Talk:Brainstem death

Merger
Oppose merger. It seems this article describes a condition that is different than brain death. Brain death refers to actual death of the brain stem, whereas brain-stem death as described in this article seems to refer to a diagnosis whereby if certain functionality is absent, the brain-stem can be presumed to be dead. 69.140.164.142 05:01, 11 April 2007 (UTC)


 * The premise that the UK criteria are prognostic rather than diagnostic is precisely this article's conclusion, which you are restating as fact. Opposing merger on the grounds that brain-stem death is not part of the same issue as the definition of cerebral death in the United States is to beg the question and to preclude an international perspective on the issue. VEBott (talk) 12:17, 8 July 2011 (UTC)

Needs to attribute sources
This article has a bunch of information, and it has a bunch of references. But there are no citations within the text pointing to the references.

Also, some of the language used in this article is emotionally loaded ("unfortunate", etc.). Mbarbier (talk) 06:27, 19 December 2007 (UTC)

Serious unrepresentative bias
This article was originally excessively argumentative and expressed a minority viewpoint as the consensus of the profession. It urgently needed complete revision by a competent neurologist, with the minority viewpoint given space proportional to the rather limited support it enjoys amongst those who understand these matters. As it stood it was an example of everything that is wrong with Wikipedia. I have edited extensively but am not qualified to do more than eliminate the most obvious bias towards views stemming essentially from a rejection of all neurological rather than cardiac definitions of death. Tharyps the Molossian (talk) 22:22, 5 April 2008 (UTC)

Bit of a quick review
I was asked to have a quick look at this, with a view to article development. It's a quick look, so excuse rough notes;

some refs lack dates; format of refs isn't all consistent - this is one of the main probs on GA
 * lede's all wrong; needs to 'adequately summarize the whole'
 * overlinks (e.g. United Kingdon)
 * Title might need changing; it is specific to 'brain stem death criteria in the uk' - it doesn't cover 'brain stem death'; this also makes it hard for me to asses if it 'adequately covers the subject' - because the subject remit is unclear
 * Makes assumptions about context - e.g. in "background", The Conference sought “to establish - what conference? Where, when? OK, it's defined in the lede, but...that's not what lede is for; see WP:LEDE
 * 3 dabs - breathe, medulla], [[anoxia
 * 'conclusion' - too short for a section, and sounds a bit WP:OR - we don't draw conclusions
 * Language could do with a going-over to reduce the techno-speak; e.g. The clinical syndrome diagnosed by the prescribed bedside tests was conflated with brain death at that time but, while held to be an irrecoverable premortal state, - most of us plebs won't understand it
 * Wikilinking needs work. For example, linking 'death' and 'heart' is not appropriate; other links such as e.g. Brain death would help 'build the web' and might help understanding - see WP:LINKING
 * other parts of the brain[6][8][9][10][11] - does it really need all those refs bunched up?
 * Images (pics) would definitely help
 * Per Wikipedia:Manual of Style (numbers), there should be a non-breaking space -  between a number and the unit of measurement.
 * Needs copyedit for MOS issues;
 * punctuation on refs, for example; Royal Colleges ]], with advice from|undefined - that comma needs to go before the &lt;ref>
 * Shouldn't have a blank line after the section headings

 Chzz  ►  08:23, 26 March 2010 (UTC)

POV issues
The "controversies" section seems hopelessly one sided and full of likely oiriginal research: "It clearly confused... It assumed... implicitly claimed that... speciousness..." etc. FT2 (Talk 18:19, 30 December 2010 (UTC)


 * I don't know what "likely original research" means here. If there is original research, there should be a statement like, "Egor and I in our basement zapped a bloke's brain w/ 200 Megavolts of 75 Herz electricity for 3.5 seconds and got these results." (That would be the forbidden original research!) Otherwise, I would just regard what someone wrote (not based on 2ndary sources) as opinion. (EnochBethany (talk) 04:03, 20 April 2011 (UTC))
 * I don't think what he's talking about is OR. It seems to be closer to weasel words. - Purplewowies (talk) 04:40, 20 April 2011 (UTC)

Differences Between Brain stem death and Brain death
Someone has conflated "brain stem death" with "brain death", thus perpetuating the confusion which has dogged discussion of these states over the years. I have tried, repeatedly, to edit the first section to put this right and have tried to remove subsequent material relevant to "brain death" so that the article refers only to "brain stem death", hopefully clarifying the issue. I have also tried to remove the disputed 'Controversial aspects' section and renumbered the references accordingly. My efforts have been unsuccessful and I see the corrupt version - no credit to Wikipedia, which I have hitherto admired as a source of accurate information - reposted after I've left. I need expert help with the citations. The automatic formatting doesn't seem to accept the reference renumbering. If someone with the technical skills required will help put this section right, I will make yet another attempt to sort it. But I seem powerless to correct it on my own. DWEDWEvansMD (talk) 15:07, 23 May 2011 (UTC)
 * I have unmerged Brain death back into a separate article. said that "Brain death was merged into this article for a reason." but there does not appear to have been any discussion as to what that reason was.  proposed the merge (last year) and then implemented the merge. The lack of vocal opposition on the talk page does not indicate support, and since this is clearly contested I have undone the bold merge in keeping with WP:BRD. Since I am thoroughly unqualified to add to this discussion from my own knowledge and have not read either article I have no opinion, but should there be further/renewed support for the merger I strongly recommend continuing this discussion here so that it can be explained why they should or should not be separate articles. VernoWhitney (talk) 18:43, 31 May 2011 (UTC)
 * I assumed that there was a consensus for it to be merged, but I didn't have time to look into it, so I didn't know that the merge was done with no discussion. - Purplewowies (talk) 17:47, 6 June 2011 (UTC)

