It has become appallingly obvious that our technology

"It has become appallingly obvious that our technology has exceeded our humanity. " Health and Everything Albert Einstein Birth and Death The Enkin Lecture January 24, 2007 THIS PRESENTATION WILL BE DOWNLOADABLE FROM OUR WEB SITE http: //www. healthandeverything. org/

Health and Everything The Enkin Lecture Celebrating the essential role of science in the service of humanity and promoting a key role for humanitarian values in science

Health and Everything Three parts of this talk • Birth and death before science • Contributions of science to birth and death • The future of humanitarian values about birth and death

Health and Everything Birth and Death Before Science

Health and Everything Birth and Death Before Science • Wide spread importance of birth and death – Most societies marked both – Wide variety of myths, rituals and processes – Associated with technology • The Adam and Eve story links birth & death – When they leave the Garden of Eden • They will age and die • Women will feel pain during childbirth

Health and Everything Adam and Eve Leave the Garden

Health and Everything Ancient Births and Deaths • Mythological Births – Of the gods • Ancient Deaths – Of figures like Socrates

Health and Everything Birth of Aphrodite?

Birth of Venus Health and Everything

Health and Everything Death of Socrates

Health and Everything Pre-scientific Birth and Death • Inuit and Aboriginal Examples • Birth and death places

Health and Everything An Inuit Birthing Room

Health and Everything Inuit Baby

Health and Everything Old Inuit

Health and Everything Inuit Death on Ice Floe

Health and Everything Native Canadian Baby (Papoose)

Health and Everything Native Canadian Mother & Child 1899

Health and Everything Old Native Americans

Health and Everything Medicine Man Death Dance

Health and Everything Death Lodge

Health and Everything Lest we think there was no technology • Technology was associated with many of these rituals and processes • Markers, buildings, processes and so on

Health and Everything Egyptian Mummy

Health and Everything Egyptian Technology

Health and Everything Egyptian Mummy Unwrapped

Health and Everything The Rise of Modern Science • Modern medicine has its roots in the early stages of modernity as far back as Galileo and Descartes

René Descartes Health and Everything

Health and Everything René Descartes’ Mechanical Man. . . if the body of man be considered as a kind of machine, so made up and composed of bones, nerves, muscles, veins, blood, and skin, that although there were in it no mind, it would still exhibit the same motions which it at present manifests involuntarily, and therefore without the aid of the mind. . René Descartes Meditations, Book VI

Health. System and Everything The Mechanical Digestive

Health and Everything A Geometry of Health • “Healthy” machine runs smoothly • Descartes said in the Discourse “The preservation of health has always been the principle end of my studies” he hoped to devise “a system of medicine which is founded on infallible demonstrations. ”

Health and Everything Science and Return to Eden • Other early scientists, like Robert Boyle, had among their objectives the indeterminate prolongation of life and the elimination of illness and pain – including the pain of childbirth. • This Edenic vision has taken many forms through the years

Health and Everything Representations 1700 -1900 • Representations of birth and death were not scientific • Most were not institutional • Many were figurative

Health and Everything Celebrating the Birth

Health and Everything Old Representations of Dying

Health and Everything Death of a Good Old Man

Death of a Wicked Man Health and Everything

Health and Everything Scientific Medicine • Originated with Cartesian and other modern Ideas • Began to come to fruition with Koch and Pasteur • Elimination of some diseases e. g. small pox • More complete understanding of others, e. g. polio and cholera

Health and Everything Promise for the Future • Clear and precise accounts of birth and death • Greater clarity about the limits surrounding birth and death Evidence based best practice around birth and death

Robert Koch Health and Everything

Louis Pasteur Health and Everything

Health and Everything Philosophical Reinforcement • The early Wittgenstein – Logical Positivism – Extreme view of knowledge and science – Only evidence is scientific evidence

Health and Everything The Early Wittgenstein

Health and Everything Bertrand Russell

The Vienna Circle (Schlick) Health and Everything

Health and Everything Before Modern Medicine • Maternal mortality in 1880 was about 500 deaths per hundred thousand. • Infant mortality as recently as the 18 th century was as high as 200 per 1000 births • Life expectancy was in the 40 s until the late 19 th century

Health and Everything Maternal Mortality Drops

Health and Everything Typical Infant mortality trends 1848 -1999 England & Wales Scotland Source : Birth Counts, 2001

Health and Everything Increased Longevity

Health and Everything Increased Longevity

Health and Everything Most Recent Canadian Data Maternal mortality rate (per 100, 000) [Lower estimate-upper estimate] 6 [4 -8] Lifetime risk of maternal death (1 in) 8, 700 Infant mortality rate (per 1000) Life expectancy at birth, male (years) [Lower estimate-upper estimate] Life expectancy at birth, female (years) [Lower estimate-upper estimate] 5 78 [78 -78] 83 [82 -83]

Health and Everything Science Supports Medical Birth and Death • From 1900 births and deaths began move to hospital • The promise was that Clear scientifically based protocols for both birthing and dying would emerge • The movement from midwives was also quick • USA 1915 - 40% 0 f births attended by midwives. – USA 1935 - 10% (54% non-white) – USA 2006 - 5% – Canada midwifery eliminated as a profession • Reemerged as certified profession 1990 in Ontario.

