Letter: Transplant concern

Sir: Dr Andrew Robinson appears to be unaware of recent developments (in Japan and Brazil particularly) which suggest that some patients declared "brain dead" less than a day after severe head injury may indeed have a chance of recovery if optimally treated (with moderate hypothermia and barbiturates) instead of being regarded as organ donors at too early a stage.

The British tests are less comprehensive and do not suffice to diagnose brain death but only a neurological syndrome inaccurately described as "brain-stem death". That diagnosis is made when some reflexes with pathways through the brain stem are absent and the brain stem respiratory centre does not respond to higher than normal carbon dioxide tensions in the blood.

The brain stem cardiovascular centres are not tested and will often be found to be still working.

The chief justification for use of that syndrome as a basis for certifying death seems to have been the oft-repeated claim that its diagnosis is inevitably followed by true death within a few days. This is simply not true. Pregnant women pronounced "brain dead" or "brain-stem dead" have been kept alive for weeks so that their babies might be viable at birth.

The claim that "the diagnosis of brain-stem death excludes the possibility of any form of conscious survival" has no sound scientific basis. Consciousness is not understood. Elements in a patient's brain may still be working when he is pronounced "brain-stem dead". Responses to the trauma of organ "harvesting" suggest that they are - and this is what worries anaesthetists such as Drs Hill and Urquhart.

DAVID W EVANS MD FRCP

Cambridge