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Definition

Death is defined as the cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem), and breathing.

Description

Death comes in many forms, whether it be expected after a diagnosis of terminal illness or an unexpected accident or medical condition.

Terminal illness

When a terminal illness is diagnosed, a person, family, friends, and physicians are all able to prepare for the impending death. A terminally ill individual goes through several levels of emotional acceptance while in the process of dying. First, there is denial and isolation. This is followed by anger and resentment. Thirdly, a person tries to escape the inevitable. With the realization that death is eminent, most people suffer from depression. Lastly, the reality of death is realized and accepted.

— L. Fleming Fallon, Jr., MD, DrPH

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n.

1. The act of dying; termination of life.
2. The state of being dead.
3. The cause of dying: Drugs were the death of him.
4. A manner of dying: a heroine's death.
5. often Death A personification of the destroyer of life, usually represented as a skeleton holding a scythe.
6. 1. Bloodshed; murder.
   2. Execution.
7. Law. Civil death.
8. The termination or extinction of something: the death of imperialism.

idioms:

at death's door

1. Near to death; gravely ill or injured.

be the death of

1. To distress or irritate to an intolerable degree.

death on

1. Opposed to or strict about: Our boss is death on casual dressing.

put to death

1. To execute.

to death

1. To an intolerable degree; extremely: worried to death.

[Middle English deeth, from Old English dēath.]

Cessation of life functions. This can involve the whole organism (somatic death), individual organs (organ death), individual cells (cellular death), and individual parts of cells (organelle death). Although the next smaller level of organization, the macromolecules which make up the cell organelles, may also cease to function, their disintegration is ordinarily not spoken of as death.

Pathogenesis

A normal animal, cell, or organelle exists in a normal state of homeostasis, or a normal “steady state.” Following a disturbance of the normal steady state, referred to as an “injury,” the living system can be assumed to undergo a change in steady-state level, that is, to exhibit an altered steady state. Such altered steady states can be regarded as having increased, decreased, or unaltered levels of ability to maintain homeostasis. An altered steady state with increased homeostatic ability might include the hypertrophy of a muscle cell resulting from continued exercise; and altered steady state with decreased homeostatic ability is the atrophy or shrinking of cells that occurs following disuse or lack of stimulation by hormones or suitable nutrients. In the case of injuries that do not result in the death of the living system, the system may persist in one of the new or altered steady states for long periods up to many years; that is, although the system differs significantly from the normal steady state, it is able to continue its existence and to maintain homeostasis. On the other hand, certain severe injurious stimuli result in an altered state that ultimately passes a point beyond which recovery of homeostatic ability is impossible even if the injurious stimulus or situation is removed. This point may be considered as a point of no return or the point of death of the living system. Following this point, the system undergoes exponential decay, leading to complete equilibrium with its environment. This period of decay, which is characterized by reactions resulting in the breakdown of structural components of the system, is referred to as necrosis. See also Homeostasis.

Somatic death

In the biological sense, somatic death refers to the cessation of characteristic life functions. In higher organisms it can be assumed to result from an interplay between the genetic background of the individual and the effects of the environment. Death is, in a sense, the price of differentiation; in another sense, protoplasm is immortal and all life springs from preexisting life. The undifferentiated amebas need never die, only divide. It would appear that death is inevitable for higher organisms such as mammals and, in a sense, life is a series of little deaths.

Developments in medicine and associated technology involving supportive therapy, resuscitation, hypothermia, extracorporeal circulation, and organ transplantation have reopened serious questions regarding the definition of when an individual is “dead.” The vagueness and inconsistency in previous legal and medical definitions have led to serious dilemmas. These are of particular importance in the selection of donors for transplantation of vital organs such as the heart.

Medical techniques have shown that individuals can be sustained for prolonged periods without spontaneous respiratory or cardiac movements as well as without electrical evidence of central nervous system activity. These techniques have also achieved the resuscitation of individuals who would formerly have been considered dead and have clearly shown the survival of transplanted organs from cadavers. Just as organs may survive after the death of the organism, the organism, properly supported by mechanical or other means, can survive the death of organs, including the brain.

The following are changes that occur in the body after somatic death: 1. Cooling (algor mortis) of the body occurs postmortem. 2. Rigidity (rigor mortis) or stiffening of the musculature usually begins within 5–10 h and begins to disappear after 3 or 4 days. 3. Staining (livor mortis) occurs, that is, there is reddish-blue discoloration in the dependent portions of the body resulting from the gradual gravitational flow of unclotted blood. 4. Blood begins to clot shortly after death and sometimes prior to cessation of cardiac function. 5. Autolysis (necrosis) occurs in the cells of the body following somatic death. 6. Putrefaction, bacterial and enzymatic decomposition, begins shortly after death, caused by microorganisms which enter the body.

Organ death

Following somatic death, all organs do not die at the same rate. Length of survival can be prolonged by reducing the temperature of the organs to near 32°F (0°C), which appreciably retards metabolic function and extends survival time. This survival of organs after the death of the host forms the basis for organ transplantation from cadavers.

Cellular death

Death and subsequent necrosis of cells form an important part of many reactions of cells to injury in disease states. The death and disintegration of cells within a living animal incite a vascular reaction called an inflammatory reaction on the part of the host. It is characterized by a series of vascular phenomena which include the migration of leukocytes (white blood cells) from the blood capillaries into the area of tissue damage with subsequent digestion and phagocytosis of the cellular debris resulting from cellular necrosis.

Issues

The advancements of modern medicine have brought significant changes in the ways of life and death, and challenge former concepts and definitions of death. As the determination of death becomes increasingly complex in a technological society, the definition of death becomes correspondingly more complex. The meaning of death is a philosophical concept which lies outside the scientific point of view. Although dying is a process which may continue over a considerable period of time, for all practical purposes death occurs at that point where there is an irreversible loss of one's essential human characteristics. Such loss indicates the death of the organism as a whole, the death of a person.

An interdisciplinary committee at the Harvard Medical School examinined possible new criteria for determining death. In 1968 they cited four criteria as determinative of a permanently nonfunctioning brain: unreceptivity and unresponsivity to externally applied stimuli and inner need; absence of spontaneous movements of breathing; absence of reflexes other than spinal column reflexes, and fixed dilated pupils; and a flat electroencephalogram (EEG) to be used as a confirmatory but not mandatory test.