Globalize
Most of this article pertains only to the United Kingdom and, to a lesser degree, to the United States. This article needs to be expanded to address other countries as well. It needs a much more global perspective. Also, info in some parts of this article does not clearly indicate what countries/regions the info pertains to. For example, in the "Diagnosis" section, there is a list describing the pre-conditions and criteria for "brain stem death". However, it does not clearly indicate what country/region that list of pre-conditions and criteria is for. It isn't for all countries, since the article already said the conditions/criteria vary. It does mention that the list is from the "Code of Practice", but it still doesn't specify what country uses it. However, since further down in that same section (underneath the list) a "UK Code of Practice" is mentioned, based on context it seems like the author might be referring to the same thing as the "Code of Practice", but I can't be sure. It should be clarified. There are numerous other places in the article that need geographic clarification. The article may be able to provide adequate global perspective by adding more information for other countries/regions, however it might be necessary to rewrite parts of the article to adequately address the current lack of global perspective. Mhadj001 (talk) 20:14, 28 May 2011 (UTC)

The Code of Practice is the UK Code specified in the reference list. 'Brain stem death' - as a clinical syndrome which, when diagnosed according to that Code's rules, allows the diagnosis and certification of a patient's death - is a peculiarly British (and British Commonwealth) entity. It is not accepted as a valid basis for the diagnosis of death in the USA or most other parts of the world. Hence there is, in my view, no global perspective. On the contrary, it is essential to recognize the idiosyncratic nature of this UK definition of death which specifically ignores remaining life in the major part of the brain. I have tried to explain this in this piece and am anxious that it be seen as objective. Please let me know what may seem biased in my, perhaps clumsy, efforts to record the history of this attempt to define death on scientifically insecure neurological grounds. DWEDWEvansMD (talk) 17:19, 1 June 2011 (UTC)

This article remains a single authored polemic.
The article concerns a major issue, namely the evolution of the criteria by which a beating-heart cadaver is recognized. Unfortunately, it is written from a perspective which is not only fundamentally critical of a neurological approach to the diagnosis, but also disguises its attack by bringing in different neurological approaches from the United States. One senses, although one cannot be sure, that the approach is motivated as much by religious considerations as by medical ones; it makes use of any medical arguments it can.

The evolution of the British criteria played a major role in the development of the US ones; the Presidential Commission, in order to secure general consent for a non-cardiological definition of death, compromised by requiring the cessation of all detectable brain activity, but the neurological grounds for doing so are weak. By giving them undue prominence, and not counterposing them to other majority viewpoints from other countries, the article ends up citing the Commission's findings as if they were scientific evidence rather than opinion.

In this controversy, cardiologists, electroencephalographers and neurologists tend to take different views according to their specialisation. It is therefore important to know where the authors of any referenced studies are coming from - and whether their primary area is even medecine rather than medical ethics.

Both this article and the one on brain death need major work, to reflect and explain perspectives from other European countries, Latin America and Asia. This is a complex task, rarely accomplished even in specialist published works on the subject. A useful start is Eeelco Wijdicks "Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria" published in the AAN's Neurology, 2002;58;20-25 which can be found at https://www.hods.org/pdf/brain%20death%20world%20wide%5B1%5D.pdf and Haupt WF, Rudolf J. "European brain death codes: a comparison of national guidelines", J Neurol 1999;246:432–437, to be found at http://www.springerlink.com/content/xd202v0ap17p8hng/  It is striking that neither of these key references figure in this articles' notes.

In the meantime, I suggest that the original author's constant reversions be marked down as vandalism and that appropriate action be taken. As it stands, this article is a disgrace to Wikipedia. VEBott (talk) 12:07, 8 July 2011 (UTC)

Thank you for your constructive criticism, to which I reply :-

The concept that "brain stem death", as diagnosed by specified clinical tests, is human death is a peculiarly UK and British Commonwealth notion. Its acceptance as death - or "equivalent to death" as it's been put - depends on the belief that there can never again be any capacity for consciousness once that state is diagnosed. Remaining life elsewhere in the brain is considered irrelevant and not looked for - as it is in countries where "brain death" is the neurological standard. There is no approved diagnostic schedule for the diagnosis of brain death in the UK and use of the term "brain dead" to describe patients certified dead on the "brain stem death" criteria is officially discouraged.

It is essential to the understanding of what "brain stem death" is that its confusion with "brain death" be avoided. I have, in the past, tried to make that clear in the preamble and may have another go if I sense encouragement. To that end, I have omitted references to the vast literature on the vexed topic of "brain death" - in its many guises - and fully agree that it would be a monumental task to undertake a balanced review of that field, highly desirable as it must be.

Re balance - I can see what is meant by perceived lack of balance in this article as it has evolved and will be pleased to see what can be done to get rid of contentious material if you'd like me to. But it has to be said that, in the wider context, there has been no balance in presentation of the case for and against acceptance of " brain stem death" as death until Wikipedia published this piece. The concept and criteria were promulgated by the BMJ - Pallis's 'ABC of brain stem death' - and the UK Medical Royal Colleges from the 1980s onwards, backed up by the Department of Health's agents and the broadcasting media, without open debate or even opportunity to read widely available criticism of the science and philosophical concepts involved. The major medical journals declined to publish critical submissions (and still do). We had to resort to the 'Catholic Medical Quarterly' to get a paper into print - though we are not Roman Catholics - and were grateful for its courage to protest. Perhaps that title has given some the idea that there is a religious element to our challenge. That is not the case. We object to the bad science and unwarranted assumptions involved and to their imposition upon sadly uncritical, perhaps because misinformed, worthy people.

I am very concerned to see on Wikipedia a reliable, objective, source of information about this highly controversial matter. There is no such readily available source anywhere else. The public is otherwise subject to less than full and frank information and assurances that this concept is now "accepted practice" and beyond debate.

