How countries determine if an organ donor is brain dead

The US and UK determine brain death based on clinical evaluation and neurological reflexes, while Japan and China require a strict testing process, independent consultation, and the consent of the family.

https://www.youtube.com/watch?v=DQ7L1TWfG94

Anthony Thomas "TJ" Hoover II, 46 years old, a resident of Laurel County, Kentucky, was declared brain dead in July 2024 at Saint Joseph London Medical Center and then transferred to the University of Louisville Hospital for organ donation. However, just before doctors were about to harvest his organs, he unexpectedly showed clear neurological responses, such as crying and moving his legs. The entire operation was immediately suspended. The shocking incident prompted the U.S. Department of Health and Human Services to launch a federal investigation on July 21, raising serious questions about the accuracy and reliability of current brain death criteria.

In reality, each country has very different approaches to determining brain death. Some prioritize speed and clinical reliability, while others emphasize safety and objective evidence.

United States: Brain Death Equals Legal Death

In the U.S., the concept of brain death is defined under the Uniform Determination of Death Act (UDDA) of 1981. According to this law, a person is considered legally dead when all functions of the brain, including the brainstem, have irreversibly ceased. The clinical guidelines of the American Academy of Neurology require three elements: irreversible coma, absence of all brainstem reflexes, and inability to breathe independently during an apnea test.

If clinical evaluation is inconclusive, doctors may use ancillary tests such as electroencephalogram (EEG) or cerebral blood flow imaging. However, in practice, brain death determination in the U.S. remains heavily reliant on clinical assessment.

The case of Anthony Thomas "TJ" Hoover II in Kentucky exposed potential flaws in this process. Although he had been declared brain dead, the patient suddenly exhibited neurological signs just before organ retrieval.

United Kingdom: Brainstem Focus

Unlike the U.S., the U.K. determines brain death based solely on brainstem function. Since 2008, the U.K. Department of Health has issued guidelines requiring clinical examination by at least two independent physicians who are not involved in the organ donation process.

Tests include evaluating the pupillary light reflex, gag reflex, response to pain, and apnea testing. Imaging is only used when the clinical exam cannot be fully performed.

In the U.K., once brainstem function is deemed irreversibly lost and the underlying cause is confirmed to be irreversible, the patient is declared legally dead—even if some cortical brain activity remains detectable through advanced testing. This is a significant difference from the whole-brain definition used in the U.S.

The simplicity of the U.K. protocol allows for faster diagnosis. However, its lack of mandatory imaging has led to legal controversies in cases involving life support withdrawal.

In 2022, the case of Archie Battersbee—a 12-year-old boy declared brainstem dead at Royal London Hospital—sparked national debate. Archie was found unconscious at home after a suicide attempt and fell into a deep coma. After days of monitoring with no improvement, doctors concluded that his brainstem had ceased functioning, meeting national criteria for brainstem death. However, his family strongly disputed the diagnosis and refused to consent to ventilator withdrawal, arguing that Archie still showed signs of life.

After several rounds of legal battles, the High Court ruled in favor of ending life support, leading to the boy's death in August that year. The case ignited a national discussion about parental rights, the reliability of brain death criteria, and the humanity of end-of-life decisions.

Japan: Organ Donation Consent Required

In Japan, a person is only considered brain dead when two conditions are met: a medical diagnosis and consent for organ donation. This means that if the individual had not previously expressed a wish to donate organs or if the family does not give consent, doctors will not declare brain death—even if the person meets all the medical criteria.

Japan's medical standards are extremely strict. Doctors must perform a full battery of tests, including electroencephalogram (EEG), cerebral blood flow measurement, and extended clinical evaluations over several hours. The interval between two rounds of testing must be at least six hours to minimize errors caused by medications or external factors.

Japan’s approach places ethical considerations and societal trust above all else. In Japanese society, where organ donation remains culturally and religiously sensitive, determining brain death is not merely a medical decision, but one closely tied to strict moral standards.

China: National Standard and Mandatory Medical Review

In 2013, China issued a national standard for determining brain death, which includes six mandatory steps. First, doctors must identify the clear cause of brain injury and rule out reversible factors such as hypothermia or drug intoxication. They then conduct clinical assessments and an apnea test to confirm the complete loss of brainstem reflexes and the inability to breathe independently.

Next, they must perform at least two out of three ancillary tests: electroencephalogram (EEG), somatosensory evoked potentials (SEP), and transcranial Doppler ultrasound (TCD). The entire process is repeated after a minimum of 12 hours and must be reviewed by at least three independent physicians.

Only when all three doctors unanimously agree after completing the full protocol can the patient be declared brain dead. This is considered one of the strictest systems in the world.

Thanks to rigorous checks, China has reported almost no mistaken brain death diagnoses during organ donation procedures. However, serious enforcement loopholes still exist. In 2020, a scandal in Anhui Province shocked the public when six individuals—including four doctors—were sentenced to prison for illegally harvesting organs from 11 patients whose families believed they had consented lawfully.

The perpetrators forged documents, removed bodies from hospitals at night, and performed liver and kidney extractions on trucks before selling the organs to other hospitals. The scheme was uncovered only when a victim's son noticed that the organ donation consent form was not filed in the national registry.

Different Approaches Reflect Deep-Seated Factors

The stark differences in how countries determine brain death reflect various factors—levels of medical advancement, legal frameworks, and moral perspectives on life and death.

“Brain death is a medical concept, but it has been assigned legal authority. When the line between life and death becomes blurred, every decision must be grounded in absolute caution,”said Dr. Robert Truog, Director of the Center for Bioethics at Harvard University.

In the U.S., following recent controversial cases, lawmakers are pushing for sweeping reforms in the national organ distribution network—including a re-evaluation of the criteria for determining brain death.

Thục Linh (According to Guardian, Washington Post, Guardian, BBC, Harvard)