These tests were to be repeated after 24 h, and in the absence of hypothermia or depressant drugs, were to be considered a confirmation of brain death. It has since been conclusively demonstrated that when the flow of blood to the brain has been interrupted for approximately 15 min there is a uniform necrosis and liquefaction of the brain. This definition appears to be a major milestone in determining new criteria for making the determination that death has occurred.

With regard to the issue of organ transplantation, it is contrary to moral intuitions that a dying person might be prematurely defined as dead in order that someone else might harvest the organs. A moral obligation exists to treat the living as such until death occurs. To avoid a conflict in the role of the physician, it has become common practice that the physician for the recipient of an organ donation is not party to the judgment that the donor has died. The needs of a patient for a viable organ must not contaminate the judgment that another person has died.

The ability to define death with more precision is important in cases involving the comatose patient. It is generally accepted as both a moral and legal right that competent persons have the right to refuse medical treatment. Increasingly, dying patients claim a more active role in self-determination regarding medical treatment in the final stage of life.

One of the more radical issues is that of actively ending the life of a suffering person or helping another to die through a positive action. Some ethicists see no moral distinction between removing life-support systems or life-saving medications which allow a patent to die and taking a direct action which causes a patient to die, since the intention and the consequence are the same in both cases. Others disagree, claiming that there is indeed a morally significant difference if a person dies of the underlying disease and is not made to endure still greater suffering by prolonging the dying process than if the person dies because another has caused the death through an intentional and fatal action.

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Termination of life. A death certificate is required by a life insurance company for a beneficiary to receive the death payment.

Reports of the first human heart transplants in 1967 made controversy over the definition of death seem as unprecedented as heart transplantation itself — a radically new issue produced by a radically new technology. But disagreements over the meaning of death long predated the 1960s, and such debates never were simply products of new technical knowledge. From the intense fear in the eighteenth and nineteenth centuries that people were being mistakenly buried alive, to current controversies over brain death, death has long been a contested and changing construct, shaped by scientific discoveries in resuscitation and vivisection, the changing social powers of the medical profession, and changing cultural values. If death means the end of life, defining death implies defining life — a long-contentious issue indeed.

1740-1880

For much of the eighteenth and nineteenth centuries, an intense fear of ‘premature burial’ haunted Western culture, from the tales of Edgar Allen Poe to European laws that imposed long waiting periods before interment. This concern was neither an isolated curiosity nor an outbreak of mass hysteria. Rather, it reflected major changes in the concept of death itself, prompted in large part by new scientific discoveries in resuscitation and experimental vivisection. For example, beginning in the 1740s a series of widely-publicized cases demonstrated that breathing and heartbeats could be restarted after they had stopped. To make sense of such resuscitations, London physician John Fothergill proposed that suspended animation was a curable form of death. Like a machine, life could be turned off and on; reanimation was a form of resurrection. However Fothergill's view was rejected by such vitalists as Scottish medical theorist William Cullen (1710-90). Cullen redefined death, not as the actual cessation of heart and lung functions, but as the loss of the potential for muscle and nerve activity (‘irritability’ and ‘sensibility’). His approach reconciled resuscitation with the belief that death was by definition irreversible. However, it offered no way of diagnosing when this vital potential had been lost, and thus no way of knowing for certain when resuscitation efforts should be ended. Others rejected both these new definitions of death, denying that ‘suspended animation’ was real. They postulated that undetectable levels of heart and lung activity must by definitions have been continuously present in all cases of successful resuscitation.

The mid seventeenth-century discovery that the heart and lungs could be maintained alive in an animal that had been decapitated also challenged concepts of death, by dramatizing the distinction between the death of an organism and the death of its component parts. The guillotine, invented by a doctor to make execution swifter and more humane, also seemed to demonstrate that human heads and bodies could show signs of separate life. Based on such observations, many eighteenth-century medical writers concluded that death was not a single event but a long process taking place at a succession of physiological levels, and that death could not be diagnosed with certainty until the process had concluded with decomposition of body tissues. Such doctors' doubts about their own ability to diagnose or define death played a key role in triggering the cultural concern that people were being buried alive.

However, the specific fear of premature burial was not simply a product of medical uncertainty. To make sure that their bodies would be dead before burial, some people requested that they be cremated or embalmed. Their terror of being buried alive was more than simply a fear of being mistaken for dead. Romantic fascination with the claustrophobia of isolated helpless confinement, anti-Semitic opposition to traditional Jewish rapid interments, and post-Enlightenment doubts about the afterlife helped shape medical uncertainty about death into the specific horror of being buried too soon.

1880-1960

While the fear of premature burial was triggered by the discoveries of eighteenth-century scientists and physicians, late nineteenth-century doctors generally concluded that new technologies, from the stethoscope to X-rays had solved the problem of diagnosing death. These new instruments did not resolve any of the underlying conceptual controversies over the meaning of death, but an unprecedented faith in technology, from the 1880s through the first half of the twentieth century, led both the medical profession and much of the lay public to stop expressing concern over the persisting philosophical uncertainties. The fear of premature burial never disappeared, but it was largely relegated to such marginal organizations as the Association for the Prevention of Premature Burial, an international group of vitalists, anti-vivisectionists, and anti-bacteriologists, united by their opposition to the growing philosophical materialism and social power of twentieth-century medicine. Women also were disproportionately active in this movement. Some opposed the new technological medicine for undermining nineteenth-century women's efforts to integrate moral and physical healing. Others worried that women were particularly at risk of premature burial, because women were believed to be especially susceptible to fainting spells, catatonic fits, and spiritual trances that mimicked death.

Dramatic new discoveries, including recoveries from prolonged hypothermia and successful animal head transplants, continued to complicate the era's concepts of death. The resulting uncertainties were widely debated by scientists and the public. Many physiologists agreed with Boston embryologist Charles Minot that organisms were illusory, and that life and death could be defined only at the cellular level. Alternatively, neurologists like Charles Sherrington redefined the life of an organism as the nerve-mediated capacity to integrate organ and tissue functions. Mass culture, from journalism to science fiction, avidly reported these discoveries and disputes. However, unlike in prior centuries, when such scientific developments sparked public panic, in the first half of the twentieth century they were represented as wonderful marvels of modern science, possibly leading to resurrection or immortality. Also, while physiologists, philosophers, and the public continued to ponder the meaning of death, few of this era's practitioners of clinical medicine joined the discussion.

