Shocked

by David Casarett

  I’m also pessimistic about the future of cryonics because most science—good science—is a numbers game. Advances are usually made by making mistakes. Lots of them. That’s multiple attempts over years, and multiple failures, in hopes of getting to something that is not a complete failure. And then hundreds more trials in order to get to something that someone would call a success.

  That’s not true all the time, of course. But if the stories of scientific advances in these pages are any indication, it’s certainly the norm. Think, for instance, of all of the rodents, rhesus monkeys, and “mongrel dogs of medium size” that have given their lives for the pursuit of science. And although I’d be the first to admit that we’ve made a lot of progress, it’s still the case that progress in terms of survival after a cardiac arrest is measured in minutes.

  You could say, of course, that the science of cryonics could be advanced with animals. And indeed it could. (Although I suspect if they could, vast swaths of the animal community, including lemurs, dogs, rhesus monkeys, mice, pigs, and of course thirteen-liners would all shout, “Not it!”)

  The problem is that whereas dog hearts work pretty much the way that human hearts do, dog brains are, sad to say, different. Dogs don’t do many of the things that people do, like admire a sunset, microwave popcorn, or splash in the pool with their kids. So it’s difficult indeed to guess at what, if anything, a thawed golden retriever’s cognitive status will tell us about a thawed cryonaut’s likely ability to do any of these things in a thousand years.

  If you want your future to include sunsets, I’m afraid cryonics may not be your answer. There’s just not enough serious science there to produce results that any of us are likely to enjoy. So my advice is not to count on a second life in a thousand years. Watch a sunset now. And—why not?—make some popcorn while you’re at it.

  “MORAL HAZARDS” AND THE PRICE OF RESURRECTION

  Absent from much of this discussion of the scientific horizons so far is any mention of costs. But those costs are very, very real. Remember, we’re talking about the costs of resuscitation, as well as the costs of hospitalization afterward. That can run more than $20,000 per day. Add the costs of implantable defibrillators, and you’re into the six-figure range.

  Finally, there is the cost of the procedures—hip replacements, heart bypass surgery—that would have been rejected as too risky in many patients twenty years ago but are now routine for almost everyone. Those price tags are just a tiny fraction of the total costs of resurrection technology. For a true reckoning, you’d need to consider the cost of a hip replacement for a woman who wouldn’t have been an operative candidate ten years ago. Or a man who is now eligible for dialysis because we’re confident that we’d be able to resuscitate him if his heart stops during a dialysis session. A patient who would have been too sick for chemotherapy, surgery, or dialysis in the past now becomes a patient who is merely “high-risk.”

  This is one of the hidden costs of the advances we’ve seen in the science of resuscitation. The ability to bring someone back to life provides a kind of safety net that makes certain treatments possible. With that safety net in place, doctors are able to be more aggressive with their recommendations for treatment than they would otherwise be. They can push the envelope because they know that, if a patient really gets into trouble on the operating table, they’ll probably be able to save her.

  This safety net effect is pivotal in the way that doctors make decisions, because doctors are generally risk-avoidant. We don’t want to use a medication or perform a procedure if there’s a chance—even a small chance—that doing so will result in a patient’s death. The Hippocratic Oath’s admonition to do no harm is in the back of our minds whenever we recommend a treatment or write a prescription.

  But what if that harm could be avoided, or mitigated substantially? What if we knew that, if the worst happened, we could bring a patient back?

  In other settings, this phenomenon is often described as a “moral hazard,” because a safety net lets people take risks that they wouldn’t ordinarily take. Think for a moment about the way that bankruptcy laws work. If you get into serious financial trouble, from which you can’t dig yourself out, there’s the option of declaring bankruptcy. That may leave you with little or nothing, and will wreck your credit for a long time, but at least you can erase your debts and start over.

  That seems like a small thing, perhaps. Although clearly it’s not so small if you’re the one who is clawing back from a ruined financial life. But it’s actually a dramatic change from a rough-and-tumble history in which debts were punishable by slavery (ancient Greece), imprisonment (nineteenth-century England), or even death (Genghis Khan’s mandate, at least for repeat offenders).

