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Are DCD Donors

Dead?

BY DON MARQUIS

Donation after cardiac death protocols are subject to two constraints. The first is that organ removal

must occur as soon as possible after cardiac arrest. The second is that it must not occur so soon that the donor

is not yet dead. Can both constraints be satisfied at once? DCD protocols are widely accepted, so arguments

for them have apparently been persuasive. But this does not mean they are sound.

E
ver since brain death came to be understood as The typical DCD case goes like this: The pro-
death of the whole human being in the 1970s, spective donor, although not brain dead, has suffered
organ transplantation has, for the most part, extensive neurological damage and is on life sup-
been closely linked to it. The typical donor has been port.1 Following a decision from the person’s family,
somebody declared brain dead while on life sup- life support is withdrawn and cardiac arrest results. If
port and while the heart continues to beat, thereby the heart does not resume beating on its own within
keeping the organs suffused with oxygen. However, two to five minutes, it will never resume beating on
because relatively few healthy people—people with its own. In a DCD protocol, after one of these in-
suitable organs—have died in just this way, the num- tervals, death is declared. Consent for organ dona-
ber of organs available for transplantation has been tion has been obtained from the donor or his family,
much less than the number of people needing them. and after death is declared, the donor’s organs are
One strategy for making up the difference has been removed for transplantation as quickly as possible.
the introduction of donation after cardiac death pro- DCD protocols are subject to two major con-
tocols, which provide for vital organ donation from straints. On the one hand, organ removal must oc-
people declared dead on the basis of cardiac death. cur as soon as possible after cardiac arrest to prevent
organ damage. The point of organ transplantation
Don Marquis, “Are DCD Donors Dead?” Hastings Center Report 40, is to provide the recipient with healthy organs,
no. 3 (2010): 24-31. but because the donor’s circulation has stopped,

24 HASTINGS C E N T E R R E P O RT May-June 2010

has pointed out that.5 transplant morally permissible. the resumption An individual who has sustained form successful heart transplantation of a heartbeat without external re. will work. dition to successfully donating a presently exist—or will exist—can In these people. however. tocol is designed to generate a source who defend DCD protocols believe one who has suffered “cardiac death” of vital organs from individuals who that both constraints can be satisfied. then it dead. organ damage is retarded or prevent- soon after cardiac arrest that the do. Other issues cannot be set aside so ed. axiom of the transplant community Veatch concluded that this consider- ommended by the Society of Critical that stipulates that vital organs may ation could be expanded to an objec- Care Medicine. but not the second. On the other hand.”6 interval minimizes damage from of all functions of the entire brain. This were genuinely dead. and adopting a shorter tions or (2) irreversible cessation on the basis of cardiac criteria. The longer the fants is arguable. however. Note that Veatch’s objection is not warm ischemia. Therefore. permanence does laration of death in a DCD protocol can be problematic. I functions in the recipient. As a result. much less than the cord with the dead donor rule—the donors plainly had not occurred. cardiac function in Boucek’s infant Irreversibility entails permanence. If the donor’s heart was not dead. ventilator-supported heart. to be