Since 1960

The brain death debates that began in the late 1960s thus did not constitute an unprecedented change in the meaning of death. But the 1960s did mark two new developments: a revival of interest in the issue on the part of clinicians, and a change from optimism to renewed concern on the part of the public. In the late 1960s, several medical leaders such as Harvard University anesthesiologist Henry K. Beecher proposed that patients be declared dead if their brains had irreversibly lost all functioning, even if their other vital functions were being maintained by mechanical ventilators. At first, ‘brain death’ was explained primarily as a means of defending organ transplantation, and of protecting medicine against the era's renewed social criticism of professional authority. But in the early 1980s, this representation of the issue was dramatically reversed. Brain death now was promoted, not as a defence of medical technology against public criticism, but as a defence of the public against that technology's invasive indignities. Redefining death was understood as logically distinct from euthanasia, but each provided a different way to answer the same clinical question: when should a physician stop treating a patient? Growing public support for a ‘right to die’ and ‘death with dignity’ proved crucial to the rapid adoption in the US of the brain death legislation advocated in the 1981 report of the President's Commission on bioethics. To diagnose brain death, the commission specified that the patient must have suffered permanent loss of all brain functions, both ‘higher-brain’ based activities, such as consciousness, and basic brain stem reflexes, such as gagging and pupil constriction. Great Britain adopted slightly different criteria, promoted by Christopher Pallis, under which the permanent loss of brain stem functions was considered sufficient to diagnose brain death.

Despite the success of brain death legislation, the fear of being treated too long was added to, not substituted for, the fear of being abandoned too soon. Mass culture continued to link brain death with organ-stealing doctors, as in the 1977 book and subsequent motion picture Coma. Orthodox Jews, traditionalist Japanese, and ‘right to life’ supporters are all deeply divided over whether to accept any brain-based definition of death. Some African Americans expressed concern that brain death was being used to take organs prematurely from blacks for transplantation to whites.

On the other hand, many philosophers, such as pioneer bioethicist Robert Veatch, attacked ‘whole brain’ legislation as failing to resolve crucial conceptual ambiguities. They promoted various ‘higher-brain’ alternatives that define human death as the permanent loss of consciousness and personal identity — as in the persistent vegetative state.

Thus, while the whole-brain definition of death has won wide acceptance, death remains a controversial and contingent concept, as it has been for centuries, at the intersection of changes in physiological research, medical practice, social structure, and cultural values.

— Martin Pernick

Bibliography

• Pernick, M. S. (1988). Back from the grave: recurring controversies over defining and diagnosing death in history. In Death: beyond whole-brain criteria, (ed. R. M. Zaner), pp. 17-74. Kluwer Academic Publishers, Dordrecht and Boston.
• Pernick, M. S. (1999). Brain death in a cultural context: the reconstruction of death 1967-1981. pp 3-33 In The definition of death, (ed. S. Younger, R. Arnold, and R. Schapiro). Johns Hopkins University Press, Baltimore.
• President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1981). Defining Death. US Government Printing Office, Washington, DC

See also brain death; coma; corpse; euthanasia; funeral practices; life support; organ donation; resurrection; resuscitation; transplantation; vegetative state; zombie.

noun

1. The act or fact of dying: decease, demise, dissolution, extinction, passing, quietus, rest. Slang curtain (used in plural). See live/die.
2. A termination of life, usually as the result of an accident or a disaster: casualty, fatality. See live/die.

Idioms beginning with death:
death of
death and taxes, certain as
death on

See also at death's door; be the death of; bore to death; catch cold (one's death); fate worse than death; in at the death; kiss of death; look like death (warmed over); matter of life and death; put to death; scare out of one's wits (to death); sign one's own death warrant; thrill to pieces (to death); tickled pink (to death); to death. Also see under dead.

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n

Definition: end of life
Antonyms: being, birth, entity, existence, life, living

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n
deth

1. cessation of life; the stoppage of life beyond the possibility of resuscitation. n 2. the cause or occasion of loss of life. n 3. the total absence of activity in the brain and central nervous system, the cardiovascular system, and the respiratory system as observed and declared by a physician or other legally authorized agent.