  Bankruptcy is no picnic. But it beats the heck out of slavery. So it stands to reason that we might be just a little more willing to ask for a loan from Aunt Mabel if we can be sure that we won’t end up in chains in her dungeon.

  Just as bankruptcy laws and insurance may encourage riskier behavior, the availability of resuscitation creates a moral hazard too. Treatments that would have been “too risky” only twenty years ago because of the risk of cardiac arrest are now routine. Many of my oncology colleagues tell me they’ve become more aggressive in using chemotherapy in older, sicker patients too.

  The most fascinating thing about this safety net is that there’s a good chance that most of us have been affected by it. If you’ve undergone any procedure as an outpatient, for instance, that procedure was possible because of advances in life-saving technology. Procedures like wisdom tooth extractions or endoscopy or even hernia repairs that used to be conducted in the operating room can now be conducted in an outpatient surgical suite.

  Why? Because the science of resuscitation (even in a limited outpatient setting) is light-years ahead of what could have been accomplished by an entire team in an operating room fifty years ago. Back then, if your heart stopped during a procedure, the best course of action involved cutting you open and applying wires directly to your heart. If you’ve had your wisdom teeth taken out, I can guarantee you that an open-chest resuscitation wasn’t on the menu if something went awry. Of course, the shift to outpatient procedures has been pushed along, too, by improvements to technology that make procedures less invasive than they once were. But none of those advances would have been possible if advances in resuscitation hadn’t kept pace.

  Taking all of those costs into account, it’s safe to say that the advances in the science of resuscitation that we’ve seen already come at an enormous cost. That’s not to mention whatever new advances are on the horizon, such as cooling techniques like the RhinoChill, deep hypothermic surgery, or—just for the sake of completeness—cryonics. Each one comes with a price tag.

  HOW MUCH IS TOO MUCH?

  If it sounds churlish to talk so bluntly about the costs of being alive after a successful resuscitation, it is. It is churlish and brutal and callous. And so we never talk about these costs. Not at the bedside, not at ethics conferences, and certainly not in public policy circles.

  I met a man once, a friend of a friend, who had survived a harrowing resuscitation after a cardiac arrest. He had every complication imaginable, and a few that his doctors had never seen before. When he finally emerged from the hospital after four months, he faced a total hospital bill upward of $5 million.

  On a hot, lazy summer afternoon, we sat on his deck talking about his experience. We talked about what he knew, and what he was told. And we talked about what his life had been like since. Our conversation meandered for more than two hours. But never in all that time did we ever talk in detail about the costs of what he went through, and whether his survival was worth it.

  I can’t imagine questioning the price of technology that allowed him to be sitting on his deck, sipping iced tea, and talking to me as his grandkids played Marco Polo in the pool behind him. I would have to be coldhearted indeed to sit there and thi
nk—much less say—that he shouldn’t be alive. Or even that there must be a point at which his being alive was just too expensive.

  Instead, we ignore those costs when we’re making decisions about treatment. We pretend they don’t exist. We talk instead about quality of life, and survival. We sometimes resort to other euphemisms, like a nod to a scarcity of ICU beds. But questioning the costs of saving a life is strictly off-limits. Of course, weeks or months later, patients and families facing bankruptcy have to talk about costs. But that’s too late.

  We ignore costs as a factor in decision making because the stakes are just too high, and the possibility of a mistake is just too great. Just as Michelle Funk’s rescuers did by the side of a swollen creek, someone will think that maybe this is a life that they can save. It’s a long shot. Maybe a very long shot. But you never know, so . . .

  That’s why I’m pretty confident no one is going to impose serious limits to technology anytime soon. As new advances become available, we’ll reach for them. In hospitals, on ambulances, and in shopping malls. Better technology that offers even a tiny chance of saving a life will be embraced.

