152
Brain Death: The Asian Perspective
Hoe Chin Chua, MBBS, MRCP, FRCP1
H irofum i Morihara, MD 3
Tong Kiat Kwek, MBBS, MMed (Anaesthesiology), FAMS2
Daiquan Gao, MD 4
1 Department of Neurology, National Neuroscience Institute, TanTock
Seng Hospital, Singapore
2 Department of Anaesthesiology, Intensive Care and Pain Medicine,
TanTock Seng Hospital, Singapore
3 Department of Neurosurgery, National Neuroscience Institute, Tan
Tock Seng Hospital, Singapore
4 Department of Neurology, XuanWu Hospital Capital Medical
University, Beijing, China
Address for correspondence Hoe Chin Chua, MBBS, MRCP, FRCP,
Department of Neurology, National Neuroscience Institute, TanTock
Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
(e-mail: hoe_chin_chua@nni.com.sg).
Semin Neurol 2015;35:152-161.
Abstract
Keywords
► brain death
► Asia
► brainstem
► whole brain
► organ transplantation
Asia is the largest and most populous continent in the world with people from many
diverse ethnic groups, religions and government systems. The authors surveyed 14
countries accounting for the majority of Asia’s population and found that, although the
concept of brain death is widely accepted, there is wide variability in the criteria for
certification. Although most Asian countries have adopted the “whole-brain” concept of
brain death, most countries with past colonial links to the United Kingdom follow the UK
“brainstem ” concept of brain death. Despite this difference, most countries require only
neurologic testing of irreversible coma and absent brainstem reflexes as criteria for
certification of brain death. Variability exists in the number of personnel required,
qualifications of certifying doctors, need for repeat examination, minimum time interval
between examinations, and requirement for and choice of confirmatory tests.
The concept of brain death has become an accepted fact in
many countries since its first formal definition by an ad hoc
committee at Flarvard Medical School in 1968.1,2 Flowever,
there remains no accepted worldwide consensus on the
criteria and procedures for certification of brain death in
adults.2 This is a rather disconcerting state of affairs, given
that brain death is being certified many times a day all over
the world, with many critical decisions of organ donation or
termination of organ support depending on the outcome of
such certifications.
Although the vast majority of countries have guidelines
detailing the examination of brainstem reflexes in brain death
certification, there is still a lack of clarity on the conduct of the
apnea test, with only 59% of guidelines specifying a PaC02
target value.2,3 There is also no consensus on the need for a
repeat examination and the optimal time interval between
examinations.
Worldwide, there is wide variability in the number and
type of specialist personnel required for certification, with
Issue Theme Brain Death; Guest Editor,
Eelco F.M. Wijdicks, MD, PhD
44% of countries requiring one doctor, 34% requiring two, and
16% requiring three or more.2 The use of confirmatory tests is
also another area of inconsistent practice, with some coun­
tries requiring at least one confirmatory test and others
leaving it to the certifying doctors to decide.
Asia is the largest and most populous continent in the
world with 4.4 billion people of multiple ethnicity, cultures,
and religious beliefs, located in 48 countries over a vast
geographical expanse. The last review of brain death guide­
lines in Asia was published in 2001, as part of a worldwide
survey of brain death criteria and practices.2 In Asian socie­
ties, life and death practices and beliefs are often influenced
by and intertwined with those of local cultures and customs.
Although the concept of brain death has been accepted in
many Asian countries, its implementation and practice have
so far been quite varied.
Over the past decade, many Asian countries have experi­
enced rapid urbanization and socioeconomic development,
giving rise to marked improvements in the educational level,
Copyright © 2015 by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
DOI http://dx.doi.org/
10.1055/s-0035-1547539.
ISSN 0271-8235.
Brain Death: The Asian Perspective
affluence, and health care services provided. In this article, we
review and update the brain death certification guidelines
and practices in Asian countries and compare them against
those practised in the rest of the world.
For this review, we obtained published guidelines from
professional societies or any documents resulting from gov­
ernment legislations on brain death from Asian countries. In
addition, a survey with questions about brain death practices
and guidelines was sent to as many countries as we were able
to contact. We sought to have the survey questions answered
by the president or an official of the relevant professional
society in each country (e.g., the critical care medicine society
or neurological medicine society.)
The Asian Perspective
We were able to gather information or receive survey replies
from 14 countries (out of 48) or approximately 29%of the 48
countries in Asia. Nonetheless, the total population of these
14 countries amounts to 3.37 billion or 77% of Asia’s total
population. We will present the guidelines for each country
separately (-T a b le 1).
China
China is the largest country in East Asia and the most
populous country in Asia and the world with 1.35 billion
people. In 2013, the Brain Injury Evaluation Quality Control
Centre of the National Health and Family Planning Commis­
sion published the country’s criteria and practical guidance
for determination of brain death in adults.4,5 Brain death in
China is defined as death of the whole brain, including the
brainstem. The certification of brain death in China requires
fulfillment of clinical testing criteria and completion of
confirmatory tests. To date, these guidelines have not been
legislated into law.
