A survey of the medical, ethical and legal issues that surround this controversial topic.

Many activities of doctors in the acute hospital sector do not improve patient outcome because they are inappropriate. Curtailing interventions that are unnecessary (because the patient is not bad enough) or are unsuccessful (because the condition is too advanced) could both save resources and improve care. Rational rationing depends on knowledge about the expected benefits of various technologies when used in different clinical circumstances.

Professor Jennett first defines the term `brain death' and the problems arising from a diagnosis of death, some the result of recent technological advances. The diagnosis is not necessarily connected with donor transplants, although in the popular mind this is still so. The criteria for establishing brain death and the sources of potential error in this diagnosis are outlined. The diagnosis of brain death can be made confidently, as is already common practice, and this should become standard good medical practice.

No apologies are needed for returning to the subject of brain death and its definition. There has been so much public discussion that it is important for public confidence that the issues should be clarified. In the following two contributions - one from a professor of neurosurgery and the other from a lawyer - an attempt is made to convince doctors (if that is needed) and lay people alike that what appears to be a new bogy is not one at (...) all but a confusion of thought arising from the use of new technology to treat brain-damaged patients. This, however, might not be the view of Mr Skegg (Journal of medical ethics, 2, 190) who, fearful of the situation, has argued for a statutory definition of death. Professor Jennett discusses the findings of a conference of the Royal Colleges of the United Kingdom which met to try and remove uncertainty surrounding the diagnosis of brain death. In his view the Colleges' document is to be welcomed for `its authority and its practicality' and `should lead to more humane medical practice'. Mr Kennedy, from a legal position, comes to the same conclusion, that with a good code of practice, as advocated by the Royal Colleges, no legislation is called for. (shrink)