Death

• 1. Introduction

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  Death is the end of life, the irreversible cessation of the biological functions that sustain a living organism. As of the early 21st century, 56 million people die per year. As of 2022, an estimated total of almost 110 billion humans have died, roughly 94% of all humans who have ever lived. And yet, for something so universal, the single hardest question is also the simplest. When, exactly, does it happen? A heart stops, then restarts under a doctor's hands. A brain falls silent, yet the body it served keeps healing wounds and fighting infections. Some creatures, like the immortal jellyfish, never have to age at all, though they can still be killed. This is a documentary about the line between life and its absence, and about how slippery that line turns out to be. It asks who decides the moment of death, what the body does in the hours and years after, why nine in ten of us in some countries die of growing old, and how the world's cultures have spent millennia trying to make sense of it all. The study of death even has a name. It is called thanatology.

• 2. The Moving Line

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  Initially, death was defined as occurring when breathing and the heartbeat ceased, a status still known as clinical death. Then cardiopulmonary resuscitation arrived, and that definition came apart. A heart that has stopped can be restarted. Prompt defibrillation can bring back a person once counted as gone. This circulatory definition of death now has both proponents and critics. Supporters argue that permanent loss of circulation and breathing means a person is dead. Critics counter that permanent is not the same as irreversible, because fast CPR can revive someone. The whole argument collapses into the meaning of two words, permanent and irreversible.

  Franklin Miller, a senior faculty member at the Department of Bioethics at the National Institutes of Health, captured why the next definition is no cleaner. By the late 1990s, he notes, the equation of brain death with death of the human being was increasingly challenged. Patients correctly diagnosed as brain dead, maintained on mechanical ventilation, kept doing remarkable things. They sustained circulation and respiration, controlled temperature, excreted wastes, healed wounds, and fought infections. Most dramatically, in the case of pregnant brain-dead women, they could gestate fetuses.

  Doctors and coroners today usually turn to brain death, declaring a person dead when the electrical activity in the brain ceases. But even that splinters. One view holds that only the neocortex matters, since it is necessary for consciousness, and that the permanent loss of cognitive function should be the criterion. A more conservative view demands irreversible cessation of all functions of the whole brain. Some jurisdictions instead follow a brainstem version. The distinction matters because brain death cannot be equated with a vegetative state or a coma, conditions that describe the living rather than the beyond-recovery.

• 3. Writing It Into Law

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  The Uniform Determination of Death Act in the United States grew out of a specific conclusion reached in 1980. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research settled on the whole-brain definition as sufficient for a uniform national standard. Their reasons were practical as much as philosophical. A uniform legal standard would end confusion. It would address the drain on a family's fiscal resources from artificial life support. And it would establish in law that brain death equals death, allowing organ donation to proceed.

  In 1995, the American Academy of Neurology established the criteria that became the medical standard for diagnosing neurologic death. Three clinical features had to be satisfied to confirm irreversible cessation of the total brain. They were coma with a clear cause, the cessation of breathing, and the absence of brainstem reflexes. Those criteria were updated again, most recently in 2010. Even so, substantial discrepancies remain across hospitals and medical specialties, because the body itself can mislead the instruments. EEGs can detect spurious electrical impulses, and certain drugs, hypoglycemia, hypoxia, or hypothermia can suppress or even halt brain activity temporarily. To guard against false readings, hospitals run EEGs at widely separated intervals under defined conditions.

  The stakes of getting this right gather around the dead donor rule. The rule holds either that death must be officially declared before organ procurement begins, or that procurement must not be what kills the donor. Advocates say it protects donors and answers moral and legal objections to taking organs. Critics argue it fails to serve donors' best interests and does not effectively promote donation. A death certificate, issued in most jurisdictions by a doctor or an administrative office, is the document that follows all of this argument to its close.

• 4. What The Body Does After

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  Pallor mortis comes first, a paleness that sets in between 15 and 120 minutes after death. Then the blood begins to settle into the lower, dependent portion of the body, a stage called livor mortis. Algor mortis follows as body temperature steadily declines until it matches the surrounding air. The limbs grow stiff in rigor mortis, taking their name from the Latin word rigor, hard to move or manipulate.

  Putrefaction marks the beginning of decomposition, the reduction of the body into simpler forms of matter, accompanied by a strong and unpleasant odor. Skeletonization ends decomposition, when all soft tissues are gone and only the skeleton remains. Over a very long period, the natural preservation of those remains can produce fossilization.

  An autopsy is the formal attempt to read this aftermath for meaning, also known as a postmortem examination or an obduction. A specialized doctor called a pathologist performs it to determine the cause and manner of death. A forensic autopsy is carried out when the cause may be a criminal matter, while a clinical or academic autopsy investigates an uncertain death or serves research. Some cases need only an external examination; others require dissection and internal inspection, with permission from next of kin sometimes required. Once an internal autopsy is complete, the body is generally reconstituted by sewing it back together. An older, unregulated version of this examination was once called a necropsy, a term now more commonly applied to the corpses of animals.

• 5. Buried Too Soon

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  From the mid-18th century onwards, an upsurge of public fear took hold, the dread of being mistakenly buried alive. There were too many anecdotal accounts of people declared dead by physicians, then coming back to life, sometimes days later in their coffin or just as embalming was about to begin. The uncertainty of the signs of death became a matter of open debate. The proposed tests for life were grim. They ranged from pouring vinegar and pepper into the corpse's mouth to applying red hot pokers to the feet or into the rectum.