Certification begins with establishing that the patient is in
a deep coma with absent brainstem reflexes and no sponta­
neous respiration. The apnea test is required and should show
no respiratory efforts at a PaC02 > 60 mm Hg or 20 mm Hg
above baseline. The accepted confirmatory tests are somato­
sensory evoked potentials (SSEPs), electroencephalogram
(EEC), and transcranial Doppler (TCD) examinations, with a
requirement that any two of these three tests yield results
consistent with brain death. These clinical and confirmatory
tests will need to be repeated 12 hours later, for brain death to
be certified.
Performance of each test requires the attendance of at
least two doctors, with both having completed at least 5 years
of clinical practice. Organ donation is allowed to proceed
after brain death has been certified if the patient has
previously indicated a desire to donate his/her organs
upon death.
The age of consent for organ donation in China is 18 years.
If the patient has not previously made a decision on organ
donation, the next of kin can be approached for consent and
organ donation can proceed if they agree. Organs that may be
donated include the heart, lungs, kidneys, liver, pancreas, and
small intestine.
Chua et al.
Japan
In 1997, Japan passed an Act on Organ Transplantation
legalizing the determination of brain death only when organs
are to be recovered from the deceased patient for donation.6
This Act is only applicable to patients who have previously
consented to organ donation and where the next of kin have
not objected. This Act was further amended in 2009, allowing
the determination of brain death and the recovery of organs
when the family has consented to donation even when the
deceased had not previously consented to organ donation.7' 9
This change has made possible the donation of organs by
children less than 15 years of age with parental consent,
except for infants less than 12 weeks old and children less
than 18 years old who may be victims of child abuse.
Japan follows the “whole-brain” concept of brain death
and requires demonstration on clinical neurologic examina­
tion of irreversible coma with absent brainstem reflexes, and
the apnea test threshold set at PaC02 > 60 mm Hg. An EEG
examination showing isoelectric activity is mandatory. Both
the clinical examination and the EEG must be repeated, at a
time interval dependent on the age of the patient, for
confirmation of brain death. For patients > 6 years old, the
required time interval is > 6 hours; for those < 6 years old,
the time interval has to be > 24 hours. During each test, there
must be at least two doctors in attendance, with only special­
ists in neurology, neurosurgery, anesthesiology, emergency
medicine, intensive care, or pediatrics allowed to certify brain
death. Doctors trained in other disciplines cannot certify
brain death unless they are also accredited in one of the
listed specialties. Organs that may be donated include the
heart, lungs, liver, kidneys, pancreas, small intestines, and
eye.
South Korea
The Korean Organ Transplantation Act, which was first passed
in February 2000 and revised in May 2010, provides the legal
basis for determination of brain death and promotion of organ
transplantation.10 Under this Act, brain death refers to a
person whose whole-brain function is determined to have
irreversibly ceased, and is only restrictively recognized for the
purpose of allowing organ donation.
Certification of brain death requires clinical determination
of irreversible coma with loss of all brainstem reflexes,
including the apnea test. The clinical examination must be
repeated at a time interval dependent on the patient’s age:
For patients > 6 years of age, it is 6 hours; for those between 1
to 6 years of age, it is 24 hours; and for patients between
2 months and < 1 year of age, the time interval is 48
hours.10' 12
There is a requirement for four to six staff to be in
attendance, with a minimum of two specialist medical staff,
one of whom must be a neurologist or a neurosurgeon, and at
least one nonmedical staff. The diagnosis of brain death is
decided by the majority of those present at the two clinical
examinations and following an EEG examination showing
isoelectric activity. The reasons cited for requiring such a
large group to certify brain death are—to avoid public scepti­
cism of the diagnosis and distrust of doctors, eliminate the
Seminars in Neurology
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153
Whole brain
Whole brain
Brainstem
Brainstem
Whole Brain
Whole brain
Whole Brain
Whole brain
Whole brain
Brainstem
Whole brain
Brainstem
Whole brain
Japan
South Korea
Taiwan
Hong Kong
Philippines
Vietnam
Thailand
Myanmar
Malaysia
Singapore
Indonesia
India
Sri Lanka
Yes
Yes
> 60 / |2 0 above
baseline
At least 2
At least 2
6 h
Yes
Yes
> 60 / |2 0 above
baseline
Not specified
> 60 / T20 above
baseline
Not specified
> 6 0 / f2 0 above
baseline
> 50/ |2 0 above
baseline
> 60 / T20 above
baseline
fN
ro
fN
rsi
r\i
ro
Not specified
25 m in -2 4 h
No
>60 and pH < 7.3
fN
Yes
Yes
Yes
Yes
Yes
Yes
Yes
12 h
Not applicable
Depends on age;
range o f 6 -48 h
Not specified
6 h
Not specified
2 h
Any tim e after 1st
examination
Depends on age;
range of 4 -2 4 h
Not specified
fN
Yes
Not specified
Depends on age;
range o f 6 -48 h
Depends on age;
range of 6 -2 4 h
12 h
Time interval to
repeat examina­
tion
4 to 6
Yes
Is repeat
clinical testing
required?
Apnea Test PaC02 threshold
(mm Hg)
Number of personnel
needed for certification
fN
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Available brain
death
certification
guidelines?
