We read with great interest Daoust and Racine's contribution to the ongoing debate about brain death and its ethical and medical implications [1]. The authors argue that little is known about how the public understands the concept of death determined by neurological criteria (DNC). They set out to trace common sources of public confusion about DNC and seek to "better define the relationship between expert and lay views of death". We wish to comment on the issue of whether or not public confusion "reflects public confusion in the media or perhaps a more profound insight into the nature of academic debates among experts". Although the authors recognize that "recent critiques have made any clear meaning of DNC more challenging and even counterintuitive", they position themselves, with no further explanation, on one side of the debate by stating that "landmark contributions and guidelines of professional societies have brought clarity and credence to the standard definition of DNC". With that, they imply that current determination of death and organ transplantation practices are rigorous and that media coverage distorts the actual process of declaring a person dead based on neurological criteria.

The two premises-- that the standard of DNC has clarity and credence and that producing a clear meaning of DNC is both challenging and counterintuitive-- are logically irreconcilable. The authors, nevertheless, conclude that all discussions in the media and with patient- families should "reinforce the genuine nature of neurological determination of death as a criterion to establish death...". Either (a) the philosophical rationale proposed in the President's Council on Bioethics "White Paper" [2] seeking to validate the concept of DNC, and the criteria and tests for determining DNC outlined in the guidelines by professional societies, definitively settled the issue, or (b) the critics have been raising legitimate concerns and have successfully challenged the validity of this concept. Regarding the President's Council of Bioethics' philosophical validation of DNC, the debate is ongoing and indeed has intensified [3-5]. In regard to professional societies' guidelines, the American Academy of Neurology has assigned level "U" (i.e., unknown, conflicting or insufficient evidence) to several recommendations in the DNC [6]. Generally, for clinical practice guidelines to be trustworthy, the Institute of Medicine requires the recommendations to be supported by a much higher level of evidence than "U" [7].

The authors also mention that some articles refer to the brain-dead patient as being "kept alive" by artificial methods rather than as being dead. Yet this brings out the fact that it is odd to declare an individual with functioning circulation and respiration (in the sense of cellular exchange of oxygen and carbon dioxide-- ventilator-dependence is irrelevant to the issue of whether a person is alive or dead) dead as is done in brain-dead patients. Even though the authors ostensibly acknowledge the academic debate about the validity of brain-death criteria, de facto they ignore it, claiming (though not arguing) that both discussions between the patient's family (note the use of the word "patient," which does not make sense if the patient is dead) and information shared with the general public should reflect the view that brain death criteria are "genuine". Therefore, Daoust and Racine's recommendation to reinforce the genuine nature of neurological determination of death is not only premature but, if followed through, would deprive the public of informed decision making about organ donation following DNC. More importantly, merely repeating the claim that brain- death criteria are "genuine" does not make them so.

Maintaining the professional integrity of medicine and public trust is a responsibility shared by the global medical community. This responsibility demands honesty, truthfulness and transparency with the general public regarding healthcare issues (e.g., organ donation at the end of life). Daoust and Racine report that critics of DNC have argued that DNC "merely represents a convenient 'redefinition' of death solely for the purpose of transplant medicine." Many in the medical community would agree with the critics. After several decades, the cumulative clinical experience with many kinds of brain-dead patients over decades, combined with logic has disproved the neurologic criterion of death. Persistent denial of caveats that donors are not certainly dead may be leading to grievously unethical medical practice namely: (1) the lack of truly informed consent in the donation process, (2) the strategic campaign of rhetoric, partial information, and misinformation designed to induce people to check the donor box on drivers licenses and to induce families to authorize donation from a "brain-dead" loved one, (3) the nondisclosure of financial conflict of interest on the part of organ procurement representatives whose job is to convince grieving families to donate.

The media have been fulfilling their primary duties of disclosing to the general public scientific, ethical and cultural controversies about neurologic criteria [8,9]. The conclusion of Daoust and Racine that "public discussions should reinforce the genuine nature of neurological determination of death as a criterion to establish death" and "scholarly debates need to be contextualized to avoid undue collateral damage to public confidence in DNC and organ donation practices" can also be construed as a call for censorship of media and suppression of scholarly debates. Costas-Lombardia and Castiel have criticized the control of information in Spain by the transplantation industry: "disinformation of society is an indispensable condition for the success of the 'Spanish Model'" [10]. Organ procurement and transplantation practice generate billions of dollars in a commodified US health care system annually [11]. The call for control of media and scholarly debates to avoid collateral damage to organ transplantation practice may indeed violate public trust in the medical profession and the First Amendment of the United States Constitution.

Michael Potts, Ph.D., Department of Philosophy, Methodist University, Fayetteville, North Carolina, USA

Joseph L. Verheijde, PhD, MBA, PT, Department Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA

David W. Evans, MA, MD, FRCP, Queens' College, Cambridge, UK

Mohamed Y. Rady, MB BChir MA MD (Cantab), Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA

D. Alan Shewmon, MD Olive View-UCLA Medical Center, Sylmar, CA, USA

References

1. Daoust A, Racine E. Depictions of 'brain death' in the media: medical and ethical implications. J Med Ethics.2013:Published Online First: 12 April 2013 doi:2010.1136/medethics-2012-101260

2. The President's Council on Bioethics. Controversies in the determination of death. A White Paper of the President's Council on Bioethics. 2008; http://bioethics.georgetown.edu/pcbe/reports/death/. Accessed 10 April 2013.

3. Shewmon A. Brain Death: Can It Be Resuscitated? Hastings Cent Rep.2009; 39(2):18-23.

4. Joffe AR. Brain death is not death: a critique of the concept, criterion, and tests of brain death. Rev. Neurosci.2009; 20(3-4):187-198.

5. Nair-Collins M. "Brain Death, Paternalism, and the Language of "Death"." Kennedy Inst Ethics J.2013; 23(1):53-104.

6. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology.2010; 74(23):1911-1918.

7. Institute of Medicine (IOM) -National Academy of Sciences. Clinical Practice Guidelines We Can Trust. 2011; http://www.nap.edu/openbook.php?record_id=13058. Accessed 10 April, 2013.

8. Rady MY, McGregor JL, Verheijde JL. Mass media campaigns and organ donation: managing conflicting messages and interests. Med Health Care Philos.2012; 15(2 ):229-241.

9. Rady M, McGregor J, Verheijde J. Transparency and accountability in mass media campaigns about organ donation: a response to Morgan and Feeley. Med Health Care Philos.2013:Published online: 25 January 2013. DOI 2010.1007/s11019-11013-19466-11014.

10. Costas-Lombardia E, Fereres Castiel J. The Easy Success of the Spanish Model for Organ Transplantation. Artif Organs.2011; 35(9):835-837.

11. Bentley TS, Hanson SG, Hauboldt RH. Milliman Research Report. 2011 U.S. organ and tissue transplant cost estimates and discussion. 2012; http://publications.milliman.com/research/health-rr/pdfs/2011-us-organ- tissue.pdf. Accessed April 1, 2013.

Conflict of Interest:

None declared