  Conversely, I can’t see any future in which there are widespread decisions to limit or withhold that technology. Remember the uproar that ensued when Lorraine Bayless wasn’t resuscitated? She was a woman for whom CPR probably wouldn’t have been successful. Even if it were, “success” would have meant waking up to a severe stroke. And, finally, remember that her family said she had wanted to die a peaceful death. And yet, when CPR was withheld, it resulted in a national incident. So it seems much more likely that new technology will be deployed as it becomes available.

  That doesn’t mean there won’t be rationing. Any new lifesaving technology almost certainly will not be evenly distributed, and it’s likely we’ll continue to see AEDs in suburban shopping malls long before they appear in inner-city bus stations. And people who live in communities with a strong tax base will stand a better chance of a successful resuscitation by first responders. That sort of rationing may not be as obvious as a hard-and-fast rule about who should be resuscitated would be, but it’s just as real.

  MICHELLE FUNK—THE MIRACLE GIRL

  Isn’t it worth it? Isn’t saving a life worth whatever it costs? If anyone could be the test case for that proposition, it would be Michelle Funk, the miracle girl who survived for three hours without a heartbeat. Can we count her story, at least, as a major victory?

  Indeed we can. I’m delighted to report that she’s alive and well. She just got married in 2012, in fact. (She and her husband, Michael, were registered at Macy’s, in case you’re curious. As far as I can tell, nobody bought them the Cuisinart food processor, so feel free to whip out that credit card.)

  Whatever doubts you might have about the rapid progress of the science of resurrection, just try sharing those doubts with Michelle Funk, now Michelle York. Try telling her that the past two decades of her life shouldn’t have happened. Try telling her that she shouldn’t need that Cuisinart because she shouldn’t be alive. Good luck with that.

  But if we want to celebrate Michelle Funk’s wedding, we also need to be ready to face the results of stories that don’t end well. We need to be ready to care for patients like Joe, the first patient I ever brought back to life. He spent eighteen days in the ICU because I was so quick to start CPR. And we need to be able to support his family who endured eighteen days of watching, waiting, and making increasingly difficult choices about whether and when to stop treatment.

  Confronting these results will be challenging because we’re still not very good at the “soft” side of medicine that helps people make choices about which treatments they want. We’re bad at supporting families who get stuck making difficult decisions as Joe’s family had to. And we’re really awful at saying no to treatment that won’t help us. So although I’m hopeful about the future and about what’s going to be possible someday, I won’t be truly optimistic about our ability to take care of hearts and brains until we get much better at taking care of people.

  ACKNOWLEDGMENTS

  This hasn’t been the sort of book that one writes in solitude, comfortably parked on the front porch of a cabin in the mountains. Writing—and researching—has required considerable travel, correspondence, telephone conversations, and the help of dozens of people. For instance, there were many researchers who took time out of their hectic schedules to talk with me. Among those, I owe special thanks to David Gaieski, Joshua Lampe, Lance Becker, Cheng Chi Lee, Hannah Carey, and Peter Klopfer. I’m also grateful to others who made connections and introductions, like Andy Kofke, Ed Dickenson, Sam Tisherman, John Nilsson, Suzannah Hughes, and Greg Marok. Along the way, Lauren Mancuso was extremely helpful in digging up obscure facts about resuscitation, many of which I deeply regret were just too bizarre to print. I’m also grateful to the animals that helped move this research along, including Penny the horse, Petunia the pig, Chucky the squirrel, a mouse known to his close friends as #0011, numerous squirrels, groundhogs, pigs, monkeys, “mongrel dogs of medium size,” and of course all of the sleeping members of Team Lemur.

  The folks at Alcor were particularly helpful (and trusting) in letting a skeptic into their midst. Despite my challenging questions about the science of cryonics, those cryonauts were uniformly open and welcoming. They probably won’t make that mistake again.