pronounced only seventy-five seconds after cessation of donor car- diac function. one made in accordance with accepted given the dead donor rule. an observation about the very term to meet the need for transplantable given the former constraint. the lat. respiratory and circulatory functions oxygenated blood. strongly suggests a contradiction. the permanence of the performed on the basis of DCD. and I set it aside. ing the likelihood that the transplant A determination of death must be but to the declaration of death that. permitted death not entail its irreversibility. Robert Veatch known to be dead. objection even further than he did.4 This issue can be supply oxygenated blood to potential deprivation. irreversible cessation of A n article in the August 2008 is- sue of the New England Journal of Medicine illuminates how the dec- then Boucek’s transplant did not ac. easily. these arguments have would not be able to function in the Both criteria for being dead refer apparently been persuasive. May-June 2010 H A S T I N G S C E N T E R R E P O RT 25 . Mark Boucek not entail irreversibility. would simply not be possible to per- suscitation (that is. tion. The most obvious starts from tial organ donors is far from sufficient A DCD protocol is justified only if. the more likely organ resolved only after the acquisition of donor organs. donor rule after death pronounced sixty seconds. If satisfy the first criterion for being Since DCD protocols have won the donor’s heart is truly dead. On the one other way. “donation after cardiac death. made the might wonder whether the patients medical standards. because the do- then the donor should not have been nated hearts in Boucek’s transplants Death and Reversibility pronounced dead on the basis of car. not just to Boucek’s transplants. in ad- interval and whether the data that second condition. is dead. given the plain and colleagues reported on three successful infant heart transplants meanings of the terms. the warm damage will be. On the other hand. two-minute minimum interval rec.” A “gift organs. the longest reported period of death in this country goes like this: DCD protocol. ischemia that otherwise would cause the organs must not be removed so pending the data. cessation of circulatory function in DCD donors does approved by the ethics committee at his institution.3 be taken only from the dead. recipients. makes it possible to expand Veatch’s whether there are now sufficient data Most cadaver organs have been ob. however. primarily to the transplantation itself. The shorter interval can be both This issue can be developed in an. tion of that function.2 Boucek’s investigational protocol. then it was function. including the brain stem. If the donor was not dead. but not the first. nor. either (1) irreversible cessation of in a manner consistent with the dead suscitation) in DCD cases has been circulatory and respiratory func. also donate other vital organs. The orthodox definition nor declared dead on the basis of the hand. To begin with. That does recipient. actually were restarted in the infant diac death.the donor’s organs are deprived of be extrapolated from adults to in. If the transplanted heart not merely to the cessation of a vital not mean they are sound. The number of brain-dead poten- nor is not actually known to be dead. Those of cardiac life” received from some. to justify the seventy-five second tained from individuals who meet the Consider DCD donors who. wide support. but to any heart transplant from a do- defended and criticized. and the DCD pro- ter constraint can be satisfied. He concluded that “it between cardiac arrest and autore. but to the irreversible cessa- shall argue that DCD donors are not not dead when it was still in the do. therefore maximiz. more data.

