Perspectives on organ preservation procedure and the definition of death in the medical community.
The United States is a country characterized by contrast. However, in a nation of unbounded economic abundance, a population the size of San Mateo, California, languishes on decades-long organ transplant lists (Penn Medicine, 2023). Although more than 170 million Americans have self-selected to become donors upon death, only a fraction will die in a viable manner or have had lifestyles that make them medically eligible (Penn Medicine, 2023). Advancements in organ preservation technology have enabled the possibility of a more efficient and successful system. One such technique is Norothermic Regional Perfusion (NRP), the infusion of a metabolic cocktail that simulates the living environment of an organ to prolong its viability. Proponents of NRP, namely the American Society of Transplantation (AST), believe that this extension is key to alleviating the existing backlog of recipients and providing better post-transplantation health outcomes. This support is not widespread and is challenged by the American College of Physicians (ACP), who believe NRP violates the “dead donor rule,” an ethical statute adopted by the medical field. This essay will examine the ACP’s argument in favor of NRP and explore the validity of its ethical premises.
The current procedure for organ procurement first requires the patient to be declared dead by their attending physician. As described in the Uniform Determination of Death Act, death can legally be defined by one of two parameters: brain death or cardiorespiratory death. In the former, this occurs when either the entire brain or the brain stem, responsible for communicating between the nervous system and the body, irreversibly stops functioning. Similarly, circulatory death can be diagnosed upon irreversible cardiac cessation (McCall, 2016). Before this, with the patient’s family’s consent, further resuscitation attempts are discontinued. Legal death can then be declared if no spontaneous resumption of brain activity or circulation occurs after a 5-minute “hands off” period. If the patient is a registered donor, a team of specialists then attempts to remove as much tissue as possible before ischemia, the loss of oxygenation, and therefore transplant viability. Unlike with the brain, where life support can be used to maintain circulation after death is declared, viability can quickly be lost during the cooldown period before diagnosing cardiac death (American College of Physicians, 2021). The AST believes that immediate post-mortem perfusion using an ECMO device is key to preventing this ischemia. To conduct NRP after circulatory death (cDCD-NRP), arteries leading to the brain are closed to prevent a potential resumption of brain activity while oxygenated blood is supplied to the organs and heart until they are removed (Caplan et al, 2022).
The AST asserts that cDCD-NRP does not violate the dead donor rule (DDR), requiring patients to be legally dead before organ procurement (Schweikart, 2020). Functionally, this is to prohibit improperly administering care or essentially killing an individual for their organs. The AST’s greater argument in favor of NRP and its compliance with the DDR rests on two premises. First, discontinuing attempts at resuscitation with satisfies that the declared death is irreversible, and therefore does not violate the DDR. This is supported by the implicit understanding that a patient’s death is made irreversible by discontinuing measures to restore circulation. This perspective of the Death Act hinges on interpreting the “irreversibility” of cardiorespiratory function as synonymous with permanence (Caplan et al., 2022). The AST supports this by arguing that the current irreversibility standard is ambiguous and inefficient because advanced life support allows “the possibility of restoring some minimal amount of function” (Caplan et al., 2022). It attempts to qualify this by asserting that attempting resuscitation would be both “medically ineffective” and “inconsistent with a [future] meaningful existence” (Caplan et al., 2022). Here, by their own admission, the AST concedes that it is possible to reverse circulation loss, therefore violating the necessary irreversibility condition for DCD. In doing so, they make a further assumption about the clinical and life quality outcome of extended life support on behalf of the patient. Although measures such as ECMO are only employed in critical cases, they are not necessarily futile. Of individuals who survived at least 30 days after ECMO intervention in circulatory failure, 70% lived for five more years (Rossong et al., 2023). While these survivors faced significant physical and cognitive barriers in their recovery from prolonged oxygen deprivation, the majority expressed no regret over their treatment course. This undermines the AST’s position that continued life support broadly provides minimal results and is medically unethical.
The second premise supported by the AST is that the in-body perfusion of a patient's organs does not constitute resuscitation, even though circulation has been induced. Therefore, the patient’s death is permanent and consistent with the dead donor rule. Unlike cases of brain death, which are definitive and unrecoverable, patients have survived for prolonged periods after ceasing cardiorespiratory function. These instances of “Lazarus syndrome” auto-resuscitation have occurred as long as 17 hours after the initial declaration of circulatory death. This is in part enabled by the relatively slow decay rate of neural tissue in comparison to the rest of the body (Rzeźniczek et al., 2023). The ACP argues that the perfusion method of cDCD-NRP, including the artificial stimulation of the heartbeat, is capable of producing a similar spontaneous recovery by re-oxygenating the brain. In theory, this would make the patient alive and therefore defy the dead donor rule. In practice, this is impossible as the carotid arteries that provide the brain with blood have been closed before NRP, essentially inducing brain death to deter this. The ACP believes that this measure is an unnatural barrier to resuscitation, used to prevent the nullification of the permanence that the death was declared upon. A key implicit principle of the DDR is that a donor “may not be made dead” for the sake of their organs (American College of Physicians, 2021). In contrast, the AST argues that given the patient is already dead by the circulatory standard, they cannot die again by cerebral standards. While the patient was not explicitly killed by the brain death of the NRP procedure, their ability to survive was removed by inducing it. The patient’s inability to be resuscitated, as a result, is synonymous with being made dead. This breach of the dead donor rule further invalidates the AST’s argument.
The AST supports the normothermic perfusion procedure in cases of circulatory death by arguing it is ethically consistent and does not violate the DDR. This is achieved by using a novel interpretation of ambiguity in the difference between permanence and irreversibility when defining a patient’s death. This literal perspective, that death is made irreversible by ceasing further attempts at saving life, is ethically justified by arguing that continued treatment would be “medically ineffective.” This is invalidated by the AST’s self-admission that life support-enabled recovery is possible in certain cases of cardiac death, hence reversing the declaration of death. Thus, discontinuing treatment does not constitute the irreversibility required for death, and therefore defies the dead donor rule. The AST’s second premise, that organ perfusion does not cause actual resuscitation, is invalidated by the actions taken to prevent this resuscitation: removing circulation to the brain. Thus, while cDCD-NRP is not a patient’s cause of death, the brain death it induces fundamentally removes their potential for survival. Therefore, they have been made dead as a result of the organ procurement, violating the DDR.