No
No
No
No
2 EECs required for
children < 1 year
old
No
No
No
No
No
No
Yes
Yes
Yes
Are ancillary tests
required?
Opt-in
Opt-in
Opt-in
Opt-in and opt-out
Opt-in
Opt-in
Opt-in
Opt-in
Opt-in
Opt-in
Opt-in
Opt-in
Opt-in
Opt-in
Consent for organ
donation
Brain Death: The Asian Perspective
Vol. 35
No. 2/2015
Abbreviations: EEG, electroencephalogram.
Whole brain
China
Seminars in Neurology
09 <
Brain death
concept
09 <
Table 1 Characteristics of brain death certification in different Asian countries
154
Chua et al.
rsi
Brain Death: The Asian Perspective
possibility of diagnostic errors, and allow swift decision
making through consensus of the group. Organ donation
can only proceed if there is prior consent from the patient
and no objections from the next of kin. Patients < 16 years of
age can donate their organs with parental consent. Organs
that may be donated include the kidneys, liver, heart, lungs,
pancreas, and small intestines.
Taiwan
In Taiwan, the Human Organ Transplantation Act was passed
in 1987, and in the same year, guidelines for brain death
determination were also established.
Brain death is defined as death of the brainstem, which is
diagnosed via two clinical assessments at separate time
intervals by two doctors showing absent brainstem reflexes.
The patient needs to have been on a ventilator for at least 12
hours before the first brain death examination can be
performed.13
For patients more than 3 years old, the time interval
between examinations must be at least 4 hours. For children
1 to 3 years old, the time interval must be least 12 hours. For
children less than 1 year old but at least a full-term baby, the
time interval must be least 24 hours. No mandatory confirma­
tory test is required. Only two groups of doctors are allowed to
certify brain death. The first group consists of specialists in
neurology, neurosurgery, or pediatric neurology. The second
group comprises specialists in surgery, medicine, general
pediatrics, anesthesiology, emergency medicine, or intensive
care. Doctors in the second group are required to complete an
8-hour brain death course before they are allowed to be
certifiers. Each pair of doctors certifying brain death will
usually comprise one doctor from each group. Individuals
who wish to register as organ donors must be at least 18 years
of age. When a deceased patient has indicated prior consent to
donate his/her organs, consent from the next of kin is still
required before organ recovery can proceed. If the deceased
has not previously registered as a donor, the next of kin can be
approached for consent. Organs that may be donated include
the heart, lungs, liver, kidneys, pancreas, and small intestines.
Hong Kong
In Hong Kong, brain death is based on the concept of
“brainstem" death, which is likely a legacy of its previous
colonial status under the United Kingdom (UK). This requires
demonstration of irreversible cessation of brainstem function
using guidelines established by the Hong Kong Society of
Critical Care Medicine in 1992 and later revised in Septem­
ber 2009.14 These criteria are valid for patients 2 years of age
or older. Two separate clinical neurologic examinations per­
formed by two doctors are required, with the first examina­
tion occurring after at least 4 hours of observation of the
patient in a deep coma (Glasgow Coma Score of 3). The second
examination can occur any time after the first, providing at
least 4 hours of observed deep coma before brain death is
certified. This duration is extended to 24 hours for brain death
certified in patients following cardiorespiratory arrest.
The doll’s eye or oculocephalic reflex is not included
among the brainstem tests required for certification. For
Chua et al.
the apnea test, the required PaC02 target is > 60 mm Hg
and a pH < 7.30. There is no mandatory requirement for a
confirmatory test, which is only required if the preconditions
for clinical testing are not met. Examples of such conditions
include metabolic disorders, residual drug levels, pre-existing
cranial neuropathies, and inability to tolerate the apnea test.
The accepted confirmatory tests are the cerebral angiogram
and the radionuclide scan.
For the two doctors performing the certification, one of
them has to be an intensivist, neurologist, or neurosurgeon.
The other doctor should preferably have the same qualifica­
tions, but can be any doctor with at least 6 years of clinical
practice and the appropriate knowledge and skills. Signed
consent from the patient or the next of kin is required for
organ donation. The organs that may be donated include the
kidneys, heart, lungs, and liver.
Philippines
In the Philippines, the Organ Donation Act was passed in
1991, which permits an individual to donate all or part of his
body by way of legacy or will.15This was followed in the same
year by the legal recognition of brain death. The Philippines
Neurological Association spearheaded a multidisciplinary
consultation that led eventually to a consensus agreement
on the clinical criteria for certification of brain death. These
criteria were last updated in February 2012. Under these
criteria, brain death is defined as irreversible coma with
permanent cessation of whole-brain function, including the
brainstem. The diagnosis is made from clinical neurologic
examination showing absent brainstem reflexes, including
the apnea test. Confirmatory tests are not required except in
situations where the preconditions for clinical testing are not
fully met, in which case an EEG or TCD examination would be
required.
A repeat clinical examination is required and must be
performed at least 2 hours after the first examination.16 Each
assessment requires the attendance of two doctors compris­
ing the attending doctor and another who should preferably
be a neurologist, neurosurgeon, anesthesiologist, or internist.
