Doctors and death: Organ donation and brain death determination in Eastern Europe
Abstract / Summary
This peer-reviewed anthropological study explores why deceased organ donation and transplantation remain exceptionally rare in Bulgaria and other post-socialist countries in Eastern Europe and the Balkans (apart from Croatia), despite full legal and institutional prerequisites. Through participant observation in a public hospital, informal interviews with clinicians and administrators, and analysis of healthcare regulations (2022–2024), the study reveals that brain death is inconsistently determined and often denied in intensive care units.
The paper connects these practices to deeper cultural, structural, and power dynamics in post-socialist medicine, where ambiguous attitudes toward death sustain institutional paralysis and ethical tension.
Theoretical framework
Drawing on Philippe Ariès (cultural history of death), Arnold van Gennep (liminality and rites of passage), Margaret Lock (cultural construction of death), and Robert Burt (ethics of mortality), the study situates Bulgarian ICU practice within global debates on medicalisation and denial of death.
It interprets brain death as a liminal, culturally charged condition — biologically defined yet socially unmarked — and links the lack of explicit ritualisation to professional anxiety and public mistrust.
Methods
Participant observation (2023–2024) in a public ICU, focusing on internal meetings, interactions with relatives, and the re-activation of donation procedures.
Document and legal analysis tracing contradictions between the Organ, Tissue and Cell Transplantation Act and Regulation No. 14/2004 on death determination.
14 unstructured interviews with ICU staff, donor coordinators, administrators, and ministry representatives.
Online survey (October 2024) among 39 intensive-care physicians across 11 regions on reasons for non-establishment of brain death.
Key findings
- Structural contradiction: Death determination by neurological criteria is legally restricted to transplant-licensed hospitals, creating systemic under-reporting of brain death.
- Economic disincentive: Reimbursement for brain-death diagnosis is contingent on successful donation, discouraging routine determination.
- Cultural liminality: Brain-dead patients exist in an ambiguous moral zone — neither alive nor dead — mirroring broader societal denial of death.
- Institutional fragmentation: Hospital hierarchies and personal dependencies form “medical feudal units,” undermining coordination and trust.
- Symbolic paradox: Transplantation functions as a “miracle” narrative affirming state and medical power, even as actual procedures remain scarce.
Keywords
organ donation · brain death · transplantation · end-of-life · medical anthropology · post-socialist healthcare · Bulgaria · Croatia · Eastern Europe · Balkans · ICU ethics · liminality · power relations · anthropology of death
Citation
Marinova, I. (2025). Doctors and death: Why deceased organ donation and organ transplants are rare in Bulgaria.Anthropology Journal, 12 (1), 24–51. ISSN 2682-9649. Online version (PDF)
Related research and projects
This publication forms the empirical foundation for the upcoming COST Action proposal coordinated through human-care.net, titled “European Network for Harmonising Death Determination, Family Communication, and Ethical End-of-Life Care. The project brings together researchers and clinicians across Europe to improve the understanding and communication of brain death and organ donation.