I leave it to others to comment on the allegation of vandalism - not what I have come to expect from Wiki editors - and await its withdrawal before taking any futher part in this endeavour. DWEvansMD (talk) 13:41, 11 July 2011 (UTC)


 * Dr Evans, your claim that “the concept that brain stem death, as diagnosed by specified clinical tests, is human death is a peculiarly UK and British Commonwealth” notion is somewhat misleading, as any reading of Wijdicks survey published in the American Academy of Neurology's journal, Neurology would show. The confusion that needs to be avoided is that between death and a permanent vegetative state (which the public often miscall brain death) rather than that between different ways of diagnosing  when “brainstem reflexes, motor responses,and respiratory drive are absent in a normothermic, nondrugged comatose patient with a known irreversible massive brain lesion and no contributing metabolic derangements”, which Wijidick presents as the basis of a universal medical agreement.


 * The countries that happen to be members of the Commonwealth (it's no longer British) account for a sizeable percentage of the world population. If one throws in Hong Kong, Malaysia, Iran and parts of the Arab world, one is talking about an even larger proportion of the world's polities. Many European countries have criteria closer to those applied in the UK than to those in effect in the US.
 * Stylistic tropes which imply that something can only be true if recognized as such in the US and in countries influenced primarily by work done in the US don't really cut the mustard on Wikipedia.


 * I'm still unclear from which direction you're approaching this.


 * I would start by asking you whether you accept the notion of a beating-heart cadaver. If you do not, you are at odds with world medical opinion, not just a section of it.


 * Secondly, I would ask if it is the issue of complete electroencephalic silence that troubles you. Many neurologists across the world, including in the US, do not recognize this as an essential feature of a corpse, any more than the cessation of the growth of fingernails was considered central to previous conceptions of death.


 * Thirdly, I would ask if it is the nature of the respiratory tests that you consider lacking in the UK. If so, particularity in this domain is again not something specific to the UK criteria.


 * Finally, I would ask whether you recognize death as a process rather than as a categorical transition involving the departure of a soul from the body.


 * OK, those substantive issues aside, let's move on to the question of style. Wikipedia is meant to be an encyclopedia. Despite your suggestion to the contrary, it is not essentially  a publisher which gives an opportunity for minority viewpoints rejected by specialist peer-reviewed journals to be published. Wikipedia's concept of balance is not to give equal emphasis, let alone primary emphasis, to minority viewpoints, and it has a specific ban on publishing one's own research. Wikipedia's concept of vandalism may not be what you think it is, but I willingly withdraw the charge in light of your courteous response. Your obvious misconception of Wikipedia's function is clear enough.


 * What you have done is to reproduce the arguments of the article you had to publish in the Catholic journal because no neurological or general medical journal found it of an acceptable standard of argument. You have advanced a basis for diagnosing death quite at odds with that of neurologists worldwide, namely “the observation of the bodily circulation” and “ascertaining the complete absence of oxygen uptake by the brain over a period of time sufficient to ensure tissue necrosis on every part of the brain”.


 * I'd rather not put an ad hominem argument, but I would really like to know whether you approve of heart and liver transplants from bodies on respirators at all. Some of your early publications suggest otherwise.


 * What I am most concerned about, however, is the irresponsibility of Wikipedia giving such prominence to a perspective which is likely to cause great alarm and distress to the relatives of victims of the kind of accidents that result in brain-stem death.


 * Constructively, I would suggest that the article be rewritten by somebody who understands and sympathises with the neurological basis of the UK criteria, integrating Wijidick's survey of differences across the planet. The article should also explain the paradoxes of a US position that defines death in terms of the loss of whole brain function but requires only testing of brainstem function to diagnose it (cf JM Elliot's  Brain Death in Trauma, SagePub, 2003) with no other mandatory tests of brain function, a fact about which Dr Evans sytematically misleads the reader.  It would then be appropriate, following Wikipedia guidelines, for Dr Evans to write a short criticism section that expressed the key points of his own approach, with the understanding that it should not aspire to be of anything like the same length as the main article.


 * If I were a neurologist, I would write the main piece myself. In the meantime, one can only hope that somebody from the Queen's Square education department will get off their bum and do so. Until something better is available, I am minded to remove all the tendentious material from the article. VEBott (talk) 05:24, 17 July 2011 (UTC)


 * I have no expertise in this area whatsoever, but from a lay person's perspective, this article appears to violate Wikipedia's policies banning original research WP:OR and requiring a neutral point of view WP:NPOV. In particular a Wikipedia article should not have a "Conclusion" section, which suggests a preferred point of view, nor should it have contentious sentences which are not tied to a source. The views presented here may be an important balance to accepted practice, but Wikipedia is not the place to publish them.--agr (talk) 02:23, 18 July 2011 (UTC)

User: VEBott, we are clearly so far apart - to judge by your assertion that the confusion to be avoided is that between death and a vegetative state, when the whole thrust of this article is aimed at avoiding confusion of 'brain stem death' with brain death and with death itself - that I must ask you to read my chapter titled 'The demise of "brain death" in Britain' in 'Beyond brain death - the case against brain based criteria for human death' edited by Potts, Byrne and Nilges and published by Kluwer Academic Publishers in 2000 - and David Hill's chapter titled 'Brain stem death : a United Kingdom anaesthetist's view' in the same volume - before we go much further into detail and specifics. You will find the essential basic information about the origins of this novel concept and UK redefinition of death therein, and further information about it in 'Finis Vitae - is brain death still life?' edited by Roberto de Mattei (of the Italian National Research Council) and published by Rubbettino in 2008 (a new edition is due shortly). The latter is a record of the Proceedings of a Pontifical Academy of Sciences conference held in Rome in 2005.

