Scientific medical assumptions have long been in conflict with a Torah-based view when it comes to defining the end of life.
“Brain death” — a diagnosis of irreversible cessation of all brain function, as measured by electroencephalography (EEG) or other brain-wave detecting technologies — is seen by modern medicine and secular law as sufficient to permit the “harvesting” of organs and removal of life-support. But in the eyes of many of the most prominent poskim, including Harav Shlomo Zalman Auerbach, zt”l, and Harav Yosef Elyashiv, zt”l, such a patient, whose heart is still beating with the aid of a ventilator, is in fact considered alive.
Then there is the diagnosis of “vegetative state,” where machines show that a patient has brain damage and is unresponsive to external stimuli. If such a state persists for a certain amount of time, the diagnosis is upped to “persistent vegetative state,” and, if it continues to yet another arbitrary date, “permanent vegetative state.” Patients who received that latter diagnosis have had nutrition and hydration lawfully withdrawn, allowing the patient, in other words, to be starved to death.
Whether “vegetative” states are what they have been assumed to be — even whether “permanent” may turn out to have been a presumptuous adjective — has been called into question, most recently by study results published last week in New England Journal of Medicine.
The study was conducted by researchers at Columbia University and New York University, who tracked 104 unresponsive patients in Columbia’s neurological Intensive Care Unit, taking EEG recordings from each in the first few days after injury. During each EEG recording, the researchers gave the patients instructions through headphones, including, “Begin opening and closing your right hand,” and “Stop opening and closing your right hand.”
The researchers fed the EEG data into a machine-learning algorithm that compared the brain activity following each command to resting-state activity, looking for distinct and consistent differences in brain activity. And in 16 patients, previously “hidden activity” became evident.
“Somewhat to our surprise,” said Dr. Jan Claassen, the lead author of the paper, “we found that about 15 percent of patients who were not responding at all had this brain activation in response to the commands. It suggests that there’s some remnant of consciousness there.” Dr. Claassen hastened to add that “we don’t know if the patients really understood what we were saying… only [that] the brain reacted.” But the question of comprehension, and even the definition of the word, are things beyond scientific measurement.
The researchers tracked the progress of all of the patients for a year following injury. Patients in both groups showed real improvement, but those with the hidden brain activation had a better prognosis overall, the study found. After a year, seven of the 16 patients with covert activity had recovered to the point where they could function without help for at least eight hours at a time. And 12 of the other 88 reached that level of recovery.
While the new study is the first to use this approach to examine a large number of patients just after the injury that caused their condition, the truth is that previous research in patients who had been unresponsive even for years has found that a subset showed hidden brain function.
Back in 2010, a group of European scientists employed functional magnetic resonance imaging (fMRI), which shows cellular activity across brain regions, to demonstrate that four patients in a group of 54 diagnosed as vegetative were in fact hearing and thinking — and could actually communicate, answering yes-or-no questions about their lives — through mental effort.
The following year, the medical journal The Lancet published a study demonstrating that three severely brain-injured people thought to be in an irreversible “vegetative” state showed signs of full consciousness, although unable to move, when asked questions during EEG tests.
Both the older and newest studies clearly reveal two important things: the mutability of scientific assumptions and the limits of science.
While the medical profession has in the past considered a body unable to move or physically react to stimuli to be something less than a person, today that assumption has been shown to have been mistaken. No longer can it be stated with impunity that “vegetative” patients should be seen as mere mines of transplantable organs.
More important still, the discovery of responsive electrical activity in such patients reminds us that medical science not only evolves but is inherently unable to measure meaningful awareness.
From a Torah perspective, even if immobile, physically unresponsive and without reasonable hope of recovery, people can still engage in some of the most important things in life — like mechilah, teshuvah, ahavas Yisrael and ahavas Hashem.
A neshamah, in other words, cannot be discerned by any medical test. The recent, and not so recent, research has revealed that there is brain activity where it was once thought to be absent. Neshamah activity will always be beyond science’s scope.