Concerning death, the Bible is primarily occupied with two questions: 1) Why must man die, and what is the force that deprives him of life? 2) What is man's fate after death? In Genesis 3:19, God informs man that he will return to the earth from which he was taken. On the other hand, after his temptation in the Garden of Eden, man was expelled lest he eat from the Tree of Life and become immortal (Gen. 3:22-23), suggesting that death is the result of sin. Various attempts have been made to reconcile the contradiction. Alongside the strict monotheism of the Bible, modern scholarship finds certain literary devices that may be traces of a conception, existing in the Ancient Near East, that death was a supernatural power independent of God (see, e.g., Isa. 25:8; Jer. 9:20; Hos. 13:14; Prov. 16:14; Job 18:13). Nevertheless, God remains the supreme arbiter of life and death. Concerning man's fate after death, the pronouncement of Genesis 3:19, that man will return to the dust of the earth, negates the Egyptian idea that led to the embalming of the Pharaohs. Burial, particularly in the family tomb, is clearly of paramount concern to the Bible (Gen. 47:29-30, 49:29; I Kings 21:19). Sacrificing to the dead and communicating with them, although common in the Ancient Near East, are forbidden in the Pentateuch (Deut. 26:14). Many biblical passages indicate that all human beings descend to a region "inhabited" by the dead. This region is known by various names, most notably sheoI, a name that appears in no other ancient language and is used as a proper noun---never appearing with the definite article (e.g., Gen. 37:35). Death, in this view, is the great equalizer; wealth and power are meaningless in sheol (Job 3:13-19). Nor does consciousness continue after death (Eccl. 9:4, 5; Job 14:21; Ps. 88:12, 13). On the other hand, a few passages indicate a different conception---that God may save man from sheoI and take the individual to Himself, e.g., Enoch and elijah (Gen. 5:24; II Kings 2:11; Ps. 49:16; I Sam. 2:6). Clear allusion to Resurrection of the dead appears in the later books of the Bible (e.g., Dan. 12:2). Thus the sources on the fate of man after death hardly present a unified picture (see Afterlife). The halakhah discusses the determination of the exact moment of death. The Talmud (Yoma 85a), in its discussion of Sabbath violation in order to save a life, rules that death occurs when breathing has ceased. With the development of modern medical technology, the halakhic definition of death has been subject to various refinements. It is now possible to detect respiration in individuals who previously would have been considered dead, or to resuscitate those whose breathing has stopped. R. Moses Sofer (Ḥatam Sofer, YD 338) indicated that death is considered to have occurred when there has been both respiratory and cardiac arrest. R. Moses Feinstein (Iggerot Mosheh, YD 3:132) ruled that a person is considered to have died with the death of his brain stem, since he is then incapable of breathing on his own. A critically ill person hovering between life and death (Heb. goses) is, in all respects, considered to be alive. The verbal instructions of a goses have the same legal force as a signed and witnessed document (Git. 13a), and thus a deathbed change of will and testament is recognized as binding. It is forbidden to hasten the death of a goses by any action to his body (YD 339). It is permitted, however, to remove some external obstacle which may be preventing his death. The example given is the case of noise outside the window, such as the chopping of wood, which may be preventing the goses from dying. In such a case, the noise may be stopped (ibid., gloss of the Rema). R. Ḥayyim Palache ruled that it is permitted to pray for the death of a critically ill person who is suffering terribly and wishes to die (Ḥikkekei Lev 1, YD 50). The Jewish attitude towards death, as developed in rabbinic literature, is a combination of defiance and acceptance. Since Judaism does not negate the reality of the here and now, death is to be fought; Life is to be cherished and preserved. Death is an evil. Early death is viewed as a misfortune and longevity as a blessing. God promises Abraham that he will live to "a ripe old age" (Gen. 15:15) and it is customary to wish one's acquaintances a life of 120 years' duration. Ritually, a Corpse is the most intense source of impurity (see Purity and Impurity). The halakhah takes it for granted that no effort will be spared to save a dying patient (see Medical Ethics), and the Talmud (RH 16b) reports that a change of name may avert a harsh decree. The custom therefore developed of executing a formal name change on behalf of one seriously ill. Most commonly, a symbolic name such as Ḥayyim ("life") or Raphael ("God heals") is given. Even after a death, the spirit of defiance is maintained. During the Mourning period, it is customary to recite the verse from Isaiah (25:8) which states that "God will destroy death forever." On the other hand, Judaism has a strong element of acceptance. The Midrash (Gen. R. 9:5) offers the opinion that when God declared the world He had created to be "very good," he was referring to death, implying that God created death to be a positive and necessary part of the universe. The Tsidduk ha-Din prayer, recited by mourners at the Funeral Service, describes God as the righteous Judge and accepts the finality of His decrees. As indicated in the text of the confession (see inset), the individual's death is considered to be the most powerful possible atonement for his sins. Maimonides (Yad, Teshuvah 1:4) delineated the various means of Atonement, but for sins involving the desecration of God's Name only death can bring full atonement. The sages of the Talmud believed, and this was accepted as fundamental Jewish doctrine, that the soul returns to God (see Soul, Immortality of). Judaism stipulates that the utmost regard be shown for both the dying and the body after the soul has departed. A dying person is not to be left alone, and it is considered meritorious to be present at the moment of death. When informing a dying patient of his responsibility to confess, every effort must be made to avoid frightening him or causing him to lose hope. The ill person should be told: "Many have confessed but have not died, and many who have not confessed have died. And many who are walking outside in the marketplace have confessed. By the merit of your confessing, you live. All who confess have a place in the world to come" (YD 338:1). (Confession in Judaism does not have the status of a final sacrament as do the last rites of the Catholic Church.) All present at the moment of death recite the blessing, Barukh Dayyan Ha-Emet ("Blessed be the True Judge"), and relatives recite the Tsidduk ha-Din. Arrangements made for care and burial of the body are known as ḥesed shel emet (true kindness), since they are made on behalf of one no longer capable of responding in kind. After death has been finally established, the eyes and mouth are closed and the mouth, if need be, tied shut. The body is placed on the floor and covered with a sheet, with a lighted candle close to the head. In the home of the deceased, mirrors are covered and any standing water poured out (YD 339:5). The origin of these last two customs is unclear; they may have been a method of announcing the death to those entering the house or they may be a relic of folklore and Superstition. Respect for the dead is basic: a dead body is not to be left alone; sitting with the body is considered a mitsvah and it is desirable to read Psalms in its presence. The watcher over the body is exempt from prayers and from putting on Tefillin<tohorah) and clothed in shrouds (takhrikhin). Mourners pray for God's mercy on the soul of the deceased. Some have the custom of visiting the graves of loved ones and saintly people, asking their souls to pray on behalf of the living. These two practices indicate the belief in an ongoing connection between the living and the dead.

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Beliefs and customs surrounding death are well documented at all periods and most social levels. Historical and literary writings amply describe those of the educated classes, while folklorists recorded any beliefs or practices among the ‘folk’ which were not part of official religion, or which struck them as differing from middle-class norms in an archaic or picturesque way. There is almost invariably a section on death and funerals in books on regional folklore, where the customs described vary very little; quotations illustrating the ‘superstitious’ beliefs can be conveniently found in Opie and Tatem (1989) under the relevant headwords.

Formerly, it was widely believed (and to some extent still is) that dreams and omens provide forewarnings of death, for oneself or another; there was a great variety of the latter, mostly drawn from the behaviour of animals and birds, or from simple household occurrences such as a picture falling, sudden creaking or rapping sounds, and so on. For the bereaved, such events hold great emotional significance, which may, paradoxically, be comforting; they suggest that death is part of a destined plan, not a mere accident. Also, until fairly recent times, there was a strong religious emphasis on the value of a ‘good death’, i.e. one fully prepared for, as opposed to a swift and sudden one; in this context, forewarnings were a blessing.

