When the heart stops: Rethinking what we owe the dying

A quiet regulatory process unfolding in a government health department rarely attracts the kind of attention it deserves. But the move to expand organ donation criteria, allowing harvesting after the heart stops, not just after brain death, is more than a procedural update. It is a window into one of the most uncomfortable questions a healthcare system can ask: how much is society willing to invest in the final hours of a life, in order to extend the lives of others?

A system built on a narrow definition
For decades, the legal and medical framework governing deceased organ donation in most countries, including India, has centered on a single clinical threshold: the irreversible cessation of all brain function. This definition, developed in the late 1960s as life-support technology made it possible to sustain biological function after neurological death, has served as both a medical standard and a moral boundary.

It was also, from the beginning, a compromise. Brain-stem death is clear, defensible, and relatively straightforward to certify, but it captures only a fraction of potential donors. The vast majority of people who die in hospital settings do so after the heart stops, not after a formal declaration of brain death. For decades, those deaths were effectively closed to the donation system.

The shift now being contemplated, formalizing donation after circulatory death as a recognized pathway, is an acknowledgment that this boundary was as much a product of caution and legal conservatism as it was of clinical necessity. Other healthcare systems made this shift years ago. The gap between what is medically possible and what is legally permitted has been narrowing in India; the question is why it took so long.

The numbers behind the urgency
The scale of unmet need in India’s transplant system is not a policy failure in the conventional sense, it is not the result of mismanagement or underfunding alone. It reflects a structural mismatch between the pace at which chronic disease is advancing and the pace at which donation systems have evolved to meet it.

Non-communicable diseases now account for nearly two-thirds of all deaths in the country. Kidney failure, liver disease, and cardiac conditions, many of them linked to diabetes, hypertension, and metabolic disorders, are generating demand for transplants at a rate that outpaces any realistic expansion of living-donor supply. The waitlist for kidneys alone represents tens of thousands of patients, most of whom will spend years on dialysis, with significant effects on quality of life, productivity, and the broader healthcare budget.

Against this backdrop, the gap between annual transplants performed and patients registered and waiting is not a rounding error. It represents a systemic failure to convert a widely available potential resource, organs from deceased individuals, into medical benefit. The potential donor pool exists. The conversion rate remains extraordinarily low.

The infrastructure problem no guideline can solve alone
What the regulatory reform acknowledges, implicitly, is that procedural ambiguity has been one constraint among many. Hospitals have operated without clear clinical protocols. Certifying death through circulatory criteria requires a different chain of events than brain-stem certification, different timing, different personnel, different legal exposure for clinicians who must make time-sensitive decisions under conditions of emotional intensity and institutional pressure.

Standardizing these procedures is necessary. But it is not sufficient. The infrastructure required to make circulatory-death donation viable, rapid organ retrieval capability, advanced preservation technology, coordinated logistics across facilities, and the clinical expertise to perform multi-organ transplants, is unevenly distributed and, in many cases, absent in the facilities where it would matter most.

There is also a medico-legal dimension that rarely surfaces in policy discussions but is deeply felt by clinicians. In a system where the threat of legal action shapes clinical decision-making, the absence of clear protocols is not a neutral gap, it is an active deterrent. Doctors who might otherwise support donation processes have limited protection if those processes are not explicitly sanctioned and procedurally defined. Reform that addresses the what without addressing the how, and the what-happens-if, will not unlock the donor pool.

Swap programmes and the ethics of exchange
Among the less-discussed elements of the reform agenda is the move to formalize organ-swap arrangements, where families with willing but biologically incompatible donors can exchange organs with other such families. These arrangements already happen informally in parts of the system, but without standardized governance.

The ethics of organ exchange deserve more public scrutiny than they typically receive. Swap programmes are generally considered acceptable, they create value from voluntary transactions between consenting parties, with no money changing hands. But they also create selection effects and coordination challenges that, without careful oversight, can disadvantage patients without family networks capable of identifying and negotiating swaps. The least connected and most vulnerable patients may benefit least from a system that rewards coordination.

Formal protocols are a prerequisite for addressing these risks, but the design of those protocols, who coordinates, who audits, how disputes are resolved, will determine whether the system is equitable in practice.

The consent question
One dimension that remains largely absent from the current policy debate is the consent architecture underlying the entire system. Most deceased donation frameworks operate on opt-in consent, meaning donation requires either the explicit prior registration of the deceased or the agreement of next of kin. Conversion rates under opt-in systems are structurally limited by registration gaps and by the difficulty of approaching bereaved families at the moment of death.

Several countries have experimented with opt-out or presumed consent frameworks, under which individuals are treated as potential donors unless they have explicitly registered an objection. Evidence on whether this increases actual donation rates is mixed, in practice, families are still consulted in most cases, but the shift in default can reshape conversations and reduce the burden on families who might otherwise feel they are being asked to make a gift rather than to exercise a veto.

Whether India is ready for such a conversation is an open question. Cultural attitudes toward the body after death are deeply varied, and any policy that is perceived as appropriating the deceased without genuine consent would face significant resistance. But the current framework’s failure to convert available potential into actual transplants suggests that default settings matter, and that the current defaults are not optimized for the public health outcome the system nominally seeks.

Reform as signal
What the proposed guidelines represent, beyond their immediate clinical scope, is a signal that the state is prepared to take organ donation seriously as a public health priority rather than treating it as a sensitive domain best left to individual conscience and hospital discretion. Standardization, governance, and protocol clarity are not glamorous policy instruments. They do not generate headlines or political capital in the way that new hospitals or technology programmes do.

But in healthcare systems where the gap between policy intent and implementation reality is wide, the procedural layer often determines outcomes more than the legislative one. A well-designed protocol, consistently followed, will save more lives than a law that leaves hospitals uncertain about how to act.

The real measure of this reform will not be the publication of guidelines. It will be whether, five years from now, the number of patients who die waiting has meaningfully fallen.
MB Bureau