reflect "emotion" in English.

me`ah means intestines or other internal organs such as stomach or uterus (also beten). Literally Psalm 22:14 reads:
I am poured out like water,
and all my bones are separated;
my heart is like wax;
it is melted within my intestines (insides);
The relevance of this to our discussion relates to the word "blood". Blood represents life in Hebrew. The question is whether this is primarily metaphorical, or symbolic, or whether blood is perceived as the source of life. "Blood" (dam) occurs over 300 times in the Old Testament. It is clearly used at times when "life" (nephesh) is meant. As such it has a figurative use. Though I am inclined to think that this is because the association with life is meant to be a literal one. After the Flood God instructs Noah concerning food and death:
But you shall not eat flesh with its life (nephesh), that is, its blood (dam). And for your lifeblood (dam nephesh) I will require a reckoning: from every beast I will require it and from man. From his fellow man I will require a reckoning for the life (nephesh) of man.
“Whoever sheds the blood (dam) of man,
by man shall his blood (dam) be shed,
for God made man in his own image. (Genesis 9:4-6)
God tells Noah that meat has to be drained of blood because the blood is life. In verse 4 blood is identified with life in a definitional manner:
  • Life is blood.
"Life" and "blood" are also juxtaposed in verse 5 which is translated by the English word "lifeblood", or alternatively "blood of your life".

Another consideration in understanding death is the word breath. Breath (neshama) and breathe (naphach) are used in the creation account.
then the LORD God formed the man of dust from the ground and breathed (naphach) into his nostrils the breath (neshama) of life (chay), and the man became a living (chay) creature (nephesh). (Genesis 2:7)
Though there is a connection between breath and life here, it does not seem to be as strong. The breath (spirit) of God is required and it is the breath of life, ie the breath that causes life, but it is not definitional. The breath itself is not identified as the life itself (even though it is the source or cause). An argument can be made for an association between breath and life, though I think it less convincing than blood.

The association of blood with life in Scripture provides us with material to deduce a biblical definition of death. If we accept that blood represents life, or is life, then the complete loss of blood or the cessation of blood flow is a coherent biblical definition of death. How does this correspond to current medical views? We know that cessation of blood flow is due the heart ceasing its function as a pump. Therefore a medical definition of cardiac death as asystole is equivalent the biblical definition of death. The Bible would also allow the loss of significant blood from bleeding, pulseless electrical activity, and ventricular fibrillation as definitions of death, though without medical intervention these situations very rapidly become asystole.

Biblically, death is the loss of blood flow, that is the non-perfusion of (all) organs with blood, this is usually due to the cessation of cardiac function.

If we were to argue that breath also relates to life, a secondary biblical definition of death is cessation of breathing, which incidentally leads quickly to cessation of blood flow, our primary definition.

Brain death is not primarily a biblical definition of death of itself, other than that it involves lack of ability to breath spontaneously.

This leads to some interesting conclusions. It should influence how we think about sentience and life. It may have implications concerning euthanasia, abortion, organ donation, mechanical ventilation and other supportive therapies.

3 comments:

  1. A couple of questions. First, I have always understood nephesh to mean 'soul', yet you define it here as 'life'. How would you distinguish therefore between the concept of nephesh and the concept of chay?

    Second, you mention that this might have implications on how we view euthanasia, abortion, ect... I don't really see how since we already define death in those terms. Within general culture the cessation of the heart is still the prinicple symbol of the moment of death. Thus, I am not sure how challenging this is. Could you elaborate on how you feel this would alter people's perceptions?

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  2. You say that brain death is not primarily a Biblical definition of death and I can see from your argument why. As someone who has worked in the ICU setting with quite a few people over the years who have been diagnosed as brain dead (worked to keep them 'alive' in the sense of staving off asystole in order for organ donation or until a family member arrives); in that particular setting I have never known of a person diagnosed as brain dead to breathe, in a manner consistent with life sustaining way, for very long. In other words the brain dead person has commenced the process of dying. Given that without life support (mechanical ventilation in the place of breathing and the frequent use of inotropes; drugs that help to defer the ensuing & often rapid deterioration in heart function by improving its pumping function)death, according to your Biblical definition, is often not far away. Would you therefore allow it as reasonable to say that the diagnosis of brain death is another example of a secondary Biblical definition of death as you do for the cessation of breathing that is not reversed? Without the interventions I have described, such a person would fit the primary or secondary Biblical definition as you give it. It is only by these artificial means that the organs remain perfused and oxygenated as long as they do and it is always a losing battle!

    One state you don't mention that your discussion is relevant to is that of is persistent vegetative state (PVS). I am aware there has been much controversy surrounding this diagnosis. My only experience of it was with a young woman, diagnosed with PVS, who had objective signs of cerebral cortex deterioration (increasing loss of cortical mass and increased amount of fluid in the chambers of the brain). Accompanying this were serial electroencephalogram (EEG) showing electrical changes consistent with deterioration of function incompatible with life over the longer term. This person did have a sleep wake cycle but no startle reflex and an absent gag. She was not dead in the Biblical sense as your describe it or in the brain dead sense. But to the clinicians and she was as good as dead in that she was deemed to have none of the higher brain functions remaining intact and therefore was described as a "living brain stem" but no more. No ability to perceive, experience (to give meaning to) & or communicate in any way. In light of this fact a ground breaking "Pink Paper" was written for the NZ Medical Association that argued in favour for the removal of food and fluids (which were being provided by a tube from the nose to the stomach). The result of this decision was that she died within the weak. I was at the time very uncomfortable with the decision (the process is another issue which I will not raise here). When I discussed this with a preacher, whose exegetical preaching I respect very much, the issue I had was responded to rather quickly with the comment that life was defined by the ability to experience it: perceive, experience (to give meaning to) & or communicate and that in the absence of this it was perfectly reasonable to withdraw food and fluid via a tube, no problem. What startled me about this response at the time was that I thought it had huge implications for those with dementia and how they are viewed and treated.

    The medical argument was that the intervention was futile and had no benefit to the patient and therefore could be withdrawn as clinicians were not obligated to give that which had no proven benefit for the individual receiving the treatment, irrespective of what others (clinicians or family wanted). It would have gone to the High Court but the objectors withdrew their objections at the possibility this action.

    Sorry that this comment is so long but your got me thinking.

    NB: The case of PVS I mention was widely publicised in the popular media at the time by the family so I have no issues in mentioning it as I have here.

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  3. JCF, good questions, I'll try and address them soon, or if it gets too long, post.

    I think we should establish the why, it may coincide with the secular coincidentally, if they change the rules we don't get to. There are arguments to change the rules, and we need biblical grounding to hold fast.

    BlairD, again several issues which we should explore at some stage. Briefly, consider: if we remove life support then we are stopping breathing for (on behalf of) the patient. If we stop tube feeding we are stopping eating for the patient.

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