The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols.

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.

Another Defense of Abortion: What Transplant Ethics Tells Us about the Ethics of Abortion after Dobbs.

In 1971, two years before Roe v. Wade affirmed federal protection for abortion, Judith Jarvis Thomson attempted to demonstrate the wrongs of forced gestation through analogy: you awake to find that the world's most esteemed violinist is wholly, physically dependent on you for life support. Here, the authors suggest that Thomson's intuition, that there is a relevant similarity between providing living kidney support and forced gestation, is realized in the contemporary practice of living organ donation. After detailing the robust analogy between living kidney donation and gestation, we turn to current ethical guidelines incorporated in the United Network for Organ Sharing's requirements for legally authorized organ donation and transplantation. We conclude that if, as we-and Thomson-suggest, organ donation and gestation are relevantly similar, then the ethical framework supporting donation may aid in articulating ethical grounds that will be compelling in informing the legal grounds for a defense of abortion.

Abigail Levin replies.

This letter responds to the letter "The Open Donor View and Procreative Beneficence," by Daniel Groll, in the same, May-June 2024, issue of the Hastings Center Report.

Ethical and Equity Guidance for Transplant Programs Considering Thoracoabdominal Normothermic Regional Perfusion (TA-NRP) for Procurement of Hearts.

Donation after circulatory determination of death (DCDD) is an accepted practice in the United States, but heart procurement under these circumstances has been debated. Although the practice is experiencing a resurgence due to the recently completed trials using ex vivo perfusion systems, interest in thoracoabdominal normothermic regional perfusion (TA-NRP), wherein the organs are reanimated in situ prior to procurement, has raised many ethical questions. We outline practical, ethical, and equity considerations to ensure transplant programs make well-informed decisions about TA-NRP. We present a multidisciplinary analysis of the relevant ethical issues arising from DCDD-NRP heart procurement, including application of the Dead Donor Rule and the Uniform Definition of Death Act, and provide recommendations to facilitate ethical analysis and input from all interested parties. We also recommend informed consent, as distinct from typical "authorization," for cadaveric organ donation using TA-NRP.

An Ethics Committee's Evaluation of Normothermic Regional Perfusion (NRP) in 2018-Unsatisfactory Answers Then-and Now.

An adult university hospital ethics committee evaluated a proposed TA-NRP protocol in the fall of 2018. The protocol raised ethical concerns about violation of the Uniform Determination of Death Act and the prohibition known as the Dead Donor Rule, with potential resultant legal consequences. An additional concern was the potential for increased mistrust by the community of organ donation and transplantation. The ethics committee evaluated the responses to these concerns as unable to surmount the ethical and legal boundaries and the ethics committee declined to endorse the procedure. These concerns endure.

Restoring the Organism as a Whole: Does NRP Resurrect the Dead?

The introduction of normothermic regional perfusion (NRP) in controlled donation after circulatory determination of death (cDCDD) protocols is by some regarded as controversial and ethically troublesome. One of the main concerns that opponents have about introducing NRP in cDCDD protocols is that reestablishing circulation will negate the determination of death by circulatory criteria, potentially resuscitating the donor. In this article, I argue that this is not the case. If we take a closer look at the concept of death underlying the circulatory criterion for determination of death, we find that the purpose of the criterion is to show whether the organism as a whole has died. I argue that this purpose is fulfilled by the circulatory criterion in cDCDD protocols, and that applying NRP does not negate the determination of death or resuscitate the donor.

Cardiac organoids do not warrant additional moral scrutiny.

Certain organoid subtypes are particularly sensitive. We explore whether moral intuitions about the heartbeat warrant unique moral consideration for newly advanced contracting cardiac organoids. Despite the heartbeat's moral significance in organ procurement and abortion discussions, we argue that this significance should not translate into moral implications for cardiac organoids.

Toward Transparency and Trust: Assessing and Addressing Key Ethical Concerns in Normothermic Regional Perfusion.

Normothermic Regional Perfusion, or NRP, is a method of donated organ reperfusion using cardiopulmonary bypass or a modified extracorporeal membrane oxygenation (ECMO) circuit after circulatory death while leaving organs in the dead donor's corpse. Despite its potential, several key ethical issues remain unaddressed by this technology.

Leading the transition to ethical human body sourcing in Africa: The South African experience.