It was believed that certain things would ease, and others hinder, the process of dying. In many parishes, a church bell was rung as death drew near, the purpose of this ‘Passing Bell’ being to remind people to pray for the dying; in earlier times, it would also have been thought to drive away demons. An ebbing tide and a waning moon hastened death, but a pillow stuffed with feathers of pigeons or wild birds made it painfully slow, and should be removed. If the bed stood across the floorboards, rather than parallel to them, this too prolonged the agony, and it should be shifted. There are several references in folklore collections to relatives helping someone who was dying ‘hard’ by jerking the pillow away, lifting him out of bed and on to the floor, or even throttling him with tape, but some seem suspect, since they all end with the same words: ‘He went off like a lamb’. A more detailed account comes from the Fens, and refers to the late 19th century; the village nurse would speed death by laying the dying man's head on a special black pillow, making him unconscious with opium and gin, and then jerking the pillow away (Porter, 1958: 119).

As soon as death occurred, doors and windows must be opened, to give the soul free passage; in Warwickshire the main door of the house remained ajar, night and day, until the funeral, because the deceased's spirit is still nearby, and must be able to enter or leave at will (N&Q 170 (1936), 231). Some people also put out the fire and stopped the clocks, presumably to mark the transition from time to eternity. A common custom of the 19th century was to turn mirrors and pictures to the wall, or cover them with cloth; this was usually said to be for fear that someone looking into them should see the ghost, or the corpse, reflected there.

Until well into the 20th century, people normally died at home, where the corpse spent the interval between death and the funeral. The laying-out, which was done by hired women (often midwives), involved washing the body, closing its eyelids and weighting them with pennies until they stiffened, holding the mouth shut by a bandage beneath the chin, and tying the feet together. The washing was symbolic as well as practical; in 1980 a Suffolk woman explained, ‘the washing is so that you're spotless to meet the Lamb of God’ (Richardson, 1987: 19). The body would then be dressed in a shroud and white stockings, or stitched into a winding-sheet; in both cases, the face remained visible until just before burial. Sprigs of rosemary, yew, box, or rue were often tucked into the shroud; flowers might also be displayed in wealthier households. A more curious custom was to lay a pewter dish of salt on the breast of the corpse, or beneath the bed where it lay; occasionally, a piece of turf might be used instead (Leather, 1912: 120; Burne, 1883: 299). This was said to prevent the corpse swelling.

From medieval times to the early 18th century, it was usually considered essential, as a mark of respect, that the body should never be left alone in the room, even for a few moments, or be left in the dark; after that period, the custom gradually weakened among the upper classes, but country people and urban poor still often observed it. It was called ‘watching’ the dead, and required only one or two people to sit quietly near the corpse; it is not the same as the lively social wake, which is rare in English tradition. On the other hand, ‘viewing’ the dead was common—indeed, almost obligatory—for both adults and children until the 1920s and 1930s; those who had known the deceased came to offer condolences to the family, and spend a few moments looking at the body, usually also touching or kissing it; this would ease grief, and ensure that one would not dream of, or be haunted by, the dead person.

The effect, however, was not always soothing. A contributor to N&Q in 1914 remembered being taken ‘as a frightened child’ to view a body in a Derbyshire village. It was laid out with its feet on a Bible, a sprig of box in its folded hands, and a plate of salt on a green turf on its breast:

Round the chin was a white cloth tied in a knot on the top of its head, and the ‘laying-out woman’ was in the act of laying two penny-pieces on the eyelids; but she could not make them keep in position. This frightened me most of all, for the right eye seemed to be glaring at me; and the woman said to the rest in the room, ‘He's lowkin’ fer th'next un.' (N&Q 11s:11(1914), 296-7)

See also BURIAL, FUNERALS, SIN-EATING, WAKES (2).

Bibliography
The full bibliography list is available here.

• There is an excellent summary of this subject in Richardson, 1987: 3-29.
• See also Roud, 2003: 140-44
• Puckle, 1926
• Clare Gittings, Death, Burial and the Individual (1984)
• Litten, 1991: 143-52

Since death is the cessation of life, it cannot be experienced, nor be a harm, nor a proper object of fear. So, at least, have argued many philosophers, notably Epicurus and Lucretius. A prime consideration has been the symmetry between the state of being dead, and the state of ‘being’ not yet in existence. On the other hand death is feared, and thought of as a harm (even if it is instant: it is not the process of dying that makes the difference). The alternative, immortality, sounds better until the detail is filled in, when it can begin to sound insupportable (see Makropoulos case). The management of death is one of the topics of bioethics.

The point at which life in any of the six realms of rebirth ceases. In Buddhist thought, repeated death encapsulates the existential problem of life in saṃsāra, from which nirvāṇa is the only release. As such, death is ennumerated as an aspect of suffering (duḥkha) under the First Noble Truth (see Four Noble Truths). In the Pāli Canon death is defined in biological terms as the cessation of vitality (āyu), heat (usmā), and consciousness (viññāna, Skt., vijñāna) (e.g. S. iii. 143). Old age and death is also the twelfth link in the chain of Dependent Origination (pratītya-samutpāda). In Buddhist scholasticism (Abhidharma), it is held that death occurs from moment to moment as phenomena arise and perish within the individual life-continuum (see bhavaṇga). The last of these moments, known as the cuti-citta, is when existence in any life ceases. Death also has great symbolic significance, and is represented mythologically by the figure of Māra, the Buddhist devil.

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This entry contains information applicable to United States law only.

Death is the end of life. Dying is the process of approaching death, including the choices and actions involved in that process.

Death has always been a central concern of the law. The many legal issues related to death include laws that determine whether a death has actually occurred, as well as when and how it occurred, and whether or not another individual will be chargeable for having caused it. Increasingly, the law has had to deal with complex issues regarding the termination of medical care — such as when an artificial respirator or a feeding tube is withdrawn from a comatose person, or when chemotherapy is withheld from a terminally ill cancer patient. With the development of increasingly complex and powerful medical procedures and devices in the middle and late twentieth century, the U.S. legal system has established rules and standards for the removal of life-sustaining medical care. These laws and judicial decisions have established, for example, the right of individuals to refuse medical treatment — sometimes called the right to die — as well as the boundaries of that right, particularly as regards the state's interest in protecting life and the medical profession's right to protect its standards. The issues involved in death and dying have often pitted patients' rights groups against physicians' professional organizations as each vies for control over the decision of how and when people die.

