Organ transplantation provides life-saving treatment for children with severe end-organ failure, using organs usually sourced from live-related or cadaveric donors.

Infants under 2 months in the UK do not donate organs, whereas in other, similarly developed, healthcare systems, such donation and transplantation are routine. Indeed, infant hearts donated in Europe are retrieved and transplanted in the UK. Furthermore, other organs may soon be realistically transplantable in the first months of life.

In 1988, the Conference of Medical Royal Colleges produced a report on neonatal organ transplantation long before this was feasible.1 Now the technical capabilities have arrived, it is surely time to reconsider this area.

This paper considers the practical, ethical and legal issues surrounding organ donation from UK neonatal units.

While philosophers debate definitions and criteria for death, for clinicians the practical tests used to certify death remain paramount.2 The Academy of Medical Royal Colleges (AoMRC) ‘Code of Practice for the Diagnosis and Confirmation of Death’3 offers authoritative guidance, maintaining the 1991 British Paediatric Association (BPA) standards4 for diagnosing death in children using either cardiorespiratory or neurological criteria. While prima facie acceptable, the devil for paediatricians is in the detail, and the relevance of the document to infant organ transplantation will be explored.

In UK neonatal practice, death is certified using cardiorespiratory criteria, the examination performed to certify death for anyone dying outside intensive care. No breath sounds, no heart sounds, pupils fixed and dilated is a frequent final entry in medical notes.

Clinicians in adult and paediatric intensive care units (PICU) are also familiar with the concept of neurological death, which in the UK is brainstem death (BSD) certifiable by bedside brainstem tests.3 BSD is usually a result of traumatic or hypoxic brain injury, causing sustained raised intracranial pressure, leading to cerebellar tonsil …