Ontologies and Epistemologies of Death: Sociological Perspectives on the ethical and the technological aspects of brain-death in Israel Sky

Gross, PhD
The definition of brain-death as equating the death of the individual began to emerge in the second half of the 20th century, and was eagerly accepted by most Western countries, with Japan showing some reticence and eventually passing a brain-death law in 1997. Israel passed a similar law more than a decade later. In 1968, the Harvard Committee1 formulated a convincing document positioning brain-death alongside the more traditional cardiopulmonary death. Scholars remain divided on the initial motivation that spawned this "brain-death" movement. Some portray an attempt to reconsider medical futility in cases where irreversibility has been ascertained, as in the newly coined "coma depass"2. Others contest the extent to which the movement can be disengaged from the contemporary demand of "fresh organs" (i.e. organs from heart-beating bodies) by a burgeoning enterprise of organ transplant. In Israel, the decision to have the "organ donation"3 and the "brain-respiratory death" laws passed on the same day of 2008 has done nothing to ease the already burning controversy with which the concept of brain-death has been received. Indeed, putting aside the utilitarian overtones of organ donation, the epistemological, technical and conceptual complex of brain-death did not easily fit into the strongly held and defended Jewish definition of death. Traditional Jewish sources stipulate that a person may be presumed dead (or "soulless, not having a neshama) upon the loss of breath (neshima). Over the years, a cardiac criterion has been grafted onto that tradition, engendering a cardiopulmonary basis for the determination of an individuals death. Understood literally, these views suggest that brain activity per se plays no role, neither as a technical criterion nor as a concept to be recognised in the consideration of life, and indeed, of death. Accordingly, some of the most important rabbinical figures entirely rejected the notion of brain-death, openly referring to physicians removing organs from brain-dead individuals as plain "murderers". Others, including those influential in the state-affiliated Chief Rabbinate, agreed to deliberate with medical authorities and pursued a thorough understanding of the biological and physiological issues. At one notable occasion, a live experiment was orchestrated in a large Jerusalem hospital, where a beheaded sheep was put on life-support only to give birth to a healthy lamb. As decapitation is considered by Judaic sources to be an indisputable sign of death, the sheep was shown to serve merely as a biological incubator, with only a seeming of "life". A brain-dead or "physiologically decapitated" human, would thus be as "alive" as the headless sheep. However one is to interpret the "findings" of this experiment, rabbis were put to the test of reckoning traditional truisms with new scientific evidence. The complex dialectics of the styles of reasoning and modes of argumentations only added to what seemed inherently incommensurable. These, I believe, can only be understood once an attempt is made to disentangle orthodox religion and advanced science from their assigned monothetic associations with homogeneous sets of epistemologies, methodologies, and regimes of truth. Let us thus consider this state of affairs: One of the bitterest bones of contention may be the Chief Rabbinate's insistence that an "objective device" (such as angiographic imaging) be added to the list of already well accepted clinical examinations. Worldwide, one finds an overwhelming agreement for these tests to be used at

Harvard Ad Hoc Committee. (1968). Report of the Ad Hoc Committee of the Harvard Medical School to examine the definition of brain death. Journal of the American Medical Association, 205. 2 Mollaret, P., Goulon, M. (1959) The depassed coma (preliminary memoire). Revue Neurologique (Paris) 101:3-15 3 The law includes a clause according to which signing an organ donation card will provide the potential donor a status of priority on the national organ recipient list.

the discretion of the clinician, and not as part as any state legislated directive. The grounds for the rabbinical inflexibility regarding the "objective" test are still not well understood. This is especially intriguing considering the argument by which the naked eye should be able to intuitively confer that a person is dead ("lying like a stone"). Indeed, resistance to brain-death often relies upon the fact that the brain-dead individual has all the seeming of a live person: the body is warm, the skin is pink, and the chest is moving up and down. Even the monitor a technological proxy par excellence is trusted to show signs of life, as the graph never actually flattens. Hence, if death is a social event (and not, say, a mere biological or physiological turning point), one should be able to trust the commonsensical over black-boxed scientific arguments to the contrary. Seeking reassurance in novel techniques, often opaque to non-experts, seems almost antithetical to the concept of death as a phenomenon of lay experience, a concept which one would readily associate with traditional religious concepts. Adding to the singularity of this field is the initiation of two interrelated ventures4 both born out of the controversy surrounding the 2008 legislation: "Arevim", a group of on-call rabbis and physicians that can be sent for if a family wishes reassurance that the brain-death determination was made according to Jewish law; and "Bilvavi", a sectorial donor card that conditions organ donation upon the approval of Arevim. The representative from Arevim would have a unique professional and semi-professional status, combining specialised medical knowledge and religious authority. Placed in the sacrosanct of the biomedical institution, the ICU, he5 would have a special hold on the output of whichever objective device was used in the definition of death, and would thus be able to translate6 the ascertained 'truth' to the family which has entrusted him in this time of need: your loved one is effectively dead. In view of this unique case study, I propose researching the ways in which death is formed, performed and transformed not only ontologically but epistemologically as well, that is, in processes of translation and hermeneutics of "technology in practice"7. These formations include new styles of expertise (and thus, of fields of knowledge) but may also consist in enactments of knowledge: for instance, in the case of the decapitated sheep, what would in a Western philosophical tradition remain a thought experiment will be enacted as a narrated experience, a story that could later be told and retold in the same form as any Talmudic "case-in-point". Thus, this research will be aimed at an appreciation of the contexts in which the definition of death is contested, the claims for "truth" are made, and the boundaries8 of knowledge are drawn and redrawn by the different actors. Understanding the involvement of technology, ideology, religion, and science in the fight over what is real and what should be made real will be advanced by a careful analysis of the texts pertaining to the subject, both in lay and professional press, and by interviewing a range of central actors. In this history of the present, I will seek to understand the dynamics involving this intricate set of institutional actors and activists, and gain some insight into the ways these may reveal divergent styles of reasoning, argumentations and axiologies in the gravest of matters: life and death, biology and existence.
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Both Arevim and Bilvavi have a website, their own appointed officials and a promise for allocations of funds by the Ministry of Health but remain "phantom" institutions at the moment, after strong protest from medical bodies. 5 This person would be invariably male, of course. 6 The concept of translation as used in Science and Technology Studies is well shown in the classical work by Callon, M. (1986). Some elements of a sociology of translation: Domestification of the scallops and the fishermen of St Brieuc Bay. In:J. Law (Ed), Power, action and belief: A new sociology of knowledge (pp. 196233). London: Routledge. 7 See for instance: Mol, A. (2002). The body multiple: Ontology in medical practice. Durham, NC & London: Duke University Press. Timmermans, S. and Berg, M. (2003). The practice of medical technology. Sociology of Health & Illness, 25, 97114. 8 By this I refer to the notion of boundaries as defined by Gieryn, see for instance: Gieryn, T.F. (1999) Cultural Boundaries of Science: Credibility on the Line. Chicago: The University of Chicago Press.