Friday, February 4, 2011

The Breath of the Nostrils

Anyone who believes that brain death is death (and even those who believe that cardiac death is death) must contend with the Gemara, which seems to establish respiration as the sole criterion for life. The Gemara says, "Everyone agrees that life is manifest through the (breathing of the) nose, as it says, 'in whose nostrils was the breath of the spirit of life'."

Now, the truth is that this Gemara even presents problems for those who accept respiration as death, since (a) Chazal held that cessation of respiration is terminal, but we know that it can be restarted, and (b) you can have someone who is quite definitely dead in terms of both brain and heart, but is still breathing via artificial means - one can even make a corpse breath. Be that as it may, let us discuss the various ways in which those who accept brain death deal with the Gemara's exegesis, and I will show that my discussion this week about Ramban offers an additional answer.

The first approach is that the exegesis only refers to someone who is spontaneously breathing, via instructions from the brain. Otherwise, the breathing is no more significant than that which can be accomplished artificially with a corpse. This is the view of the Chief Rabbinate of Israel, and it is perfectly reasonable.

Another approach is to say that the Passuk is only being used to say that if one is looking for respiration, the nose is the place to look for it, but not that respiration is the sole determinant of life. (This was said by R. Moshe Feinstein.) As an elaboration or variant on this, some say that the exegesis is an asmachta rather than a derashah - it's just a Scriptural hook on which to hang a pre-existing idea, but not a Scriptural source for an idea. (Some would say that even a derashah itself is not authoritative - even Chasam Sofer says that derashos are not Sinaitic - and we see that there were derashos performed to show that the firmament is solid.)

But now we have a new answer. The exegesis from the passuk shows that life is detectable at the nostrils. But what kind of life? The original passuk is talking about animals as well as man, which all died in the deluge: "Everything with the soul of the spirit of life in its nostrils, from everything in the dry land, died" (Gen 7:22). So the breath which is detected in the human nostrils need not necessarily be the breath of the nefesh hamaskeles - it may be the breath of the nefesh habehemah. The presence of the breath of the nefesh habehemah is nearly always a perfect indicator that the nefesh hamaskeles is also present, and certainly functions that way for the case discussed in the Gemara. But in the unusual modern case of a brain-dead person, the presence of a nefesh habehemah, indicated by breathing, does not mean that there is a nefesh hamaskeles is present.

Unfortunately, one really can't prove anything either way about what the Gemara meant. To my mind, it really shows why this Gemara can't be used as a source for determining time of death in modern situations, which are so different from the situations that Chazal dealt with. The RCA document expresses this point very well: "the entire purpose of this סוגיא in יומא is to offer practical direction to those involved in a rescue from a collapsed building, and not to address the deeper issue of what actually marks the end of life." (Unfortunately the RCA quotes various Poskim who do not seem to have appreciated that point.) The deeper issue of what actually marks the end of life has to be figured out by studying traditional views of what human life actually is, not making inferences from a discussion in the Gemara which is speaking about an entirely different topic.


  1. and of course until we have a "ytziat haneshama hamaskeles" detector, we will have to use some proxy which will be subject to debate if it wasn't specifically approved by chazal
    Joel Rich

  2. @Joel: We do have a ytziat haneshama hamaskeles detector, in the form of brain scanning equipment.

    As with the Rakiah drasha, couldn't this drasha be factually inaccurate about what is actually death? If so, then there is even less reason for it to figure significantly in the discussion of death.

  3. > Chazal held that cessation of respiration is terminal, but we know that it can be restarted,

    Not necessarily. As I've noted before, there are THREE types of death that need to be listed:
    1) Brain death
    2) Cardiac death
    3) Brain stem death

    A precise reading of the gemara in Yoma as well as the famous mishnah in Oholos (and brought in Chullin) about beheaded animals strongly supports the brain stem definition of death. Specifically:
    1) In the absence of spontaneous respiration, everything else soon dies.
    2) You CANNOT restart a dead brain stem. The cases where respirations can be restarted are sadly few and far between.
    So yes, the gemara gives practical advice but it also accepts something that wouldn't be anatomically explained until centuries later.

