Honesty is best policy

EDITOR—Altruistic organ donors (and potential donors) have never had explained to them the implications of the process of donation, as is required for fully informed consent. The editorial by Baumgarten and Gerstenbrand does little to clarify the situation.1 They still retain the term “brain death,” which has long been replaced by “brain stem death,” and, more recently, “death for transplant purposes” has been used by the Department of Health. At the very least it should be made clear precisely what the (potential) donor understands by death. Without that understanding, consent will surely be invalid.

If it is only neurologists who should apply the tests for the “fatal syndrome” of death, have we been negligent for 25 years in allowing any practitioners of five years' seniority to apply the tests? Can those who are prepared to make the critical diagnosis of death on the brain stem test criteria not be considered as part of the transplant team? Is it understood that the apnoea test itself can cause further brain damage or even death, as has been shown clearly by Coimbra?2

Anaesthetists are uneasy with the diagnosis of death. There is a division of practice among anaesthetists.3 Some give full anaesthesia to organ donors (because they respond to surgery much like any other patient), whereas others withhold anaesthesia (which might look like an admission that the donors are still alive) but suppress the responses to surgery by other means.

A recent Australian opinion is that, rather than redefining those who are brain dead as dead, it may be more honest to acknowledge that such individuals are not dead and that removing their organs is in fact killing them and, and that the long term viability of the transplantation programmes is likely to be better served by telling the truth than by trading in fiction.4 This must be a better approach than writing that we should not disturb the current pragmatic consensus that lets the brain dead be dead.1 Honesty is still the best policy.

Guidelines for United Kingdom were not described

EDITOR—The article by Baumgartner and Gerstenbrand discussed the diagnosis of brain stem death from an international perspective but did not describe the well established principles used in clinical practice in the United Kingdom.1 We would like to place on record the following points.

In the United Kingdom, the criteria for the diagnosis of brain stem death and the clinical method of confirming it have been accepted for many years.

There is no need for the obligatory involvement of a neurologist; properly trained doctors of appropriate seniority of any specialty can perform the tests and make the diagnosis.

It is established practice that the medical staff making the diagnosis must be separate from staff involved in the recovery and transplantation of donor organs.

The guidelines concerning management of an organ donor, including the mechanism for establishing brain stem death, were published by the Intensive Care Society in June 1999. These guidelines are available from the society (www.ics.ac.uk/).