On that understanding. which I shall call “the ap. such donors are really plain meanings of the terms. Justifications of the reversible. permanence does not entail versible. But of long been implicit in discussions of a patient’s medical condition was ir. A condition is permanent tory function was permanent. There are two basic kinds of sis was a permanent condition of his permanent for the very simple reason responses.” follow that the patient’s aortic steno. in any whole. if a patient is pronounced dead Veatch’s objection can be ex. The point stops. In short. donation of any vital the DCD protocol by appealing to tory function in DCD donors does organ would. for not entail its irreversibility. the cessation of circula- to a norm. however. cessation of cardiac function is per. not one of the organs transplanted. cessation of Joe’s circulatory death in a DCD protocol. it might well be manence. The DCD protocol is justified eliminated it. Consider cases of has defended the orthodox defini. the reversibility objection has in the developed world. the person is not now breathing and ingly. If cardiac it his whole life. Joe. for he had no obli- ever. a physician standing next function could have been reversed. But a patient might function. One could argue that because cessa. unless the patient is brain dead. John Robertson has defended manence of the cessation of circula- not really dead. then in any all DCD donors. of pronouncing death after cardiac to Joe. have been eliminated had they lived was not wrong. Joe protocol “the reversibility objection. the heart could have been culatory and respiratory function in nence. Accord- the dead donor rule. Since the donors were dead. reversible—medical as soon as his circulatory function shall call this objection to the DCD condition. If irreversibility and perma. then DCD resuscitation would have been suc- Boucek’s transplants ultimately leads organ donors are dead. for perhaps the their hearts were removed. even though death was permanent. is permanent. even in Boucek’s in. Was Fred’s tral point is that the donor’s loss of ity the same? To say that a patient’s refusal to act wrong? Not if we un- cardiac function is. but it does not these infants.”8 Plainly. stopped. A condition is irreversible if reversed in these cases. cardiac donation critical functions of the organism as a An example also shows what is may have been possible. manent. The Appeal to Permanence if the condition is never actually re- tion of cardiac function was actually versed. To say that gation to resuscitate a corpse. Suppose that Joe has a heart transplanted successfully. DCD donation in which the heart is tion of death on many occasions. In peal to permanence” and “the appeal with it his whole life. attack and his circulatory function such donor. then the no longer possible is to ensure that Joe is a rival for the affections of his donor was not dead and the dead do. course this conclusion is absurd. function was permanent. refuses to perform cardiopul- If cessation of circulatory function arrest only when autoresuscitation is monary resuscitation on Joe because could have been reversed. Since cessation of cardiac function was re- T he DCD protocol has been de- fended on the grounds that because the cessation of circula- the condition never could be reversed. This 26 HASTINGS C E N T E R R E P O RT May-June 2010 . such DCD cases. no known intervention could have reason for rejecting the appeal to per- tion. is to say that after Consideration of Boucek’s heart DCD protocol can be understood as the medical condition was acquired. I and. Suppose that cardiopulmonary Reflection on Veatch’s critique of nence are the same thing. love interest. Thus. for after he acquired it he lived that the donor heart was removed. tory function in Boucek’s donors was is sound.” ing countries live their entire lives was dead as soon as he collapsed. then there is live his whole life with a curable— tory function in Joe was permanent no basis for a declaration of death. cessation of circulatory fant donors.9 formed. and the patient could have undergone open. Many people in develop. has then. Are permanence and irreversibil. never will again. heart. therefore. If. the cessation of cir. Fred. The cen. then cardiac was acquired. medical condition was permanent is derstand the irreversible cessation of reversible. transplants provides an additional responses to this reversibility objec. the patient lived with the permanent cessation of circulatory death has not occurred. No one else resuscitates nor rule was violated. How. violate “commonsense views of death.”7 James Bernat. who solely on the basis of the permanent panded even more. Therefore. The cessation of circula- only if at least one of these responses the case that a patient’s aortic steno. the DCD donors were not tory function in a DCD donor is irreversibility. cessation of cardiac function was reversible. cessation of circulatory function. and Boucek’s transplants make the with medical conditions that would Fred’s failure to perform resuscitation reversibility objection vivid. argued that we should understand the sufficient conditions for being de- Boucek’s transplants suggest that in death as “the permanent cessation of clared dead have not been met. If the cessation of cardiac to say that after his medical condition circulatory function as equivalent to function is reversible. removal of their hearts was permis- heart surgery and had the stenosis sible because the cessation of circula- corrected. wrong with the appeal to perma- such case. given the really dead. but because it was not per- to a critique of any declaration of argument. or so goes the cessful. for all we know. for the cessation of circula- death has not occurred. irreversibility entails perma- nence. tory function was permanent because sis was irreversible. DCD protocols. in these cases. the per- pronounced.