Health and Everything Born in Hospital

Health and Everything Dying in Hospital

Health and Everything The promise was not kept • Instead of a clear safe satisfying processes, there was a growing sense that hospital based birthing and dying was increasingly mechanistic and distanced from human values • That humans were treated as machines and not persons

Health and Everything Mechanical Man

Health and Everything Mechanical Men

Health and Everything Mechanical Mimes

Health and Everything Philosophical Anxiety • The worry about the loss of human values • Questions about the impact of technology on the human experience • Some concern about the limits of scientific enquiry

Health and Everything The Late Wittgenstein

Health and Everything Hans Georg Gadamer

Richard Rorty Health and Everything

Health and Everything Greater Knowledge & Differentiation • Division of labour in the acquisition of medical knowledge - worry about growing level of specialization as early as 1950 • Fear that medicine would become too technical and lose the human connections became intense by 1970.

Health and Everything Increasingly Differentiated Understandings • Deeper scientific knowledge has resulted in greater differentiation and a grey zone of uncertainty • Process of gestation clarified but at the same time – Introduction of Neonatology to save premature babies – Legalization of abortion. • Death defying interventions increased – Introduction of a variety of life supports – Increased ability to keep patients alive longer – Introduction of a wide range of organ transplants that required human donors

Health and Everything Two Examples of Grey Zones • Establishing the precise moment when birth or death occur are good examples of the growing uncertainty resulting from deepening scientific knowledge – Establishing a “limit of viability” for birth – Establishing when death occurs •

Health and Everything “Limit of Viability” • “Limit of viability” - the point in gestation when an infant can survive outside its mother’s womb. • Some definitions – The gestational age at which 50% of infants or more died within 28 days of life. – The gestational age at which infants can survive without a serious risk of disability

Health and Everything Changes in the Limit of Viability • NICUs have steadily lowered the limit of viability over the last 50 years. – Some say as early as the 20 th week of pregnancy – Most say at around the 23 rd week • Vast majority of premature babies (under 37 weeks) now survive unharmed • Many infants that would have died or been severely disabled are now developed without harm • These numbers are not fixed nor entirely agreed upon

Health and Everything A Neonatal Intensive Care Unit

Health and Everything Legalized Late Term Abortion • “Late-term abortion” is similarly ambiguous – It can refer to abortions after the 20 th week of pregnancy – It can also refer to abortions after week 27 in the third trimester of pregnancy. – Still others would use it to refer to abortions that occur after fetal viability • Abortion on demand varies from country to country, but is extended until as late as the 24 th week of pregnancy in Canada and even beyond this date in countries like Spain

Health and Everything Henry Morgentaler

Health and Everything The Grey Zone for Birth Some relevant facts: – almost no pregnancies are viable before the 20 th week and nearly all are viable after the 27 th week • The “Grey Zone”: – Between the 20 th and 27 th week of pregnancy – In Canada the grey zone is between weeks 20 and 24

Health and Everything Grey Zone Babies

Health and Everything Prolonging Life • Clinical death: when the heart stops beating and breathing stops – Resuscitation procedures reverse clinical death – Life support machines maintain patients – Pacemakers can avert clinical death • Brain Death – when the electrical activity in their brain ceases – the permanent and irreversible loss of cognitive function, as evidenced by the death of the cerebral cortex • Determination of brain death can be difficult – EEGs can detect spurious electrical impulses when none exists – Electrical activity in a living brain can be too low for EEGs to detect.

Prolonging Life Health and Everything

Health and Everything Organ Transplant • Organs are best harvested after brain death and close to the time of clinical death • Many patients are kept clinically alive by artificial means before their organs are harvested • There is reason to think that medical innovation will change our notions of when irreversible brain death occurs

Health and Everything Transplant Rush

Health and Everything The Grey Zones of Death • A grey zone now exists between the death of the cerebral cortex and the irreversible cessation of all brain activity – There is reason to think that this zone will shrink • Another grey zone exists between clinical death and brain death and there is good reason to think that this zone will increase

Health and Everything Evidence Based Policy • Over the last twenty years many commissions have sought to find a way to reduce the grey zones surrounding birth and death. All have so far failed – some have declared that the issue is no longer worth pursuing. • Do these grey zones of uncertainty reflect reality?

