The words covered in this article are futile and futility, prognosis, prognosticate and prognostication, concomitant, prophecy and prophesy, and agnostic. Previously done words that will reoccur today are advent, cessation, ambiguity, preclude, engender, discretion, infallible, discrepancy, cerebral, unequivocal, and skeptical.
From the advent of the stethoscope in 1816 to the 1960s, the determination of death was straightforward: the cessation of heart and lung function could be determined without ambiguity through a stethoscope and a cold mirror held close to the nose to check for condensation of breath.
However, once modern ventilators became available, the heart-lung criterion was quickly felt to be inadequate. It was feared that the number of permanently comatose patients maintained by mechanical ventilators in hospital ICUs would keep increasing every year. Furthermore, how could one know that a patient lying on an ICU bed was not in fact a long-dead body whose decomposition had been prevented by mechanical ventilation? ICU beds, mechanical ventilators, and the attention of nurses and doctors were all precious and limited resources – was it not unethical to waste them on futile care of patients who would never wake up when they could be used instead to save patients with a better prognosis?
Futile
The adjective futile means useless; incapable of producing any result. The noun form of the word is futility.
Prognosis
The noun prognosis is a medical term used to denote a prediction of the likely course and outcome of a disease, esp. of the chances of recovery. If Abe has a better prognosis than Bill, this means that Abe’s chances of recovering from whatever disease he is suffering are better than those of Bill.
Prognosis should not be confused with ‘diagnosis.’ A diagnosis is a statement of fact – the disease was already present in the body; the doctor or the diagnostic test has merely discovered it – while a prognosis is a prediction about what will happen in the future. For example, a patient may be diagnosed with malaria and, as the doctor fills the prescription slip, she will inform the patient about the prognosis of the disease with treatment. If the patient declares that he does not believe in taking medicine, the doctor may warn him about the prognosis without treatment.
The word prognosis is also used more generally in the sense of prediction. A related verb is prognosticate, which means to predict, based on symptoms or circumstances; itis not a medical term, and you’ll find the verb prognosticate and the noun prognostication used mainly in non-medical contexts.
You know now some of the difficult questions that were engendered by the artificial respirator and concomitant life-support systems.
Concomitant
The adjective concomitant means occurring together with something else and connected to it, simultaneous. The life-support systems that are concomitant with the artificial respirator are those that usually occur together with it, for example, artificial nutrition (tube feeding systems), blood glucose level management system, and mechanical devices that aid the heart in pumping blood to the body.
The word concomitant can also be used as a noun, in which case it means a thing that happens together with something else and is connected to it. For example, gray hair is a natural concomitant of ageing. The adverb form of the word is concomitantly.
The attractiveness of the concept of “brain death” increased concomitantly with the spread of life support systems in clinical medicine. Brain scans seemed like a sure way to know if a permanently comatose patient would recover or not. The heart, lung and in fact all organs of the body are directly or indirectly controlled by the brain. If the brain of a patient was found to be completely and irreversibly destroyed, then one could be certain that this person was not going to ever wake up again. Therefore, brain death was not a new kind of death. It was merely another way of seeing that death had occurred. Just as the family members of a patient could see when the heart of a person stopped beating or when condensation no longer formed on a cold mirror placed close to the nostrils, similarly, brain scans could now show family members the dead brain of their patient, and therefore, preclude any controversies about whether the person had actually died.
It’s understandable, therefore, why the President’s Commission decided to update the death criterion to include ‘brain death.’ However, the fact that the commission made this new definition legally binding and non-discretionary betrays its assumption that the tests that determined brain death were infallible and could determine the stopping of brain function with 100 percent accuracy.
Every measuring instrument has a least count, the minimum value that it can measure accurately. For example, the least count of an ordinary ruler is 0.1 cm while that of a vernier calliper is 0.01 cm. The brain scans that were administered on Jahi McMath measured the amount of blood flow to her brain. They too had a least count, a minimum value of blood flow that they could detect. If the flow was lower than that, they were not sensitive enough to pick it up and their reading simply showed ‘zero blood flow.’ It was on the basis of a ‘zero blood flow’ reading that Jahi was declared brain dead.
It has been well-documented that if dead people are maintained on artificial respirator, their brain undergoes total liquefaction. However, as earlier described on Day 5, Jahi’s brain scans done months after her supposed brain death showed remarkable structural preservation. The only way to reconcile this discrepancy between the expected and the actual result is to accept that Jahi’s cerebral blood flow must have been reduced to a level below the resolution of the initial brain scans done on her, in December 2013, days after her tonsillectomy, but there would never have been a time when the blood flow was zero or else her brain would not have retained its structure to the extent it did.
If a test result for a patient contradicts the primary caregiver’s observations, which should be trusted more? Jahi’s test results declared unequivocally that she was brain dead and brain-dead people, by definition, cannot be conscious; her mother, on the other hand, had video evidence to prove that she became conscious sometimes.
Of course, it was reasonable to be skeptical about the mother’s claims and to show abundant caution before accepting them. This was also the response of Alan D. Shewmon, the neurologist I quoted in Day 5. Fairness however demanded that for the period during which one was not sure about which of the two opposite claims was correct, one should suspend judgment and be skeptical about both. This was not what happened. Most medical practitioners, bioethicists, and common people had such absolute faith in the brain scan results that they could think of only one explanation for the video evidence of Jahi’s consciousness: it was doctored.
If Jahi’s case had had the same trajectory as most brain death diagnoses, she would have been removed from life-support a few hours or days after the death determination and given a funeral. The measurement error of a brain test would actually have taken her life. Her case was extraordinary because of how hard her family fought to maintain her life support in spite of the brain death verdict. In most cases, however, brain death becomes a self-fulfilling prophecy.