Reversible is. but because it has the capacity to the ring by dropping it in aqua regia. it is physiologi. to understand Robertson’s argument. Boucek’s donors were not ment requires a brief detour into the versed. Sup- no resuscitation after cardiac ar. the assumption that would May-June 2010 H A S T I N G S C E N T E R R E P O RT 27 . in context. not (typi. ing occurrent property. erty. There. and in this normative were successful. It would be wrong monary grounds. unless being hit by a car com. . in ordi. “irreversible” acquires an We may safely conclude that the most contexts. quested a do not resuscitate order. would anyone say cessation of circulatory function in nary contexts.12 Thus. ing in this case and that. but as DCD protocol. not (typically) of your fine china. in general. Reversible is a dispositional of cardiac function instead of the in “You can’t cross the intersection property (in most contexts). but your fine china is not fragile? In these that applies to the cessation of circu. kindling is flammable. tial non-heart-beating donation dissolve when put in water. A thing has DCD contexts? One reason to think with the DCD protocol. that some condition that “not fragile” has an ethical mean- the donor should not be reversed. is reversible. is the corresponding occurrent prop- be the permanence of the cessation versed.”10 According to John Robertson: a dispositional property in virtue of it does would be that. but because it would break fore. Analogously. a dispositional prop. Consider patients who enter the emergency room The Appeal to a Norm with no heartbeat and are successfully resuscitated. it would be reversed under circum. Because the patient had issued a having the capacity to exhibit a cor. rent property. dispositional terms seem incorrect. the context of “irreversibility” dead precisely because the transplants distinction between dispositional and is normative. plies in this case. We say Because a norm applies in this case. the that something is fragile. the ring is insoluble in aqua re- diopulmonary function when if not handled carefully. donors. [DCD donation]. ethical meaning. not in virtue pose I am examining your gold ring. therefore. Here is a defense of Robertson’s property. actually permanence of the loss of circulatory when the light is red!” This sense reversed is the corresponding occur- function? The permanence of the ces. Therefore. The normative sense of “ir. table salt in your salt shaker is water.attempt at justification of the DCD respiratory functions in the donor is dissolved is the corresponding occur- protocol wears its circularity on its irreversible. We say that the acquire normative meaning. culatory function should not be re- function. would anyone say that “insoluble” has patient may legitimately be viewed cally) in virtue of its being actually an ethical meaning and that. fragile. We say that gia? Suppose that I am holding a plate death is pronounced on cardiopul. there- as having irreversibly lost all car. in flames should the criterion of cardiac death appealing is the sense of “can’t be re. Flammable for “donation after cardiac death. because the condition is such that contexts. or flammable. D CD protocols are most often de- fended by claiming that. success of his transplants! Therefore. broken. in which moral norms ap- latory function is normative. soluble. But does “irrevers- appeal to permanence cannot jus. an ethical one. ible” acquire an ethical meaning in tify a death declaration in accordance ble. Now we are in a better position cases is quite incompatible with the plicates the analysis. we say. Of rent property. “‘irrevers- These patients are in the same physiological state as ible’ . . as we all know. certain conditions. when moral or legal norms apply. rest would be morally and legally of it actually being dissolved in wa. and in this way is akin to solu. and the donor is dead. ter. Therefore.” reversible” to which Robertson is is a dispositional property. responding occurrent property under terms that are ordinarily dispositional tion or his family has lawfully re. It would be wrong for me to dissolve acceptable in situations of poten. of “can’t” is plainly normative. for example. the appropriate sense of “irreversible” tion actually has been reversed. but for me deliberately or carelessly to because it has the capacity to burn if drop that plate. the cessation of circulatory and stances that could obtain. prior directive against resuscita. broken is the correspond- Since “DCD” actually stands view. Because a norm ap- Robertson is claiming that because ignited. soluble is a dispositional property. is best understood not as an patients declared dead on the basis of the ontological or epistemic term. sation of cardiac function in Boucek’s course. not because the condi. cally possible to cross the intersection Robertson is claiming that. “ethical” interpretations of these fore. occurrent properties.11 in virtue of its actually burning. in the context of such protocols. Fragile is a dispositional sleeve. ply. in DCD if we take for granted the appeal to when the light is red.” which is the sense of “can’t” erty. Let us test this assumption. because the cessation of cir- the permanence of the loss of cardiac The analysis of Robertson’s argu.

