Anyone who’s read Edgar Allan Poe knows that he was fascinated—alongside many others of his era—by the prospect of premature burial. It’s not hard to imagine why: Prior to modern imaging equipment, and particularly in Western traditions where corpses were buried intact, a person could, at the hand of their own well-meaning family, end up interred and helpless to do anything but slowly run out of sustenance and air. No malice required, just ignorance.
Poe has one particularly on-the-nose story about this fear, “The Premature Burial.” In it, the narrator has a “catalepsy”—explicitly a disease of unknown etiology—in which, sometimes with no warning, he becomes insensate for periods as long as weeks. Haunted by dreams and increasingly nervous of being interred by people unfamiliar with his condition, he sets up the family vault so that it can easily be opened from the inside, and even stops travelling to ensure he will always be near someone who knows his medical history.1
I cannot imagine this same plot in a contemporary context. With the introduction of the EEG and modern neuroscience, we now have the ability to ascertain when a person’s truly beyond saving, when there’s been enough damage to the brainstem—which regulates the body’s autonomic systems—when, no matter how good the clinical team, there’s no lingering hope of revival. Since brains don’t regenerate and can’t be transplanted, there’s no mystery left, right?
Right?
Much to my own surprise—having watched plenty of television shows where the EEG goes flat and an actor in a lab coat sticks a flashlight into the eyes of an actor lying in a hospital bed before solemnly announcing the time of death—despite its quantitative criteria2, a product of modern medicine, “brain death” is not quite so unambiguous as it seems.
For starters, what even constitutes brain death varies by country. What I said about the brainstem above is centered on what I’ve gleaned as an American; Germany, for instance, uses whole-brain criteria, while some countries have different requirements for number of certifying clinicians and lab tests.3
In their review evaluating brain death criteria, Rayner et al. do not simply dismiss lawsuits against physician-determined brain death as being the product of bereaved families or religious and/or societal doctrine. Instead, they point to contradictions in the guidelines we use, in particular highlighting two case studies where patients who were documented as brain dead were then able to breathe independently again—one of those autonomic systems the brainstem controls. I’ve chosen to quote this paragraph in its entirety because it addresses several important points:
“Without hyperbolizing these examples to offer far-fetched conclusions, the magnitude of these patients’ neurological devastation and extremely dire prognosis cannot be overstated. While the documented reversibility does not infer a favorable patient recovery or physician negligence, it does demonstrate ambiguity to the central tenant of ‘irreversibility’ and violates the medical concept of death. ‘Surviving’ BD suggests that current clinical criteria need to be reevaluated.”
In the long run, a patient might never recover from being declared brain dead. The point at which a person is being assessed for brain death is substantially dire, not the nineteenth century vision of an untraumatized but mysteriously cataleptic body. The issue is that these objective criteria do not cover all scenarios as neatly as they are supposed to, given what follows brain death: the termination of life support, organ harvesting for the purposes of donation, and of course our modern-day funerary practices, which in my family end with cremation.
When I worked in a mouse lab, I learned three different ways to sacrifice them (we use this term because it indicates the animal’s contributions to science), all of which are approved by a committee because they ensure both a relatively painless and unambiguous ending: asphyxiation followed by breaking the neck; quick decapitation; perfusion of the veins. In humans, these generally constitute either murder or mutilating the corpse (although, speaking of perfusion, people clearly think plastination is cool). As such, there will always be some degree of ambiguity in defining a human as dead, when it’s not otherwise obvious.
The ambiguity mentioned above is of a kind that would, with current medicine, have absolutely no material impact on quality of life. But that’s the biologist in me talking, and from a literary and more generally philosophical perspective, there’s more to consider.
In the BMC journal Philosophy, Ethics, and Humanities in Medicine, Joffe et al.4 immediately challenge the implicit assumption that brain death is the same as biological death. Even in a case of irreversible brainstem and cortical damage—affecting, respectively, autonomic systems and consciousness—the body’s other systems can remain functional. As they say, “The brain is more an enhancer than an indispensable integrator of bodily functions.”
It’s not difficult to extrapolate this to speculative fiction, starting with zombies5, in which mindless bodies devolve to their instincts, particularly hunger. More influenced by Night of the Living Dead than their Voodoo origins, zombies in contemporary staples across the globe—including but hardly limited to The Walking Dead, Dead Snow and Train to Busan—are depicted as reanimated corpses. Once more the body moves, both limbs and digestive tract, but the brain is gone forever.
Joffe et al. explore several alternatives to the current definition of brain death, starting with accepting higher brain death as death of the person—which, although it’s medically convenient in how it accounts for sentience, comes with “[u]nacceptable implications for some,” including both religious and societal norms.
The option they recommend, ultimately, is to solve a specific problem: “The main reasons for accepting [brain death] as [biological] death have been to free up scarce intensive care beds and resources, and to allow vital organ donation without the procurement killing the patient.” They suggest that, if brain death is confirmed—specifically, if the chances of the person returning to consciousness are considered to be zero—then they allow organ donation and the termination of life support while acknowledging that, technically, these will cause biological death. In their words, “society could decide that vital organ donation in the state of [brain death], with prior patient or family consent, although killing, would not be considered murder.”
Without modern medicine to sustain and heal a body regardless of catastrophic brain trauma, and without the technologies which allow us to measure far more subtle functions than prior eras’ reliance on visible reflexes, this debate wouldn’t exist. Before, society had reason to fear being buried alive; now, we can question whether someone is being declared dead too soon, 6 and, like Mary Shelley, explore the consequences of technological progression beyond the current day.
“The Premature Burial” is distinct from Poe’s other stories about being buried alive. Unlike “Berenice” or “The Fall of the House of Usher,” narrated by outside observers, it’s the narrator who is buried alive—except, as it turns out, his coffin is actually a berth on a boat, and he wasn’t even cataleptic, just deeply asleep. After this incident, he leaves behind his obsession with premature burial, and in the process his cataleptic disorder goes away as well.
Reflecting on his greatly improved life, the narrator closes with, “Alas! the grim legion of sepulchral terrors cannot be regarded as altogether fanciful—but, like the Demons in whose company Afrasiab made his voyage down the Oxus, they must sleep, or they will devour us—they must be suffered to slumber, or we perish.” We can’t live perpetually in fear, at least not if we want to enjoy life; presumably, this is why so much of Poe’s horror is steeped in paranoia.
Modern society generally7 doesn’t fear being buried alive. The ambiguities around brain death are nuanced—to reemphasize, when someone is declared brain dead, the chance of them returning to their prior state of sentience is minimal (mainly because biologists struggle with making definitive statements, a habit I will probably never shake off)—but do offer challenging speculative possibilities.
1. poemuseum.org/the-premature-burial
2. bit.ly/4gAAFrJ: Unfortunately, since I can’t read German, I haven’t read the article in full. The abstract suggests an unambiguous counter to the problem of declaring brain death by instead using whole-brain criteria; however, Rayner et al. note problems with this approach in their paper (citation #4).
3. bit.ly/4gK0Ufd
4. bit.ly/4gv4YzT
5. Given how ubiquitous zombies have become in horror, I would like to take a moment to remind everyone that Zora Neale Hurston’s Tell My Horse is one of the main factors in introducing them to America. Some details in this article: bit.ly/4a5et6E. But I really learned about this in Gods of the Upper Air by Charles King (which is admittedly more centered on Margaret Mead).
6. As a (nonclinical) healthcare employee, this is the point where I tell everyone to establish your advance directives.
7. Respect to anyone into underwater spelunking, but also nope.
