conversations.from: human
conversations.value: a description for a book titled Death before Dying about Jamal, Elias, Sufi with the genre: New, Used & Rental Textbooks, Humanities. Start with the sentence '"Jamal Elias has done a great service to those with an interest in poetry, in translation, and in the mystical by producing this volume'.
conversations.from: assistant
conversations.value: "Jamal Elias has done a great service to those with an interest in poetry, in translation, and in the mystical by producing this volume.... A splendid guide to the poetry of the author, and to a Sufi poetry that continues to electrify."--"Parabola
conversations.from: human
conversations.value: the first four paragraphs for this book. Start with the sentence 'Death before Dying
  Robert Schwab first advised colleagues to turn off a respirator in 1954, based upon EEG and clinical exam findings'.
conversations.from: assistant
conversations.value: Death before Dying
  Robert Schwab first advised colleagues to turn off a respirator in 1954, based upon EEG and clinical exam findings. The criteria he proposed for the Harvard Report, however, evolved through a series of studies, published through the 1960s, that looked at the outcomes of comatose patients. These studies, and the uses of EEG and examination to guide care for those with severe coma, drew in part upon EEG research on the "waking brain." Many commentators critical of the Harvard criteria faulted its lack of an empirical basis and failure to explicitly describe a concept of death. However, any assessment of the Report should include attention to the actual care of these patients at MGH, and to Schwab' s efforts to develop and use the criteria he presented to the Committee.
  Schwab did not use EEG in order to advise colleagues to end treatment simply because some mechanism of consciousness was no longer functioning. He wanted to solve a concrete problem for his colleagues: Could interobserver replicable findings indicate when these patients were no longer subjects for medical attention? The interaction of EEG and neurological research, expectations about extraordinariness of care, the specific capabilities and limitations of medical practice in the 1960s, and the behavior of the brain and the body under these circumstances contributed to the possibility that brain death was death. So was brain death a straightforward "mere" fact, or a contexted practice? Brain death, as a President's Council on Bioethics senior consultant put it, "is far from a mere social construct. It is a biologically well-grounded response to the lived phenomenon of the 'brain dead' patient." Medical practices and the empirical strategies from which they emerge as "biologically well-grounded responses," have to be central to any serious look at social uses, benefits, and implications of these facts. But at the same time, and as I will argue in the following chapter, the social contingency and purposes of medical facts are also crucial to understanding them and bothering to use them. Later bioethics debates often simplified this complexity and took brain death out of its sources.
  From the outset, then, the Report contained various ways to understand its opening claim that "our primary purpose is to define irreversible coma as a new criterion for death." The Report, especially in its earlier drafts, alternated between descriptions of a coma that predicted heart-based death and a coma that was death itself. While this became a focus of criticism in the decades following the appearance of the Report, this potential ambiguity, and its evolution in Report drafts, reflects an important moment in medical practice that needs to be understood—as does the discomfort it generated.
  Schwab responded to the April 11 draft by emphasizing that what the Committee was trying to do was to identify a particular form of irreversible coma that predicted death with certainty in the absence of life support. On his copy of the early Report draft that he sent to Beecher, he scribbled in his characteristically large hand that "it is not necessary to change definition of death to define Brain Death. If we establish the concept of irreversible coma with cessation of function at all levels of the CNS it will not be difficult... to withhold or discontinue [treatment.]" Schwab initially argued that the Committee's focus on redefining death was not the right posture, strategically. The key function of the Report, he reasoned, was to define irreversible coma as a distinct and unique neurological entity, and assumed that the consequences of that definition would follow. Schwab shared (apparently at the prior Committee meeting) a confidential memorandum summarizing initial findings from what would be a widely quoted study conducted by the American EEG Society on EEG, survival, and coma that appeared the following year. He wrote to Beecher in May 1968 about the first set of what would be a review of over two thousand reports of EEG and coma outcomes. While over seven hundred reports had been gathered by that point, no patients with a "flat" EEG had survived. However, there were many "flat EEGs" that did not meet his full triad. This seemed to underscore his own experience with varying presentations of isoelectric coma and to the potential confusion over what signs constituted irreversible and compete loss of brain function—an issue Schwab explored with colleagues for at least decade, as will be reviewed here.
conversations.from: human
conversations.value: five more paragraphs
conversations.from: assistant
conversations.value: Knowledge about the "diencephalic regulator" lent confidence, but also the expectation that the scope of the criteria described the lack of a "waking" brain as well as the absence of a "working" brain and body. Based on comments by William Sweet, the "summary" section likely emerged out of debates between Sweet, Adams, and Schwab around how completely physical signs of brainstem dysfunction alone described irreversible coma and death. Why suggest a confirmatory EEG? Why require (and then later seem to backtrack on) absent spinal reflexes and all movement? Sweet recalls taking the British view that all that was needed was clinical evidence of no brainstem, which primarily included apnea, absent cranial reflexes, and unresponsivity. But the other three "beat on me," and remained concerned about whether evidence was indeed adequate that there would be no recovery of consciousness if there were remnants of EEG activity (e.g., nests of cells in the cortex) as the British view could allow. Sweet felt the more restrictive view of the Report would "hold up" transplantation. Adams, though, proved decisive. He cited the line of research, beginning with Moruzzi, Magoun, Dempsy, and Morison, which established that the regulator of consciousness was in a small part of the brainstem. But, as with Sweet's recollection, Adams also was mindful that for the purposes of describing a coma that pronounced death, the data (such as Schwab's) that more reliably demonstrated not just irreversible unconsciousness but nonsurvivability pointed to broader criteria.