and death’s ir. not on moral norms. justification. there are two individuals. then she would be guilty meaning. The dependency re. legal norm. habit my house! Tomlinson is correct: basically about statements concern- does have an ethical meaning. However. The fact that corpses cannot claims (correctly) that the judgment ible” in criteria for determining be reconstituted into living individu. that an individual is dead depends death. there are argu. stand in a relation to another is that ethical judgments that follow. unpersuasive. matter of fact. he claims and this translation has useful ap. ple. The fact that a person is dead is ests could not have ended with death.14 an irreversible state. When a woman’s husband an explanation. of bigamy. then. The obligation of my children tion to Joe is that both Fred and Joe quires a normative meaning in DCD (who are my beneficiaries) to respect exist. whatever condition for having an obligation implications for the demise of our moral norms might be. (Those individual not to resuscitate him if a Almost everything that Tomlinson who are religious may want to add. people can come back from a tough one to have the obligation to. an individual’s condition is irrevers- protocol. The claim of irrevers. Consider another exam. the ethical importance of no longer a “him” to whom one has obligations to protect or account irreversibility depends on the actual duties. DNR order was requested. one can no longer have duties tion necessary for supporting the death seems different. when your life is over. In order for A to stand in the DCD protocol appeals to this un. think obligation to B only if both A and B that the judgment that someone is of the complications that could ensue exist. B” can be true only if both A and B rizes many decisions and actions ibility in DCD contexts is based on exist. or his surrogate’s. can’t come back from sary condition for one individual to ficiently secure to warrant the the dead. When A is ert Veatch has defended this view at our concept of death. Rob. after an individual that presume that the deceased has an individual’s. This is a presump. is irreversible. it is position. as a basis for pronouncing death. Rather.”) son’s argument gets the dependency is true. death is based. (incorrectly) that the judgment that plication to the Pittsburgh [DCD] ally over. Although to someone is that there is some- our obligations to the deceased. statements like “A is ibility and ethical judgment is more taller than B” and “A is to the left of the determination of death autho. If it nature of death. problematic. Similarly. Put collo. istence is central to our notion of this. as a the reason for this is that a neces- a judgment of irreversibility suf. people. condition of Fred’s having an obliga- ing the view that “irreversible” ac. ligations to that individual are con- lieved to be irreversible. exist. tions. This reversal has an explanation. A has an ments that being dead is special. Joe’s remains are not Joe. unlike judging that something after they had sold or begun to in. quially. 28 HASTINGS C E N T E R R E P O RT May-June 2010 . If Fred no longer has to Joe’s remains. then our The notion of irreversible nonex. vidual human being no longer exists judgment of irreversibility and. irreversibility is an important part of ing relational properties. Therefore. A not be reconstituted into living indi. my property rights will cease when I generally and abstractly. obligated to B. And its determination must include bout with pneumonia. A stands in a moral re- length. The irreversibility of “dies”). suppose her dead husband Fred had to Joe when Joe was alive seem to be true. For and never will again. she no longer has the obligation ing human beings. The obligations fore. meantime. transitions into irreversible nonexis- lost most of the interests which right to refuse care—on a moral and tence (the colloquial term for this is she had in life. justify Robertson’s inference does not example. However. truth about obligations. the connection is obligations to protect those inter. death of an individual and our ob- interests was not reasonably be. and never will be again. In the absence of this came back to life after another year. Robertson’s claim seems she had married another man in the not because “death” has an ethical to be merely special pleading. At the moment There is another problem with the not to marry another individual. Its centrality to our notion of the basis for a change in our obliga- the determination of her death. We are essentially liv. is “the possibility of als explains why we have no moral on the judgment that his condition reversal is not ethically significant” qualms about cremation. it is is soluble or that something is fragile. Therefore. Tomlinson is mostly correct: The were the case that her loss of those lation is reversed. death ible depends on our obligation to an is irreversible nonexistence. Tomlin- says about the irreversibility of death “on this earth. viduals. Death is. and die. Tomlinson’s view of the nature any relation to B. appeal to a norm as a basis for the her husband’s death were reversible. nected. Tomlinson revealing translation of “irrevers. if death has these ethical but on biological reality.13 Tom Tomlinson’s defense of reversibility has ethical consequences.15 This claim is not based on a dead. there- then this would be problematic. that indi. it is re. as a matter of fact. for those interests have ended. Put situations? In fact. The reason is that a necessary Thus. Some examples illuminate his The ethical significance of this has relation backwards. dies. Indeed. both A and B must derstanding of what death is: of the relationship between irrevers. but because a necessary Is there some other way of defend. In the above to what is remaining because there is ethical conclusion that our former examples. lation to B. That is because corpses can. If my death were reversible. If of a human being’s death.

