Ethics of Non-ideal Cryonics Cases
From Cryonics, Fall 2006: Volume 27:4.
by Brian Wowk
Cryonics can be defined as the low temperature preservation of people who cannot be saved by medicine today until they can be revived and treated in the future. While the idea is simple, it involves many complex issues. This article will address only one of them: the question of to whom cryonics technology should be ethically applied, and when.
Ideal Cryonics
A truly ideal cryonics case might consist of a patient with a terminal disease consenting to placement in reversible suspended animation until treatment is possible. However such perfected “medical time travel” is still hypothetical since no technology exists for long-term suspended animation that is demonstrably reversible. In that sense, all cryonics cases today are “non-ideal” because the preservation method itself is not proven to work.
Nevertheless, even if the final result of cryopreservation is uncertain, an “ideal” cryonics case can still be defined as one in which the survival status of the patient is not in doubt at the time cryopreservation begins. This could be achieved by connecting an anesthetized living patient to a heart-lung machine to maintain blood circulation as temperature was lowered. In practice this cannot be done because cryonics is not an approved medical procedure.
Cryonics deals with this problem via the mechanism of legal death. When an illness is terminal, legal death may be declared on the basis of cardiac arrest (heart stoppage) even though resuscitation is still possible. It is therefore possible to be legally dead, but biologically viable, for a short period of time. It is during this period of several minutes that “ideal” cryonics cases can be performed under existing law. This window of time is also used by conventional medicine for harvesting living organs for transplant in cases of donation after cardiac death (DCD)[1].
The cornerstone of ideal cryonics is the idea of “Standby.” Standby is the process in which a team of cryonics technicians wait at bedside for the heart of a terminal patient to naturally stop beating, at which time legal death is declared. Legal death in this context means that further care by conventional medicine is not appropriate. The team then artificially restores blood circulation and begins cooling. This stabilizes the biological viability of the patient. Although difficult to achieve in practice, the goal of standby is to maintain the same biological viability in a cryonics patient as would exist if cryonics were an elective medical procedure, not a post-mortem intervention [2].
Non-ideal Cryonics
A non-ideal cryonics case occurs when cryonics stabilization procedures, such as cooling, are begun long after resuscitation by contemporary medicine is impossible and thus biological viability is believed to have ceased. Such cases, which account for more than half of all cryonics cases, are often the result of unexpected legal death. Non-ideal cases may involve hours, or even a day or more, of clinical death without intervention.
In extreme cases, a non-ideal cryonics case may involve salvaging and freezing brain tissue that has been subjected to both trauma and decomposition. Use of chemicals to prevent freezing damage (cryoprotectants) is often impossible for non-ideal cases, which adds freezing damage to damage already caused by a lengthy period of clinical death.
Interestingly, the general public perception of cryonics seems to be that all cryonics cases are “non-ideal” as described above. It is widely believed that cryonics companies receive patients the same way that funeral homes receive bodies, many hours or days after legal death. The concept that cryopreservation can ideally be begun at bedside, with little or no brain injury by conventional criteria at the start of the procedure, is generally unknown.
Rationale for Non-ideal Cases
The biological rationale for non-ideal cases is that death is a process, not an event. It is generally known that clinical death can be reversed for up to 4 to 6 minutes after the heart stops before the brain is believed to die. It is less well known that this limit can be extended to as long as 15 minutes using experimental resuscitation methods.
In some animal models, up to 60 minutes of clinical death at normal temperatures has been reversible, with most damage confined to a particular area of the brain (CA1 region of the hippocampus). Even hours after blood circulation stops, living cells can still be retrieved from brains assumed to be long dead by contemporary medical standards. The brain does not suddenly fall apart when it is deprived of oxygen. These facts have been discussed at length in cryonics literature [3, 4, 5, 6].