The time of death is the time when the patient was initially
diagnosed to be brain dead. Their criteria also advise caution
when diagnosing brain death in children less than 5 years of
age.
The Philippines Network for Organ Sharing was estab­
lished by the Department of Health to develop a national
system for promoting organ donation from deceased donors
and to ensure equitable allocation of organs. Those who wish
to donate their organs upon death can register their consent
and be issued an organ donor card. For those who have not
made a choice, consent can be sought from the next of kin of
the deceased.
Vietnam
In Vietnam, the law-governing organ and tissue transplanta­
tion was passed and implemented in 2007. Brain death is
defined as death of the whole brain including the brainstem.
There are no national guidelines for certification of brain
death, with the diagnosis made on clinical neurologic
Seminars in Neurology
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156
Brain Death: The Asian Perspective
Chua et al.
examination with absence of brainstem reflexes by two
doctors. Repeat examination is required, although there is
no mandated minimum time interval between the two
examinations. No confirmatory test is required. Consent for
organ donation is obtained from the next of kin.
Thailand
Thailand has well established brain death certification crite­
ria endorsed by the General Medical Council of Thailand
since 1989. Certification of brain death requires two clinical
assessments showing absent brainstem reflexes, performed
at least 6 hours apart. No mandatory confirmatory test is
required.17'18
Three doctors are required for brain death certification
comprising the attending doctor, a neurologist, or neuro­
surgeon, and the director of the hospital or his representative.
Deceased donation of organs is possible with either prior
signed consent by the deceased or consent from the next of
kin. Potential donors must be less than 60 years of age.
Myanmar
In Myanmar, brain death was legally recognized in 2009 and
is defined as death of the whole brain, including the brain­
stem. However, there are no national criteria or guidelines for
certification. Brain death is diagnosed by clinical neurologic
testing demonstrating absence of brainstem function. Repeat
clinical testing is required, although there is no mandated
time interval between examinations. No confirmatory test is
required.
Two certifying doctors are required, one of whom needs to
be a neurologist and the other a neurosurgeon if organ
donation is being considered. When organ donation is not
being considered, certification can be performed by an inter­
nist and an intensivist. Consent for organ donation is obtained
from the next of kin.
Malaysia
In Malaysia, brain death is defined as the irreversible loss of
brain function as a whole, including that of the brainstem. The
patient must be in a deep coma, apneic, and been on
mechanical ventilation for at least 24 hours. A consensus
statement on brain death was written by an expert committee
in 2003 and endorsed by the Malaysian Medical Council in
2006.19,20 These guidelines have been adopted by the Minis­
try of Health, although it has not been legislated into law by
the Malaysian Parliament. In adults, brain death is diagnosed
through clinical neurologic testing of brainstem reflexes,
including the apnea test. Two examinations must be per­
formed by two specialists at least 6 hours apart. No confir­
matory test is required. For children, the interval between
examinations will vary depending on the age: For those aged
between 7 days to 2 months, it is 48 hours; for those aged
2 months to 1 year, it is 24 hours; and for those older than
1 year, it is 12 hours. In addition, for those less than 1 year
old, an EEG examination is required to accompany each
clinical examination to complete the certification.19 When
hypoxic ischemic encephalopathy is the cause of brain death,
the interval between examinations will need to be at least 24
Seminars in Neurology
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hours, unless the EEG shows isoelectric silence or the radio­
nuclide scan shows absence of intracranial blood flow.
Specialists performing brain death certification must have
at least 3 years of postgraduate experience and be trained in
brain death certification. They should preferably be anes­
thesiologists, intensivists, internists, neurologists, or
neurosurgeons.
The legal age for consent for organ donation is 18 years. For
those below this age, consent from the parents must be
sought. The organs that may be donated include the heart,
lungs, liver, and kidneys.
Singapore
In 1987, parliament passed the Human Organ Transplant Act,
which allowed the certification of brain death from traumatic
causes when the deceased had not opted-out of donating his/
her organs upon death. In 1998, the Interpretation Act of
Section 2A was passed, which legally recognized brain death
from all causes, even in the absence of planned organ dona­
tion.21 Brain death is defined as the irreversible loss of
brainstem function, which is diagnosed through bedside
testing of seven brainstem reflexes, including the apnea
test. The PaC02 target for apnea testing is 50 mm Hg or an
increase of > 20 mm Hg above baseline.
Certification must be performed by two independent
doctors iforgan donation by the deceased is being considered.
If organ donation is not being considered, only one indepen­
dent doctor is required and the other doctor can be the
attending neurologist, neurosurgeon, or intensivist. The
two certifying doctors may perform the clinical testing
together or separately. Although there is no mandatory
need to repeat the brainstem tests, this is often performed
as part of the workflow for certification of brain death in the
intensive care unit (ICU). The certifying doctors must be
specialists from surgery, medicine, anesthesia, or pediatrics
and have completed a half-day brain death certification
course co-organized by the Ministry of Health.
Confirmatory tests are not routinely required and are only
employed when the preconditions for clinical testing are not
met or when the observed responses to the clinical brainstem
testing are ambiguous. The only two legally recognized
confirmatory tests are the cerebral angiogram and the radio­
nuclide scan.
