Elective ventilation describes the procedure of transferring selected patients dying from rapidly progressive intracranial haemorrhage from general medical wards to intensive care units for a brief period of ventilation before confirmation of brain stem death and harvesting of organs. This approach in Exeter has led to a rate of kidney retrieval and transplant higher than has been achieved elsewhere in the United Kingdom, with a stabilisation of numbers on patients on dialysis. Recently doubt has been cast on the legality of our practice of elective ventilation on the grounds that relatives are not permitted to consent to treatment of an incompetent person when that treatment is not in the patient's best interests. We are thus faced with the dilemma of a protocol that is ethical, practical, and operates for the greater good but which may be illegal. This article explores various objections to the protocol and calls for public, medical, and legal debate on the issues.

It is four years since the Exeter protocol for elective ventilation of potential organ donors was published.1 Briefly, patients admitted to general medical wards with rapidly deepening coma from irremediable intracranial haemorrhage are considered for organ donation. After assessment by a senior doctor suitability as a donor is established with the transplant team, and the intensive care unit is approached about bed availability. The relatives are informed of the poor prognosis and near inevitability of death, and organ donation is then discussed, focusing on the wishes of the dying …