A review of The Undead: Organ Harvesting, the Ice-Water Test, Beating Heart Cadavers – How Medicine Is Blurring the Line Between Life and Death by Dick Teresi
368 pages. Random House, 2012

Dick Teresi will hold your hand, incite you to argument, and dare you to contradict him. But first, he needs to be perfectly blunt. “You, the reader, will die,” he proclaims within the first five pages. He wants you to think about death as much as he does, which is quite a lot, according to his therapist who declares him not so much clinically depressed as exceptionally morbid. But for Teresi, it’s not so interesting that you’ll die but rather, how we’ll know you’re dead.

Known for his journalistic musings on the God Particle and our understanding of the number zero, in his humorous and extensively researched third book, The Undead, Teresi tackles how modern society and its past counterparts have decided when people are dead. As it turns out, it’s not nearly as straightforward as it sounds and most people can’t tell the difference between a dead guy and a plate of jello (really, they have similar brain scan readings). While he states at the beginning of the book, “My job as a journalist is to reveal data. You can do with that information what you wish,” it is clear he has strong opinions on the matter.

Divided into several miniature sections per chapter, the book looks at the moment of death through five major frames including human physiology, neurobiology, irreversibility, religion, and what the author calls “personhood.” Our inability to accurately determine the dead, argues Teresi, has huge implications for society from the costs of housing beating heart cadavers, to the way we use organ donors, to how family status governs what you do with the dead. Of course, it also asks the question, how will you be diagnosed as deceased? Is it as simple as death of a single organ? If so, the heart or the brain?

Death, rather ironically, has always been important to a species’ survival. It is death by which natural selection moves forward, slaughtering those whose reproductive fitness is lower than its counterparts. Without death, there cannot be progress. In early accounts, dying was considered both a cultural and religious affair, not a medical one. From the Egyptians to the early Christians, death was the move to a different spiritual place. This changed with the advent of modern medicine in the 18th century.

In 1968, a group of thirteen Harvard men, including Henry K. Beecher as chair, “lowered the bar” for our understanding of the phenomena, stating that “irreversible coma,” otherwise known as brain death, confirmed by an electroencephalography (EEG), should be considered a primary criterion for death. While the men acknowledged in their paper published in the The Journal of the American Medical Association that there were other hallmarks of death: a lack of response, no movement or breathing, and no reflexes, their proposal of brain death was new. This scientific idea had an interesting philosophical side effect: it implied that the brain was the person. By saying a dead brain was a dead person, the committee had proposed that to even be a person was to be an active brain.

However, three short years later, a study completed by the Minnesota Health Sciences Center knocked the criterion off its feet. The study tested nine “brain dead” patients by EEG and of these, two tested positive for activity—a supposedly a sign of higher brain activity and thus, life. Even more confusingly, faint electrical signals were detected in another five of the brains. In other words, the supposedly dead showed signs of life. (And in reverse, studies now report ten percent of all adults will register a flatline, or low amplitude EEG, when tested, much like a dead man.) However, instead of the natural conclusion that the Harvard criterion was wrong, clinical professionals threw out the idea of confirming death by EEG. They cited that such a scan only tested higher brain activity (such as movement) and that if the brain stem, an area of lower brain activity (for example, breathing and the gag reflex), was found to be dead, the rest of the brain was a goner anyway.

This controversy continues, and we’ve now settled on two distinct types of death: brain death and the “plain-vanilla” cardiopulmonary death, when the heart stops. Teresi witheringly argues, however, that our belief in brain death as death lacks substance. Most of all, he challenges the motives of the Harvard committee in stating the brain dead are actually dead by framing their arguments against the backdrop of organ harvesting, the high profits to be had, and the shaky moral and logistical grounds of taking hearts, lungs, and livers from the newly dead. If a person is their brain and the brain is dead, is it justified to take the organs of their “beating heart cadaver” for someone else? He points out that the transplant industry is a $20-billion-per-year machine. Yet these patients, as if to prove they’re not quite gone, can show signs of sexual arousal. Pregnant brain dead women can even gestate babies. Teresi contends brain death predicts a person will die, not that they are already dead.

While The Undead is filled with incredible facts, no doubt led by the author’s insatiable curiosity and ability to press people effectively on a sensitive topic, he is most effective when he chooses depth over breadth and tears open an example. To explain a brain-death exam, Teresi uses an audiotape transcript from the exam of a patient named Fernanda, admitted to Baystate Medical Center. The section titled “Fernanda’s Last Few Minutes” details a conversation between a reporter Judith Hooper, Dr. Thomas Higgins, and Dennis O., a nurse. Between the dialogues, actions of the characters are written in brackets, explaining each step in the exam and precautions taken for preventing false negatives or false positives. We test to make sure the brain dead are truly dead using the onomatopoeically named “flash-splash-gasp” test. Among other gag and reflex tests, patients are flashed a light in their eyes and splashed ice water in the ears. “If the patient ‘passes’ all of these tests—which is to say he passes for dead— the apnea test is performed,” explains Teresi. The apnea test is the last “gasp” in the name; the patient’s breathing ventilator is removed, and if he fights to breathe on his own, he’s still alive.

However, as Higgins comes to the end of the tests, concluding that the patient is in fact dead, the conversation takes a turn from the physical to the psychological:

HIGGINS: It’s important to note that she can’t hear or understand anything we’re saying now. Normally I would not talk in front of patients like this.

DENNIS: Whatever it was that made her her isn’t there anymore.

This captured moment then allows Teresi to display his ability to balance the scientific with the philosophical. He dives into a dissection of our understanding of death as a society, admittedly very different than death as a fated physical condition. Teresi’s eye for bringing the absurd to light shines here, though the peppering of anecdotes is likely too fast for a reader to dwell on their conclusions. He ponders how even when bringing a prisoner to death row, should the inmate have a heart attack on the way to the execution, law requires them to be revived before receiving their lethal injection. Furthermore, people falsely believe deaths are more likely to occur in hospitals in the morning when really morning is the first cycle of nurse’s rounds. As Teresi says, “You are dead, then, when someone notices?”

Least effective is his section on Near Death Experiences where Teresi wonders how what happens to those who are dead for moments or minutes can tell us more about life. The section, while structured around the story of a woman named Pam, scientifically unpacks supposed explanations for why people experience the out-of-body death experience. However, it doesn’t contribute to his larger point about the harvesting of organs and why the declaration of death must be a medical one, not just one for profit.

Teresi is most easily compared to Mary Roach and her tour de force of dead bodies in Stiff. However, while Roach’s wit is contained to the surely dead, Teresi is content to bother his interview subjects about if they really, truly know someone is dead and if they can prove it to him. Most cannot. Like Roach, his incredible breadth of interviews and extensive use of humorous footnotes are refreshing, though some of the latter lead to interesting avenues a reader may wish were explored in the text. In particular, one footnote includes a long back-and-forth email chain between Teresi and an organ donation coordinator who tries his very best to keep up with the author’s demands for an EEG upon his death and anesthesia during the removal of his organs. Such an argument poses the question, how prepared are we for our own death?

So while The Undead may be about those lacking pulse and breath, it is certainly a very lively read.