India stands at a delicate crossroads. A recent Supreme Court order has reopened the debate on how we define death — specifically, brainstem death — and whether long-standing medical protocols should be re-examined. Public scrutiny is welcome. But when it comes to defining death, the margin for error is zero. The discussion must be guided by science.
Allegations and Judicial Scrutiny
The petition before the Supreme Court alleges “serious malpractices… [where] patients … are being declared ‘brain-dead’ even in cases where the clinical parameters … do not justify such a determination.” These are grave concerns. Any misuse of brain death certification must be dealt with transparently.
These allegations were examined earlier by the Kerala High Court. After reviewing submissions from the Union government, the state, and medical experts, the court did not dismantle the existing framework but emphasised stricter implementation, greater transparency, and accountability. It even suggested safeguards such as videography of the apnoea test process to ensure integrity. The message was to strengthen the system, not discard it. Yet the current discourse risks doing exactly that.
Understanding Brain Death
The suggestion that the apnoea test should not be central and that EEG or cerebral angiography should replace or precede it is a fundamental misunderstanding of brain death. Brain death is a clinical determination of irreversible loss of brainstem function. It is not a mere scan.
The apnoea test is indispensable because it directly answers the basic question: Does the brainstem still drive breathing? It is the only bedside test that evaluates this function physiologically. Remove it, and you are left with indirect proxies.
EEG measures electrical activity of the cortex, not the brainstem. A flat EEG does not confirm brainstem death. It is also vulnerable to sedation, hypothermia, and metabolic disturbances. Cerebral angiography measures blood flow, not neuronal function. It is invasive, technically dependent, and not universally available.
Neither test can replace what the apnoea test uniquely establishes. To substitute a direct physiological test with indirect surrogate markers is regression.
Global Standards and Indian Context
This is not a new or evolving experiment. Brain death criteria have developed over more than six decades, beginning with the 1968 Harvard Ad Hoc Committee that first defined neurological standards for death. These principles have since been refined and globally harmonised, reflected in modern guidelines from the American Academy of Neurology and the World Brain Death Project report published recently in JAMA. Across jurisdictions, the foundation remains consistent: a structured clinical examination, including the final apnoea test, with ancillary tests used only when required and as an added layer of safety, not as a replacement.
The Supreme Court, to its credit, has exercised caution. It has acknowledged that it “does not profess the requisite technical expertise in the field” and referred the matter to an expert committee at AIIMS. This is an important recognition. Medicine must be guided by those trained in it.
The court also observed that the petitioner’s concerns “at least prima facie, do carry a ring of truth.” This has understandably raised public anxiety, but it should be read as a call for scrutiny.
The Path Forward
The real issue is not whether the apnoea test is valid, but whether protocols are consistently and transparently followed. If there are gaps, the answer is clear: better training, stricter audits, and enforceable accountability. Not a shift to tests that do not measure what truly matters.
India does not yet have a universally codified definition of death that fully integrates brain death into its civil registration system. While brainstem death is recognised under the Transplantation of Human Organs and Tissues Act, it is not seamlessly embedded in the Registration of Births and Deaths framework. This creates avoidable ambiguity.
A modern healthcare system cannot afford dual definitions of death. India needs a single, legally and clinically coherent standard, where brain death is recognised across medical practice, law, and public administration.
Conclusion
The stakes are high. Brain death is not only a medical diagnosis; it underpins organ donation, end-of-life care, and public trust in the healthcare system. Inconsistency risks undermining all three. This is not a debate between old and new medicine. It is a test of whether we uphold evidence over perception.
(The writer is a transplant surgeon and trustee of Mohan Foundation, an NGO that champions organ donation.)