BACKGROUND: The use of human bodies for anatomy education and research forms an integral part of the training of health professionals around the world. However, the ethical acquisition of human remains for this purpose has been a challenge in many countries, particularly for those on the African continent. South African institutions have however, been able to progressively transition to a more ethical approach to human body acquisition. The aim of the current study was to investigate the provenance of human bodies and the number used in South African health sciences institutions during the period 2017-2021. METHODS: an online self-administered anonymised questionnaire was circulated to all health sciences institutions in South Africa. Questions were focused on establishing the provenance and the associated number of bodies and body donor programmes. RESULTS: responses were received from thirteen of the fourteen South African institutions. All thirteen institutions use human bodies for teaching and research, with the majority of the institutions being reliant on bequests (77%) and family donations (62%), and less on unclaimed remains (46%). Most institutions have established body donor programmes. Four institutions were negatively affected by the effects of the pandemic. Memorial services, which continued during the pandemic, were conducted by eight of the thirteen institutions. CONCLUSION: South Africa is leading the transition to the ethical acquisition of human remains on the African continent. It is hoped that South African institutions will soon transform to the exclusive sourcing of bodies through willed donation and provide guidance and support for the other countries on the continent.

Organismal Superposition Problem and Nihilist Challenge in the Definition of Death.

According to the mainstream bioethical stance, death constitutes the termination of an organism. This essay argues that such an understanding of death is inappropriate in the usual context of determining death, since it also has a social bearing. There are two reasons to justify this argument. First, the mainstream bioethical definition generates an organismal superposition challenge, according to which a given patient in a single physiological state might be both alive and dead, like Schrödinger's cat. Therefore, there is no clear answer as to whether organ retrieval from a brain-dead patient is an act of killing or not. Second, when combined with the dead donor rule, the mainstream position in the definition of death might lead to ethically unacceptable verdicts, since there is a discrepancy between terminating an organism and depriving someone of moral status.

Historical trends and current experiences of anatomical body donation in two Zimbabwean medical schools.

BACKGROUND: Body donation is integral to anatomy education, but procurement can be ethically fraught. While voluntary donation is preferred, the use of unclaimed bodies, although considered unethical, is a primary means for body procurement in some countries. This mixed methods study examined historical trends and anatomy technical staff perspectives on body donation in two Zimbabwean medical schools. METHODOLOGY AND MAIN FINDINGS: In Phase 1, 194 cadaver paper records from January 1984 to January 2021 were reviewed. Unclaimed bodies accounted for 67% while 33% (all white Zimbabweans) were voluntarily donated. Most cadavers were black Africans (62.4%) followed by white Zimbabweans (34.0%). Race was not indicated in seven (3.6%) records. In Phase 2, semi-structured interviews were conducted with seven technicians responsible for sourcing cadavers at the two institutions. Data were thematically analysed resulting in the development of eight themes, arranged into three domains. Cadaver procurement themes related to (1) cadaver source, (2) adherence to procurement guidelines, (3) screening for suitability, and (4) cultural and religious beliefs. Cadaver embalmment focused on (5) embalming practices, and (6) hospital mortuary-based embalming. Finally, (7) disposal processes and (8) resource constraints were found to influence cadaver disposal practices. CONCLUSIONS: Contrary to best practice, there is continued reliance on the use of unclaimed bodies to support anatomy education in the two Zimbabwean medical schools. Improving the ethical sourcing of bodies requires increased efforts to educate all Zimbabweans, especially the black majority, about the role and importance of voluntary body donation in medical education. Additionally, well-structured, and well-resourced body donation programs could enhance ethical procurement.

Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute.

In a workshop sponsored by the U.S. National Heart, Lung, and Blood Institute, experts identified current knowledge gaps and research opportunities in the scientific, conceptual, and ethical understanding of organ donation after the circulatory determination of death and its technologies. To minimize organ injury from warm ischemia and produce better recipient outcomes, innovative techniques to perfuse and oxygenate organs postmortem in situ, such as thoracoabdominal normothermic regional perfusion, are being implemented in several medical centers in the US and elsewhere. These technologies have improved organ outcomes but have raised ethical and legal questions. Re-establishing donor circulation postmortem can be viewed as invalidating the condition of permanent cessation of circulation on which the earlier death determination was made and clamping arch vessels to exclude brain circulation can be viewed as inducing brain death. Alternatively, TA-NRP can be viewed as localized in-situ organ perfusion, not whole-body resuscitation, that does not invalidate death determination. Further scientific, conceptual, and ethical studies, such as those identified in this workshop, can inform and help resolve controversies raised by this practice.