  This book was also possible because I’m fortunate to work with wonderful people at the University of Pennsylvania who are supportive, encouraging, and tolerant of the demands of my writing. They are also generous in working around my schedule when I venture out into the wide world to meet hibernating ground squirrels, cryonauts, and other anomalies of nature. So I’ve been able to write this book in large part thanks to the flexibility of people like Joan Doyle, PJ Brennan, and Zeke Emanuel, who don’t seem to mind when I skip a meeting to chase lemurs. I’ve also been able to embark on these expeditions because I’m fortunate to work with people who keep things running smoothly in my absence, like Laura Bender, Meredith Dougherty, Sue Foster, Sue Kristiniak, Amy Corcoran, Barbara Reville, Nina O’Connor, and Beth Reimet.

  On the writing side, my agent, Chris Bucci, at Ann McDermid & Associates, provided much-needed encouragement and guidance as this book was taking shape. He handed that role seamlessly to my editor, Niki Papadopoulos, who has been a welcome source of boundless enthusiasm and constructive editorial advice.

  Finally, I’m also grateful to the patients and others who were willing to share their stories. To protect their confidentiality, I’ve described them using pseudonyms only. But they know who they are.

  NOTES

  1: The Big Mac Rule of Resuscitation and the Search for the Limits of Life

  The full story: The Michelle Funk case report comes from RG Bolte et al. (1988) “The use of extracorporeal rewarming in a child submerged for 66 minutes,” Journal of the American Medical Association 260(3): 377–79.

  In fact, the conventional wisdom: JP Orlowski (1987) “Drowning, near-drowning, and ice-water submersions,” Pediatric Clinics of North America 34(1): 75–92.

  an editorial accompanying that article: JP Orlowski (1988) “Drowning, near-drowning, and ice-water drowning,” Journal of the American Medical Association 260(3): 390–91.

  “When hateful old age”: HG Evelyn-White, trans., “Homeric Hymn to Aphrodite,” theoi.com/Text/HomericHymns3.html [accessed January 10, 2014].

  2: Why Amsterdam Used to Be a Good Place to Commit Suicide

  Anne Wortman is lying facedown: The Wortman case report comes from the translated notes of the Amsterdam Society. Dr. Thomas Cogan, trans., Memoirs of the Society Instituted at Amsterdam in Favour of Drowned Persons: For the Years 1767, 1768, 1769, 1770, and 1771 (London: Printed for G Robinson, Pater-Noster Row, 1773) vol. 27; chapter XV.

  “hospitals and public charities”: Ibid.

  “To blow into the intestines” . . . “the warm irritating f
umes”: These suggestions regarding the inflation of the intestines come from Cogan, Memoirs.

  “Yet in vain is it condemned” . . . “The populace will not easily renounce”: Ibid., chapter VII.

  “Let one of the assistants, applying his mouth” . . . “Since no body can affirm with certainty”: Ibid.

  “a neat structure”: Illustrated London News, August 19, 1844, p. 144.

  “within a reasonable time of immersion”: Accounts differ about just how long these early pioneers thought someone could be dead before being brought back to life. See, for instance, en.wikipedia.org/wiki/Royal_Humane_Society. However, in the first annual report, Hawes specifies two hours as the upper limit. W. Hawes, Transactions of the Royal Humane Society; Dedicated by Permission to His Majesty by W. Hawes. Volume 1 (Eighteenth Century Editions Online; Print Editions. 2013; originally published 1794), p. 11.

  two each brought fifteen citizens: The Forty-Eighth Annual Report of the Royal Humane Society for the Recovery of Persons Apparently Drowned or Dead (London: Printed for the Society and to be had at the Society’s House, 29 Bridge-Street, Blackfriars, 1882).

  “a father to the fatherless”: Royal Humane Society, “History,” royalhumanesociety.org.uk/html/history.html [accessed January 10, 2014].

  Of these, some of the strongest recommendations: Annual Report of the Royal Humane Society for the Recovery of Persons Apparently Dead. Seventieth Annual Report. London: Compton and Ritchie, 1844.

  its seventieth annual report: Ibid.

  “For some time” . . . “the metallic trachea tube”: Ibid.