You question in an Editorial the determination of death for organ-transplant purposes in the United States, where explantation can go ahead once all functions of the entire brain have irreversibly ceased (Nature 461, 570; 2009). Nothing so rigorous is demanded in the United Kingdom.

For successful transplantation, major organs such as the heart, lungs, bowel and liver must be alive. For some 30 years, UK practice has required only bedside tests purporting to show an irreversible loss of ability to breathe and the irreversible cessation of some brainstem functions. Higher parts of the brain may continue to function. As a consultant anaesthetist (now retired), it greatly concerns me that the donor will need some form of paralysis and anaesthesia to control the responses to explantation surgery.

The UK technical definition of death for transplantation purposes is not explained on donor cards or on the donor register, so those who sign up may have a quite different concept of “my death”. This may explain the 40–50% refusal rate among relatives when they observe the condition of someone declared dead but still showing signs associated with life.