When you have read our chapters and the many other contributions to those anthologies - some of them much weightier than ours - I dare to hope that you will understand that "brain stem death" originated in the UK as a clinical syndrome, diagnosable on the basis of a series of simple bedside tests applied in carefully prescribed circumstances (the preconditions) which reliably heralded imminent, or fairly imminent, death and which therefore justified or required the withdrawal of useless and unkind life-support measures (particularly mechanical ventilation). The diagnostic criteria were officially promulgated in 1976 for that prognostic purpose. Their subsequent change of use - to criteria for the diagnosis of death itself - had no scientific or philosophical basis. There was no open, informed, debate about this enormous leap. It appeared to be driven by transplant considerations - specifically the need to obtain hearts in viable condition. There was no other purpose to be served by it. The adoption of the concept and practice had much to do with the publications of one neurologist - Chris Pallis - whose 'ABC of brain stem death' was the truly un-peer-reviewed polemic (sponsored by the BMJ). It was very difficult to get criticism into journals for which he acted as reviewer or referee. In more recent times, it has been possible to get criticism into on-line publications, open-access peer-reviewed journals, and www.bmj.com 'Rapid responses'.

I trust you will appreciate that the presence of this article on Wikipedia, imperfect as it is (though we will try to improve it, maintaining objectivity), has provided the only readily available source of unalloyed information for those dissatisfied with the didactic statements asserting the acceptance of "brain stem death" as (a form of) death which are all they get from the Department of Health and its transplant agencies. I know that many, including young doctors and medical students, have had their eyes opened to the facts of this matter - having been taught that there's no longer any controversy about it - and have been grateful to Wikipedia for making them available.

The term "beating-heart cadaver" is an oxymoron. A cadaver is a dead body, a corpse.

David W.Evans 81.107.34.21 (talk) 21:24, 18 July 2011 (UTC)


 * Dr Evans, you are making it more and more evident that you are the last person who should be writing this article for Wikipedia. Wikipedia is not supposed to be "the only readily available source of unalloyed information" on any subject whatsoever. Somebody who considers that a beating heart cadaver is an oxymoron, in other words that only a cardiological definition of death is valid, stands at odds with the definition prevailing in just about every country in the world.


 * I fail to see how your objections do not extend to the US conception of a diagnosis of brain death which requires no mandatory tests other than those of brain stem function and which certainly allows organs to be removed when the heart is still beating. There are plenty of articles by the top neurologists in the US, such as the late Fred Plum, head of the neurology department at Cornell University Medical School and Nixon's doctor, or the Mayo Clinic's EF Wijdicks, that evince the same scientific conception that is the basis for the UK criteria. You didn't even see fit to mention this, in your eagerness to push your own perspective. That is a serious failure, both as a scientific writer and as a Wikipedia editor.


 * At the moment, I can see no way out of this impasse other than to call for the subject to be merged into the article on brain death in general, which is where it properly belongs. The alternative would be that you allow me to remove all tendentious material, notably the entire historical and backround sections. For instance, the development of the UK criteria was very important in the evolution of those now prevailing in the US and elsewhere; what you misrepresent as admission of error and a mere prognostic approach was in fact the application of scientific analysis to an issue, with consequent increased rigour in terminology. The resulting new conception, which is in one way or another prevalent worldwide, has made it possible to improve and save thousands of lives rather than to ventilate corpses till they rot.


 * If we did proceed with such a radical edit, your objections to "brain based criteria for human death", certainly worth noting, would fit into the 'Criticism' section present in many Wikipedia articles.


 * The fundamental point is that even if you're right, you should not use Wikipedia as an outlet for esoteric views and your own research, especially as the sole author on a subject as important and emotive as this, the understanding of which may have direct, practical impact on people's lives. It would make Wikipedia not just an object of ridicule but, potentially, a subject of scandal. VEBott (talk) 00:03, 19 July 2011 (UTC)

User Bott's hostility is now explained by his or her admission that concern for the success of the organ transplant industry motivates the desire for suppression of uncomfortable facts regarding this attempt to redefine human death for the purpose of procuring transplantable organs. That influence has bedevilled efforts to present and discuss the scientific and philosophical aspects of death diagnosis from the first - despite calls for its separation from transplant considerations. Robert Truog and others have made eloquent pleas in recent years that all obfuscation about diagnosis of death on neurological grounds be abandoned in favour of telling the truth openly and unequivocally and seeking organ donation on that basis instead of a false premise, as now. It may be that his voice is now being heard on this side of the Atlantic too.

I do not think I should withdraw from involvement with the Wikipedia project in response to one individual's charge that I am not a fit person to write on this topic. But I will, of course, do so - as gracefully as may be but with profound regret at yet another successful suppression of reliable relevant information on this controversial issue (no factual criticism of this article's content having been advanced) - if it transpires that it's the general view that I'm unsuited to this task. I take comfort from the knowledge that others consider me almost uniquely qualified for the purpose, having pioneered resuscitation and intensive care and consequently having been involved from the earliest days in the problems those new therapeutic techniques threw up. I was much concerned with the development of consensus guidelines for discontinuation of pointless life-support - which readers of 'Beyond brain death ...' and 'Finis Vitae ...' will find were the origin of the Code of Practice "brain stem death" criteria now used to diagnose and certify death - and have maintained an active and informed interest in the evolution of this field ever since.

I am deeply concerned to improve this site along the lines of objectivity and full and fair information without evident or suspected bias. To that end I am grateful for the constructive criticism offered and would like the opportunity to edit the article accordingly - omitting the 'Conclusion' as recommended and, perhaps, incorporating 'Controversial aspects' into the text without need for a sub-section. There may now be a reference or two to be added. There must be no question of re-merging this article with that on 'Brain death' - an "entity" from which it is now clearly, and officially, distinguished in the UK (Conf. Med. Roy. Colls. 1995, and subsequently). It has, of course, nothing whatsoever to do with persistent or permanent vegetative state (PVS).