Health and Everything More knowledge more possibilities • These are only a few examples of grey zones • The idea of a single protocol for birth and death will likely be abandoned, if it has not already • A deeper scientific understanding of the processes and technologies associated with birthing result in a greater number of ways to have a baby safely rather than one scientifically preferable way • The deeper understanding of the processes of dying have similarly expanded the ways of death rather than identify a single or even small number of scientifically appropriate ways of dying

Health and Everything Some Varieties of Birth and Death • The post technological varieties of birth and death have increased • Here is a small subset of them found in a trawl through the Internet

Health and Everything A Variety Technical Births In Vitro Fertilization Surrogate Mothers 1 st Test Tube Baby Caesarian Section by Appointment Fertility Drug Multiple Births

A Variety of Other Birth Experiences Health and Everything Home Birth as a Family Experience Unassisted Home Birth as a Private Sexual “orgasmic” Experience Home Water Birth

Health and Everything A Variety of Hospital Deaths

Health and Everything Mantle's Last Medical Bills by Allen R. Myerson Sunday, August 20, 1995 Mickey Mantle, suffering with cancer, spent 11 days in Hospital before having a liver transplant, and then was kept alive for 3 more weeks before he died. Because he chose to die in a regular room rather than the intensive care unit, the costs were kept under $300, 000.

Health and Everything December 12, 2006 By Benjamin Poground Ariel Sharon is lying comatose in hospital since suffering a stroke in January - a victim of Divine punishment because of his disengagement from the Gaza Strip in August last year, according to some religious Jews.

A Variety of Other Death Experiences Health and Everything Sue Rodriguez Assisted Suicide Home Death Watch Terri Schiavo Euthanasia Nursing Home Death Hospice Death

Health and Everything May 20, 1994 By ROBERT D. Mc. FADDEN Jacqueline Kennedy Onassis died of cancer yesterday at her apartment in New York City. She was 64 years old. Mrs. Onassis had been undergoing chemotherapy, but the disease grew progressively worse. Mrs. Onassis entered the New York Hospital-Cornell Medical Center for the last time on Monday but returned to her Fifth Avenue apartment on Wednesday after her doctors said there was no more they could do. She went for her last walk in her beloved Central Park on Thursday and died in her sleep At 10: 15 PM on Friday evening.

Health and Everything April 17, 1998 Linda Mc. Cartney, the wife of the former Beatle Paul Mc. Cartney, died on Friday in Santa Barbara, California, with Paul at her bedside. A statement from Paul Mc. Cartney's office said the cancer had spread to her liver since she had been receiving treatment A family spokesman said: "The blessing was that the end came quickly and she didn't suffer. " Two days before her death, she and Paul had been enjoying one of their main passions, horse-riding

Health and Everything February 6, 2002, Wednesday By Christopher Lehmann Haupt Annalee Whitmore Fadiman, screenwriter and World War II correspondent, dies at 85; her daughter says that Fadiman, who as member of Hemlock Society supported right to suicide, took her own life.

Health and Everything Jan 16 2007 Armin Meiwes, accused of killing Bernd-Jurgen Brandes eating his genitalia, and then freezing the rest of his body to consume in later repasts, was convicted of manslaughter. He will spend eight years and six months in prison. State prosecutors, who had been pushing for a life sentence for murder motivated by sexual urges, failed to make their case. The defense lawyer had argued that his client, known as the "cannibal of Rotenburg", should get off lightly because his victim had been willing to die and be eaten

Health and Everything An Aside: A new death related technology • Life. Gems are artificial diamonds that are made from the carbon of cremated bodies that allow you to wear your departed loved ones as jewels (or sell them on e. Bay)

Health and Everything Some Non-medical Values • Economics of birth and death • Arguments for home birth and death have been made on economic grounds and are increasingly part of the discourse – A savings in the US of $20 Billion annually calculated for home birth – Most health expenditure happens in last 6 months of life • Ecology of Death – A “Green Death Movement” and “green burial” (death planning that promotes environmentally sound ways to "recycle" or compost human remains). • Can these lead to excesses similar to the ones resulting from the medicalization of birth and death?

Health and Everything The future of birth and death • We are faced with the problem of how to deal with the increase in “grey zones” that arise from our deepening scientific understanding • Science itself cannot solve the puzzles associated with such grey zones • It is by recognizing this that we may work towards a richer understanding and acceptance of what it is to be human and to further humanize the processes of birthing and dying

Health and Everything Thinking about Birth and Death • Murray and Eleanor Enkin have struggled against the dehumanizing tendency of narrow views about birthing and dying. • They have helped us to see the error of reducing these processes to medical procedures • We must recognize and discourage similar tendencies to reduce them in other ways – E. g. to economic or ecological consequences

Murray and Eleanor Enkin Health and Everything

Health and Everything Celebrating the Great Variety • An important humanizing feature of Murray and Eleanor’s view was not merely to learn to tolerate disparate views about birthing and dying • We are beginning to recognize and value the range of human interests, desires and practices related to birth and death. • We can celebrate the variety of scientifically supported ways of begin born and dying

Health and Everything Bemoaning the Lack of Choice • So far although the variety of scientifically supported ways of being born and dying expand the choices available to most people remain heavily restricted by professional practice and government policy. • A challenge for this audience might be to find ways to increase the range of choices most people can actually make