Death before Dying: History, Medicine, and Brain Death by Gary S. Belkin (review)

Current debates about advance directives and organ trafficking are evidence of the importance of Gary Belkin’s new history, Death before Dying. Belkin is a psychiatrist who earned a Ph.D. in history of science during his medical residency. The book builds on his dissertation research and looks at the self-appointed Harvard committee that in 1968 set criteria for brain death in the only report that it wrote. For the most part, what appeared to be the work of the committee was the handicraft of its creator, chairman, and autocrat at the conference table, Dr. Henry Beecher. During the summer of 1968, Beecher pieced together his previous writing and marshaled the words of twelve additional committee members, all Harvard men, most from the medical school. In August, their final product appeared in the Journal of the American Medical Association. Since then, definitions of brain death have remained controversial (see the Terri Schiavo debates) and have defied efforts to universalize one meaning. Yet the committee’s report set a new, dominant default position among clinicians, in which an irreversible coma equaled brain death, and brain death was as good as death itself.

Belkin refines a story that has been told as a tale of two postwar technologies: the positive-pressure ventilator that could extend life and the electroencephalogram that could mark its end. In six chapters, the book self-consciously follows the structure of the report itself and relies on the documents that the committee and its members archived at Harvard, as well as on published primary and secondary sources.

Belkin writes against the conventional wisdom about the committee on two issues. First, scholars have previously argued that the committee had an unseemly interest in harvesting organs for transplantation, and thus were zealous to declare death—legally, morally—for comatose patients who seemed bound indefinitely to life support. Belkin aims to rehabilitate the moral integrity of the committee’s work by arguing that its biggest background concern was the problem of human experimentation (i.e., the moment when care shades into discovery) more so than with transplantation. Such an account is consonant with Beecher’s previous work on experiment, though Belkin has to read assertively against the grain of the materials he presents in order to make the claim.

Second, scholars have claimed that the committee had little empirical basis for the four criteria it promoted as evidence of irreversible coma. As counterpoint, Belkin presents exciting and persuasive evidence of the committee’s empirical basis for the report. Snuggled into the middle of the book is a seemingly modest section that displays Belkin’s finest materials and smartest analysis (pp. 173–200). Ingeniously, Belkin sought and was granted access to medical records of 421 comatose patients that committee member Robert Schwab and colleagues treated (and removed from life support) in the decade prior to his work on the brain death report. Belkin uses the records to show how Harvard neurologists gradually refined a social routine and a technique for interpreting EEGs between 1958 and 1967. To his credit, Belkin avoids weighing in the “correct” diagnosis, dodging the temptation to evaluate the clinicians’ judgments with hindsight. Instead, Belkin uses the patient records as evidence of his claim that the committee’s report was empirically grounded, and was specifically based on clinicians’ own bedside experience at Massachusetts General Hospital in years that preceded their summer’s work on it. Belkin reproduces clinicians’ notes about patients, allowing readers to witness the neurologists in the process of thinking. As John Harley Warner and others have observed, medical records are important forms of evidence for historians of medicine. They are also nearly impossible to access. Belkin has done a service to his argument and also to the field through his intelligent analysis and helpful reproduction of fragments of these patient records.

Another fine chapter looks at the status of (brain) death in American law. Belkin shows that committee...