81.107.34.21 (talk) 11:52, 20 July 2011 (UTC)


 * David, while this may be hard to understand for someone newer to Wikipedia (it is a different animal) your statement that this article "has provided the only readily available source of unalloyed information for those dissatisfied with the didactic statements asserting the acceptance of "brain stem death" as (a form of) death which are all they get from the Department of Health and its transplant agencies" is (with the minor exception of the "readily" qualifier) an absolutely clear, explicit statement that the article is in direct violation of Wikipedia's core content policies and guidelines. (wp:ver and wp:nor) Sincerely, North8000 (talk) 12:10, 20 July 2011 (UTC)

Thanks for that refreshingly kind advice North 8000. I had not seen it when I wrote in response to your post below. Clearly I must await authoritative advice or instructions - in whatever form they may come - ere venturing further into this minefield. All the best - David 81.107.34.21 (talk) 12:26, 20 July 2011 (UTC)
 * Just to keep our perspective while wrestling with these challenges, on behalf of readers, thank you for all of your hard expert work on this. Sincerely, North8000 (talk) 13:57, 21 July 2011 (UTC)


 * Wikipedia is an alternate universe which took me two intensive years to somewhat learn. In writing a substantial article early in your Wikipedia career you are faced with all of these issues immediately, so I can only help a little on that big task.  First, to illustrate that this is not a reflection on your knowledge,(maybe via a tiny overstatement) Einstein would not be allowed to simply write an article on relativity in Wikipedia.  He could not even sort of give a dissertation and then give his books as sources.  Instead, his wording would have to be along the lines of "here is what wp:reliable sources (="reliable" per the Wikipedia definition) say about Relativity, and could give summaries of anything he had published (worded as such).  Well, there's a tiny piece.  :-)  North8000 (talk) 13:43, 20 July 2011 (UTC)


 * Thank you, North8000, for explaining Wikipedia practice more expertly, succintly and I have to admit, more tactfully, than I have managed. VEBott (talk) 15:54, 20 July 2011 (UTC)

Issues
I came from the "assistance" notice board. I added a couple tags. One for Wikify....this reads like a polemic rather than an article. The other for globalize ....legal aspect is a focus of the article and there it is UK-specific. I suspect that several other tags are applicable. Sincerely, North8000 (talk) 03:34, 19 July 2011 (UTC)

I'm sorry it reads like a polemic and would like the opportunity to deal with that as best I can (see above). Perhaps I should say that there is none of my "original research" involved and all material is available and the sources quoted. Perhaps it's the style that offends. If so, I apologize and offer the excuse that I have become used to writing scientific articles in the required turgid style - once memorably described as "decorated mediaeval gothic" - over the years and decades.

You mention legal aspects - but "brain stem death" has no certain legal status in the UK (where there is no legal definition of death), unlike "brain death" which has statutory legal status in the United States. "Brain stem death" is, of course, not recognized as a valid basis for the diagnosis and certification of death in the USA. The US President's Council on Bioethics again distanced itself from that standard - "the UK neurological standard" as they call it - in their December 2008 White Paper. I quote from page 66 of that publication :- "The UK standard follows Pallis in accepting 'death of the brainstem', rather than total brain failure, as a sufficient criterion for declaring a patient dead. Such a reduction, in addition to being conceptually suspect, is clinically dangerous because it suggests that the confirmatory tests that go beyond the bedside checks for apnea and brainstem reflexes are simply superfluous".

That non-acceptance in the USA - and many or most other countries - perhaps answers the "globalize" call?

81.107.34.21 (talk) 12:15, 20 July 2011 (UTC)

I'll place/move my answer thread to the previous section. Sincerely, North8000 (talk) 13:15, 20 July 2011 (UTC)


 * Dr Evans, you must be aware that the mandatory tests in the US do not differ significantly from those in the UK. As Wijdicks points out "The determination of brain death is based on a comprehensive clinical assessment. A confirmatory test-at least, in adult patients in the United States-is not mandatory, but it typically is used as a safeguard or added when findings on clinical examination are unwontedly incomplete. In other countries, confirmatory tests are mandatory; in many, they are optional."  The non-mandatory confirmatory tests, usually measurements to check that the EEG is flat, occasionally complement the clinical tests that examine brain stem function. It is clear, therefore, that in terms of medical practice, it is brain stem function that is fundamental to the diagnosis of death in the US as well as in the UK. Of course, you know this, and I assume you object to it just as much as you do to the UK code of practice.


 * I understand that you care deeply about the moral issues involved here, but an article about the particular neurological criteria of death accepted in the UK is not the place to present them, especially since your core argument is directed against any neurological definition of death and the whole concept of a beating-heart cadaver. Please read (click on the links) WP:OR and the explanation of what Wikipedia means by a neutral point of view in WP:NPOV. especially the section about the relative emphasis to be given to majority and minority views. I don't know enough about Wikipedia practice, but it strikes me that it might be a better idea for you to write a separate article tackling the whole issue of objections to the world-wide acceptance of a neurological definition of death, a worthwhile topic in itself. VEBott (talk) 15:54, 20 July 2011 (UTC)

Major revision
I have begun the work of rewriting the article in line with NPOV guidelines. I'm trying to get hold of the key document on the subject, the  ABC of Brain Stem Death commissioned by the BMJ, for guidance. Of course the criticism section remains way too long, and the whole construction reflects the original polemical rather than encyclopaedic purpose of the article, but perhaps it will do till we can get a neurologist to look at it. VEBott (talk) 22:13, 20 July 2011 (UTC)

