How to Know If You're Dead Beating-heart cadavers, live burial, and the scientific search for the soul A patient on the way to surgery travels at twice the speed of a patient on the way to the morgue. Gurneys that ferry the living through hospital corridors move forward in an aura of purpose and push, flanked by caregivers with long strides and set faces, steadying IVs, pumping ambu bags, barreling into double doors. A gurney with a cadaver commands no urgency. It is wheeled by a single person, calmly and with little notice, like a shopping cart. For this reason, I thought I would be able to tell when the dead woman was wheeled past. I have been standing around at the nurses' station on one of the surgery floors of the University of California at San Francisco Medical Center, watching gurneys go by and waiting for Von Peterson, public affairs manager of the California Transplant Donor Network, and a cadaver I will call H. "There's your patient," says the charge nurse. A commotion of turquoise legs passes with unexpected forward-leaning urgency. H is unique in that she is both a dead person and a patient on the way to surgery. She is what's known as a "beating-heart cadaver," alive and well everywhere but her brain. Up until artificial respiration was developed, there was no such entity; without a functioning brain, a body will not breathe on its own. But hook it up to a respirator and its heart will beat, and the rest of its organs will, for a matter of days, continue to thrive. H doesn't look or smell or feel dead. If you leaned in close over the gurney, you could see her pulse beating in the arteries of her neck. If you touched her arm, you would find it warm and resilient, like your own. This is perhaps why the nurses and doctors refer to H as a patient, and why she makes her entrance to the OR at the customary presurgery clip. Since brain death is the legal definition of death in this country, H the person is certifiably dead. But H the organs and tissues is very much alive. These two seemingly contradictory facts afford her an opportunity most corpses do not have: that of extending the lives of two or three dying strangers. Over the next four hours, H will surrender her liver, kidneys, and heart. One at a time, surgeons will come and go, taking an organ and returning in haste to their stricken patients. Until recently, the process was known among transplant professionals as an "organ harvest," which had a joyous, celebratory ring to it, perhaps a little too joyous, as it has been of late replaced by the more businesslike "organ recovery." In H's case, one surgeon will be traveling from Utah to recover her heart, and another, the one recovering both the liver and the kidneys, will be taking them two floors down. UCSF is a major transplant center, and organs removed here often remain in house. More typically, a transplant patient's surgeon will travel from UCSF to a small town somewhere to retrieve the organ— often from an accident victim, someone young with strong, healthy organs, whose brain took an unexpected hit. The doctor does this because typically there is no doctor in that small town with experience in organ recovery. Contrary to rumors about surgically trained thugs cutting people open in hotel rooms and stealing their kidneys, organ recovery is tricky work. If you want to be sure it's done right, you get on a plane and go do it yourself. Today's abdominal recovery surgeon is named Andy Posselt. He is holding an electric cauterizing wand, which looks like a cheap bank pen on a cord but functions like a scalpel. The wand both cuts and burns, so that as the incision is made, any vessels that are severed are simultaneously melted shut. The result is that there is a good deal less bleeding and a good deal more smoke and smell. It's not a bad smell, but simply a seared-meat sort of smell. I want to ask Dr. Posselt whether he likes it, but I can't bring myself to, so instead I ask whether he thinks it's bad that I like the smell, which I don't really, or maybe just a little. He replies that it is neither bad nor good, just morbid. I have never before seen major surgery, only its scars. From the length of them, I had imagined surgeons doing their business, taking things out and putting them in, through an opening maybe eight or nine inches long, like a woman poking around for her glasses at the bottom of her purse. Dr. Posselt begins just above H's pubic hair and proceeds a good two feet north, to the base of her neck. He's unzipping her like a parka. Her sternum is sawed lengthwise so that her rib cage can be parted, and a large retractor is installed to pull the two sides of the incision apart so that it is now as wide as it is long. To see her this way, held open like a Gladstone bag, forces a view of the human torso for what it basically is: a large, sturdy container for guts. On the inside, H looks very much alive. You can see the pulse of her heartbeat in her liver and all the way down her aorta. She bleeds where she is cut and her organs are plump and slippery-looking. The electronic beat of the heart monitor reinforces the impression that this is a living, breathing, thriving person. It is strange, almost impossible, really, to think of her as a corpse. When I tried to explain beating-heart cadavers to my stepdaughter Phoebe yesterday, it didn't make sense to her. But if their heart is beating, aren't they still a person? she wanted to know. In the end she decided they were "a kind of person you could play tricks on but they wouldn't know." Which, I think, is a pretty good way of summing up most donated cadavers. The things that happen to the dead in labs and ORs are like gossip passed behind one's back. They are not felt or known and so they cause no pain. The contradictions and counterintuitions of the beating-heart cadaver can exact an emotional toll on the intensive care unit (ICU) staff, who must, in the days preceding the harvest, not only think of patients like H as living beings, but treat and care for them that way as well. The cadaver must be monitored around the clock and "life-saving" interventions undertaken on its behalf. Since the brain can no longer regulate blood pressure or the levels of hormones and their release into the bloodstream, these things must be done by ICU staff, in order to keep the organs from degrading. Observed a group of Case Western Reserve University School of Medicine physicians in a New England Journal of Medicine article entitled "Psychosocial and Ethical Implications of Organ Retrieval": "Intensive care unit personnel may feel confused about having to perform cardiopulmonary resuscitation on a patient who has been declared dead, whereas a 'do not resuscitate' order has been written for a living patient in the next bed." The confusion people feel over beating-heart cadavers reflects centuries of confusion over how, exactly, to define death, to pinpoint the precise moment when the spirit—the soul, the chi, whatever you wish to call it— has ceased to exist and all that remains is a corpse. Before brain activity could be measured, the stopping of the heart had long been considered the defining moment. In point of fact, the brain survives for six to ten minutes after the heart has stopped pumping blood to it, but this is splitting hairs, and the definition works quite well for the most part. The problem, for centuries, was that doctors couldn't tell for sure whether the heart had ceased to beat or whether they were merely having trouble hearing it. The stethoscope wasn't invented until the mid-1800s, and the early models amounted to little more than a sort of medical ear trumpet. In cases where the heartbeat and pulse are especially faint—drownings, stroke, certain types of narcotic poisoning—even the most scrupulous physician had difficulty telling, and patients ran the risk of being dispatched to the undertaker before they'd actually expired. 2 To allay patients' considerable fears of live burial, as well as their own insecurities, eighteenth- and nineteenth-century physicians devised a diverting roster of methods for verifying death. Welsh physician and medical historian Jan Bondeson collected dozens of them for his witty and admirably researched book Buried Alive. The techniques seemed to fall into two categories: those that purported to rouse the unconscious patient with unspeakable pain, and those that threw in a measure of humiliation. The soles of the feet were sliced with razors, and needles jammed beneath toenails. Ears were assaulted with bugle fanfares and "hideous Shrieks and excessive Noises." One French clergyman recommended thrusting a red-hot poker up what Bondeson genteelly refers to as "the rear passage." A French physician invented a set of nipple pincers specifically for the purpose of reanimation. Another invented a bagpipelike contraption for administering tobacco enemas, which he demonstrated enthusiastically on cadavers in the morgues of Paris. The seventeenth-century anatomist Jacob Winslow entreated his colleagues to pour boiling Spanish wax on patients' foreheads and warm urine into their mouths.