The dead donor rule (DDR) has facilitated the saving of hundreds of thousands of lives. Recent advances in heart donation, however, have exposed how DDR has limited donation of all organs. We propose advancing the moment in the dying process at which death can be determined to increase substantially the supply of organs for transplantation. We justify this approach by identifying certain flaws in the Uniform Determination of Death Act and proposing a modification of that law that permits earlier procurement (...) of healthier organs in greater numbers. (shrink)

The mainstream concept of death—the biological one—identifies death with the cessation of an organism. In this article, I challenge the mainstream position, showing that there is no single well-established concept of an organism and no universal concept of death in biological terms. Moreover, some of the biological views on death, if applied in the context of bedside decisions, might imply unacceptable consequences. I argue the moral concept of death—one similar to that of Robert Veatch—overcomes such difficulties. The moral view identifies (...) death with the irreversible cessation of a patient’s moral status, that is, a state when she can no longer be harmed or wronged. The death of a patient takes place when she is no longer capable of regaining her consciousness. In this regard, the proposal elaborated herein resembles that of Veatch yet differs from Veatch’s original project since it is universal. In essence, it is applicable in the case of other living beings such as animals and plants, provided that they have some moral status. (shrink)

Controlled donation after circulatory determination of death (cDCDD) is an important strategy for increasing the pool of eligible organ donors.

The vital status of patients who are a part of controlled donation after circulatory death (cDCD) is widely debated in bioethical literature. Opponents to currently applied cDCD protocols argue that they violate the dead donor rule, while proponents of the protocols advocate compatibility. In this article, we argue that both parties often misinterpret the moral implications of the dead donor rule. The rule as such does not require an assessment of a donor’s vital status, we contend, but rather an assessment (...) of whether procurement of organs in cDCD cause the death of the donor or not. We then argue that commonly practiced cDCD protocols do not violate the dead donor rule, since the donation does not trigger or cause the death of the donors. (shrink)

This collection features comprehensive overviews of the various ethical challenges in organ transplantation. International readings well-grounded in the latest developments in the life sciences are organized into systematic sections and engage with one another, offering complementary views. All core issues in the global ethical debate are covered: donating and procuring organs, allocating and receiving organs, as well as considering alternatives. Due to its systematic structure, the volume provides an excellent orientation for researchers, students, and practitioners alike to enable a deeper (...) understanding of some of the most controversial issues in modern medicine. (shrink)

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard (...) criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

The dead donor rule (DDR) originally stated that organ donors must not be killed by and for organ donation. Scholars later added the requirement that vital organs should not be procured before death. Some now argue that the DDR is breached in donation after circulatory determination of death (DCDD) programs. DCDD programs do not breach the original version of the DDR because vital organs are procured only after circulation has ceased permanently as a consequence of withdrawal of life-sustaining therapy. We (...) hold that the original rendition of the DDR banning killing by and for organ donation is the fundamental norm that should be maintained in transplantation ethics. We propose separating the DDR from two other fundamental normative rules: the duties to prevent harm and to obtain informed consent. (shrink)

ZusammenfassungIn zahlreichen Ländern nimmt die Zahl von Organspenden nach Kreislaufstillstand zu, obwohl in der Medizinethik verschiedene Aspekte der DCDD kritisch diskutiert werden. In unserer Arbeit identifizieren wir ethisch relevante Aspekte der DCDD basierend auf einer umfassenden Literaturanalyse. Wir fokussieren dabei insbesondere auf zwei Aspekte: vorbereitende Maßnahmen und Irreversibilität des Todeskriteriums. Danach untersuchen wir in einer weltweit durchgeführten Auswertung von Webseiten von Organspende-Organisationen und einer begleitenden Umfrage, inwieweit diese ethisch relevanten Aspekte von DCDD in der Information potenziell spendewilliger Personen eine Rolle (...) spielen. Es zeigt sich, dass in der Mehrheit der Webseiten der Organisationen auf die Thematik DCDD nicht oder kaum eingegangen wird, die befragten Verantwortlichen der Organisationen aber die Wichtigkeit der Aufklärung bei spendewilligen Personen betonen. Wir diskutieren diese Diskrepanz und weisen auf zentrale Punkte hin, über welche spendewillige Personen informiert werden sollen, wenn diese Form der Organspende in ihrem jeweiligen Land praktiziert wird. Zudem plädieren wir dafür, dass das Todeskriterium und die Prozeduren zur Todesfeststellung in der Transplantationsmedizin einheitlich sein sollen, um kritisch diskutierte Aspekte im Kontext der DCDD entschärfen zu können. (shrink)

John Lizza says that to define death well, we must go beyond biological considerations. Death is the absence of life in an entity that was once alive. Biology is the study of life. Therefore, the definition of death should not involve non-biological concerns.