After a couple of reads, I believe that the current article is essentially about: A brain stem standard for death being advocated in the UK, and which has gained some ground in the UK. Sincerely, North8000 (talk) 02:26, 21 July 2011 (UTC)
 * (added later) Thought I drop in a copy of an answer from my talk page on whether or not my second "UK" was a typo. "Thanks.  Actually I did mean UK; let me explain.  I'm no expert on the topic, so I'm just talking about what is in the article.  And, based on what is in there, it is not clear whether or not that is the official standard within the UK. When one looks closely, they see that there was no cite/sourcing in the article for that / such a  statement.  And so my statement was more cautions /minimal, saying that it has gained some ground in the UK."  Sincerely, North8000 (talk) 10:14, 21 July 2011 (UTC)
 * Fixed, I think VEBott (talk) 16:09, 21 July 2011 (UTC)
 * Wikipedia articles should generally take a world view of their subject. An alternative would be to name the article "Brain stem death in the UK" or "Diagnosis of neurological death in the UK" or some such. Also Wikipeia articles normally start with a declarative sentence saying what the title is, something like: "Brain stem death is a diagnosis that all functions of the brain stem are irreversibly lost. It has been the criterion in use in the United Kingdom for declaring death...". If there is interest in a wider outlook, here is another source that combines both medical and religious thought on the matter: http://www.jewishvirtuallibrary.org/jsource/Judaism/HeartTransplants.pdf --agr (talk) 02:53, 21 July 2011 (UTC)


 * Thanks Arnold. It is notable that the Israeli criteria are very similar to the ones in the UK, with no mention of 'whole brain' death and no requirement of complete electroencephalographic silence even as a possible confirmatory test. VEBott (talk) 07:35, 21 July 2011 (UTC)
 * Pardon my intrusion (coming here through agr's contributions), but I agree with WP:Worldwide view. We can't have our articles mainly being dedicated to Americans and the British, even with this being the English Wikipedia. There are some topics, like Yuri (genre), that cannot help but be mostly about one country. But I agree we should generally try to represent topics as they relate to the whole world. JacobTrue (talk) 17:43, 29 July 2011 (UTC)

Suggest you have a look at BMJ 2011; 342:d275 doi: 10.1136/bmj.d275 (Published 14 January 2011) Cite this as: BMJ 2011; 342:d275 Chief rabbi rules against donor cards and organ donation after brain stem death DWEvansMD (talk) 16:55, 24 July 2011 (UTC)

Also :- BMJ 2011; 342:d332 doi: 10.1136/bmj.d332 (Published 18 January 2011) Cite this as: BMJ 2011; 342:d332 - from which you will see that Israel does currently require "confirmatory tests" for the diagnosis of "brain death". "Brain stem death" - as diagnosed by purely bedisde clinical testing - is not accepted as death in Israel

And - as you seem keen to include religious aspects - for the Islamic view see J Med Ethics2011;37:290-294 doi:10.1136/jme.2010.040238 Brain death revisited: it is not ‘complete death’ according to Islamic sources 81.107.34.21 (talk) 15:00, 26 July 2011 (UTC)


 * Oh dear, once again the topic has been hijacked by a proponent of an extreme minority viewpoint - namely that there is no scientifically valid neurological definition of death, no such thing as a beating heart cadaver.
 * It is this perspective which leads the author to pigeonhole the topic as a specifically UK subject, which it most definitely is not. The choice of criteria has broad philosophical and medical implications. The use of brain-stem function criteria alone in order to declare the patient dead, and the implications thereof, are as much US issues as they are British ones. Dr Evans' removal of all references to the major works on the subject by the most prominent US authors, such as as EFM Wijidicks, and to the international context and history of the debate, is very misleading; I will now start the substantial reversion process necessary. Cleary arbitration will be necessary. VEBott (talk) 16:39, 19 January 2012 (UTC)


 * If you have sourced material, please add it. And, contrary to your mistaken assessment of the situation, such would be WELCOMED.   And if there are specific statements that you think are wrong, polemical, etc., bring them up on the article talk page.  But if you are saying the article is too narrow, I would think that the main focus should be adding sourced material on whatever areas you feel are missing or uncovered.   You are saying a lot of things about Dr. Evans's work on the article which are inaccurate, insulting and uncivil, and missed wp:agf by about 2 miles.  Like baselessly inventing bad faith.  Let's skip the drama and insults and instead build the article. North8000 (talk) 21:29, 19 January 2012 (UTC)


 * With that dealt with, you have touched on an important ongoing question regarding scope of this article which I will bring up separately below. North8000 (talk) 10:40, 20 January 2012 (UTC)

Reference formatting work
Per request at my talk page I put the references into the most common wiki format. Three references were not cited. Since this format displays only cited references, I left those three listed. For the record, here is the whole list just before I removed all but the 3 unused ones. North8000 (talk) 03:36, 17 December 2011 (UTC)

1.	A Code of Practice for the Diagnosis and Confirmation of Death. Academy of Medical Royal Colleges, 70 Wimpole Street, London, 2008

2.	Criteria for the diagnosis of brain stem death. J Roy Coll Physns of London 1995;29:381-2

3.	Conference of Medical Royal Colleges and their Faculties in the UK. BMJ 1976;2:1187-8

4.	Conference of Medical Royal Colleges and their Faculties in the UK. BMJ 1979;1:332

5.	Pallis,C. From Brain Death to Brain Stem Death, BMJ, 285, November 1982

6.	Coimbra CG. Implications of ischemic penumbra for the diagnosis of brain death. Brazilian Journal of Medical and Biological Research 1999;32:1479-87

7.	Coimbra CG. The apnoea test – a bedside lethal ‘disaster’ to avoid a legal ‘disaster’ in the operating room. In Finis Vitae – is brain death still life? pp.113-145

8.	Coimbra CG. Hypopituitarism in brain death. In preparation.

9.	Pallis C, Harley DH. ABC of brain stem death. BMJ Publishing Group, 1996, p.30

10.	Shewmon DA. ‘Brain body’ disconnection : implications for the theoretical basis of ‘brain death’. In Finis Vitae – is brain death still life? Ed. De Mattei R. Consiglio Nazionale delle Richerche. Rubbettino, 2006, pp. 211-250