  Writing in 1895, the physician J.C. Ouseley claimed that as many as 2,700 people were buried prematurely each year in England and Wales, though some estimates put the figure closer to 800. The fear had a basis in how easily apparent death can deceive. In cases of electric shock, CPR for an hour or longer can let stunned nerves recover, allowing an apparently dead person to survive. People found unconscious under icy water may live if their faces are kept continuously cold until they reach an emergency room. This diving response, in which metabolic activity and oxygen requirements fall to a minimum, is something humans share with cetaceans, a trait known as the mammalian diving reflex.

  Each advance in medical technology forces another look at when death truly occurs. CPR and defibrillation already proved that a stopped heart is an inadequate indicator. The absence of electrical brain activity may not be enough either. For that reason, the concept of information-theoretic death has been proposed as a more stringent measure, though it has few practical applications outside the field of cryonics.

• 6. What Kills Us

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  Of the roughly 150,000 people who die each day across the globe, about two-thirds die of age-related causes, and in industrialized nations the proportion approaches 90%. The single largest unifying cause of death in the developed world is biological aging, which brings on aging-associated diseases. These cause a loss of homeostasis that leads to cardiac arrest, cutting off oxygen and nutrients and triggering irreversible deterioration of the brain and other tissues. In the United Kingdom, nine out of ten daily deaths relate to senescence, the life sciences term for this slow decline.

  In developing nations, inferior sanitary conditions and limited access to modern medicine make infectious disease the leading killer. Tuberculosis killed 1.8 million people in 2015. In 2004, malaria caused about 2.7 million deaths annually. The AIDS death toll in Africa may reach 90 to 100 million by 2025. Jean Ziegler, the United Nations Special Reporter on the Right to Food, reported that malnutrition accounted for 58% of the total mortality rate in 2006, with more than 36 million of roughly 62 million total deaths tied to hunger or micronutrient deficiencies. A World Health Organization report warned that tobacco smoking, which killed 100 million people in the 20th century, could kill 1 billion in the 21st.

  The deadliest single incidents reach staggering numbers. The 1975 Banqiao Dam failure left up to 240,000 dead. The Wanggongchang explosion at a gunpowder factory killed 20,000. A collapsing wall of the Circus Maximus killed 13,000, and the Chernobyl disaster killed between 95 and 4,000. Natural disasters kill around 45,000 people annually, though the 1931 China floods alone killed an estimated 4 million. In 2012, suicide overtook car crashes as the leading cause of injury deaths in the U.S., followed by poisoning, falls, and murder.

• 7. The Cultures Of Mortality

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  In Tibet, the body is given a sky burial and left on a mountain top, while preparing the spirit to transfer its attainments into another body is a subject of detailed study. The world's responses to a corpse diverge sharply from there. Western societies may treat the dead with material respect, with an official embalmer and associated rites. Eastern societies such as India may be more open to accepting death as a fait accompli, ending in an open-air burning of the body to ashes. In the English language, blessings for the dead include rest in peace, originally the Latin requiescat in pace, and its initialism RIP.

  The phrase dulce et decorum est pro patria mori, meaning it is sweet and proper to die for one's country, dates to antiquity and threads through the culture of death in warfare. Suicide attacks carry their own charged meanings, from the kamikaze missions of World War II to suicide bombings and the terrorism that followed the September 11 attacks. Yet a chosen death can be honored in one tradition and condemned in another. In Japan, ending a life with honor by seppuku was considered a desirable death, whereas traditional Christian and Islamic cultures view suicide as a sin.

  Death is personified across cultures, as the Grim Reaper, as Azrael, as the Hindu god Yama, and as Father Time, with the Grim Reaper the most popular depiction in the West. The afterlife splits along similar lines. Abrahamic religions hold to resurrection or an afterlife, Dharmic religions to reincarnation or rebirth, and secular humanism to eternal oblivion. Awareness of death motivated Prince Siddhartha to seek the deathless and finally attain enlightenment. In Islam, the afterlife, or akhirah, is one of the six main beliefs, and the Quran emphasizes that death is inevitable, reaching everyone no matter how they try to escape it.

• 8. Refusing The End

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  Aubrey de Grey describes a phenomenon he calls the pro-aging trance, the assumption that aging is inevitable, which means little is spent researching anti-aging therapies. Life extension aims to break that assumption by increasing maximum or average lifespan through measures that slow or reverse aging. Average lifespan turns on vulnerability to accidents and to afflictions like cancer or cardiovascular disease, and it can be stretched by good diet, exercise, and avoiding hazards such as smoking. Maximum lifespan is set by the rate of aging coded in a species' genes, and one recognized method of extending it is calorie restriction.

  Researchers in this field can be called biomedical gerontologists, while those who apply the findings to themselves are called life extensionists or longevists. A United States poll found broadly similar support across religious and irreligious people and across economic classes, with Africans and Hispanics more supportive than white people, and 38% saying they would want their aging process cured. The current strategy is modest. It is to use anti-aging methods to live long enough to benefit from a future cure for aging.

  Cryonics takes the wager further. The word comes from the Greek kryos, meaning icy cold, and it is the low-temperature preservation of animals, including humans, who cannot be sustained by contemporary medicine. The hope is that healing and resuscitation may be possible in the future. Cryopreservation of people and large animals is not reversible with current technology, and medical science and cryobiologists generally regard it with skepticism. Its rationale rests on that more stringent information-theoretic definition, the idea that someone dead by today's legal or medical standards may not be dead by the standard that finally settles the question this documentary began with.