A study conducted by the Kerala State Organ and Tissue Transplant Organization (K-SOTTO) among its empanelled doctors for brainstem death certification in the State has reported that despite their high clinical knowledge and legal awareness, the fear of future medicolegal litigation remained the single critical factor that prevented them from being more proactive about making brainstem death (BSD) certification a standard practice in ICUs.

This was a cross-sectional online survey using a structured questionnaire, conducted amongst neurologists, neurosurgeons, anaesthesiologists, intensivists and other empanelled BSD certifiers, to assess their knowledge, attitudes and perceived barriers to BSD certification.

What the survey found

Of the 78 clinicians who responded to the widely circulated questionnaire, the knowledge of the definition of BSD was universal—98.7% of the respondents correctly identified BSD as the irreversible cessation of brain stem functions. About 70.5% of the empanelled doctors knew that once brain stem death was certified as per protocol, treatment support in ICU could be discontinued, while 19.2% disagreed.

About 64.1% had the legal awareness that BSD certification in ICUs was a separate and distinct clinical process, which was not connected to organ donation under Indian law.

Perceived fear

“Despite possessing all clinical knowledge and awareness about the legalities surrounding brain stem death certification, it was the perceived fear of future litigation that prevented the majority from being more positive about BSD certification. In reality, till now, no doctor has been involved in any medicolegal case for BSD certification, whereas doctors are being foisted with litigation over so many other issues. The fear of litigation is a perceived one, not real,” pointed out Noble Gracious, the executive director of K-SOTTO.

Kerala is perhaps one of the few States which has been systematically investing in building a fool-proof deceased donor organ donation programme, by clearing red tape, data analysis and follow-up and by building systems, logistics, capacity, training personnel and through awareness creation.

In 2020, Kerala became the first State to formally de-link the process of BSD certification from organ donation, so that the process became a standard clinical practice in ICUs, rather than a process for enabling organ donation. This put an end to the ethical dilemma of clinicians, so that once a patient had been pronounced as brain-dead as per the protocol, all treatment, including cardio-respiratory support, could be discontinued.

Where the gaps lie

“Over the last two years, we have invested so much in BSD awareness creation amongst doctors and trained close to 500 clinicians in the processes and legalities surrounding it. Public trust has gone up in deceased organ donation, our ICU capacities have been enhanced. Yet, our deceased donor organ donation rates have remained sub par. In 2025, we had just 25 deceased donor organ donations. We did this study to assess the actual reasons that made our empanelled doctors remain indifferent to BSD certification,” Dr. Gracious added.

Clinician attitudes, legal confidence, and institutional readiness directly influence BSD certification and families’ consent for organ donation. Unless hospitals incorporate BSD certification in ICUs as an institutional policy—not for enabling organ donation, but to prevent unnecessary waste of valuable ICU resources, inflated hospital bills and needless trauma for families—deceased organ donation rates are unlikely to go up.

Strengthening Kerala’s deceased donation system requires mandatory training for clinicians, legal sensitisation, institutional standard operating procedures, State‑level protection mechanisms against litigation and ICU‑level implementation of BSD protocols.