PERSPECTIVE LIFE OR DEATH FOR THE DEAD-DONOR RULES Living donors 14.000 rain criteria Deceased donors 11,000 9,000 oE86z 5.000 1,000 2002200320042005200620072008200920102011 Organ Donation in the United States by Donor Status, 2002-2011. Data are from the Scientific Registry of Transplant Recipients ertson, the scholar most closely medical practice and that it im- ally declared. 4 The standards for associated with the DDR, has pedes increased organ donation the circulatory determination provided its ethical and legal (see Perspective article by truog death remain a matter of debate, footing. Robertson explains that et al., pages 1287-1289).3 Such though reasoned standards are than a utilitarian rule because it the dDR with the voluntary con- sions are ongoing about a scus. the ddr is a deontological rather scholars have proposed replacing emerging. In particular, di forbids causing a person,s death sent of the dying patient who is imum required duration of asy by removing organs for needy re- beyond harm to donate organs tole before death can be declared cipients, even with the potential before death. These conditions, and whether cessation of circula- donor's consent. Arguing that the they argue, represent sufficient tion must be irreversible(cannot DDR protects vulnerable people, grounds for surgeons to remove be reversed), as stipulated in many such as anencephalic infants and organs, even if doing so causes death statutes, or merely perma- incarcerated prisoners(whose use the donor's death 3 I believe that, nent(will not be reversed), as is as organ donors had previously although there are informed pa- traditionally accepted by physi been proposed and rejected), he tients for whom this practice cians. 5 The Institute of Medicine considers the rule " a centerpiece would work, violating the DDR is and the U.S. Department of of the social orders commitment misguided and will lead fearful Health and Human Services to respect for persons and hu- patients to lose trust in physicians strongly support DCDD and rec- man life. "And he emphasizes and confidence in the organ- ommend its more widespread that the ddR helps to maintain donation system and will result implementation in hospitals-a public trust in the organ-pro- in an overall decline in organ process that is well under way curement system, calling it"the donation. Some critics of the brain or cal linchpin ary One barrier to implementing circulatory determination of death system of organ donation. "2 DCDD protocols is the concern, reject the prevailing choice for Over the past decade, several expressed in surveys of the pub- the moment of death -that scholars have called for the aban- lic and of health care profession- point separating the process of donment of the DDR, claiming als, that the donor is not actually dying in a living patient from the that it is routinely violated in dead at the moment death is usu- process of bodily disintegration 1290 N ENGL J MED 369: 14 NEJM.ORG OCTOBER 3, 2013PERSPECTIVE 1290 n engl j med 369;14 nejm.org october 3, 2013 ertson, the scholar most closely associated with the DDR, has provided its ethical and legal footing. Robertson explains that the DDR is a deontological rather than a utilitarian rule because it forbids causing a person’s death by removing organs for needy re￾cipients, even with the potential donor’s consent. Arguing that the DDR protects vulnerable people, such as anencephalic infants and incarcerated prisoners (whose use as organ donors had previously been proposed and rejected), he considers the rule “a centerpiece of the social order’s commitment to respect for persons and hu￾man life.” And he emphasizes that the DDR helps to maintain public trust in the organ-pro￾curement system, calling it “the ethical linchpin of a voluntary system of organ donation.”2 Over the past decade, several scholars have called for the aban￾donment of the DDR, claiming that it is routinely violated in medical practice and that it im￾pedes increased organ donation (see Perspective article by Truog et al., pages 1287–1289).3 Such scholars have proposed replacing the DDR with the voluntary con￾sent of the dying patient who is beyond harm to donate organs before death. These conditions, they argue, represent sufficient grounds for surgeons to remove organs, even if doing so causes the donor’s death.3 I believe that, although there are informed pa￾tients for whom this practice would work, violating the DDR is misguided and will lead fearful patients to lose trust in physicians and confidence in the organ￾donation system and will result in an overall decline in organ donation. One barrier to implementing DCDD protocols is the concern, expressed in surveys of the pub￾lic and of health care profession￾als, that the donor is not actually dead at the moment death is usu￾ally declared.4 The standards for the circulatory determination of death remain a matter of debate, though reasoned standards are emerging.5 In particular, discus￾sions are ongoing about the min￾imum required duration of asys￾tole before death can be declared and whether cessation of circula￾tion must be irreversible (cannot be reversed), as stipulated in many death statutes, or merely perma￾nent (will not be reversed), as is traditionally accepted by physi￾cians.5 The Institute of Medicine and the U.S. Department of Health and Human Services strongly support DCDD and rec￾ommend its more widespread implementation in hospitals — a process that is well under way. Some critics of the brain or circulatory determination of death reject the prevailing choice for the moment of death — that point separating the process of dying in a living patient from the process of bodily disintegration Life or Death for the Dead-Donor Rule? No. of Donors 10,000 4,000 5,000 1,000 6,000 2,000 3,000 0 7,000 8,000 9,000 11,000 12,000 13,000 14,000 15,000 Deceased donors, declared dead by brain criteria Deceased donors, declared dead by circulatory criteria Living donors 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Organ Donation in the United States by Donor Status, 2002–2011. Data are from the Scientific Registry of Transplant Recipients