The words covered in this article are infallible and fallible, discretion, advent, cadaver and cadaverous, and preclude. Previously done words that will reoccur today are cessation, ambiguity, and viable. 

You know Jahi McMath’s story now.

One cannot help but wonder, how much pain her family would have been spared if she had not been misdiagnosed as brain-dead. They would not have had to wage a legal battle just days after her surgery-gone-wrong turned their world upside down; the continuance of life-support to their beloved child would not have been questioned; they would not have had to sell their home, scatter their family unit and live in a faraway state for more than four years.

But then one realizes that the misdiagnosis would not have mattered much if the state of California had not considered ‘brain death’ to be death.

Recall what the California law says:

“An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, OR (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.”

Note how certain and confident the phrase “is dead” sounds; that the lawmakers chose it over probabilistic words such as ‘may be dead’ tells us that they had absolute faith in the ability of brain-tests to determine irreversible cessation of brain functions. They must have thought these tests to be infallible.

Infallible

The adjective infallible means incapable of making mistakes or failing. The noun form of the word is infallibility. The opposite adjective is fallible, meaning capable of making mistakes.  

It is because of the supposed infallibility of brain tests that the lawmakers allowed no personal discretion to a patient’s family or to doctors regarding the fact of death.

Discretion

The noun discretion means freedom to decide or act according to one’s own judgment.

Because common people are not very familiar with the concept of ‘brain death’, most doctors do try to be sensitive to the confusion the family members of the patient might feel, as the following passage illustrates:

“Before and during the diagnostic evaluation of brain death, the patient’s family is informed not only of the patient’s medical condition but also of the concept of brain death, its diagnosis, and the consequences of death certification in these cases. Because the declaration of death is the legal responsibility of the medical practitioner, the family’s permission for this procedure is not sought but their questions and concerns must be answered honestly and with the necessary education and communication regarding the events following discontinuation of cardiopulmonary support…. When transplantation is not planned, family members may request to be at the bedside when the ventilator is removed. This is permitted but the family is advised that peripheral muscle movements may be observed during the ensuing anoxia and that these are not dependent on remaining brain function.”

David J. Pawner & Ake Grenvik, Triage in Patient Care: From Expected Recovery to Brain Death (1979).

(Anoxia means absence of oxygen)

Note in this quote that before starting a brain-death evaluation, the doctors do not ask for permission to do so from the family of the patient; the family cannot prevent the conducting of such a test. The determination of death is not at their discretion.  Doctors too have no say in the matter; if brain tests support a brain death diagnosis, then a doctor must declare the patient to be dead, no matter what their personal opinion about the patient’s state and outlook may be.

Every state in America defines death in the exact same manner as California. Only two states – New York and New Jersey – allow some personal discretion in the matter, by letting family members reject, on religious grounds, a determination of death based on the neurologic criterion. This exemption was the reason that Jahi’s family shifted her to New Jersey. They argued that as Christians, they believed that only a person whose soul has left the body is dead and that soul does not leave till the heart is beating; this plea was sufficient for Jahi to be treated as a living person in New Jersey.

Definitions are important, as Jahi’s story clearly illustrates. And the definition of death that all American states use was not made lightly. It was formulated in 1981 by the President’s Commission on Medical Ethics, which had been formed specially to discuss this issue with various stakeholders. The commission met with doctors, biomedical scientists, lawyers, politicians, philosophers, and priests before arriving at its recommended definition.

The need to form this commission had arisen because the earlier definitions of death had become inadequate after the advent of mechanical ventilators and transplantation from cadaver organs.

Advent

The noun advent means arrival, especially of something important.

Cadaver

The noun cadaver is a medical term used for a dead body, especially a dead human body that is intended for dissection.

The associated adjective cadaverous is used in two senses: (i) related to a cadaver, and (ii) looking like a cadaver, such as someone who looks so thin, skeletal or ill that they remind you of a ghost or a dead body.

Till the eighteenth century, incidents of “dead” people getting up during their funerals were not uncommon. This was why many states made it legally necessary to have a delay before burial. In 1740, a French anatomist named Jean-Jacques Winslow published a paper titled The Uncertainty of the Signs of Death, in which he argued that the only way to be sure that a person had died was when his body started to decompose. Of course, this was not a practical standard to follow for common folk.

Doctors kept looking for other infallible signs of death, and finally, they found one.

In 1816, the French physician René Laennec invented the stethoscope, a device that enabled doctors to detect heartbeat with heightened sensitivity.  From here on, the stopping of heartbeat and breathing provided a reliable sign of death. So, this medical invention in fact decreased ambiguity about whether death had occurred.