Prophecy
The noun prophecy means a declaration made by a prophet (a holy person who speaks by divine inspiration), especially a prediction of what is to come. The verb form of the word is prophesy (the noun has a ‘c’ in it while the verb has an ‘s’; another word-pair for which the ‘c’ in the noun chances into an ‘s’ in the verb is ‘advice’, a noun, and ‘advise’, a verb).
A self-fulfilling prophecy is such a prediction that comes true because we have made the prediction.If a patient’s brain scan result is a false positive for brain death, the doctor will not know this and, following protocol, will declare the patient to be dead; his life-support will then be removed, thereby causing his actual death. So, the death declaration will come true because the death declaration was made (incorrectly at the time of its making).
Jahi’s case has led to a fierce medical, legal and bioethical debate around the acceptance of brain death as a sufficient condition of death, especially as experience has also proved that some of the fears that had led to the inclusion of the ‘brain death’ criterion have not come to pass. To quote a bioethicist:
“[While] the fear that. . . without brain death, intensive care units (ICUs) would be full of neurologically devastated patients and we would not have room for others in need. . . may have had some validity then, it makes no sense now. The majority of deaths in ICUs today follow the withdrawal of life support from patients who are not brain dead, based on the patient’s poor prognosis. The vast majority of patients and families no more desire the use of life support when hopes for a meaningful recovery are lost than physicians and nurses desire to provide it. There is no evidence to support the fear that substantial numbers of families of brain-dead patients would insist on continued treatment if brain death were not recognized as biological death.”
Robert D. Truog, Boston Children’s Hospital and Harvard Medical School, Changing the Conversation About Brain Death
The last word for today is agnostic, which comes from the same Greek root as prognosis and prognostication.
The Greek word gnosis means ‘knowledge.’ Say out ‘gno’ and then ‘know’. They sound similar, don’t they? The English word ‘know’ is a cousin of the Greek gnosis. In Old English, all the ‘kn’ words, like ‘know’ and ‘kneel’, were pronounced with the ‘k’. The Sanskrit words gyaan and jaan (the one in jaan-pehchaan and jaankaari, not the ‘jaan bachi toh lakhon paaye‘ one) are also cousins of the Greek gnosis, having originated from the same IndoEuropean root word gno-, which means ‘to know.’
An ‘ignorant’ man is one who does not know anything. To ‘diagnose’ a disease means to know what it is from its symptoms. As the prefix pro- means ‘before’, prognosis means foreknowledge, to know beforehand what will happen.
Agnostic
An agnostic is a person who claims to not know for sure the answer to a particular question (the prefix a- means ‘without’). This word is used not in the context of questions that have straightforward answers – such as, what is the capital of India? – but in the context of questions that are more open-ended – such as, does God exist? The person who says “I don’t know” to the second type of questions is called an agnostic. This is a person who chooses to remain doubtful or noncommittal about the issue at hand. For example, when asked if God exists,
- Some people answer with an unequivocal “Yes, of course!” These are the believers, also called ‘theists’(Greek theos means ‘god’)
- People on the other end of the spectrum answer with a no that is full of certainty and confidence. These non-believers are labelled ‘atheists’ (Greek a-, without, + theos, god -> these are the godless people, meaning people who do not have god and religion in their lives)
- People in the middle of the spectrum, the agnostics, answer, “May be yes, may be no; I am not sure either way.”
With this, we come to an end of our discussion of possible ambiguity in the meaning of ‘death.’
Tomorrow, we will look at the ambiguous meaning of the word ‘worship.’ For now, here are a few more usage examples of the words you’ve learnt today:
- Most victims of the office-fire were killed not by the fire but by the concomitant smoke.
- The guards mercilessly beat the slave who had been caught within hours of running away from the farm. This unusually cruel public spectacle was intended to serve as an object-lesson to all other slaves about the dangers and futility of attempted escape.
- The heavy clouds prognosticated rain.
- When asked if organ transplant was compatible with Zen Buddhism, a research institute representing this religion admitted its agnostic view, stating that ‘Zen Buddhism does not provide a definitive argument for the acceptance or refusal of organ transplant.’
- If wishes were horses, beggars would be riders. Mere wishing solves nothing without concomitant action.
- “[The average British ghost] does love prophesying a misfortune . . . Send him out to prognosticate trouble to somebody, and he is happy. Let him force his way into a peaceful home, and turn the whole house upside down by foretelling a funeral, or predicting a bankruptcy, or hinting at a coming disgrace, or some other terrible disaster, about which nobody in their senses would want to know sooner than they could possible help, and the prior knowledge of which can serve no useful purpose whatsoever, and he feels that he is combining duty with pleasure.” Jerome K. Jerome
- “Being an agnostic means all things are possible, even God, even the Holy Trinity. This world is so strange that anything may happen, or may not happen. Being an agnostic makes me live in a larger, a more fantastic kind of world. . . It makes me more tolerant.” — Jorge Luis Borges
- “If a writer, despite his natural gifts, gives up writing because no one will publish him, then he is no writer. The artist is distinguished by his urge to create, which by very definition is a concomitant of talent.” — Andrei Tarkovsky
There are thousands to tell you it cannot be done,
There are thousands to prophesy failure,
There are thousands to point out to you one by one,
The dangers that wait to assail you.
But just buckle in with a bit of a grin,
Just take off your coat and go to it;
Just start in to sing as you tackle the thing
That “cannot be done,” and you’ll do it.
Edgar A. Guest