In this paper, I defend brain death as a criterion for determining death against objections raised by Don Marquis, Michael Nair-Collins, Doyen Nguyen, and Laura Specker Sullivan. I argue that any definition of death for beings like us relies on some sortal concept by which we are individuated and identified and that the choice of that concept in a practical context is not determined by strictly biological considerations but involves metaphysical, moral, social, and cultural considerations. This view supports acceptance of (...) a more pluralistic legal definition of death as well as acceptance of brain death as death. (shrink)

The articles in this issue cover a wide range of topics, including the moral status of human embryos and human-animal chimeras and hybrids, the determination of death, theories of human cognition, and policies on the identity of mitochondrial donors. Despite this variety, there are two underlying questions that tie the articles together: what is a human being? And, what is the basis of moral status? First, I discuss these two questions and why they are important for bioethics. Then I provide (...) summaries of the six articles in this issue and explain how each of them is connected to the questions of human nature and moral status. (shrink)

Although much has been written on the dead-donor rule in the last twenty-five years, scant attention has been paid to how it should be formulated, what its rationale is, and why it was accepted. The DDR can be formulated in terms of either a Don’t Kill rule or a Death Requirement, the former being historically rooted in absolutist ethics and the latter in a prudential policy aimed at securing trust in the transplant enterprise. I contend that the moral core of (...) the rule is the Don’t Kill rule, not the Death Requirement. This, I show, is how the DDR was understood by the transplanters of the 1960s, who sought to conform their practices to their ethics—unlike today’s critics of the DDR, who rethink their ethics in a question-begging fashion to accommodate their practices. A better discussion of the ethics of killing is needed to move the debate forward. (shrink)

Patients in a minimally conscious state (MCS) fall into a different diagnostic category than patients in the more familiar vegetative states (VS). Not only are MCS patients conscious in some sense, they have a higher chance for recovery than VS patients. Because of these differences, we ostensibly have reason to provide MCS patients with care that goes beyond what we provide to patients with some VS patients. But how to justify this differential treatment? I argue we can’t justify it solely (...) by looking to MCS patients’ actual levels of consciousness. We must look also to the ways in which these patients are potentially conscious. Specifically, I argue that certain sensible and well-regarded policy recommendations cannot be justified by looking solely to patients’ actual levels of consciousness, but that they can be justified by looking to patients’ potential for consciousness. Insofar then as we have prima facie reason to follow the recommendations, we also have prima facie reason to view the potential for consciousness as morally salient. If that is true, however, several important implications follow: first, if the potential for consciousness is morally salient, this translates into actual and pressing obligations to patients with disorders of consciousness generally. Second, if the potential for consciousness is morally salient, this has implications that go beyond our obligations to patients with disorders of consciousness. Indeed, if the potential for consciousness is morally salient, this adds an important layer of complexity to the normative landscape, a layer we may not have sufficiently noticed before. (shrink)

A combination of emerging life support technologies and entrenched organ donation practices are complicating the physician's task of determining death. On the one hand, technologies that support or replace ventilation and circulation may render the diagnosis of death ambiguous. On the other, transplantation of vital organs requires timely and accurate declaration of death of the donor to keep the organs as healthy as possible. These two factors have led to disagreements among physicians and scholars on the precise moment of death. (...) In this article, I suggest that the debate about exactly when a person dies can benefit from distinguishing the strict biological concept of death from the medical standards for determining human death, and I show how an appreciation of the difference between the permanent and irreversible cessation of circulation is helpful in understanding the reasons for the two approaches to determining when death should be declared. (shrink)

The American Journal of Bioethics, Volume 11, Issue 8, Page W4-W6, August 2011.

Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation that (...) must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act. (shrink)

In response to recent debates on the need to abandon the Dead Donor Rule (DDR) to facilitate vital-organ transplantation, I claim that, through a detailed philosophical analysis of the Uniform Determination of Death Act (UDDA) and the DDR, some acts that seem to violate DDR in fact do not, thus DDR can be upheld. The paper consists of two parts. First, standard apparatuses of the philosophy of language, such as sense, referent, truth condition, and definite description are employed to show (...) that there exists an internally consistent and coherent interpretation of UDDA which resolves the Reduction Problem and the Ambiguity Problem that allegedly threaten the UDDA framework, and as a corollary, the practice of Donation after the Circulatory Determination of Death (DCDD) does not violate DDR. Second, an interpretation of the DDR, termed ‘No Hastening Death Rule’ (NHDR), is formulated so that, given that autonomy and non-maleficence principles are observed, the waiting time for organ procurement can be further shortened without DDR being violated. (shrink)

This study examined health professionals’ (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)—controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios—BD, uncontrolled DCD and controlled DCD—were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the (...) context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors’ loss of circulatory function could be reversed, and raises questions about “death” as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs’ discomfort must be further identified and addressed. (shrink)

Family disputes over the diagnosis of brain death have caused much controversy in the bioethics literature over the conceptual validity of the brain death standard. Given the tenuous status of brain death as death, it is pragmatically fruitful to reframe intractable debates about the metaphysical nature of brain death as metalinguistic disputes about its conceptual deployment. This new framework leaves the metaphysical debate open and brings into focus the social functions that are served by deploying the concept of brain death. (...) In doing so, it highlights the epistemic injustice of medicolegal authorities that force people to uniformly accept brain death as a diagnosis of death based on normative considerations of institutional interests, such as saving hospital resources and organ supplies, rather than empirical evidence of brain death as death, which is insufficient at best and nonexistent at worst. In light of this injustice, I propose the rejection of the uniform standard of brain death in favor of a choice-based system that respects families’ individualized views of death. (shrink)

In recent time the critique of the whole brain death as the criterion of human death, that was introduced in 1968, has been growing. The paper aims to show in systematically that there are good reasons based on empirical findings combined with Thomistic Christian anthropology to accept the traditional cardiopulmonary criterion as the criterion of human death. This will be shown through a systematic critique of other criteria of death: whole brain death, higher brain death, brain stem death, and controlled (...) cardiac/circulatory death. The traditional cardiopulmonary criterion of death provides the opportunity to maintain the dead donor rule for organ transplantation. This also affirms the respect for human life required by the ethics of the sanctity of human life. The paper further provides a justification of dead donor rule. The paper proposes 35 minutes period after cardiac arrest to declare the patient dead, since at that time there is no possibility to autoresuscitate the heart. (shrink)

Critics of organ donation after circulatory death (DCD) argue that, even if donors are past the point of autoresuscitation, they have not satisfied the “irreversibility” requirement in the circulatory and respiratory criteria for determining death, since their circulation and respiration could be artificially restored. Thus, removing their vital organs violates the “dead-donor” rule. I defend DCD donation against this criticism. I argue that practical medical-ethical considerations, including respect for do-not-resuscitate orders, support interpreting “irreversibility” to mean permanent cessation of circulation and (...) respiration. Assuming a consciousness-related formulation of human death, I then argue that the loss of circulation and respiration is significant, because it leads to the permanent loss of consciousness and thus to the death of the human person. The DNR request by an organ donor should thus be interpreted to mean “do not restore to consciousness.” Finally, I respond to an objection that if “irreversibility” has a medical-ethical meaning, it would entail the absurd possibility that one of two individuals in the same physical state could be alive and the other dead—an implication that some think is inconsistent with understanding death as an objective biological state of the organism. I argue that advances in medical technology have created phenomena that challenge the assumption that human death can be understood in strictly biological terms. I argue that ethical and ontological considerations about our nature bear on the definition and determination of death and thus on the permissibility of DCD. (shrink)

According to international scientific medical consensus, death is a biological, unidirectional, ontological state of an organism, the event that separates the process of dying from the process of disintegration. Death is not merely a social contrivance or a normative concept; it is a scientific reality. Using this paradigm, the international consensus is that, regardless of context, death is operationally defined as “the permanent loss of the capacity for consciousness and all brainstem function. This may result from permanent cessation of circulation (...) or catastrophic brain injury. In the context of death determination, ‘permanent’ refers to loss of function that cannot resume spontaneously and will not be restored through intervention.” The word “permanent” replaces “irreversible” (used in the United States’ 1980 Uniform Declaration of Death Act) in this new definition, arguably invented to allow donation after circulatory determination of death (DCDD) while still complying with the dead donor rule. I will show that this invention fails, for at least four reasons. (shrink)

Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: (...) irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD. (shrink)

The so-called uncontrolled donation after circulatory determination of death (uDCDD) have been implemented in several countries, including Spain and France, to increase the availability of organs for transplantation. These protocols allow obtaining kidneys, livers and lungs of patients who do not survive cardio-pulmonary resuscitation performed in out-of-hospital settings. Simultaneously with the development and recent proliferation of these protocols, some emergency teams have begun to employ unconventional methods of CPR, with still uncertain but promising results. The coexistence of these two possibilities (...) raises some questions: At what point should attempts to save a patient with circulatory arrest be abandoned so that this individual can begin to be considered as a potential organ donor? How to manage potential conflicts of loyalties that may arise within emergency and procurement teams? How should the information to the families of those patients and potential organ donors be managed? This article gathers the conclusions of a workshop in which an interdisciplinary working group addressed these and other questions related to DCDD and non-conventional CPR. (shrink)

The literature on the determination of death has often if not always assumed that the concept of human death should be defined in terms of the end of the human organism. I argue that this broadly biological conceptualization of human death cannot constitute a basis for agreement in a pluralistic society characterized by a variety of reasonable views on the nature of our existence as embodied beings. Rather, following Robert Veatch, I suggest that we must define death in moralized terms, (...) as the loss of an especially significant sort of moral standing. Departing from Veatch, however, I argue that we should not understand death in terms of the loss of all moral status whatsoever. Rather, I argue, what we should argue about, when we argue about death, is when and why people lose their rights-claims to the protection and promotion of their basic bodily functioning. (shrink)

Singer claims that there are two ways of challenging the fact that brain-dead patients, from whom organs are usually retrieved, are in fact biologically alive. By means of the first, the so called dead donor rule may be abandoned, opening the way to lethal organ donation. In the second, it might be posited that terms such as “life” and “death” do not have any primary biological meaning and are applicable to persons instead of organisms. This second possibility permits one to (...) acknowledge that brain-dead patients are deceased because they are irreversibly unconscious. In the commentary which follows, I will argue that Singer’s second option is preferable since it provides a higher amount of organs available for transplant, and is better suited to the meaning of “death” which occurs in ordinary language. I will also defend such a concept of death against the objections raised by Michael Nair-Collins in the article Can the brain-dead be harmed or wronged? On the moral status of brain death and its implications for organ transplantation. (shrink)

We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between “legally dead” and “legally blind” (...) demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike. (shrink)

The basic question concerning the compatibility of donation after circulatory death protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term “death” nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death can (...) be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of “irreversibility” need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty. (shrink)

A provocative question has emerged since the Supreme Court of Canada’s decision on assisted dying: Should Canadians who request, and are granted, an assisted death be considered a legitimate source of transplantable organs? A related question is addressed in this paper: is controlled organ donation after assisted death (cDAD) more or less ethically-problematic than standard, controlled organ donation after circulatory determination of death (cDCDD)? Controversial, ethics-related dimensions of cDCD that are of relevance to this research question are explored, and morally-relevant (...) distinctions between cDAD and cDCD are identified. In addition, a set of morally-relevant advantages of one practice over the other is uncovered, and a few potential, theoretical issues specifically related to cDAD practice are articulated. Despite these concerns, the analysis suggests a counterintuitive conclusion: cDAD is, overall, less ethically-problematic than cDCDD. The former practice better respects the autonomy interests of the potential donor, and a claim regarding irreversibility of cessation of the donor’s circulatory function in the cDAD context can be supported. Further, with cDAD, there is no possibility that the donor will have negative sensory experiences during organ procurement surgery. Although the development of appropriate policy-decision and regulatory approaches in this domain will be complex and challenging, the comparative ethical analysis of these two organ donation practices has the potential to constructively inform the deliberations of relevant stakeholders, resource persons and decision makers. (shrink)

