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The main source of transplanted organs all over the world, though not in India, is dead bodies, also known as cadavers. Recent refinements in language made people feel that the term cadaver was crude, and also it applies to any dead body. Since organs can be used for transplantation only soon after death, the term has since been modified. The Oxford English Dictionary defines deceased as “dead, especially lately dead…” or “A [recently] dead person.” Therefore the correct term used these days is “deceased donor organ donation”, though old fogies like me sometimes use the term cadaver out of habit.

Let me reassure the reader. This is not a philosophical treatise. I will stick to mundane medical matters. The accepted definition of death till the 1960s was “the entire and continuous cessation of respiration and circulation.” The brain contains the whole apparatus that thinks and keeps us alive. When the heart no longer pumps blood to the brain, or when the blood no longer contains adequate oxygen, it is only a matter of minutes before the brain is destroyed. Death could therefore be due to sudden stoppage of the heart due to what we call a heart attack or to disturbed regularity of the heart beat affecting the volume of blood it pumps out, or to damage to the brain stem, that part of the brain that controls consciousness, blood pressure, the rate and rhythm of the heartbeat and the breathing apparatus. The development of mechanical ventilators from the 1920s onwards, increasingly sophisticated gadgets that could blow air or oxygen in and out of the lungs, meant that a person who had lost the ability to breathe could still be kept alive for a period ranging from a few hours to several days.

The widespread use of these machines taught us that at times the vital brainstem could be totally, permanently and irreversibly destroyed. Such damage irrevocably leads to cessation of the heartbeat, whatever the treatment administered. A brain dead person is unconscious, cannot think, cannot move any muscle voluntarily, cannot even breathe without the machine, in short, is no longer a person but only a body, a mass of flesh and organs, with the individual parts alive but no longer coordinated into that supreme organism, a human being. These organs could be made to ‘survive’ for a limited period of time. It is important to remember that inevitably, after a few hours or days, even this ‘survival’ will cease. Brain death is distinct from coma, a state of unconsciousness, in which breathing may be absent and the ventilator may be needed to sustain life. It is possible to recover from a coma. There are now medical ways in which brain death or brain stem death (slightly different in the major areas affected, but both leaving the person equally dead) could be diagnosed and differentiated from a reversible coma without any possibility of error. The body survives temporarily with the help of the machines, and will die when the machine is stopped. Even if the ventilator is kept functioning, the body will die after a while. Brain death is permanent and irreversible, not a temporary malfunction or non-function.

The world accepted the concept of brain death or brain stem death in the 1970s, but in India it was first recognised only with the Transplantation of Human Organs Act of 1994. This act also made it legal for human organs to be used for transplantation after the death of the donor, either by the conventional definition or by brain death. The Act stipulates the criteria which must exist for brain death to be diagnosed, and spells out the people who may certify brain death.

It is a painful experience for anyone to see a loved one in a critical care unit. With tubes running in and out of the body, oblivious to the world around, with the very act of breathing dependent on a machine, it takes away all the dignity and majesty of the human body. Further, intensive care is very expensive, and costs several thousands of rupees every day. It is worth any expense or trouble, if in the end your patient will recover and be with you again. However, when we know the person is brain dead, that there is no hope of recovery, it would be better for the person and for the whole family to turn off the machines, to withdraw the support systems, and face the fact that life has ended. After brain death occurs, the heart may continue its futile beating for hours or days, prolonging the agony of the family and draining its resources. Now that we have clear methods of diagnosing brain death, the suffering and the expense can be averted.

Our knowledge of brainstem death has another advantage. The eyes and the kidneys are the only major organs that can be removed from the body and successfully used even after the heart has stopped beating, and even after oxygen and nutrients have ceased to flow to the cells. The eyes can be taken up to six hours after circulation stops, and the kidneys within one hour. However, the heart, the lungs and the liver can only be used for transplantation if blood is still flowing through them, which requires a beating heart. The period between the diagnosis of brain death and cessation of the heartbeat permits the use of these organs for transplantation into desperately ill persons who will die without them.

The most commonly donated organ is the eye, mainly because the time taken to remove the eye is very little, and it can be removed at home. Since most people die outside a hospital, there are far more eyes available than any other organs. Eye donation is relatively well established in India.

All other organs can be used only if the donor dies in a hospital. While the ideal donor would be one who is brain dead but has his organs sustained by his being on a ventilator (a heart beating donor) the kidneys can be taken even after the heart stops beating (a non-heart beating donor), provided they are taken within an hour of death. That allows the kidneys to be second only to the eyes in the number of organs used. There are two kidneys in the body, and the recipient can lead a completely normal life with just one, so two patients with kidney failure can get a fresh lease of life from one donor.

The other organs often used in India are the heart and the liver. These can be used only if they are removed from a heart beating donor, who must be brain dead and has the organs sustained by artificial ventilation. The Transplantation of Human Organs Act has opened the doors to this gift of life.

Less commonly used organs include the pancreas, the intestines, heart valves, and many others.

In a forthcoming article, I will spell out what you can do to save lives by organ donation, and how you should set about it.

I am grateful to Dr. Sunil K Pandya, senior neurosurgeon of Jaslok Hospital, Mumbai, for his comments and suggestions regarding this article.

(Dr. M.K. Mani, Chief Nephrologist at Apollo Hospitals, Chennai, is a pioneer of renal transplantation in India.)

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