tient. medical ethics. tation in DCD cases is sufficient to recent decades. respect the refusal and she dies. but this line of reasoning is respect the wishes of the patient or principle concerning death: If an in. the patient should have ment are regularly dismissed by pro- to set out the conditions of a human been viewed as being in an irrevers. gates decline the transfusion because of the transplant recipients. would say. There. view that since reversing the patient’s DCD protocol is unsound. then all other indi. nitions. As a consequence. An individual is in a severe au. Such patients. According to this ligation to respect that request. his family “is everywhere accepted in dividual is dead in virtue of his body to-a-norm defense of the DCD pro. tion of cardiac function could actual- be many pairs of patients whose bod. Therefore. given the ible loss of circulatory and respiratory function. when they enter makes the condition of the patient seems false. DCD donors are not someone has argued that a body is known to be dead at all. surrogate refusal of resusci- concerning the definition of death in the DCD protocol is sound. even the patient’s blood loss is so great that were in fact successful. underwrite irreversibility. Perhaps others have argued that only rigor mortis is suf. Let us return to actual proper meaning of “irreversible” for resuscitated. Therefore. They presuppose a general correct. Consider pa. of course: “Her condition derwrite the irreversibility of cardiac gument is based is important and was reversible! I wish I could have function. There has been controversy If the appeal-to-a-norm defense of protocol.”16 This defense of the being in state S. This certainly tated. have condition was not legally or morally Objections to Robertson’s argu- something in common. the appeal-to-a-norm defense of the and because physicians had an ob- tients in the television show ER who DCD protocol. it is not known definitions. ficient for death. You that surrogate refusal of resuscitation declarations is unacceptable. It follows fore. and respiratory functions. Those who adopt the appeal. been reversed for the sake of the lives But death is a state of a body. You in DCD cases is not sufficient to un- The principle on which this ar. You are the emer. as different as they are. ceives a blood transfusion. the parents of Boucek’s infants re- should be judged dead on the basis Here is another difficulty with quested the removal of life supports of an appeal to a norm. Rob. patient’s right to refuse medical care infants was irreversible. case. Folks who do bioeth- ics have proposed many candidate When a DCD donor is declared dead. tion of cardiac function ought to have considered dead and the other alive. then all other individuals Many of the arguments given so the wishes of the family or the pa- whose bodies are in the same state are far against the appeal-to-a-norm de. perhaps standard legal definition of death. The cessation of cardiac the emergency room. the obligation to respect a cessation of cardiac function in those heartbeat and are successfully resusci. justification of the DCD protocol in to-a-norm defense of DCD death May-June 2010 H A S T I N G S C E N T E R R E P O RT 29 . transfused her!” to-a-norm defense of the DCD nation. Since many individuals in fense of DCD death declarations argument is the inference from that the same bodily state as DCD donors have involved a considerable level of obligation to the conclusion that the are plainly not dead because they are abstraction. however. The donors. ponents of the DCD protocol on body that justify calling that body ible condition. declarations will claim that because to the consequence that DCD donors fore fails. gency room physician. there will emergency room. You judge that ly be reversed because the transplants ies are in exactly the same state. Her surro. Therefore. the line of reasoning argument commits the straw man fal- viduals in state S are also dead. the same as that used in the appeal. This used in the appeal-to-a-norm defense lacy. you would be wrong to say that. The mistake in Robertson’s also dead. This seems clearly in. It is important to ertson seems to be committed to the the appeal-to-a-norm defense of the note that all of these candidate defi. Consider the following function in Boucek’s infants was not physiological state as patients de. Some of the candidates are irreversible loss of higher brain that he has suffered irreversible loss of circulatory function. The cessa- protocol.The Tomlinson-Robertson view leads terms of the appeal to a norm there. Rejecting Robertson’s argument principle entails that if DCD donors of the DCD protocol is unsound. irreversible loss of all func- tions of the entire brain. and irrevers. tocol. the grounds that the obligation to dead. we may conclude that cases and consider Boucek’s infant the purpose of death declarations is not all DCD donors are dead. They propose permissible. this consequence of DCD death the patient is a Jehovah’s Witness. irreversible. and the cessa- though one member of the pair is the patient will soon die unless she re. are in the same irreversible. is quite compatible with respecting are dead. the enter the emergency room with no defense. normative. According to the appeal- deserves a bit of comment and expla. either in a physiological clared dead on the basis of the DCD tomobile accident and arrives in the sense or in an ethical sense. dead only when it is no warmer than its surroundings. For all I know.

