Death provides renewed life for some, but ethical hazards for transplant teams

The exploration of new possibilities suggested by Campbell and Sutherland is also timely in light of the disturbing questions raised by Truog9 and others10-12 about the criterion of "irreversible function of the whole brain and brain stem," or so-called brain death. Although it is not the case that our use of the brain death diagnosis has led to patients being declared dead who had even the remotest chance of recovery, the issue of brain death is complex, one that involves philosophical concepts, physiological definitions, legal definitions and clinical criteria. Some commentators have pointed out that we often fail to wait for all the components of brain death to develop, such as accompanying diabetes insipidus, loss of all vasomotor tone, loss of other neurohumoral effects and loss of temperature control. These components are additional evidence of residual brain function but are not normally considered essential criteria for the brain death diagnosis. The pathophysiology of incipient brain death is complicated by the "autonomic storm" and altered hormonal function arising from increasing intracranial pressure.13 Further, our increasing ability to compensate for the loss of brain stem functions by mechanical and pharmacologic means introduces new difficulties in diagnosing brain death.14 Recently, Bernat came to the defense of the "whole brain and brain stem" concept by redefining death as "permanent cessation of the critical functions of the organism as a whole"; by this definition, relatively intact neuro-posterior-hypophyseal function is considered a noncritical function,15 but this perhaps also begs the question. Traditional criteria for cardiopulmonary arrest are accepted by most, whether they occur as a result of a lethal disease process (which Campbell and Sutherland term "uncontrolled") or as a consequence of a decision to withdraw life support ("controlled") from those who cannot benefit further and have irreversible brain damage. One of the problems that Campbell and Sutherland specifically elect not to address is the following: How much time is required to establish complete "death of the brain and brain stem" after final cardiopulmonary arrest? Death must be established before one can begin such postmortem preservative measures as immediate cold perfusion, elective ventilation - when there is prior agreement, a donor card or legislation that permits such interventions on a dead body16 - or immediate organ procurement in a previously prepared