Defining Death in the Law

The law recognizes different forms of death, not all of them meaning the end of physical life. The term civil death is used in some states to describe the circumstance of an individual who has been convicted of a serious crime or sentenced to life imprisonment. Such an individual forfeits his or her civil rights, including the ability to marry, the capacity to own property, and the right to contract. Legal death is a presumption by law that a person has died. It arises following a prolonged absence, generally for a prescribed number of years, during which no one has seen or heard from the person and there is no known reason for the person's disappearance that would be incompatible with a finding that the individual is dead (e.g., the individual had not planned to move to another place). Natural death is death by action of natural causes without the aid or inducement of any intervening instrumentality. Violent death is death caused or accelerated by the application of extreme or excessive force. Brain death, a medical term first used in the late 1960s, is the cessation of all functions of the whole brain. Wrongful death is the end of life through a willful or negligent act.

In the eyes of the law, death is not a continuing event but something that takes place at a precise moment in time. The courts will not wield authority concerning a death. The determination of whether an individual has died, and the way in which this is proved by the person's vital signs, is not a legal decision but rather a medical judgment. The opinion of qualified medical personnel will be taken into consideration by judges when a controversy exists as to whether an individual is still alive or has died.

Legal Death and Missing Persons

There is a legal presumption that an individual is alive until proved dead. In attempting to determine whether a person has died after having been missing for a certain period of time, the law assumes that the person is alive until a reason exists to believe otherwise.

The common-law rule is that where evidence indicates that the absent person was subject to a particular peril, she or he will be legally presumed dead after seven years unless the disappearance can be otherwise explained. The seven-year interval may be shortened if the state decides to enact legislation to change it. Some states may permit the dissolution of a marriage or the administration of an estate based on a mysterious disappearance that endures for less than seven years. A majority of states will not make the assumption that a missing person is dead unless it is reasonable to assume that the person would return if still alive.

A special problem emerges in a situation where a person disappears following a threat made on his or her life. Such an individual would have a valid reason for voluntarily leaving and concealing his or her identity. Conversely, however, the person would in fact be dead if the plot succeeded. A court would have to examine carefully the facts of a particular case of this nature.

In some states, the court will not hold that an individual has died without proof that an earnest search was made for her or him. During such a search, public records must be consulted, wherever the person might have resided, for information regarding marriage, death, payment of taxes, or application for government benefits. The investigation must also include questioning of the missing person's friends or relatives as to her or his whereabouts.

Death Certificates

The laws of each state require that the manner in which an individual has died be determined and recorded on a death certificate. Coroners or medical examiners must deal with issues establishing whether someone can be legally blamed for causing the death. Such issues are subsequently determined by criminal law in the event that someone is charged with homicide, and by tort law in the event of a civil suit for wrongful death.

Dying and End-of-Life Decisions

Because of the many changes in modern medicine, the nature of death and dying has changed greatly in the past several centuries. A majority of people in industrial societies such as the United States no longer perish, as they once did, from infectious or parasitic diseases. Instead, life expectancies range above seventy years and the major causes of mortality are illnesses such as cancer and heart disease. Medicine is able to prolong life by many means, including artificial circulatory and respiratory systems, intravenous feeding and hydration, chemotherapy, and antibiotics.

The cultural circumstances of death have changed as well. A 1988 study indicated that 85 percent of deaths in the United States occur in health care institutions, and of those, about 70 percent involve withholding some type of life-sustaining medical care. In 1990, it was estimated that of the 2 million deaths each year in the United States, 1.3 million followed decisions to withhold life support. The law has had to change and adapt in order to cope effectively with the new realities involved in death and dying in the United States.

Since the landmark decision of the New Jersey Supreme Court In re Quinlan, 70 N.J. 10, 355 A.2d 647, in 1976, the law has been greatly concerned with establishing the precise circumstances in which it is legal to withhold or withdraw various forms of life-supporting medical treatment. Quinlan established the first guidelines governing the removal of life-support systems from patients who no longer have the mental capacity, or competence, to make their own decisions. (See The Right to Die: Individual Autonomy and State Interests later in this article for details of the Quinlan case.)

Euthanasia

Allowing people to die by withdrawing or withholding life support is a form of euthanasia (a Greek word meaning "easy or good death") and is the only legally protected alternative in the United States to maximum health care treatment. Euthanasia is the act of killing an incurably ill person out of concern and compassion for that person's suffering. It is sometimes called mercy killing, but many advocates of euthanasia define mercy killing more precisely as the ending of another person's life without his or her request. Euthanasia is usually separated into two categories: passive euthanasia and active euthanasia. Withholding or withdrawing life-sustaining medical care is often classified as a form of passive euthanasia. Active euthanasia, sometimes called aid in dying, on the other hand, can consist, for example, of a physician's giving a patient a lethal injection of medication. It can also consist of a physician's providing the means for a patient to take his or her own life, as when a doctor prescribes a drug knowing that it will be used by the patient to commit suicide. This last form of active euthanasia is also called physician-assisted suicide (see Assisted Suicide later in this article). In the United States, active euthanasia is generally recognized as murder or manslaughter, whereas passive euthanasia is accepted by professional medical societies and the law in certain circumstances.

Euthanasia is a divisive topic, and different interpretations of its meaning, practice, and morality abound. Those who favor active euthanasia and a patient's right to die do not acknowledge a distinction between active and passive euthanasia. They assert that the withdrawal of life-sustaining treatment cannot be distinguished in principle from affirmative steps to hasten a patient's death. In both situations, they argue, a person intends to cause the patient's death, acts out of compassionate motives, and causes the same outcome. In their view, turning off a life-sustaining respirator switch and giving a lethal injection are morally equivalent actions.

Opponents of active euthanasia argue that it undermines the value of, and respect for, all human life; erodes trust in physicians; desensitizes society to killing; and contradicts many people's religious beliefs. Moreover, they maintain that the intentions and natures of active and passive euthanasia are not essentially the same. In active euthanasia, a person directly intends to cause death and uses available means to achieve this end. In passive euthanasia, a person decides against using a certain form of treatment and then directs that such treatment be withdrawn or withheld, accepting but not intending the patient's death, which is caused by the underlying illness.

The American Medical Association (AMA), in its Code of Medical Ethics, considers euthanasia to be different from the removal of life-sustaining medical care. Although accepting the removal of life support as a sometimes necessary duty of the physician to relieve suffering and obey the principle of patient self-determination, the AMA considers euthanasia — which it defines as "the administration of a lethal agent by another person to a patient" — to be a breach of professional ethics (Code of Medical Ethics, rule 2.21 [1994]).