might be used to argue that excep. lives ought to be halted. because removing their life supports. a permanence standard is patible with DCD donation even if reversibility objection to the DCD an “acceptable compromise. We have ibility standard for declaring death in Catholic doctrine is based is com- good reasons for supposing that the DCD cases. they are not known to be dead or renal failure.17 James for a DCD protocol have destroyed The analysis in this essay has Bernat has argued that. is acceptable would involve a far the basis for declaring DCD donors not removing their livers and kidneys. entail that remov- ing vital organs from the kinds of in- The relevant principle is that inten- tionally killing one innocent human being in order to save the life of an- ing to benefit another is to treat that human being as a means only. more careful description of that par- dead does not obtain. able. appeal to what sent of surrogates is no different in devastating neurological injuries that is more general than that which is principle and is another instance of typically qualify one for candidacy justified. the principle on tifications for DCD determinations manence standard and an irrevers. is a dignity that is beyond all price. Furthermore. then a procedure that saves many might argue that. and not as an end. removing livers Are any of these proposals accept- ible loss of circulatory and respira. Some How should we go about answer. One might argue that to remove ently justifies the rule does not apply. 30 HASTINGS C E N T E R R E P O RT May-June 2010 . They do ticular proposal than I have offered. When a Menikoff has pointed out that even them is incompatible with Catholic DCD donor is declared dead. provided the appeal-to-a-norm defense of DCD donation after cardiac death is uneth. riding the dead donor rule on rare Whether this argument carries the nation after cardiac death is unethical occasions would appeal to the view day requires much more analysis. Is the appeal-to-a-norm cent human life. and kidneys from these not-yet-dead able? I have offered no more than a tory functions. and ending his life that appeal is to rebut the reversibility involve the wrongful ending of inno. The explicitly or tacitly.”18 Jerry DCD donors are not dead and killing death declaration is sound. They have does support the view that abortion about reversibility in them. understood as the ethically permis. because DCD donors are not brain not live long enough to die from liver Any such proposal requires a defense. dividuals falsely declared dead on the other is wrong. A number of strategies might be thodox Catholic doctrine. in such cases. there is a “mismatch” between a per. which. rule in narrow circumstances. That principle is not is always wrong. violated in at least some DCD cases. although the basic natural capacity for rational shown that both of the standard jus. offered to justify the moral permis. If ences he would value. human dignity. is another strategy. or can it be justified? sibility of violating the dead donor of an innocent human being. or (2) the dead prospective organ donor’s neurologi- called “the reversibility objection to donor rule should be either jettisoned cal injuries are so severe that he lacks the DCD protocol” might seem to or carefully qualified or fudged. Therefore. as Kant said. one might argue. an in- erations bequeath a normative mean. it is hard to see ing these other contexts is important removing vital organs from the same how it could support the wrongness because justification involves. wrong intentionally to end the life able organs. It is a violation of basis of a DCD protocol is wrong. tating neurological injuries with the pacity for rational agency. the vital organs of a living human be- T he analysis presented here does not. an argument is available tions to the dead donor rule may be that none of these proposals is accept- Removing Vital Organs made when the principle that appar. This. according to some authors. either kinds of patients with the valid con. It is useful to put the above because. Rejecting or dividual is not harmed by the removal ing to “irreversibility. is the cause of their deaths.” The point of revising the dead donor rule seems to of his vital organs. According to or- defense a bit of special pleading be. as far as is known. Fur- at all. which. the dead that organ donation is permissible if a points in context. normative consid. Consider. given the donors does not kill them. Franklin Miller and Robert this Catholic doctrine by appealing contexts involving what we would say Truog have argued that withdrawing to the principle that it is wrong to about other (ordinarily) dispositional life support from patients with devas. this principle ply. It implies that either (1) do. dead. lated in DCD cases. appropriate consent is in place. This is sketch of any of them. of killing a typical DCD donor.19 Menikoff ’s point which I have also not offered.21 Because We can also look at other medical valid consent of surrogates should be fetuses have the basic natural capac- contexts in which moral norms ap. agency. of death are unconvincing. Therefore. however. a future that would contain experi- some to have force. complex. kill anyone with the basic natural ca- properties when moral norms apply. What was above donor rule is violated. It implies something more Another strategy to justify over. gone on to defend the inference that is wrong. To show any standard legal definition of death. by itself. it is not though the dead donor rule is vio. therefore does not wrong him. ity for rational agency. Nei.20 Here objection. For leading scholars have tried to defend ing this question? We can look at example. ethically permissible killing. to see what someone would say sible killing it really is. According to the ther alternative seems appealing. ical. One death declarations. thermore. doctrine itself. known that he has suffered irrevers. it is always cause of the need for more transplant. However.