Why, then, is it believed that people go out “like a light” when the heart stops? Many important functions do stop suddenly. When the heart stops beating, the brain runs out of energy, and all brain electrical activity stops after about 30 seconds. But people can and have recovered after far longer periods without any brain activity. This is because people are not really light bulbs. The structure and chemistry of the brain ultimately determines whether someone can be revived. Brain function does not matter. The brain is like a computer hard drive, not volatile electronic memory.
Whether a clinically deceased person can be revived depends on whether whatever is wrong with the structure and chemistry of their brain can be set right. Today nothing can be done about repairing structure, and setting chemistry right is limited to re-supplying oxygen, nutrients, and a few simple drugs. Whether a patient lives or dies when blood circulation is restored depends on whether the brain can naturally recover from damage that accumulated during the interval without oxygen.
Future technologies for molecular repair of the brain will be able to directly reverse structural and chemical changes caused by long periods without oxygen, making resuscitation after hours of clinical death theoretically possible. A century from now, doctors may speak of the critical need to treat cardiac arrest within the first 4 to 6 hours rather than the first 4 to 6 minutes as they do today.
In the limiting case of a technology capable of completely general molecular repairs, restoration of a healthy state would always be possible. Whatever repairs were necessary to repair/reconstruct a functional, biologically healthy brain and body could always be performed. What would happen is that long periods of clinical death followed by repair would result in varying degrees of memory loss about prior events. If decomposition were severe enough, “repair” would result in a new person. How much memory loss is required before the original patient is considered deceased? It is a tradition in medicine that if brain function can be restored, the original patient is considered recovered despite amnesia. This custom seems likely to continue in the future whenever clinically deceased patients can be restored to consciousness, even when the repaired injuries were severe.
Ethics of Non-ideal Cases
The ethical justification for non-ideal cryonics cases begins with the ethical justification for cryonics generally, which is that medicine should not be limited to treating conditions that can only be treated in real-time with a certain outcome. Any remedial strategy that is scientifically defensible, even if requiring very long time scales, is a legitimate strategy for protection of human life. Cryonics under ideal conditions is scientifically defensible [7, 8, 9, 10].
If it is stipulated that performing cryonics under ideal conditions can be ethical, what of the non-ideal cryonics case? Clearly there are degrees of biological decay that will obliterate so much of the original person that future repair will not recover the original person. This state has been called information theoretic death [7]. But short of complete destruction of a person, how can information theoretic death be determined?
Present medical practice is to suddenly stop care of patients that reach certain stages of illness, and destroy them. This is done by a legal and social ritual that strips them of personhood. That ritual is legal death. The sudden transition from living patient to “remains” is so inculcated in popular culture that the very idea that a person without blood circulation or brain function could still be a person is unthinkable. In reality, there is no sudden loss of personhood when the heart stops, only a relatively sudden loss of ability to be resuscitated by current technology. That loss used to occur at the very moment the heart stopped. Now it occurs after 4 to 6 minutes. If post-resuscitation cooling is used, it can be over 10 minutes. Drug interventions show promise for extending it to 20 minutes. Eventually nanomedicine will extend it to hours. There is no sudden moment at which a brain, or person, ceases to be viable.
The idea that human life is something that disappears slowly hours after clinical death, even as disposal rituals are already underway, is an aspect of biology that is rarely examined because the implications are so disturbing. Yet the availability of technologies for stabilizing patients for indefinite periods of time (cryonics) forces hard examination of this issue.
Ralph Merkle has called cryonics “conservative” medicine that is in keeping with the medical ethical imperative, “First, do no harm.” A triage process that commits viable patients to destruction certainly does harm, at least to the patient concerned. Thus “do no harm” would seem to require the cryopreservation of any patient with remaining brain structure until such time as tools become available to adequately examine and reconstitute the patient.
According to this paradigm, almost all conditions now considered “death” are actually disease states in which future treatment would result in resuscitation, albeit with varying degrees of loss of memory of prior events. No patient would be left behind. No patient should be left behind based on short-sighted judgments.