Brain Death

In traditional Western medical practice, death was defined as the cessation of the body's circulatory and respiratory (blood pumping and breathing) functions. With the invention of machines that provide artificial circulation and respiration, that definition has ceased to be practical and has been modified to include another category of death called brain death. People can now be kept alive using such machines even when their brains have effectively died and are no longer able to control their bodily functions. Moreover, in certain medical procedures, such as open-heart surgery, individuals do not breathe or pump blood on their own. Since it would be wrong to declare as dead all persons whose circulatory or respiratory systems are temporarily maintained by artificial means (a category that includes many patients undergoing surgery), the medical community has determined that an individual may be declared dead if brain death has occurred— that is, if the whole brain has ceased to function, or has entered what is sometimes called a persistent vegetative state. An individual whose brain stem (lower brain) has died is not able to maintain the vegetative functions of life, including respiration, circulation, and swallowing. According to the Uniform Determination of Death Act (§ 1, U.L.A. [1980]), from which most states have developed their brain death statutes, "An individual who has sustained either (1) irreversible cessation of circulatory and respiratory function, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead."

Brain death becomes a crucial issue in part because of the importance of organ transplants. A brain-dead person may have organs — a heart, a liver, and lungs, for example — that could save other people's lives. And for an individual to be an acceptable organ donor, she or he must be dead but still breathing and circulating blood. If a brain-dead person were maintained on artificial respiration until her or his heart failed, then these usable organs would perish. Thus, the medical category of brain death makes it possible to accomplish another goal: saving lives with organ transplants.

The Right to Die: Individual Autonomy and State Interests

The first significant legal case to deal with the issue of termination of life-sustaining medical care was Quinlan. This 1976 case helped resolve the question of whether a person could be held liable for withdrawing a life-support system even if the patient's condition is irreversible. In 1975, Karen Ann Quinlan unexplainedly became comatose and was put on a mechanical respirator. Her parents authorized physicians to use every possible means to revive her, but no treatment improved her condition. Although doctors agreed that the possibility of her recovering consciousness was remote, they would not pronounce her case hopeless. When her parents themselves lost all hope of Quinlan's recovery, they presented the hospital with an authorization for the removal of the respirator and an exemption of the hospital and doctors from responsibility for the result. However, the attending doctor refused to turn off the respirator on the grounds that doing so would violate his professional oath. Quinlan's parents then initiated a lawsuit asking the court to keep the doctors and the hospital from interfering with their decision to remove Quinlan's respirator.

In a unanimous decision, the New Jersey Supreme Court ruled that Quinlan had a constitutional right of privacy that could be safeguarded by her legal guardian; that the private decision of Quinlan's guardian and family should be honored; and that the hospital could be exempted from criminal liability for turning off a respirator if a hospital ethics committee agreed that the chance for recovery is remote. Quinlan was removed from the respirator, and she continued to live in a coma for ten years, nourished through a nasal feeding tube.

In cases following Quinlan, courts have ruled that life-sustaining procedures such as artificial feeding and hydration are the legal equivalent of mechanical respirators and may be removed using the same standards (Gray v. Romeo, 697 F. Supp. 580 [D.R.I. 1988]). Courts have also defined the right to die according to standards other than that of a constitutional right to privacy. The patient's legal right to refuse medical treatment has been grounded as well on the common-law right of bodily integrity, also called bodily self-determination, and on the liberty interest under the Due Process Clause of the Fourteenth Amendment. These concepts are often collected under the term individual autonomy, or patient autonomy.

Subsequent cases have also defined the limits of the right to die, particularly the state's interest in those limits. The state's interests in cases concerning the termination of medical care are the preservation of life (including the prevention of suicide), the protection of dependent third parties such as children, and the protection of the standards of the medical profession. The interests of the state may, in some cases, outweigh those of the patient.

In 1990, the U.S. Supreme Court issued its first decision on the right-to-die issue, Cruzan v. Director of Missouri Department of Health, 497 U.S. 261, 110 S. Ct. 2841, 111 L. Ed. 2d 224. Cruzan illustrates the way in which individual and state interests are construed on this issue, but leaves many of the legal questions on the issue still unresolved. Nancy Cruzan was in a persistent vegetative state as a result of severe brain injuries suffered in an automobile accident in 1983. She had no chance of recovery, although with artificial nutrition and hydration could have lived another thirty years. Her parents' attempts to authorize removal of Cruzan's medical support were first approved by a trial court and then denied by the Missouri Supreme Court. Her parents then appealed the case to the U.S. Supreme Court.

The Court held that the guarantee of liberty contained in the Fourteenth Amendment to the Constitution does not prohibit Missouri from insisting that "evidence of the incompetent [patient's] wishes as to the withdrawal of treatment be proved by clear and convincing evidence." The Court left other states free to adopt this "clear-and-convincing evidence" standard but did not compel them to do so. Thus, existing state laws remained the same after the Cruzan decision. Although the Court affirmed that a competent patient has a constitutionally protected freedom to refuse unwanted medical treatment, it emphasized that an incompetent person is unable to make an informed choice to exercise that freedom. The Court explained that the state has an interest in the preservation of human life and in safeguarding against potential abuses by surrogates and is therefore not required to accept the "substituted judgment" of the patient's family. The Court agreed with the Missouri Supreme Court ruling that statements made by Cruzan to a housemate a year before her accident did not amount to ‘‘clear and convincing proof" that she desired to have hydration and nutrition withdrawn. Cruzan had allegedly made statements to the effect that she would not want to live should she face life as a "vegetable." There was no testimony that she had actually discussed withdrawal of medical treatment, hydration, or nutrition.

After the Court's decision, Cruzan's parents went back to the Missouri probate court with new evidence regarding their daughter's wishes. On December 14, 1990, a Missouri judge ruled that clear evidence of Cruzan's wishes existed, and permitted her parents to authorize withdrawing artificial nutrition and hydration. Cruzan died on December 27, twelve days after feeding tubes were removed.

A court must consider many factors and standards in right-to-die cases. It must determine, for example, whether a patient is competent or incompetent. A competent patient is deemed by the court to be able to give informed consent or refusal relative to the treatment under consideration, whereas an incompetent patient (e.g., a patient in a coma) lacks the decision-making capacity to do so. According to the principle of individual autonomy, the court must honor the informed consent of competent patients regarding their medical care. For incompetent patients who cannot make informed decisions regarding their care, an advance directive may provide a means of decision making for the termination of life-supporting treatment.

