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 current main source of transplantable organs is from heart-beating donors. These are patients who have suffered a catastrophic brain injury, been ventilated, declared dead by neurological criteria, and had their vital functions maintained mechanically until the point of transplantation. But the demand for organs far outstrips the supply, and these patients are not the only potential donors. The idea behind non-heart-beating transplantation is to expand the donor pool by including in it patients who are in hopeless conditions but who (...) are not dying because of brain injury and hence will not suffer the neurological death necessary to become heart-beating donors. As long as we continue to hold the so-called dead donor rule, according to which dying donors cannot have their organs taken before they are dead, this requires that death be able to be declared by alternative criteria, specifically by cardiopulmonary criteria. The challenge is to find such criteria that will identify a state that the public will readily recognize as death and that will facilitate non-heart-beating transplantation. a. (shrink)

It is said there are only two things in life that are certain: death and taxes … maybe only taxes.

Traditionally, organ retrieval from cadavers has taken place only in cases where the declaration of death has occurred using “brain death” criteria. Under these criteria, specific tests are performed to demonstrate directly a lack of brain activity. Recently, as a result of efforts to increase organ procurement, attention has been directed at the use of so-called “non-heart-beating” donors : individuals who are declared dead not as a result of direct measurements of brain function, but rather as a result of the (...) cessation of heart and respiratory functions. Attempts to obtain organs from such individuals have recently resulted in substantial negative publicity. Claims were made that the deaths of patients were being accelerated in order to get organs, and that sometimes organs were being removed from patients who were not yet dead. (shrink)

Transplantation of vital organs has been premised ethically and legally on "the dead donor rule" (DDR)—the requirement that donors are determined to be dead before these organs are procured. Nevertheless, scholars have argued cogently that donors of vital organs, including those diagnosed as "brain dead" and those declared dead according to cardiopulmonary criteria, are not in fact dead at the time that vital organs are being procured. In this article, we challenge the normative rationale for the DDR by rejecting the (...) underlying premise that it is necessarily wrong for physicians to cause the death of patients and the claim that abandoning this rule would exploit vulnerable patients. We contend that it is ethical to procure vital organs from living patients sustained on life support prior to treatment withdrawal, provided that there is valid consent for both withdrawing treatment and organ donation. However, the conservatism of medical ethics and practical concerns make it doubtful that the DDR will be abandoned in the near future. This leaves the current practice of organ transplantation based on the "moral fiction" that donors are dead when vital organs are procured. (shrink)

Donation after cardiac death protocols are widely accepted, so arguments for them have apparently been persuasive. But this does not mean they are sound.

The modern practice of organ donation after cardiocirculatory death (DCD) emerged in the 1990s as a response to the alarmingly wide gap between the number of transplantable organs available through organ donation after neurological death and the urgent organ transplantation needs of persons in end-organ failure. Various important ethical dimensions of DCD have been considered and debated by prominent organ donation/transplantation theorists and clinicians.In this article, consideration of some of these ethical elements provides a foundation for a proposed set of (...) ethically informed, pragmatic conditions that could assist in the development of health policies to guide the practice of organ donation after cardiocirculatory death. (shrink)