  Practice at MGH relied upon this mutual reinforcement of EEG and physical findings in ultimately describing the features of the brain dead condition. Beecher's confidence in Schwab's triad, both at Eliasburg and in drafting the Report, rested to a large degree on his experience at MGH (and the growing practice in other centers) of including isolelectric EEG as a criterion. Almost eighteen months after the Report appeared, Beecher gave advice to a Johns Hopkins surgeon—who was also leading an effort in Maryland to establish guidelines for brain death—reiterating the importance of EEGs within Schwab's timeframe and emphasizing that data did not yet support a change in practice. Adams' edits to the criteria positioning EEG as a fourth and conditional criteria don't seem, then, to have been intended to diminish EEG use, but more likely to underscore, as he later put it, that "the point of the article was that you could circulate with no brain and that society should recognize that to be without a brain was more equivalent to death then stopping of the heart." Eventually, though, additional data and clinical consensus would move more toward agreement on a limited need for EEG and on Adam's highlighting the loss of receptivity and response to inner need as key to what the criteria described.
  This was further underscored by cases where it seemed that brainstem function remained but cortical function apparently did not. In 1963, for example, a fifty-year-old man was unresponsive with absence of most midbrain and brainstem findings, such as response to pain, pupillary reflexes, and other cranial, ocular, and auditory nerve reflexes. But on exam, he had some residual lower brainstem reflexes, including slight gag and tongue reflexes, and the record noted this activity:
  The pt's upper brainstem (midbrain) was functionally transected in the EW as shown by fixed dilated pupils s globe movement to doll's head or ice water calorics—now the medulla is failing as shown by absent spontaneous respirations and now falling BP. Would favor EEG today and in 24 hrs if pt 'lives' that long—anticipate both will be flat.
  I have discussed in detail with Mr. and Mrs. C—about the significance of the EEG with absent brain waves; they understand fully that his respirations are being controlled completely and that his heart continues to function because of respiratory assistance. They have agreed that if additional EEG shows no electrical activity that the respirator be discontinued.
conversations.from: human
conversations.value: Delete the first sentence.
conversations.from: assistant
conversations.value: Based on comments by William Sweet, the "summary" section likely emerged out of debates between Sweet, Adams, and Schwab around how completely physical signs of brainstem dysfunction alone described irreversible coma and death. Why suggest a confirmatory EEG? Why require (and then later seem to backtrack on) absent spinal reflexes and all movement? Sweet recalls taking the British view that all that was needed was clinical evidence of no brainstem, which primarily included apnea, absent cranial reflexes, and unresponsivity. But the other three "beat on me," and remained concerned about whether evidence was indeed adequate that there would be no recovery of consciousness if there were remnants of EEG activity (e.g., nests of cells in the cortex) as the British view could allow. Sweet felt the more restrictive view of the Report would "hold up" transplantation. Adams, though, proved decisive. He cited the line of research, beginning with Moruzzi, Magoun, Dempsy, and Morison, which established that the regulator of consciousness was in a small part of the brainstem. But, as with Sweet's recollection, Adams also was mindful that for the purposes of describing a coma that pronounced death, the data (such as Schwab's) that more reliably demonstrated not just irreversible unconsciousness but nonsurvivability pointed to broader criteria.
  Practice at MGH relied upon this mutual reinforcement of EEG and physical findings in ultimately describing the features of the brain dead condition. Beecher's confidence in Schwab's triad, both at Eliasburg and in drafting the Report, rested to a large degree on his experience at MGH (and the growing practice in other centers) of including isolelectric EEG as a criterion. Almost eighteen months after the Report appeared, Beecher gave advice to a Johns Hopkins surgeon—who was also leading an effort in Maryland to establish guidelines for brain death—reiterating the importance of EEGs within Schwab's timeframe and emphasizing that data did not yet support a change in practice. Adams' edits to the criteria positioning EEG as a fourth and conditional criteria don't seem, then, to have been intended to diminish EEG use, but more likely to underscore, as he later put it, that "the point of the article was that you could circulate with no brain and that society should recognize that to be without a brain was more equivalent to death then stopping of the heart." Eventually, though, additional data and clinical consensus would move more toward agreement on a limited need for EEG and on Adam's highlighting the loss of receptivity and response to inner need as key to what the criteria described.