  4. I disagree with the portion of the post that cites the RCA statement approvingly. It is very strange to assert that an halachic discussion in the talmud must be not be generalized at all. If that were the case, halachic development since the closure of the talmud would be nil. Such a statement would never have been made by those RCA authors for other issues. It is a meritless defensive posture in this case to support a preconceived notion about the significance of heart and circulation cessation.

    While the proponents of a brain-stem criterion which includes the cessation of spontaneous breathing have support from the gemara in Yoma 85a and other halachic discussions in the talmud, the heart/circulation proponents have none. They appear to base themselves on the views of a few prominent later decisors, Moshe Sofer and Zvi Ashkenazi, who lived in a time when the function of the heart and blood circulation had been clarified. Well, now medical science has clarified the more critical role of a functioning brain-stem in supporting life. If they could innovate the added criterion of a heartbeat and pulse based on their medical knowledge, then we should be able to innovate a brain-stem criterion based on our greater medical knowledge.

  5. Just for clarification's sake, I thought you would be interested in knowing what is considered clinical brain death. I am currently taking my Neuro class in Med school and I just happen to be going through my notes where this definition is given.

    Clinical brain death is defined as having a flat EEG (Zero brain activity) + brain stem damage (measured by ABSENT reflexes and ABSENT respiratory drive). If this person is maintained on a respirator there is autolysis of the brain.

    I know this is off topic and I do not expect you to post it, I just wanted you to be aware of a more precise definition of what, in practice, is used.

  6. E-Man, your notes are not strictly correct. Look up the original references. In particular, twitching and spinal reflexes can be present, as they do not require a brain at all.

    RNS, you are FINALLY coming around to the POV that I and others were pushing on your earlier posts. The Yoma gemara says nothing about the "definition" of death.

    Many of the poskim who won't rely on brainstem death probably think it's the best approach, but can't bring themselves to rule against rishonim. The problem is that the rishonim could not possibly have understood the physiology.

    Even if they hold like Yuma, and say no breathing = death, then they MUST hold that brain stem death is really death. You can't breath without a working brainstem. If they don't hold this way, then they surely don;t understand brainstem death.

    The only problem is with those poskim who hold that "beating heart" = "alive."

  7. AL- It means no cranial nerve reflexes. OBVIOUSLY, lower reflexes that act without communicating with the brain are still present.

  8. e-man, thanks for the contribution. for the sake of accuracy, not every brain dead patient mantained on respirator develops total autolysis. Those who became brain dead because of cessation of cerebral blood flow frequently will develop autolysis of a lot(but not necessarily all) of the brain. However, there is a small subset who lose neurological function and still have some blood flow(for example, hypoxia enough to affect the neurons which are more sensitive but not enough to cause significant white matter damage-thus limiting the amount of edema). In this case, even extended ventillator support will not result in a significant amount of autolysis. If you are interested, I reccomend looking at the pathology reports of brain death from the early '70s when patients were routinely mantained on respirators for as long as possible. They are easily found on pubmed, but if you want specific references please feel free to email me noamstadlan-at-gmail-dot-com

  9. Noam,

    I am just giving the clinical definition that is given to define brain death that allows people's organs to be taken and transplanted.

    Also, I am pretty sure I didn't say total autolysis. Mainly, because it doesn't say that in my notes. But, there is always, I believe, some level of autolysis.

  10. Everyone agrees that life is manifest...

    "Manifest" means to be shown or demonstrated. The presence of life may be displayed by breathing but that is not the same as saying that life=breathing.

    I agree with others that all we have are proxies for "life" or the presence of the neshama.

  11. The Rambam would also agree with this formula equating breath with life, however he still held that one is tumat meis at the moment of decapitaion.

    May be exploring this paradox within the Rambam might answer our question.


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