11.	Powner DJ, Bernstein IM. Extended somatic support for pregnant women after brain death. Crit Care Med 2003;31:1241-49

12.	Evans DW, Lum LC. Cardiac transplantation. Lancet 1980;1:933-4

13.	Evans DW, Lum LC. Brain death. Lancet 1980;2:1022

14.	Evans DW. The demise of 'brain death' in Britain. In Beyond brain death – the case against brain based criteria for human death. Eds. Potts M, Byrne PA, Nilges RG. Kluwer Academic Publishers, 2006, pp. 139-158

15.	Moruzzi G, Magoun HW. Brain stem reticular formation and activation of the EEG. Electroencephalog Clin neurophysiol 1949;1:455-73

16.	Ward AA. The relationship between the bulbar-reticular suppressor region and the EEG. Clin Neurophysiol 1949;1:120

17.	Lindsley DB et al. Effect upon the EEG of acute injury to the brain stem activating system. EEG Clin Neurophysiol 1949;1:475-8627

18.	Parvizi J, Damasio AR. Neuroanatomical correlates of brainstem coma. Brain 2003;126:1524-36

19.	Textbook of clinical neurology, 2nd Edn. Ed. Goetz CG. Elsevier Science, 2003

20.	Bleck TP. In Textbook of clinical neurology, 3rd Edn. Ed. Goetz CG. Elsevier Science, 2007

21.	Tononi G. An information integration theory of consciousness. BMC Neuroscience 2004;5:42

22.	Hall GM et al. Hypothalamic-pituitary function in the ‘brain dead’ patient. Lancet 1980;2:1259 This ref not cited in article.

23.	Wetzel RC et al. Hemodynamic responses in brain dead organ donor patients. Anesthesia and Analgesia 1985;64:125-8  This ref not cited in article.

24.	Pennefather SH, Dark JH, Bullock RE. Haemodynamic responses to surgery in brain-dead organ donors. Anaesthesia 1993;48:1034-38  This ref not cited in article.

North8000 (talk) 03:36, 17 December 2011 (UTC)

There is also one cite ([33,34,35]) which calls for reference numbers that don't exist. North8000 (talk) 03:39, 17 December 2011 (UTC)
 * These loose ends have now all been resolved. North8000 (talk) 13:28, 18 December 2011 (UTC)

Update 12/16/11
(Copied from my talk page, written to DW Evans:)


 * Nice work. With all of the changes in the article, culminated by your recent changes in response to my notes, I think that the POV tag can go and I'll try taking it off.  Regarding the last top level tag, "globalization" would be an issue if the concept is significant elsewhere but not covered in the article.   You don't have to "prove a negative" in order for that tag to go, but some due diligence and exploration owuld be good for that purpose and also a good idea for for making a good article. Sincerely, North8000 (talk) 13:54, 26 December 2011 (UTC)

There have been substantial discussions regarding this article at my talk page
Note: there have been substantial discussions regarding this at my talk page. User_talk:North8000   North8000 (talk) 23:20, 3 January 2012 (UTC)

Globalization tag
Beside the changes in the article and limited discussion here, there have been substantial discussions regarding this at my talk page. User_talk:North8000. I think that the immense amount of changes removed the wording that sort of "presumed" Great Britain. Further discussions seemed to have established that this topic exists primarily or only for a legal standard for death, and one which applies only in the UK, India and Trinidad & Tobago. And, aside from that it is not a general academic or medial topic. So, coverage of it in the UK UK, India and Trinidad & Tobago is coverage everywhere that it exists and so I think we can remove the globalization tag. Sincerely, North8000 (talk) 23:02, 4 January 2012 (UTC)

Scope of article content
This has been an ongoing question is various forms and contexts. Let me make a statement of what appears to be the case, and then I invite folks to tell me if I'm wrong or right:

The whole topic of medically understanding death, legally defining death, medically assessing death is an immense topic and field, far outside the scope of this article. This article is about the specific narrower topic / term "Brain stem death". This PARTICULAR term refers to a particular legal standard of death that is only used in a few countries. There is no sourcing or evidence that the particular term/topic is being used elsewhere in the broader topic described at the beginning of this paragraph. And so this article inherently is about the much much much narrower topic of a particular legal standard for death that is used in only a few countries, especially the UK. Arguments that "Brain stem death" should include other material besides this are easily resolved. Simply find material (sources) covering other matters BY THAT TERM and put material based on that into the article. Such is WELCOMED. Sincerely, North8000 (talk) 10:59, 20 January 2012 (UTC)

It seems clear that both Evans and I have failed to convey the significance of the concept, North8000. As WFM Wijidicks, Chair of the Mayo Clinic's College of Medicine Critical Care Neurology Division puts it:
 * "The brainstem formulation of death implies that without a functioning brainstem, the person is irreversibly unconscious and apneic. The formulation of brainstem death is largely pragmatic. In Pallis's words "Brainstem death is the physiological kernel of brain death, the anatomical substratum of its cardinal signs (apneic coma with absent brainstem signs)." The line of thinking here - and scientifically the most convincing one - is that the brainstem in evolutionary biology has been the major structure preceding the development of the neocortex. When clinical examination in a comatose patient without confounders shows absence of brainstem reflexes and apnea, the presence of normal brain tissue elsewhere is not relevant. Brainstem formulation of death stipulates that the brainstem is, in fact, an indispensably necessary system and not just part of a group of important neuronal systems."

It is precisely because this understanding of the role of the brainstem is widespread that neurological tests other than those for brainstem function are only recommended and not mandatory in so many countries across the world, including in the United States, when pronouncing a comatose patient dead. Brainstem Death is not a British or Indian legal formulation. It is not even merely the effective basis of neurological diagnostic practice in all countries which do not mandate electroencephalographic confirmatory tests. It is, along with whole brain death and higher brain death, one of the three major conceptual formulations of what brain death itself means, and is treated as such in every scientific publication throughout the world.

