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This lecture will focus on ethical issues facing doctors in relation to contemporary
determinations of death. Developments in modern intensive care and transplant medicine
have motivated changes in the definition of death, and given rise to controversies surrounding
new criteria of death in hospitalised patients.

Students will learn the different concepts of death (cardio-respiratory death vs brain death)
and brain death (whole brain death, higher brain death, and brain stem death) and the
arguments that have been proposed for each as the appropriate standard of death.
The physicians obligations in the determination and certification of brain death,
communication with the family of the deceased, and procurement of deceased donor organs
for transplantation will be discussed. Attention will be given to explaining relevant legislation
and ethical guidelines in Singapore.


To enable students to appreciate controversies surrounding concepts and definitions of

death and brain death, and how brain stem death is clinically assessed and ascertained.
Through active participation in a discussion forum, students will be given the opportunity
to discuss issues relating to the definition and determination of brain death.


Students will be able to:

Describe developments in organ transplantation and intensive care and how these have
led to changes in the definition of death, and given rise to controversies surrounding new
criteria of death.
Outline the different concepts of:
a) death (cardio respiratory death versus brain death)
b) brain death (whole brain death versus higher brain death versus brain stem
death), and relevant arguments for each as the appropriate standard of death
c) relating to the status of anencephalic infants and whether they could be organ donors
Outline objections to the definition of death from clinical, philosophical, ethical and
religious perspectives.
Describe clinical processes in the determination and certification of brain stem death and
the interactions with families of a person who is declared brain dead.
Discuss ethical issues in brain death certification with respect to organ transplantation
including conflicts of duty between physicians caring for a patient in need of an organ
and for doctors with an obligation to procure organs for transplantation procurement.

Required Reading

RD Troug. Brain death too flawed to endure, too ingrained to abandon. Journal of Law,
Medicine and Ethics 2007; 35(2): 273-82
EFM Wijdicks and RE Cranford. Clinical Diagnosis of Prolonged States of Impaired
Consciousness in Adults. Mayo Clin Proc. 2005;80(8):1037-1046 (Extract only)
Links to Relevant Law and Guidelines

Interpretation Act
Human Organ Tranplant Act (HOTA)
Medical (Therapy, Education and Research) Act (MTERA)
Brain Death Certification Standards in Singapore (To be Confirm)
SMC Ethical Code and Guidelines


Dr Tan Hui Ling, Consultant, Department of Anaesthesiology, Tan Tock Seng Hospital
A/Professor Jacqueline Chin, Director of Graduate Studies, Centre for Biomedical Ethics

Lecture Cases to be discussed:

Case 1
Lawyer Suzanne Chin is convinced that what happened to her four years ago is nothing short
of a miracle. The mother of two was living and working in Hong Kong when she suffered a
heart attack, was hospitalised in a coma and declared brain dead. The head of the intensive
care unit, two neurologists and a cardiologist told her husband to prepare for the worst. Soon,
he was advised to take her off life support because, simply put, there was no hope. Then,
three days after she was admitted, she woke up from her coma. She recovered within a week
and left the hospital. Today, she is living in Singapore, still working as a lawyer, still a wife
and mum. She is well, and she is alive.

Case 2
Swenson Tan, 22, lapsed into a coma 3 weeks ago. He was hit by a van, and was declared
brain dead by doctors soon after arrival at Changi General Hospital (CGH). His traumatised
parents refused to accept outcome. He suffered serious head injuries and underwent a six-
hour operation. The patients mother, Madam Lisa Mah, 54, could be heard yelling at hospital
staff for wanting to take him away and wailing for him to wake up. Earlier they had lodged a
police report against CGH, hoping to secure a police order to keep Swenson alive. 30 friends
and family members rallied around Mr Tan at the hospital on a Sunday night (he was
admitted on Friday), as his body was wheeled into operating theatre by nurses for his organs
to be lawfully retrieved for transplantation under the HOTA.

Questions for Reflection

1. Does Case 1 (Suzanne Chin) show that determination of death using brain death criteria
is never justified? Why?

2. In the case of Svenson Tan (Case 2), the patient was presumed to have consented to organ
donation since he had not registered an opt-out of the HOTA provision. Are opt-out schemes
of organ procurement ethically justified under certain conditions? Under what conditions are
they not ethically justified?