Singapore has both opt-in and opt-out consent laws for
organ donation, which were passed in 1972 and 1987,
respectively.21 The opt-in law allows for donation of any
specified organ while the Human Organ Transplant Act or
opt-out law only allows for donation of the heart, liver,
kidneys, and cornea for purpose of transplantation. When
the deceased has consented to organ donation, no further
consent is required from the next of kin, nor are they able to
object to donation.
Indonesia
The Indonesian criteria for brain death certification were
issued by the Indonesian Medical Association in 1988 and
defined brain death as the irreversible cessation of all func­
tions of the entire brain, including the brainstem.22,23 The
Brain Death: The Asian Perspective
most common reason for certification of brain death in
Indonesia is to facilitate end-of-life care and termination of
organ support. The diagnosis involves an examination dem­
onstrating irreversible coma from a structural brain injury
and absent brainstem function, including the apnea test with
the PaC02 threshold at > 60 mm Hg. Repeat testing is re­
quired and can be performed anytime w ithin an interval
ranging from 25 minutes to 24 hours. No routine confirmato­
ry testing is required. Three doctors are required to certify
brain death and they should be specialists in anesthesiology,
intensive care medicine, or neurology.
India
India is the largest country in South Asia and the second most
populous country in the world w ith 1.2 billion people. The
Transplantation of Human Organ Act was passed in 1994 and
regulates the removal, storage, and transplantation of human
organs.24,25 In India, brain death is defined as death of the
brainstem, which requires two clinical assessments, per­
formed at least 6 hours apart, showing absence of brainstem
function. The apnea test requires a PaC02 > 60 mm Hg or a
rise o f > 20 mm Hg above the baseline. No confirmatory test
is required.
A panel of four doctors is required, comprising a registered
medical practitioner, a neurologist, or neurosurgeon from a
notified panel, a registered medical practitioner in charge of
the institution, and a registered medical practitioner treating
the patient. If a neurosurgeon or neurologist is not available,
the doctor in charge of the hospital may nominate an inde­
pendent doctor who can be a surgeon, internist, anesthesiol­
ogist, or intensivist.24-26
If the intent of the patient regarding organ donation is
unknown, doctors may approach the next of kin for consent.
Organs that may be donated include the heart, lungs, liver,
and kidneys.
Sri Lanka
In Sri Lanka, the 1987 Transplantation of Human Tissues Act
provides for the donation of human bodies and tissues for
therapeutic, scientific, educational, and research purposes,
and for the removal of such tissues and their use on living
persons.27 Under this Act, death is defined as the irreversible
cessation of all functions of the entire brain, which is deter­
mined by prolonged absence of spontaneous circulatory and
respiratory function. When the patient is mechanically ven­
tilated, irreversible cessation of brain function shall be deter­
mined by prevailing best medical practice. The Act does not
stipulate what the exact criteria should be.28
Currently, brain death is certified when repeated clinical
examinations by two doctors 12 hours apart show absence of
brainstem function. The PaC02 threshold for the apnea test is
not specified. No confirmatory tests are needed.
Potential organ donors must be at least 21 years old. If the
deceased had not given prior consent, consent may be
obtained from the next of kin. Organs that may be donated
include the kidneys and liver. Organ donation is coordinated
by the Sri Lanka Association of Nephrology and
Transplantation.29
Chua et al.
Discussion
A summary of the main characteristics of brain death certifi­
cation of each country is shown in -T a b le 1 . We found that in
the majority of countries in Asia that we surveyed, guidelines
and criteria for certification of brain death exist. These guide­
lines often stipulated the tests to be performed, the expected
findings in brain death, the need for repeat testing, the time
interval between testing, and the number and type of medical
personnel needed for certification. Most Asian countries have
adopted the whole-brain concept definition of brain death,
while most countries w ith past colonial links to the UK have
adopted brainstem death as the definition of brain death.
Despite this distinction, not all countries having the wholebrain concept of brain death mandate a whole-brain test to
confirm brain death. The Philippines, Thailand, Indonesia,
Malaysia, Sri Lanka, Myanmar, and Vietnam only require
clinical neurologic evidence of irreversible coma and absence
of brainstem reflexes, including the apnea test. These are
largely the same criteria employed by countries having the
brainstem death concept of brain death.
The preconditions to brain death certification are fairly
similar throughout Asia and the rest of the world. These
involve first establishing an anatomical cause of extensive
irreversible brain damage, usually w ith CT imaging. Second,
other reversible causes of coma, such as severe hypothermia
(core temperature < 32°C), severe electrolyte, acid-base or
endocrine disturbances, drug intoxications, severe hepatic or
renal dysfunction, must be excluded through clinical exami­
nation and laboratory testing.30 Third, residual neuromuscu­
lar blockade should be ruled out w ith a peripheral nerve
stimulator for patients who have received neuromuscular
blocking agents in the preceding 4 hours.