An advance directive gives patients some control over their health care after they have lost the ability to make decisions owing to a medical condition. It may consist of detailed instructions about medical treatment, as in a living will; or the appointment of a proxy, or substitute, who will make the difficult choices regarding medical care with the patient's earlier directions in mind. The appointment of a proxy is sometimes called a proxy directive or durable power of attorney. Sometimes, the patient appoints a proxy decision maker when he or she is competent; often, the physician appoints a proxy. Usually, a relative such as a spouse, adult child, or sibling is chosen as a proxy. Sometimes, the court appoints a legal guardian who acts on behalf of an incompetent person. If an advance directive provides adequate evidence of a patient's wishes, a decision about the termination of life support can often be made without involving a court of law.

For an incompetent patient whose preferences regarding medical care are known from prior oral statements, the patient's proxy may make a substituted judgment — that is, a judgment consistent with what the patient would have chosen for herself or himself. If no preference regarding medical treatment is known, the standard for the proxy's decision is the "best interests of the patient." According to that standard, the proxy's decision should approximate what most reasonable individuals in the same circumstances as the patient would choose.

By 1991, over forty states had living-will statutes, and all fifty states had durable-power-of-attorney statutes that allowed an individual to appoint a proxy decision maker. By the early 1990s, proxy directives had become a preferred alternative to living wills. Most living-will statutes are applicable only to patients who are terminally ill, limit the types of treatment that can be refused, and require a person to predict accurately his or her final illness and what medical interventions might be available at that time. Only a small minority of adults in the United States have executed advance directives.

Assisted Suicide

Despite the many advances in medicine's ability to control pain, some terminally or chronically ill patients experience what they consider to be an intolerable decline in quality of life. This situation has led to a call for a practice known as physician-assisted suicide, in which a doctor helps a patient take her or his own life. However, assisted suicide, even by a physician, is a felony offense in most states. Moreover, the AMA considers physician-assisted suicide a violation of professional ethics (Code of Medical Ethics, rule 2.22 [1994]).

<>Physician-assisted suicide received greater public attention after Jack Kevorkian, a retired pathologist from Michigan, participated in his first such procedure in 1990. Kevorkian set up a machine that allowed a fifty-four-year-old woman suffering from Alzheimer's disease (a degenerative neurological condition) to press a button that delivered a lethal poison into her veins. Kevorkian went on to assist in the suicides of dozens of individuals suffering from terminal, debilitating, or chronic illnesses. In 1992, Michigan passed an assisted suicide bill (Mich. Comp. Laws § 752.1021) specifically designed to stop Kevorkian's activities, but technicalities and questions as to its constitutionality delayed its implementation, allowing Kevorkian to continue assisting suicides — often in direct opposition to court injunctions.

Kevorkian has been charged with murder several times but has never been found guilty. When murder charges were brought against him for his first three assisted suicides, for example, they were dismissed because Michigan at that time had no law against assisted suicide. In 1994, Kevorkian was tried and found not guilty of assisting in the August 1993 suicide of Thomas W. Hyde, Jr. However, in December 1994, Michigan's supreme court ruled in People v. Kevorkian, 447 Mich. 436, 527 N.W. 2d 714, that there is no constitutional right to commit suicide, with or without assistance, and upheld the Michigan statute making assisted suicide a crime. The following year, the U.S. Supreme Court refused to hear Kevorkian's appeal from the state supreme court's ruling (Kevorkian v. Michigan, ___U.S.___, 115 S. Ct. 1795, 131 L. Ed. 2d 723).

Observers disagree about the humanity of Kevorkian's activities. Some see him as a hero seeking to give suffering people greater choice and dignity in dying. Others point to his lack of procedural precautions and fear that the widespread practice of assisted suicide will lead to the unnecessary death of people who may have been helped by other means, including treatment for depression. Many opponents of assisted suicide find the same faults in the practice that they see in other forms of euthanasia. They envision its leading to a devaluation of human life and even a genocidal killing of vulnerable or so-called undesirable individuals.

More than thirty states have passed statutes criminalizing assisted suicide. The statutes forbid a person to knowingly assist or aid another in committing suicide. Some also prohibit soliciting, advising, or encouraging another to commit suicide. Some statutes penalize assisted suicide under guidelines established for murder or manslaughter, whereas others make it a unique offense with separate penalties. Few courts have interpreted the assisted suicide statutes, because prosecutions for assisted suicide are rare. In cases of assisted suicide, a state usually prosecutes individuals for murder or manslaughter.

See: physicians and surgeons.

Accounts of the moments before and after death abound with reports of paranormal phenomena, including apparitions of the dying in distant places and phantom forms seen by the dying and occasionally by others. Such near-death apparitions remain a topic of intense debate in both psychological and parapsychological circles. Those who accept a psychic explanation of near-death experiences assert that the individual's spirit, when near to being freed from its connection to the body, is immersed in two planes of existence and acts in both the material and spiritual worlds. Many reports also exist in which persons who were dead returned to life and remembered their experience of death. They verify an often-told story that in the last moments of earthly existence a panorama of the person's life flashes by.

Near-Death Experiences

A Professor Heiron of Zurich slipped in the Alps on a snow covered crag, slid head first about a mile, and then shot 60 feet through the air, landing on his head and shoulders. He was not killed. Returning to consciousness, he not only testified to having seen a panoramic view of his life but also said he had heard the most delightful music. He interviewed many people who had a similar experiences; the great rapidity of mental action and the absence of terror and pain was narrated by all of them.

Prof. A. Pastore of the Royal Lyceum at Genoa relates his experience in the Annals of Psychic Science of February 1906: "I have been through a very severe illness. At the crisis, when I had entirely lost consciousness of physical pain, the power of my imagination was increased by an extraordinary degree, and I saw clearly in a most distinct confusion (two words which do not accord, but which, in this case, are the only ones which will express the idea). I saw myself as a little boy, a youth, a man, at various periods of my life; a dream, but a most powerful, intense living dream. In that immense, blue, luminous space my mother met me—my mother who had died four years previously. It was an indescribable sensation. Rere