Two weeks ago, when the Supreme Court disposed of a petition filed by the Organ Transplant Society of India seeking a uniform national framework to ensure equity, access and efficiency in organ donation and transplantation across India, the Supreme Court issued a series of directives to the Center to eventually come up with a model national policy for organ allocation.
One of the directives suggested that the government consider amending Forms 4 and 4A of the Registration of Births and Deaths Rules 1999 to add a new column stating whether the deceased was a case of brain stem death and whether the family was given the option of organ donation.
This would make brain death certification a normal, non-negotiable definition of death, just like cardiac death, opening the possibility for brain death declaration and eventual organ donation to become standard hospital procedure rather than a transplant-driven activity.
Kerala became the first state to do so when it took the bold step of abolishing certification of brain death and organ donation in 2020.
In India, brain death was defined only in the context of organ donation in the Human Organ Transplantation Act, 1994. Thus, clinicians understood brain death certification as a procedure performed solely to aid in organ donation. Doctors were not clear on what to do if a family refused the option of organ donation after being certified brain dead.
To end the ethical dilemma of clinicians, the GO issued by Kerala laid down the parameters for certification of brain death in the ICU and stated that once a patient is declared brain dead as per the protocol, all treatment, including cardiorespiratory support, should be discontinued.
Organ donation counseling would come as a follow-up to brain death certification, leaving the final decision on organ donation to families.
It was hoped that this clarification and legal approval would make clinicians more proactive and fearless about brain death certification. But nothing has changed in the past five years, and doctors continue to avoid the process.
Brain death certification and deceased donation continue to be an activity that only happens in Kerala when some well-informed families demand and apply pressure to donate their loved one’s organs.
“Certification of brain death is not a concept that doctors at the time were familiar with, given that the topic was not something that was covered during their undergraduate studies. It seems that the knowledge gap persists, so brain death certification, which is the standard of care worldwide, continues to be foreign to them,” opines one of the leading doctors.
Determining neurologic death is both a resource and a knowledge-intensive process, and despite the rigorous training they have received, most physicians are still unsure how to handle the process of determining brain death.
“At least 400 doctors in the state have undergone intensive training in brain death determination and certification process. But it is sad that none of them are taking proactive steps to make brain death determination the standard of care. Brain death determination must be a zero-error process and we rarely see this level of confidence among our doctors,” says Noble Gracious, Executive Director, Kerala State Organ and Tissue Transplantation (K-STO Transplantation).
He feels that it is this intense scrutiny of the process and the pressure that there is no room for error that seems to discourage doctors from making brain death determinations.
“Leading countries in organ donation such as the US and Spain have developed their organ transplant program over 30 years, with doctors undergoing continuous, rigorous hands-on training on various scenarios before determining brain death has become practice in their ICUs. This is a huge learning curve that takes a lot of time and practice to master, and we have to be patient,” says Dr. Gracious.
This is why the state needs to take another look at its organ transplant scene.
Kerala’s unique challenges in the way of organ donation should be analyzed and the confidence of the medical community in the brain death determination process should be built through continuous training and systemic support to make it a routine practice in state ICUs.
Published – 13 Dec 2025 18:50 IST