The clinician should only proceed to perform the bedside
brainstem tests after the three preceding steps have been
performed. Though guidelines for brainstem testing are avail­
able in most Asian countries, these guidelines recommend
practices that vary widely from country to country. These
differences likely reflect the lack of evidence to support a
standard way of certifying brain death. There are seven main
brainstem tests that are often employed for brain death
certification. They are fixed pupils in a mid-dilated position
(4-6 mm in diameter) w ith no response to light, absent
corneal reflex, absent oculocephalic (doll’s eye) reflex to rapid
turning of the head, absent oculovestibular (caloric) reflex to
instillation of cold saline into each ear canal, absent pharyn­
geal (gag) and laryngeal (cough) reflexes, absent facial move­
ments to pressure on the supraorbital nerve, and apnea to a
maximal PaC02 stimulus.30 There is consensus that the
brainstem reflexes need to be absent; however, not all
countries require testing of all seven brainstem tests. Further­
more, the PaC02 threshold required for apnea testing varies,
w ith most countries adopting a threshold of > 60 mm Hg or
an increase o f > 20 mm Hg above the baseline. Some coun­
tries do not have a specified threshold, leaving it to certifying
doctors to decide.
Almost all the Asian countries surveyed reported require­
ment of a repeat neurologic examination to confirm irrevers­
ibility of lost brain function. However, the minimum time
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Brain Death: The Asian Perspective
Chua et al.
interval between examinations again varies widely, ranging
from not specified to between 6 and 48 hours. This variability
may again be a reflection of the lack of evidence to guide
practice.
To date, there is no evidence that performing a second
examination improves the accuracy of the brain death
diagnosis. A recent retrospective study of 100 New York
hospitals involving 1,229 adult and 82 pediatric brain death
certifications did not find a single second examination that
showed a reversal of previously absent brainstem re­
flexes.31 The study concluded that a single neurologic
examination would suffice for patients older than 1 year
of age. While not adding value, dual examinations have also
been found to increase costs, cause unnecessary delays in
confirming death and may adversely affect organ donation
potential.31,32 All Asian countries require two or more
doctors to certify brain death, with India requiring as
many as four doctors. Although it is reasonable and appro­
priate to have at least two certifying doctors, especially
when only one of them is required to be a neurologist,
neurosurgeon, intensivist, or anesthesiologist, requiring
more would seem unnecessary and cause delays in certify­
ing brain death. This would not be ideal if ICU beds are in
short supply or when organ donation is being considered.
Most Asian countries require that one or both certifying
doctors be a neurologist, neurosurgeon, or intensivist. In
some countries, nonspecialist doctors who have received
special training in brain death certification are also allowed
to be certifiers. This concession may reflect the logistic
difficulty of limiting certification to only a small pool of
specialists, especially for large countries with many smaller
city hospitals. Common to all countries, doctors involved in
the organ transplant process or subsequent care of the
transplant recipient cannot be part of the team certifying
brain death for the organ donor.
The need for confirmatory tests also varies widely across
Asia. There are broadly two groups of confirmatory tests: The
first group measures brain electrophysiology and include
tests such as EEG and SSEPs; the second group measures
intracranial blood flow and includes tests such as cerebral
angiography, CT angiography, MR angiography, radionuclide
scan, and TCD.
The countries that require routine confirmatory testing are
China, South Korea, and Japan. All the other countries only
require confirmatory tests when preconditions for clinical
testing cannot be fulfilled or if there are ambiguous findings
observed during clinical testing. The type and choice of
confirmatory tests also varies from country to country, deter­
mined by factors such as round-the-clock availability, infra­
structure limitations, availability of specialized manpower,
and costs.
It has recently been argued that confirmatory tests are not
really necessary in certification of brain death in adults.33
Such tests are usually ordered as safeguards in the diagnosis
of brain death; yet, they are not really confirmatory, with each
test having false-positive and false-negative results.33
South Korea requires an EEG examination after two clinical
neurologic examinations to confirm brain death. Japan re­
Seminars in Neurology
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No. 2/2015
quires the EEG examination to follow each clinical examina­
tion and for both to be repeated. China has by far the most
onerous requirement, needing two out of the three accepted
confirmatory tests (SSEPs, EEG, and TCD) to be repeated after
each clinical examination. This level of testing is probably
unnecessary and may reflect distrust of the public in their
health care providers. In addition to adding unnecessary
costs, it will also delay certification and hence the viability
of transplantable organs.
It has been reported that confirmatory tests that measure
intracranial blood flow, such as cerebral angiography and
radionuclide scans, are more reliable and therefore preferred
to the EEG and SSEPs, which are more susceptible to con­
founding by hypothermia and drugs.34 It would seem more
logical and cost effective to depend on a single reliable
confirmatory test than to do multiple unreliable tests.
In Asia, the policies and laws on certification of brain death
are often intricately interwoven with those governing de­
ceased organ donations. Most Asian countries have adopted
an opt-in approach to obtaining consent for organ donation,
whereby potential deceased organ donors need to have
previously signed a pledge to be an organ donor or have
consent signed by a willing next of kin.