The concept of death and its relationship to organ transplantation continue to be sources of debate and confusion among academics, clinicians, and the public. Recently, an international group of scholars and clinicians, in collaboration with the World Health Organization, met in the first phase of an effort to develop international guidelines for determination of death. The goal of this first phase was to focus on the biology of death and the dying process while bracketing legal, ethical, cultural, and religious perspectives. (...) The next phase of the project will include a broader group of stakeholders in the development of clinical practice guidelines and will use expert consensus on biomedical criteria for death from the first phase as scientific input into normative deliberation about appropriate policies and practices. Surely, science alone cannot resolve the normative and philosophical questions intertwined in debates about moral status, legal and moral rights, the ethics of killing, and personhood and the nature of the self; however, scientific input is necessary for informed moral deliberation. An objective and unbiased investigation of the biology of death is independent of, and should be undertaken prior to, an analysis of the normative questions engendered by debate about determination of death. This strategy is explicitly endorsed by the International Guidelines for Determination of Death and reflects the prevailing view of these issues in the mainstream medical literature. However, this mainstream literature, exemplified by the IGDD group's recent report, does not exhibit any of the characteristics usually associated with a scientifically rigorous investigation, such as making empirically testable and falsifiable claims, a commitment to evidence and logic over authoritative assertion, or a willingness to revise hypotheses and theories in light of new evidence. Indeed, the core claims and methodologies of the mainstream medical literature on death, both of which are represented by the IGDD report, are not merely scientifically unjustified; they are not science at all. This situation creates a problem for the integrity of science and the academy, and it unjustly obscures and prevents legitimate democratic and moral deliberation about issues that, at bottom, are normative, not scientific. (shrink)

The utilitarian construct of two alternative criteria of human death increases the supply of transplantable organs at the end of life. Neither the neurological criterion (heart-beating donation) nor the circulatory criterion (non-heart-beating donation) is grounded in scientific evidence but based on philosophical reasoning. A utilitarian death definition can have unintended consequences for dying Muslim patients: (1) the expedited process of determining death for retrieval of transplantable organs can lead to diagnostic errors, (2) the equivalence of brain death with human death (...) may be incorrect, and (3) end-of-life religious values and traditional rituals may be sacrificed. Therefore, it is imperative to reevaluate the two different types and criteria of death introduced by the Resolution (Fatwa) of the Council of Islamic Jurisprudence on Resuscitation Apparatus in 1986. Although we recognize that this Fatwa was based on best scientific evidence available at that time, more recent evidence shows that it rests on outdated knowledge and understanding of the phenomenon of human death. We recommend redefining death in Islam to reaffirm the singularity of this biological phenomenon as revealed in the Quran 14 centuries ago. (shrink)

The American Journal of Bioethics, Volume 12, Issue 6, Page 9-10, June 2012.

The American Journal of Bioethics, Volume 12, Issue 6, Page 10-11, June 2012.

The American Journal of Bioethics, Volume 11, Issue 8, Page 44-45, August 2011.

In their target article, Nielsen Busch and Mjaaland seek to shift focus away from controversy over whether donors in protocols of controlled donation after circulatory death (cDCD) are dead. Citing...

Overby and colleagues (2015) draw our critical attention to a variety of ethical challenges associated with the practice of controlled donation after circulatory determination of death (cDCDD). Alt...

This article defends the criterion of permanence as a valid criterion for declaring death against some well-known recent objections. We argue that it is reasonable to adopt the criterion of permanence for declaring death, given how difficult it is to know when the point of irreversibility is actually reached. We claim that this point applies in all contexts, including the donation after circulatory determination of death context. We also examine some of the potentially unpalatable ramifications, for current death declaration practices, (...) of adopting the irreversibility criterion. (shrink)

Despite continuing controversies regarding the vital status of both brain-dead donors and individuals who undergo donation after circulatory death (DCD), respecting the dead donor rule (DDR) remains the standard moral framework for organ procurement. The DDR increases organ supply without jeopardizing trust in transplantation systems, reassuring society that donors will not experience harm during organ procurement. While the assumption that individuals cannot be harmed once they are dead is reasonable in the case of brain-dead protocols, we argue that the DDR (...) is not an acceptable strategy to protect donors from harm in DCD protocols. We propose a threefold alternative to justify organ procurement practices: (1) ensuring that donors are sufficiently protected from harm; (2) ensuring that they are respected through informed consent; and (3) ensuring that society is fully informed of the inherently debatable nature of any criterion to declare death. (shrink)

In their target article, Nielsen Busch and Mjaaland (2023) exhort us to stop “focus[ing] on the validity of the criteria for determination of [circulatory] death” and “instead [look at] DCD protoco...