However, the advent of the modern ventilator muddied the waters again. As long as blood carrying oxygen reaches the heart, it can continue to beat, even if the rest of the organs have stopped functioning. So, the presence of a mechanical ventilator precludes the use of traditional vital signs (i.e., respiration and heartbeat) to ascertain whether a person is alive.

Preclude

To preclude means to prevent from happening, to make impossible.

A mechanical ventilator can artificially maintain respiration and heartbeat; so the use of this device precludes – makes it impossible – to determine from these two traditional signs of life that a person is indeed alive. In such cases, the use of brain-based criteria provides another means of making such a determination.

We will continue the discussion tomorrow. Here are some more usage examples for the words you’ve learnt today:

• Jahi McMath’s case challenges the supposed infallibility of diagnostic tests for brain death.
• The sum total of human misery is difficult to measure, but it is not obvious that it has declined with the advent of the antidepressant drugs.
• A weak, stooping, cadaverous old man lived alone in the spooky ruins.
• With the advent of transplant surgery employing cadaver donors—first with kidney transplantation in the 1950’s and later, and still more dramatically, with heart transplantation in the 1960’s—interest in “brain death” took on a new urgency. For such transplants to be successful, a viable, intact organ is needed. The suitability of organs for transplantation diminishes rapidly once the donor’s respiration and circulation stop. The most desirable organ donors are otherwise healthy individuals who have died following traumatic head injuries and whose breathing and blood flow are being artificially maintained. Yet even with proper care, the organs of these potential donors will deteriorate. Thus, it became important for physicians to be able to determine when the brains of mechanically-supported patients irretrievably ceased functioning.
• The increased viability of organ transplantation was not the only reason why it was felt important to include brain death as a criterion for determining death. Another reason was that the using up of scarce and expensive intensive care facilities by bodies without brain functions may preclude access to these facilities for patients with reversible conditions.
• All states of America use the same criteria to determine if death has taken place, but the states of New York and New Jersey are exceptional in that they do not preclude flexibility in accepting or rejecting a determination of death.
• “Each of us, man or beast, has his own peculiar odor, and it is mostly by this that the beasts of the jungle, endowed with miraculous powers of scent, recognize individuals. It is the final proof. You have seen it demonstrated a thousand times–a dog recognizes your voice and looks at you. He knows your face and figure. Good, there can be no doubt in his mind but that it is you; but is he satisfied? No, sir-he must come up and smell of you. All his other senses may be fallible, but not his sense of smell, and so he makes assurance positive by the final test.” From Tarzan, the Untamed.
• Being much trusted and favored by his employer, George had free liberty to come and go at discretion.
• GRE score is only one part of your application; a low GRE score does not preclude admission to a good program.
• The people whose inferior social position precluded them from entering the king’s palace looked in at the festivities from the road.
• Uriah Heep is a character in Charles Dickens’ David Copperfield. The novel is narrated by the hero David, who describes Uriah Heep as cadaverous. Here is David’s first impression of Uriah Heep (the words in bold or italics have been thus emphasized by me):

When the pony-chaise stopped at the door, and my eyes were intent upon the house, I saw a cadaverous face appear at a small window on the ground-floor (in a little round tower that formed one side of the house), and quickly disappear. The low arched door then opened, and the face came out. It was quite as cadaverous as it had looked in the window. . . it belonged to a red-haired person-a youth of fifteen, so I take it now, but looking much older – whose hair was cropped as close as the closest stubble; who had hardly any eyebrows, and no eyelashes, and eyes . . . so unsheltered and unshaded, that I remember wondering how he went to sleep. He was high-shouldered and bony; dressed in decent black, with a white wisp of a neckcloth; buttoned up to the throat; and had a long, lank, skeleton hand, which particularly attracted my attention, as he stood at the pony’s head, rubbing his chin with it, and looking up at us in the chaise.

“Is Mr. Wickfield at home, Uriah Heep?” asked my aunt.

Chapter 15, David Copperfield by Charles Dickens

Later, at the end of this first meeting, David offers a friendly handshake to Uriah. However, when Uriah takes his hand, this is how David describes the experience:

But oh, what a clammy hand his was! as ghostly to the touch as to the sight! I rubbed mine afterwards, to warm it, AND TO RUB HIS OFF.

It was such an uncomfortable hand, that, when I went to my room, it was still cold and wet upon my memory.

Note how the words in italics all contribute to a picture of Uriah Heep as a rather creepy, spine-chilling creature: he had no eyebrows and eyelashes, his hand was like that of a skeleton, his touch was ghostly and left David’s hand feeling so cold that he needed afterwards to warm it by rubbing.

Such is the image conveyed by the word cadaverous.

References

My most-used resource for information and usage sentences in this article was Defining Death, the report submitted by the 1981 President’s Commission on Medical Ethics.