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Introduction: Death

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If there is one thing we can be certain of in life, it's that eventually we will die - that is, we will no longer be alive. Sadly we are not completely certain what "being dead" means: defining death is much more complicated than it appears, and it's getting harder to define all the time.

As recently as a century ago, it was priests not doctors who declared a person dead. When in doubt, they looked for signs of putrefaction. As medicine advanced, however, it became apparent that death was not an event, but a process.

Even so, for practical purposes an arbitrary line had to be drawn. First it was taken as the heart stopping. Then came the notion of brain death and in the 1960's this seemed like the way forward. For a while it was even considered foolproof: once activity ceases in the brain and brain stem you can never regain consciousness, and without intervention the body will quickly shut down.

But foolproof it is not, and the fact that several hundred neurologists and philosophers are gathering next May for the fifth International Symposium on the Definition of Death shows this only too well.

Technology brings problems

The real spanner in the works was the invention of ventilators - machines that keep lungs breathing and hearts pumping even after the brain has suffered extensive damage. This raised for the first time the question of whether people could or should be treated as dead simply because their brain was dead.

One set of philosophers argues that the destruction of the frontal lobes, with the memories and personality they store, is enough to declare someone dead. This definition includes those in a "permanent vegetative state". Others resist the idea of brain death altogether and insist that the heart must stop beating before a body can be treated as dead.

The compromise "whole-brain-death" position, which has been written into law in most of the industrialised world, is that a person can only be declared dead if almost all brain function has been irreversibly destroyed.

Whichever definition is adopted, there are many practical and political implications: after all, doctors are generally obliged to treat the living and stop treating the dead. Some bioethicists have even proposed that individuals should choose their own definition of death.

As diagnostic technologies have advanced, declaring total and irreversible brain death has become ever more problematic. In the 1990's medical advances allowed residual brain activity to be detected in many patients who would have previously been considered brain-dead.

Death of identity

The growing ability to compensate for loss of the brain's regulation over the body means doctors can maintain some brain-dead bodies indefinitely. We have also discovered more about the brain's self-repair mechanisms and are rapidly developing new ways to repair damaged brains. It may soon be possible to engineer new neural tissue from patients' cells and transplant it into damaged areas. Progress in nanotechnology and the miniaturisation of computing will also eventually allow brain damage to be repaired with implantable machines.

All these advances make defining brain death increasingly difficult - and our ability to rebuild destroyed brains may eventually force us to develop a brand new definition of death, based not on brain activity but on personal identity: would you be the same person if your entire brain, including all your memories and personality, were destroyed and then grown anew?

What is it like to die?

It seems it is not death per se that scares most people: once you're dead (really dead, that is) you won't know anything about it. What does seem to frighten people is the process of dying, and whether it will be painful. So do we have any idea about how it might feel to die? Of course there are not many people to ask.

But a few people have died and been brought back. Their tales, together with extrapolating from medical experience, can shed light on what it's like to meet your end in various different ways: from electrocution to hanging, and from drowning to lethal injection (beware - this article is not for the faint-hearted!). The latter - lethal injection - is another extremely contentious issue. It's been branded too unreliable, too painful and just plain inhumane.

But it's not always blood and gore: if you're lucky enough to die peacefully of old age, that is.

Dealing with loss

Another potentially frightening event is the death of a loved one. It can certainly be a very sad and painful time. There are thought to be five main stages of grief: disbelief, yearning, anger, depression and finally, acceptance. The most common emotional difficulty experienced is, unsurprisingly, emotional loneliness.

Losing a partner is generally assumed to be one of the most stressful experiences that people encounter. Marriage is such a strong bond that if one partner dies, the person left behind is put at a significant risk of following suit: it's known as the "widower effect".

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