Truog. R. both for granted in the main analysis of this 15. “Commentary: forded by this appointment.” 2.” 18. Culver. Clear Thinking and Open Discussion indebted to Rachel Sachs.M. in (2006): 122-32. what counts as “circum. and B. “The Dead Donor Rule.. permanence is what counts in declar. Tomlinson. no. I am also 9. May-June 2010 H A S T I N G S C E N T E R R E P O RT 31 . Others have indicated that in DCD About Death: The Silence of the Institute indebted to an anonymous referee for cases.M. DeVita. draft.. Beckwith.” 16. Morissey. “Report of a National 11. Defending Life (Cambridge.M. R. Morissey. R. See his “The Boundaries of afield because the subject of this essay is not at 161-62. DeVita. Jerry Menikoff. “Donating Hearts after case can be made for the view that we have be dead at all. Bernat. Boucek et al. George. U. at 82 and F.K. “On the Definition and Criterion existing beings (at another time). “Cardiac the Disaggregators. M. “Cardiac Transplantation in 10.” Journal of Philosophy 86 (1989): Cardiocirculatory Death. 6 (1999): 16. view that we have obligations to those who 7.M. C. and known to be dead. Organ Donation after Circulatory Death. of Death. I believe that a are dead when they are not known to 6.” Progress in Transplantation 11 the Ethics of Vital Organ Donations. no. in New England Journal of Medicine 359 13. 21. Arnold. Robertson. on us by that conclusion. for the opportunity for research af. and for the Acknowledgments (2008): 672-73. Bernat. J. “When Is ‘Dead’?” Hastings 19. Tomlinson. ligations of existing beings (at one time) to Center for Human Values at Princeton Gert.” Bowers.T.” Annals of Internal Medicine 94 they are not counterexamples to the above University. These obligations are transtemporal Laurance S. responding to Jerry Menikoff ’s and Ron Stephens for helping me. Therefore. and Drazen. “Are Organ Donors After Cardiac Death Journal of Law.K. and Bernat et al. Rockefeller Visiting Profes. Youngner. tions are unnecessary here. 1. Medicine and very helpful comments on an earlier ing death. I am grateful to Princeton (1981): 389-94. 6 (2008): a National Conference on Donation after 38-46.D. It (2008): 669-71. J. Obviously. with this essay. objections to the DCD protocol in “Doubts various ways. Cardiac Death—Reversing the Irreversible. of Medicine. but the complica- native is to pretend that DCD donors essay. “Are Organ Donors after J. The alter. Lee and R. “The Death of This essay has shown two things.. 4. Marquis. and Cardiac Death Really Dead?” Infants. Center Report 29. S. and Cardiac Death. Jim Bernat pointed out this to me in That difficult analysis would take us too far U. of the Whole-Brain Concept of Death. “Rethinking Criteria.” References (2001): 59. T. Miller and R. Curfman.J. Amanda Bernat no longer holds this view. The Silence of the Institute of Medicine. no. See M. I shall take Death.J. obligations. Jr. stances that could obtain” needs analysis. conversation.” New England Journal of Medicine M. However. “Pediatric Heart ing with approval T. “The Death Ethics 26 (1998): 157-65. P. There are reasons for skepticism con. D. and the discussion in Whole-Brain Death: The Plague of has shown that DCD donors are not Curfman. Jim Bernat. J. F.: Cambridge University Press. Body- 3.” the nature of dispositional properties. Somaticists. Bernat et al. “The Irreversibility of definition of death. quot. Bernat. 2 (1998): 18.: Cambridge Death. 2007).P.” 161. It has also shown Transplantation in Infants.” obligations to those who do not exist now New England Journal of Medicine 359 but will exist at a later time. “The Dead Donor do not exist now but have existed in the This essay was begun while I was a Rule.” Immoral.A.” American Journal of Transplantation 12.” Journal of Law. no..A. “A Defense claim. 157. et al. Robertson.M.. Menikoff. S. but very interesting discussion forced cerning both the dead donor rule and this 14.” Mentalists. “The 20. “Why Abortion Is Transplantation after Declaration of Irreversibility of Death: Reply to Cole.M. These special cases concern ob- sor for Distinguished Teaching at the 8. Veatch. I am also Hastings Center Report 28.” Journal of Medicine and that we should engage in the difficult 5. Watch: Certifying Death Using Cardiac 17. Journal of Medicine 359 (2008): 709-714. Drazen. Philosophy 30 (2005): 353-78 and elsewhere. 6 past. (1999): 12.” Hastings Center Report 29. Politics (Cambridge. G. “Doubts about Death: 359 (2008): 749-50. My bracketed comment. This is too simple. Medicine and Ethics 26 Really Dead?” Journal of Clinical Ethics 17 (1998): 167.” Self Dualism in Contemporary Ethics and Conference on Donation after Cardiac The bracketed explanation is mine. University Press. J. Potts. See his Guide IOM’s Report on Organ Donation. and J. 6 (2006): 281-91. Veatch.” New England Kennedy Institute of Ethics Journal 3 (1993): 183-202. 2008). “Report on Hastings Center Report 38.