The deceased organ donation rates in many Asian coun­
tries are not published, but are believed to be generally very
low compared with those reported in Europe and North
America. The deceased donor rate for Asia was reported to
be 1.1 per million population (pmp) compared with Europe
and the United States at 15 to 20 pmp in Year 2000.35 There
are many reasons for this low rate: wide disparity in pre­
hospital emergency services, underdeveloped health care and
ICU facilities, lack of support for treatment of neurologic
injuries leading to premature deaths, and the lack of a
national organ procurement agency to coordinate identifica­
tion and recruitment of donors.36
Although there are laws allowing organ donation, many Asian
societies have ethnic, cultural, and religious beliefs that influence
their views of death and the physical body, and remain barriers
to their buy-in for organ donation after death.36This is especially
so in Japan, where deceased organ donation is not generally
accepted despite brain death being widely accepted as equiva­
lent to death from cardiorespiratory arrest.
Past improprieties by the medical community in deter­
mining brain death may have contributed to this.37 In 1968, a
cardiac surgeon from Sapporo removed the heart from a
donor who was not yet brain dead. The condition of the
recipient was also reportedly noncritical and did not warrant
a transplant. As a result, great public distrust of organ
transplant developed, particularly of transplants involving
brain dead donors.
This low buy-in for organ donation in Asia has resulted in
a small and limited supply of transplantable organs from
deceased donors. The rising incidence of chronic diseases
among Asian societies has resulted in a corresponding rise
in the incidence of organ failures and demand for organ
transplantation. These trends have resulted in a widening
gap between the demand and supply of transplantable
organs.
Brain Death: The Asian Perspective
The Influence of Religion on Brain Death and
Organ Donation
In Asian societies, brain death and organ donation are affect­
ed by religious concerns. We highlight the major religions
below.
Buddhism
Buddhism has a large following in Asia. The basic teachings of
Buddhism are the Four Noble Truths and the 8-fold Path.38' 41
The Four Noble Truths teach that all existence is suffering
(dukha). To bring an end to suffering, insatiable human
desires must be illuminated and this can be achieved by
following the 8-fold Path. The central theme of Buddhism is
eternal release from suffering and entering the blessed state
of nirvana. Followers view life on earth as transitory and
transplanting organs to keep life going as foolishness. If life is
nothing but suffering, why receive an organ to prolong
suffering? Individuals should let go because letting go is the
end of suffering.
Buddhism does not accept death as the absence of brain
function, heartbeat, or breathing. Followers believe that after
breathing stops, the soul remains in the body. Death is defined
at the moment of departure of the soul from the body. The
body must not be disturbed so that the soul can have a
peaceful migration to a new destiny. Rituals are performed
to complete the dying process. These customs hamper early
organ retrieval.
In favor of organ donation, a fundamental tenet of
Buddhism is that there is virtue in eliminating suffering.
This position lends itself to acts of altruism toward those in
need, and suggests that donating one’s organs is to be
encouraged.
Confucianism
Confucianism is a philosophical and quasi-religious system
that emphasizes filial piety.38 Confucianism teaches that
one is born with a complete body and should die the same
way. Family members desire the deceased to depart to
another world with an intact body rather than with missing
parts. Through the concept of Ren, or benevolence/kindness, modern scholars expound the virtues of organ
donation.
Taoism
Taoism emphasizes naturalness, peace, vitality, and “follow­
ing the flow of nature.’’38 If dying is a natural process,
attempts to abort it are unnatural. Upon death, the body
must be preserved to provide the soul with a resting place to
ensure immortality. Elaborate rituals are performed to chan­
nel life-enhancing spirits into the body. Followers believe that
death is another form of life where food, drink, clothing,
money, and so on, are needed. Any damage to the body will
affect the dead life’s completeness.
In support of organ donation, modern scholars argue that
the body is only a shelter that does not have any substantive
meaning. Flence donating organs to sustain another life
should not be opposed.
Chua et al.
Shintoism
Shintoism is the indigenous religion of Japan.42 The three
goals of Shintoism are the preservation of life, promotion of
good health, and harmonization with nature. To pronounce
death in a heart-beating deceased brain dead patient is
unnatural. Interfering with the dead body is believed to bring
bad luck and damage the relationship between the deceased
and family. The practice of allowing a waiting time after death
to ensure the soul does not return to the body is another
hurdle to organ donation.
The typical Japanese household adopts a combination of
Shintoism, Taoism, Buddhism, and Confucianism. This com­
bination of factors affects organ donation adversely.
Hinduism
Hinduism, often described as a way of life, embraces a
diversity of traditions and beliefs.41-43-44 This life is believed
to be a transition between the previous life and the next. An
important tenet of Hinduism is to help those who are suffer­
ing and Daan, or selfless giving, ranks third among its
Niyamas (virtuous acts). There are many references that
support the concept of organ donation in Hinduism. The
physical integrity of the dead body is not seen as crucial to
the reincarnation of the soul. Scientific and medical treatises
(Charaka and Sushruta Samhita) form an important part of
the Vedas. Sage Sushruta includes features of organ and limb
transplants and is supportive of organ donation.
