HEARTLANDS

By Dr. Pam Johnston

ANATOMY OF THE HUMAN HEART.

My relationship with my heart is close; intimate. I heard it beating before I was born. I have heard it beating all my life. I will hear my last heartbeat as I die. It is what I share with all in the family of humanity.

This heart of mine has been elated, has been broken, has despaired, has been both faithful and untrue, is staunch and is weak, and abides. It flows my blood and beats my life and connects me to all who are me and mine, and beyond. It is my life. It holds within it all that I believe and all that I love.

The heart has been an ongoing symbol of love. The human heart is difficult for an artist to paint or draw. On the one hand it is such a GOOD symbol as it needs no 'propping', no explanation. We know and understand its symbolism. The problems that arise in the representation of the human heart are not so much related to its symbolism; but more to the risk of sentimentality, of over-statement if you like, or of simplification.

It seems logical to me that with my death, all death, comes the cessation of the beating of our human heart. Makes sense doesn't it? The heart stops, the life stops. When I think of the language around the human heart and what that language embodies, it makes even more sense to me that – the heart stops, the life stops. The heart makes us human. Life makes us human. If one stops then of course the other stops.

That this is not the case has left me wondering about my heart, your heart, the heart of the matter. I am assured that medically the heart is merely a pump with a job that it is very good at. That job is to circulate the blood throughout the human body. The heart, I am told, has no memory I wonder then, how does it remember to pump…… and pump…… and pump. The heart is not a machine that I can pull apart to examine its intricate engineering features. It is not a machine that is ……. mechanical.

In current Australian medical practice and relevant legislation, a person is dead when there is either irreversible cessation of the circulation of blood or irreversible cessation of all function of the brain. When death is determined in the second way, which is current legal and medical definition of death, a person is commonly said to be 'brain dead'.

Though the certification of death using a brain function criterion has been closely linked to issues of organ donation and transplantation, the concept of brain death was not developed purely to subserve the interests of transplantation although it is interesting to note that brain death as a final definition of death did come about through discussion on transplant and euthanasia.

Although the technological possibilities for transplantation and for maintaining bodily functions in patients with profound brain injuries developed somewhat contemporaneously, at the time when brain death was first described, transplantation was exclusively concerned with the use of organs from subjects in whom cardiac arrest had already occurred and the traditional criteria for death had been met.

While most organ donation after death currently occurs from patients certified as dead using the brain function criterion, it is increasingly possible to transplant organs from 'non-beating heart donors' who may or may not also meet the brain function criterion. It is important, therefore, to note that someone who has difficulty accepting the concept of brain death may have no difficulty accepting organ and/or tissue donation after the certification of cardiovascular death.
I've found these words that Pam wrote for an exhibition of her work, called Heartlands..

Death of course, must be defined before it can be determined and certified. The certification of death is a quasi-scientific process depending on reasonably objective assessments. The definition of death, however, lies in the philosophical rather than the scientific domain because it involves judgements about the nature of the human person and about what it is for someone to be alive or dead.

The terms 'alive' and 'dead' are used in different ways in different contexts, and with considerable social, cultural and historical overtones. In the context of Australian legislation the concept of 'brain death' concerns what it is for a human person to be alive or dead. Various philosophical justifications for a legal definition of death in terms of loss of all brain function have been put forward.

The most widely accepted view emphasises the unity of mind and body in the living human being. On this view, the death of a human person is understood to consist in the irreversible loss of the integrated and coordinated life of the person as a single living organism. When this functional unity is lost irreversibly, the person has died, even if 'life' continues at the sub-personal level of cells, individual organs or isolated physiological systems.

In the light of this definition of death, medical science seeks to delineate those clinical characteristics which indicate with certainty the loss of all brain function. The concept of 'brain death' is not intended to introduce a novel kind of death, but to identify the irreversible loss of the organic unity and integrated activity of a living human person.

The past thirty years have see a reappraisal of both the meaning of, and the criteria for, the certification of human death. The need for this reappraisal has resulted from
(i) the development and widespread application of medical technology to support and replace the failing human organ systems, and
(ii) the need to resolve controversy surrounding organ donation for purposes of transplantation. These technological advances have challenged traditional and conventional attitudes to death and dying.

There have been three traditional clinical markers for death: the absence of consciousness, cessation of breathing, and, once the importance of the circulation was appreciated, the cessation of cardiac function (heart stops beating).

These markers are associated with different views of the nature of the human person. While reference to the 'breath of life' has been historically pervasive, since the seventeenth century, especially, some philosophers (following Descartes [1596-1650]) have tended to equate consciousness with 'the person'. In criticising this idea, other philosophers have emphasised the importance of the human body and the embodiment of the person in the natural world.

The precise relationship among these three clinical markers of life and death has only become important in recent times. Previously any ambiguity or uncertainty in the assessment of these clinical features was not especially important because they were so closely linked. That is to say, if any of breathing, circulation or consciousness ceased, cessation of the other two would rapidly follow. Any clinical uncertainty was of no particular importance.

Medical technology has now severed the links among these three features. Mechanical ventilators can now support respiratory function for an indefinite period after breathing has ceased. Cardiac function can be suspended therapeutically for long periods and restored uneventfully. Cardiac function can also be successfully restored after it has ceased spontaneously.

The development of artificial hearts and of cardiac transplantation has allowed people to live on, and indeed to live well, long after their own hearts have been replaced. Reliable mechanical ventilators have enabled patients with spinal cord injuries to continue to be conscious, interactive and intellectually functional in the absence of any form of spontaneous breathing. These technological advances have necessitated a re-evaluation of the centrality of breathing and cardiac function to the understanding of life and death.

And therefore my human heart can beat on long after I am certified as dead. This is not an argument for or against a definition of death nor it is an argument for or against organ transplant. I am left wondering what it is about my heart that connects me to all living things. If it is merely a pump whose ability is irrelevant to life and death, why does it break, soar, radiate, love? Why is it my heart that I reach for when I am beyond words and want to communicate deep love, deep loss, deep despair.

Without my heart I cannot connect, cannot feel, cannot love, cannot understand the meaning or the connection to life. Yet my heart is a pump medically and legally I am told, that can stop, or not, at death.

Death is, as is life, elemental and defining with heart at its centre. The heart has always been part of human belonging and human connection. The heart is part of a spiritual landscape that beats its connectedness to all things living. The Heart has a Land that it wanders, that it occupies, that it claims. That land, HEARTLAND, makes us human.

Dr. Pam Johnston,
Woolloomooloo.
August, 2007