PERSPECTIVE THE DEAD-DONOR RULE to accept this active role in the dy- others to live, even if that means ments of Medicine, Biostatistics and Epide Policy, and the Fostering Impro rather than eroded, the public their death. We believe that poli- End-of-Life Decision Science(FIELDS) trust in the profession. cymakers should take these Our society generally supports zens' requests seriously and be- nia, Philadelphia(SDH ) the view that people should be gin to engage in a discussion 1. Sanghavi D When does death start? New granted the broadest range of about abandoning the DDr. freedomscompatiblewithassurTheviewsexpressedarethoseoftheau.(http://www.nytimes.com/2009/12/20/ azine/20organ-t html pagewanted=all& ance of the same for others som e thors and do not necessarily reflect the pol- _r-O icy of the National Institutes of Health, the 2. Bernat JL, Culver CM, Gert B. On the defi. people may sona mora Public Health Service, or the Department of nition and criterion of death. Ar views that preclude the approach Health and Human Service 198194389-94. should be respected. Neverthe- are available with the full text of this article 5. car>11998 511538-4al conseque ath we describe here. and these views Disclosure forms provided by the author 3. Shewmon DA.Chronic"brain less, the views of people who provide no basis for denying such of Global k mope and the Department Univer itfF LA. B: 2012 opt organ transplantation: recor and so eal ethics at the end of life. New york oxford liberties to those who wish to of Anesthesiology, Perioperative and Pain 5. Simin Youngner S). Death pursue them. When death is very Medicine, Boston Children's Hospital- and organ procurement: public beliefs and at near, some patients may want to Bioethics, National Institutes of Health, DOl: 10.1056/NEJMp1307220 die in the process of helping Bethesda, MD(FG M); and the Depart. Copyright e 2013 Massachusetts Medical Society Life or death for the dead-Donor rule? James L Bernat, M D he increasing disproportion cently proposed by Paul Morrissey an informal, succinct standard between the supply of donor of Brown University. This proto- highlighting the relationship be- organs and the demand for col permits a lawful surrogate tween the two most relevant laws transplants as well as the tragic decision maker for a patient with governing organ donation from deaths of patients awaiting or- a severe, irreversible brain injury deceased do the Uniform gans have encouraged the devel-(but who is not "brain dead")to Anatomical Gift Act and state opment of creative solutions to authorize withdrawal of life-sus- homicide law. The DDR states increase the donor supply. In the taining treatment and premortem that organ donation must not domain of donation from de- donation of both kidneys. Where- kill the donor; thus, the donor ceased donors, the protocols for as DCDD protocols entail removal must first be declared dead. It organ donation after the circu- of organs after the cessation of applies only to organ donation latory determination of death life-sustaining therapy and the from deceased donors, not to liv (DCDD) have been one such re- subsequent declaration of death, ing donation, such as that of one sponse. Most U.S. organ-procure- the Morrissey protocol provides kidney or a partial liver. Morris ment organizations have seen for procuring organs while the sey's protocol does not violate organs from DCDd protocols patient remains alive. Life-sus- the ddr because it is a type of account for a growing percent- taining treatment is withdrawn living organ donation that does age of all organs donated from after the donation has been ac- not kill the donor. The donor deceased donors(see graph). In complished. The patient dies of dies not as a result of the azo- England, DCDD organs currently the respiratory complications of temic consequences of the dona constitute a greater percentage the original brain which tion of both kidneys but earlier, than organs donated after the is fatal in the absence of life-sus- of respiratory arrest. determination of death by brain taining treatment. hat the act of organ donation criteria ("donation after the brain Some commentators have must not kill the donor has been determination of death, "or DBDD). claimed that Morrissey's proto- regarded as the ethical and legal Another innovative strategy is col violates the dead-donor rule foundation of organ donation the kidney-donation protocol re- (DDR). The ddr is not a law but from its earliest days. John Rob N ENGLJ MED 369: 14 NEJM.ORG OCTOBER 3, 2013n engl j med 369;14 nejm.org october 3, 2013 PERSPECTIVE 1289 The Dead-Donor Rule to accept this active role in the dy￾ing process has probably enhanced, rather than eroded, the public trust in the profession. Our society generally supports the view that people should be granted