Irreversible apnoeic coma 35 years later. Towards a more rigorous definition of brain death?

The concept of brain death (BD) has been widely accepted by medical and lay communities in the Western world and is the basis of policies of organ retrieval for transplantation from brain-dead donors. Nevertheless, concerns still exist over various aspects of the clinical condition it refers to. They include the utilitarian origin of the concept, the substantial international variation in BD definitions and criteria, the equivalence between BD and the donor's biological death, the practice of retrieving organs from donors who are not brain-dead (as in non-heart-beating organ donor protocols), the proposal to abandon the dead donor rule and attempts to overcome these problems by adapting rules and definitions. Suggesting that BD, as it was originally proposed by the Harvard Committee, is more a moral than a scientific concept, we argue that current criteria do not empirically justify the definition of BD; yet they consistently identify a clinical condition in which organ retrieval can be morally and socially justified. We propose to revert to the old term of "irreversible coma" or, better yet, of "irreversible apnoeic coma", thus abandoning the presumption of diagnosing the death of all intracranial neurons and/or the patient's biological death. On the other hand, we think that a (re)definition of the vital status of donors identified on neurological criteria can only occur through a prior (re)definition of death, a task which is not only medical but societal.