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Review
. 2025 Aug;43(1):8-18.
doi: 10.1007/s12028-025-02300-6. Epub 2025 Jun 19.

Contextualizing India's Medicolegal Controversies Related to Brain Death/Death by Neurologic Criteria: Regulation, Religion, and Resource Allocation

Ariane Lewis  1 , Kapil Zirpe  2
Affiliations
Review

Contextualizing India's Medicolegal Controversies Related to Brain Death/Death by Neurologic Criteria: Regulation, Religion, and Resource Allocation

Ariane Lewis et al. Neurocrit Care. 2025 Aug.

Abstract

Brain death/death by neurologic criteria (BD/DNC) is accepted as legal death throughout much of the world. The World Brain Death Project and a subsequent review of the literature through 2023 highlighted several medicolegal controversies related to BD/DNC in Canada, the United Kingdom, and the United States but did not discuss medicolegal controversies related to BD/DNC in low- and middle-income countries, such as India. Although the Transplantation of Human Organs Act of 1994 acknowledged BD/DNC as death in India, BD/DNC evaluations are not always completed when BD/DNC is suspected. This has been attributed to lack of awareness/acceptance by medical professionals, lack of public awareness/acceptance of BD/DNC, communication challenges, fear, time limitations, and the inclusion of BD/DNC in organ donation law (but not general law). There has been a gradual rise in the number of donations after BD/DNC (a correlate for the number of BD/DNC determinations) in southern and western states, but the number of donations after BD/DNC has decreased in the southwestern state of Kerala in the setting of recent medicolegal controversies. This article reviews the history of BD/DNC determination in India as a whole, then describes the recent medicolegal controversies related to BD/DNC in the state of Kerala. Finally, these controversies are contextualized relative to the aforementioned controversies in high-income countries. Three key international themes of medicolegal controversies related to BD/DNC are regulation, religion, and resource allocation. The global neurocritical care community must advocate for consistency and accuracy in BD/DNC determination and collaborate with legal and policy experts to develop means to mitigate these challenges through revisions to the law, standardization of practice and policies, education, and communication.

Keywords: Asia; Brain death; Ethics; Medicolegal.

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Conflict of interest statement

Declarations. Conflicts of interest: The authors have no financial conflicts of interest. Ariane Lewis was an author of the AAN/AAP/CNS/SCCM 2023 guidelines on BD/DNC determination. Kapil Zirpe authored a position statement by the ISCCM on management of potential organ donors after BD/DNC. Ariane Lewis and Kapil Zirpe were both authors on the WBDP.

References

    1. Silvester W, Dawson R, Quayyum S, Pope TM, Bernat JL, Greer D, et al. Brain death/death by neurologic criteria and the law. Supplement 13 of Determination of brain death/death by neurologic criteria: the world brain death project. JAMA. 2020;324:1078–97.
    1. Wahlster S, Wijdicks E, Patel P, Greer D, Hemphill J, Carone M, et al. Brain death declaration: practices and perceptions worldwide. Neurology. 2015;84:1870–9.
    1. Lewis A. An overview of ethical issues raised by medicolegal challenges to death by neurologic criteria in the United Kingdom and a comparison to management of these challenges in the USA. AJOB. 2024;24:79–96.
    1. Lewis A. An update on brain death/death by neurologic criteria since the world brain death project. Semin Neurol. 2024;44:236–62.
    1. Greer D, Shemie S, Lewis A, Torrance S, Varelas P, Goldenberg F, et al. Determination of brain death/death by neurologic criteria: the world brain death project. JAMA. 2020;324:1078–97.

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