the broadest range of freedoms compatible with assur￾ance of the same for others. Some people may have personal moral views that preclude the approach we describe here, and these views should be respected. Neverthe￾less, the views of people who may freely avoid these options provide no basis for denying such liberties to those who wish to pursue them. When death is very near, some patients may want to die in the process of helping others to live, even if that means altering the timing or manner of their death. We believe that poli￾cymakers should take these citi￾zens’ requests seriously and be￾gin to engage in a discussion about abandoning the DDR. The views expressed are those of the au￾thors and do not necessarily reflect the pol￾icy of the National Institutes of Health, the Public Health Service, or the Department of Health and Human Services. Disclosure forms provided by the author are available with the full text of this article at NEJM.org. From the Departments of Anesthesia and of Global Heath and Social Medicine, Har￾vard Medical School, and the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital — both in Boston (R.D.T.); the Department of Bioethics, National Institutes of Health, Bethesda, MD (F.G.M.); and the Depart￾ments of Medicine, Biostatistics and Epide￾miology, and Medical Ethics and Health Policy, and the Fostering Improvement in End-of-Life Decision Science (FIELDS) pro￾gram — all at the University of Pennsylva￾nia, Philadelphia (S.D.H.). 1. Sanghavi D. When does death start? New York Times Magazine. December 16, 2009 (http://www.nytimes.com/2009/12/20/ magazine/20organ-t.html?pagewanted=all& _r=0). 2. Bernat JL, Culver CM, Gert B. On the defi￾nition and criterion of death. Ann Intern Med 1981;94:389-94. 3. Shewmon DA. Chronic “brain death”: meta-analysis and conceptual consequences. Neurology 1998;51:1538-45. 4. Miller FG, Truog RD. Death, dying, and organ transplantation: reconstructing medi￾cal ethics at the end of life. New York: Oxford University Press, 2012. 5. Siminoff LA, Burant C, Youngner SJ. Death and organ procurement: public beliefs and at￾titudes. Kennedy Inst Ethics J 2004;14:217-34. DOI: 10.1056/NEJMp1307220 Copyright © 2013 Massachusetts Medical Society. Life or Death for the Dead-Donor Rule? James L. Bernat, M.D. The increasing disproportion between the supply of donor organs and the demand for transplants as well as the tragic deaths of patients awaiting or￾gans have encouraged the devel￾opment of creative solutions to increase the donor supply. In the domain of donation from de￾ceased donors, the protocols for organ donation after the circu￾latory determination of death (DCDD) have been one such re￾sponse. Most U.S. organ-procure￾ment organizations have seen organs from DCDD protocols account for a growing percent￾age of all organs donated from deceased donors (see graph). In England, DCDD organs currently constitute a greater percentage than organs donated after the determination of death by brain criteria (“donation after the brain determination of death,” or DBDD). Another innovative strategy is the kidney-donation protocol re￾cently proposed by Paul Morrissey of Brown University.1 This proto￾col permits a lawful surrogate decision maker for a patient with a severe, irreversible brain injury (but who is not “brain dead”) to authorize withdrawal of life-sus￾taining treatment and premortem donation of both kidneys. Where￾as DCDD protocols entail removal of organs after the cessation of life-sustaining therapy and the subsequent declaration of death, the Morrissey protocol provides for procuring organs while the patient remains alive. Life-sus￾taining treatment is withdrawn after the donation has been ac￾complished. The patient dies of the respiratory complications of the original brain injury, which is fatal in the absence of life-sus￾taining treatment. Some commentators have claimed that Morrissey’s proto￾col violates the dead-donor rule (DDR). The DDR is not a law but an informal, succinct standard highlighting the relationship be￾tween the two most relevant laws governing organ donation from deceased donors: the Uniform Anatomical Gift Act and state homicide law. The DDR states that organ donation must not kill the donor; thus, the donor must first be declared dead. It applies only to organ donation from deceased donors, not to liv￾ing donation, such as that of one kidney or a partial liver. Morris￾sey’s protocol does not violate the DDR because it is a type of living organ donation that does not kill the donor. The donor dies not as a result of the azo￾temic consequences of the dona￾tion of both kidneys but earlier, of respiratory arrest. That the act of organ donation must not kill the donor has been regarded as the ethical and legal foundation of organ donation from its earliest days. John Rob-