Islam
The majority opinion of Muslim jurists and scholars is that
organ donation is permissible in Islam. This ruling is made by
international fiqh councils and prominent scholars, such as
the Islamic Fiqh Academy, the Highest Council of Scholars in
Riyadh, the former Mufti of Egypt Dr. Muhammad Syed
Tantawi, the Fatwa Council of Kuwait, the prominent Muslim
scholar Dr. Yusuf Al-Qaradhawi, the National Scholar’s Coun­
cil of Malaysia, and the Fatwa Committee of the Islamic
Religious Council of Singapore.45
The arguments in favor of organ donation are as follows.
First, Islam calls for the seeking of cure and treatment for
illnesses. Currently, the most effective treatment for those
who suffer from organ failure is to receive a new organ in
place of the failed one. Second, the objectives (maqasid) of the
Syariah clearly state the importance of protecting and saving
human lives. This is mentioned in the Holy Quran, “whoever
saves one life, it is as though he has saved the whole of
humanity” (Quran 5:32). Third, the Syariah is built upon
values such as care and compassion. The Syariah thus calls
for mankind to help one another and to alleviate human
suffering and pain. Traditions attributed to the Prophet
Muhammad also encourage Muslims to help their fellow
human beings: “Whoever helps another will be granted
help from Allah in the Hereafter." Fourth, donating one’s
organs is an act of amal jariyah (continuous charitable
deed) in which the rewards accrue even after one’s death.45’46
The arguments against organ donation are as follows. First,
Islam places a great emphasis on respect and sanctity of the
human body. Violating the human body, whether living or
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160
Brain Death: The Asian Perspective
Chua et al.
dead, is forbidden in Islam. It could be argued that organ
donation, for example, kidney transplantation, may not be an
absolute necessity in view of the availability of dialysis
(though the quality of life is suboptimal). Second, there is
the conflict between free will and predetermination: If God
has foreordained the failure of an organ, what right do
humans have to replace the function of that organ by trans­
plantation? Third, Muslims have a perception that they are
not owners of their own body or organs and have no right to
give their organs away. Fourth, Muslims believe that on the
Day of Judgement their bodily parts and organs will testify
before God the good and bad deeds they had done in life. How
can such testimony occur if an organ had been donated away
in life or after death? Fifth, brain death is not considered death
from an Islamic perspective.41,45,46
Death in Islam is an active process, a transition for the soul
from the physical to the spiritual world. As regards end-of-life
rituals, a person is not considered dead until the body has
become cold and rigor mortis has set in. The family should be
allowed to stay with the patient and continue with end-of-life
rituals until cardiopulmonary arrest has occurred. Given this
set of beliefs linked to Islamic theology, the reluctance of
family members to allow physicians to incise the breathing
body of their loved one sustained by life support is under­
standable. This belief is not easily reversed.41
Worldwide, most Islamic scholars endorse organ donation,
with a dissenting voice from the minority.
Christianity
Most Christians, Roman Catholics, and Protestants do not
have theological objections to brain death or organ dona­
tion.41 Christians are taught to “love your neighbor" (Mat­
thew 5:43) and because organ donation has the potential to
save lives and help others, its teachings favor organ donation.
Conclusions
Asia is the contingent with the largest land mass and popula­
tion in the world. Many countries in Asia have experienced
massive urbanization and socioeconomic development in the
past decade. This has brought rising affluence and demands
for high-quality health care.
Most Asian countries today have recognized brain death,
adopting the whole-brain concept of brain death, defined as
the irreversible loss of all brain functions including those of
the brainstem. Although many countries have brain death
certification guidelines, the criteria applied are not always
uniform, especially for the apnea test. There are also differ­
ences in the need for repeat neurologic examinations, the
minimum interval between examinations, and the number
and type of personnel needed for certification. Most countries
do not require the routine use of a confirmatory test for
certification.
Organ donation is a complicated issue influenced not only
by medical decisions, but also by religion, traditions, and
ethics. The buy-in for deceased organ donation is still very
low in Asia despite the acceptance of brain death. Coupled
with a rising incidence of chronic diseases and organ failures,
Seminars in Neurology
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No. 2/2015
this has resulted in a widening gap between the demand and
supply for transplantable solid organs. It may be an oppor­
tune time for governments and health care organizations in
Asia to work together to improve this situation.
Acknowledgments
The authors thank the following specialists (neurologists,
neurosurgeons, anesthesiologists, and others) who gave of
their precious time to complete the survey and answer
questions on the policies and laws in their respective
countries: Daiquan Gao, Feng Gang (China); Hirofumi
Morihara, Nonaka Sinseh, Masahiro Sonoo, Miyaji, Shozo
Tobimatsu (Japan); Dong Chan Kim, Cheol Woong Jung,
Benjamin Youchan Shin (South Korea); Lung Chan, ShanJin Ryu (Taiwan); So Hing Yu (Hong Kong); Jose Navarro,
Paul Matthew Pasco, Jose Emmanuel Palo, Antonio Mangubat (Philippines); Huy Thang Nguyen (Vietnam); Sombat Muengtaweepongsa (Thailand); Win Min Thit
(Myanmar); Lim Wee Leong, Goh Khean Jin (Malaysia);
Sandhi Christanto (Indonesia); Hari Har Dash, Man Mohan
Mehndiratta, Parampreet Kharbanda (India); Thashi
Chang (Sri Lanka).
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