Not a Reliable Method for Determining Death: An Analysis of Potential in Germany Based on Retrospective Data From European Countries

Letters to the Editor Cardiac Arrest as an Extended Indication for Organ Donation by Friedrich A. von Samson-Himmelstjerna, Hans de Ferrante, Christoph B. Niehus, Agita Strelniece, Nassim Kakavand, Sarah-Yasmin Thomsen, Rainer Guenther, Steffen Augsberg, Serge Vogelaar, Erwin de Buijzer, Ineke Tieken, Roland Schmitt, Benedikt Kolbrink, and Kevin Schulte in issue 8/2026

The authors (1) are of the opinion that organ retrieval following controlled cardiopulmonary arrest could be considered if a restrictive donation protocol with a very long no-touch period (for example, 20 min) is used. Question: Under these circumstances, are the donors deceased? After 20 min of cardiac arrest, none of the traditional signs of certain death is typically present. Irreversible loss of brain function (ILBF) cannot be diagnosed, as the time required to perform all diagnostic tests, including confirmation that brain function has irreversibly ceased (2), would be too long.

It is also doubtful whether ILBF can be considered a reliable sign of death in the first place. The assertion made in the guideline issued by the German Medical Association (Bundesärztekammer) that ILBF “scientifically and medically confirms a person’s death” is not substantiated in any way, contrary to § 16(2), second sentence, of the German Transplantation Act (Transplantationsgesetz, TPG). It is fundamentally open to challenge from both a philosophical and a legal perspective (3).

Research suggests that brain resuscitation may be possible for longer periods than previously assumed (4). The fact that in an international comparison, waiting times before organ retrieval following cardiac arrest vary widely—from 5 to 30 min—demonstrates that this is not a reliable method for determining death.

The authors’ assertion that, in Germany, ILBF must be “confirmed ... through repeated clinical examinations and ancillary tests” is inaccurate. Additional ancillary tests are not mandatory. It is sufficient to repeat the clinical examination after a longer time interval (2).

DOI: 10.3238/arztebl.m2026.0100

Dr. jur. Rainer Beckmann

Lehrbeauftragter für Medizinrecht, Mannheim, Germany

Conflict of interest statement

The author states that no conflict of interest exists.

References

1. von Samson-Himmelstjerna FA, de Ferrante H, Niehus CB, et al.: Cardiac arrest as an extended indication for organ donation: An analysis of potential in Germany based on retrospective data from European countries. Dtsch Arztebl Int 2026; 123: 207–12

2. Bundesärztekammer: Richtlinie gemäß § 16 Abs. 1 S. 1 Nr. 1 TPG für die Regeln zur Feststellung des Todes nach § 3 Abs. 1 S. 1 Nr. 2 TPG und die Verfahrensregeln zur Feststellung des endgültigen, nicht behebbaren Ausfalls der Gesamtfunktion des Großhirns, des Kleinhirns und des Hirnstamms nach § 3 Abs. 2 Nr. 2 TPG, Fünfte Fortschreibung. www.bundesaerztekammer.de/fileadmin/user_upload/BAEK/Themen/Medizin_und_Ethik/RichtlinieIHA_FuenfteFortschreibung.pdf.

3. Beckmann RJ: A structured analysis of the concept of brain death. Theor Med Bioethics 2026; 47: 231–58

4. Daniele SG, Trummer G, Hossmann KA, et al.: Brain vulnerability and viability after ischaemia. Nat Rev Neurosci 2021; 22: 553–71