  This was further underscored by cases where it seemed that brainstem function remained but cortical function apparently did not. In 1963, for example, a fifty-year-old man was unresponsive with absence of most midbrain and brainstem findings, such as response to pain, pupillary reflexes, and other cranial, ocular, and auditory nerve reflexes. But on exam, he had some residual lower brainstem reflexes, including slight gag and tongue reflexes, and the record noted this activity:
  The pt's upper brainstem (midbrain) was functionally transected in the EW as shown by fixed dilated pupils s globe movement to doll's head or ice water calorics—now the medulla is failing as shown by absent spontaneous respirations and now falling BP. Would favor EEG today and in 24 hrs if pt 'lives' that long—anticipate both will be flat.
  I have discussed in detail with Mr. and Mrs. C—about the significance of the EEG with absent brain waves; they understand fully that his respirations are being controlled completely and that his heart continues to function because of respiratory assistance. They have agreed that if additional EEG shows no electrical activity that the respirator be discontinued.
conversations.from: human
conversations.value: the last four paragraphs
conversations.from: assistant
conversations.value: Medical knowledge needs to be put to better use as a resource for managing wicked complexity; far too often it is not. Instead of artful argument over a moral point of view, innovation and understanding of how medical knowledge works will be needed for real transformation and for the achievement of progressive values with which to navigate the continued intensification of biomedical culture, and the sometimes overwhelming combination of living lives of both agency, and embodiment. The ethical dimensions of all that are interesting but have not, and from experience so far likely will not, lead to the level of needed public engagement and intelligence around the uses of medicine and science.
  Shigehisa Kuriyama beautifully explored what he called the "geography of medical understanding," spanning millennia and civilizations, as a way to capture efforts to compile knowledge of the working mechanisms of the body through touching and probing it in ways, whether in the East or the West, that were deeply contextualized and cultural and yet deeply empirical, tangible, physical, experiential, and verifiable. This is a pervasive, dynamic, and historically powerful form of knowledge, translating "the expressiveness of the body" into empirical knowledge that resonates with the most basic working beliefs of a society.
  Whatever values, interests, or abuses attach to the always imperfect but still quite instrumentally powerful fact-finding capabilities of medicine, the problems or prospects it offers should be engaged directly, rather than circumspectly through professionally derived rules governing discussion of morals and ethics. All dilemmas have moral dimensions. It is not clear, however, when they have or require moral solutions—that is, solutions primarily arrived at through moral analysis, reasoning, or related conceptual categories. The Committee reached their consensus through squaring medical descriptions of the body, with "RIGHTS." Looking back at what the Committee drew upon to define the complex fact of brain death complicates the predominant historical narrative of bioethical rescue. It directs curiosity and historical attention instead to the form and composition of medical knowledge, evidence, and practice itself, and how they contribute to and source values we want and need. These were and often still are the stated purposes of the medical humanities and social sciences, purposes overshadowed and diminished in the turn to ethics.
  President's Commission on Ethical Problems in Medicine and Biomedical and Biobehavioral, Research, xv, xxviii n3, , n24
conversations.from: human
conversations.value: Delete the first sentence.
conversations.from: assistant
conversations.value: Instead of artful argument over a moral point of view, innovation and understanding of how medical knowledge works will be needed for real transformation and for the achievement of progressive values with which to navigate the continued intensification of biomedical culture, and the sometimes overwhelming combination of living lives of both agency, and embodiment. The ethical dimensions of all that are interesting but have not, and from experience so far likely will not, lead to the level of needed public engagement and intelligence around the uses of medicine and science.
  Shigehisa Kuriyama beautifully explored what he called the "geography of medical understanding," spanning millennia and civilizations, as a way to capture efforts to compile knowledge of the working mechanisms of the body through touching and probing it in ways, whether in the East or the West, that were deeply contextualized and cultural and yet deeply empirical, tangible, physical, experiential, and verifiable. This is a pervasive, dynamic, and historically powerful form of knowledge, translating "the expressiveness of the body" into empirical knowledge that resonates with the most basic working beliefs of a society.
  Whatever values, interests, or abuses attach to the always imperfect but still quite instrumentally powerful fact-finding capabilities of medicine, the problems or prospects it offers should be engaged directly, rather than circumspectly through professionally derived rules governing discussion of morals and ethics. All dilemmas have moral dimensions. It is not clear, however, when they have or require moral solutions—that is, solutions primarily arrived at through moral analysis, reasoning, or related conceptual categories. The Committee reached their consensus through squaring medical descriptions of the body, with "RIGHTS." Looking back at what the Committee drew upon to define the complex fact of brain death complicates the predominant historical narrative of bioethical rescue. It directs curiosity and historical attention instead to the form and composition of medical knowledge, evidence, and practice itself, and how they contribute to and source values we want and need. These were and often still are the stated purposes of the medical humanities and social sciences, purposes overshadowed and diminished in the turn to ethics.
  President's Commission on Ethical Problems in Medicine and Biomedical and Biobehavioral, Research, xv, xxviii n3, , n24