I expended considerable time and effort explaining all this in the article before, outlining the distant French and more recent American antecedents of the British criteria and how the British contribution fitted into the international debate. All of that material, including the painstaking footnoting, has been removed, reverting the article to its original form, based on Evans' misconception that Wikipedia is an appropriate place for a critique of established British medical practice rather than an explanation thereof. The fact that Dr Evans is now the most quoted source in the article despite the fact that his views have found practically no echo amongst British medical scientists, and that the critique section occupies so disproportionate an amount of space speaks for itself.

British medical scientists' influence in this field has been substantial throughout the world, including in the US. It would be quite inappropriate to treat the history and development of the brainstem death concept, both in the UK and elsewhere, as a parochial legal issue rather than as a scientific contribution. I shall now embark on the attempt to salvage the material I worked on earlier. I hope I can rely on your good offices to explain to Dr Evans the notion of appropriate weight for minority views. VEBott (talk) 01:51, 21 January 2012 (UTC)


 * I'm not knowledgeable in this field, I ended up here due to a request elsewhere for help (possibly by you?) Most importantly at this moment, I don't know about the usage of this particular term or concept by that name outside of being just a legal standard for death in those few countries.  I went looking for the removed material that you described but was unable to find it.  I looked at a version of the article (July 22, 2011) which was just after your largest group of edits and did not see it.   If you could point me to it (or to an article date that had it) I would be very interested in reading it.


 * My thought and suggestion would be to (as long as it it sourced) start adding the material that you are discussing. So, start by just adding material.   Once that is in, that would help guide the process regarding material, summaries etc. that are already in the article.  Sincerely, North8000 (talk) 11:12, 21 January 2012 (UTC)

Your statement of 20 January explains the specificity and limits of this article admirably North8000. It would, I think, be a great mistake to widen its scope into the fields of philosophy and basic science - beyond the current necessary mention of the dependence of this legally accepted definition of death upon the (controversial) consciousness-based concept and the (scientifically insecure) idea that clinically diagnosed death of the brain stem suffices for its satisfaction.

There is very active debate about all attempted redefinitions of death - see Shah SK, Miller FG. Can we handle the truth? Legal fictions in the determination of death. Am J Law Med 2010;36:540-585, and their more recent article, with Robert Truog, titled 'Death and legal fictions' in J Med Ethics 2011;37:719-722. In an editorial headed 'Brain death : time for an international consensus'in the British Journal of Anaesthesia this year, Smith, of the National Hospital for Nervous diseases in London, thinks the debate "likely to require the UK to reconsider its reliance on the brainstem formulation" (Smith M, Br J Anaesth 2012,108(S1):i6-i9).

It might be argued that the Wikipedia article on 'Brain death' should venture some way into those - as you say - vast fields of discussion and debate but there is no place for such confusing material in the article on 'Brain stem death' as a sufficient basis for the diagnosis of human death (in those parts of the world which accept, either by virtue of statutory definition or as "accepted practice" where there is no definition of death) it as sufficient. The 'Brain stem death' article should certainly not be seen to support the practice of diagnosing death on grounds of brain stem tests alone where, as in all the States of the USA and most of Europe (and Australia), the law requires "whole brain death" - the final cessation of ALL brain function - before a diagnosis of death on neurological grounds can be nade.

Your concise statement does, I suppose, raise again the question of the article's title. While the text quickly makes it clear that it's about the diagnosis of death on "b.s.d." grounds, should that restricted coverage be made clear in the title somehow, do you think? How about 'Brain stem death - a basis for the diagnosis of death on neurological grounds'. Looks clumsy to me. I'm sure you can do better if you think such modification is desirable. 81.107.34.21 (talk) 15:21, 4 February 2012 (UTC)


 * I think that clarity in the article rather than re-titling takes care of things.  And, just clarifying in Wikipedian terms, if there were other areas which had sourced coverage as it being under this particular term, then such should be in the article; so far we've not seen such to be the case. North8000 (talk) 03:47, 5 February 2012 (UTC)

Possibility of survival after diagnosis
At the moment the intro reads Identification of this state carries a very grave prognosis for survival, cessation of heartbeat often occurring within a few days although it may continue for weeks or even months if intensive support is maintained.[1]" I can find no support in the literature for the suggestion that a heartbeat can continue for weeks or months. Pallis in ABC of Brain Stem Death'' cites a number of studies which suggest a maximum of under two weeks before asystole. Unless this claim can be verified I shall remove it. Cooke (talk) 12:06, 19 June 2013 (UTC)
 * I'd suggest only trimming the part (e.g. phrase) that is problematic. North8000 (talk) 14:15, 19 June 2013 (UTC)
 * Sure - that's all I meant, North8000 . I've had a look at the justification for this claim, but it's based on work that has been derided by many of the author's peers, and which anyway does not apply to 'brain stem death' as diagnosed by standard criteria. I must say that the more I read this article the weirder it looks. I think it needs a radical rewrite by someone who knows more than I do. 88.97.15.184 (talk) 14:34, 19 June 2013 (UTC)
 * The person who wrote it is an expert on this specialized concept, but new to Wikipedia.  I was just the opposite and helped.   The "rosetta stone" for interpreting this article is to understand that "brain stem death" here does not refer to a condition, it is a particular (uncommon) standard for defining death.  North8000 (talk) 15:49, 19 June 2013 (UTC)

Undiscussed attempted move and change
There was an undiscussed attempted move from "Brain stem" to Brainstem. Also a mass change of the same type in the wording of the article. This conflicts with sources. If anyone is seriously contemplating this, please discuss and obtain consensus first.  North8000  (talk) 13:51, 26 March 2014 (UTC)