The Best and Worst of Cryonics Ethics
It is ironic that what some might call the noblest ethical statement in cryonics— the “no patient left behind” doctrine –can lead to the worst ethical criticism of cryonics. Cryopreserving “bodies” in states of severe deterioration appears scientifically indefensible. Doing so in exchange for money appears ethically indefensible. Which view is correct?
It may be that they are both correct, depending on circumstances. Most people who arrange for cryonics do so while young and healthy. They plan for, save for, and consent to cryonics many years in advance of need. Many specify in their signup paperwork that “any biological remains whatsoever” are to be cryopreserved, consistent with the “no patient left behind” doctrine. They do so in full knowledge that there is a line of deterioration beyond which cryonics cannot work.
But they elect not to guess at where that line might be. Since funds have been set aside long ago, proceeding with cryonics under poor conditions is not a financial hardship or decision burden on family or society. It is a matter of personal planning and choice, and even medical ethical idealism. Were the “no patient left behind” doctrine ever to be accepted by society generally, with common funding mechanisms established, it would arguably be ethically superior to the current system of discarding patients whenever contemporary medical capability is unable to meet their needs. The expense would be small compared to total lifetime medical expenses in the industrialized world.
The most serious ethical problems of non-ideal cases arise in the context of “last minute” cases. A “last minute” case is a case in which a cryonics organization is contacted when legal death is imminent, or has already occurred, for a non-member of the organization.
These cases typically involve distraught families, high emotion, lack of informed consent, and even lack of patient consent when the patient is unconscious or already legally deceased. Families are faced with the decision of paying a large amount of money for something they do not understand, is not likely to work, and that cryonics organizations can barely defend. Such cases conform to the worst negative stereotypes of cryonics preying on grieving families for financial gain. “Last minute” cases are rarely accepted by Alcor for many of these reasons.
Two Ideas, One Word
The word “cryonics” is actually a name for two different ideas. The first idea is that human cryopreservation under ideal conditions today could be reversible in the future. The second idea is that medicine should never leave patients behind; every patient beyond the capabilities of contemporary care should be cryopreserved instead of destroyed, even if found in poor condition. The distinction is necessary because it is possible to agree with the first idea even while not accepting the second. The first idea is a scientific proposition, while the second is a philosophical imperative.
For those who advocate the broader second view of cryonics, it is important to remember that non-ideal cases can be an expression of both the best and worst of cryonics ethics. It is the responsibility of cryonicists to ensure that non-ideal cases are handled with the highest ethical standards. This is best done by upholding “no patient left behind” as an ideal of medicine and personal planning, while discouraging sale of cryonics under poor conditions where no prior cryopreservation plans exist.
1) L. Whetstine, S. Streat, M. Darwin, D. Crippen, Pro/con ethics debate: When is dead really dead? Critical Care 9 (2005) 538-542. and Cryonics Commentary.
2) B. Wowk, Cardiopulmonary Support in Cryonics, monograph published by the Alcor Life Extension Foundation (2003).
3) The Cryobiological Case for Cryonics, monograph published by the the Alcor Life Extension Foundation (1988).
4) T. Donaldson, A Brief Scientific Introduction to Cryonics, monograph published by the Alcor Life Extension Foundation (1976).
5) T. Donaldson, Neural Archaeology, Cryonics, February, 1987.
6) T. Donaldson, Prospects of a Cure for “Death”, Cryonics, May, 1990.
7) R. Merkle, The Technical Feasibility of Cryonics, Medical Hypotheses 39 (1992) 6-16.
8) J. Lemler, S.B. Harris, C. Platt, T.M. Huffman, The Arrest of Biological Time as a Bridge to Engineered Negligible Senescence, Annals of the New York Academy of Sciences 1019 (2004) 559-563.
9) Scientists’ Cryonics FAQ, monograph published by the Alcor Life Extension Foundation (2005).