Ethics of Normothermic Regional Perfusion for Donors and Definition of Death - The Response

We are writing about the Point/Counterpoint discussion recently published in CHEST (August 2022) on the ethics of the use of normothermic regional perfusion in the recovery of organs from controlled donation after circulatory determination of death (cDCD).1DeCamp M. Snyder Sulmasy L. Fins J.J. Point: Does normothermic regional perfusion violate the ethical principles underlying organ procurement? Yes.Chest. 2022; 162: 288-290Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,2James L. Parent B. Moazami N. Smith D.E. Counterpoint: Does normothermic regional perfusion violate the ethical principles underlying organ procurement? No.Chest. 2022; 162: 290-292Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Both articles misrepresented the definition of death and failed to consider the ethical obligation to the donor, in particular registered organ donors (RODs) under state Uniform Animal Gift Act (UAGA) laws. The Uniform Definition of Death Act, which defines death as “irreversible cessation of circulatory and respiratory functions…,” was drafted after a President’s Commission published “Defining Death.”3President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral ResearchDefining death: a report on the medical, legal and ethical issues in the determination of death.http://tinyurl.com/zq6p5toDate accessed: August 6, 2022Google Scholar The President’s Commission clearly articulated that respiratory function required functioning muscles of respiration; maintaining ventilation with a mechanical ventilator does not restore function, which requires a functioning brainstem, and respiratory muscles. Similarly, the President’s Commission understood that restoring circulatory function requires a functioning heart and that maintaining circulation artificially did not prevent death declaration. Restarting circulation does not restart circulatory function. The President’s Commission erred by implying a precise time of death could be determined. We understand now that death of the brain is a process after circulation stops. Even if resuming circulation briefly prolongs that process, that is not illegal or unethical. More than 50% of Americans are RODs. All states have passed the amended UAGA, which specifically excludes next-of-kin from participating in the organ donation decision of RODs, clearly explained by Kurtz et al,4Kurtz S.F. Strong C.W. Gerasimow D. The 2006 Revised Uniform Anatomical Gift Act: a law to save lives. Health Lawyers News, 2007: 44-49Google Scholar first-authored by the attorney who was the reporter for the group who wrote the amended UAGA. The UAGA makes the ROD’s decision practically equivalent to an advanced directive. We may have not only an ethical obligation to honor the expressed consent to donate organs from RODs, but we may also have a legal obligation to do so. The UAGA has a serious impact on organ donation from cDCDs, which was not mentioned in either article or rebuttals.1DeCamp M. Snyder Sulmasy L. Fins J.J. Point: Does normothermic regional perfusion violate the ethical principles underlying organ procurement? Yes.Chest. 2022; 162: 288-290Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,2James L. Parent B. Moazami N. Smith D.E. Counterpoint: Does normothermic regional perfusion violate the ethical principles underlying organ procurement? No.Chest. 2022; 162: 290-292Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar If individuals expressed a desire to be organ donors on their death, and death is “planned” by withdrawal of life support, when is it appropriate to recover organs? And what should be done to maintain or enhance function of organs from RODs? These are critically important ethical issues. We believe adhering to the expressed premortal ROD consent has a substantial impact on the ethics and timing of normothermic regional perfusion in cDCDs and that normothermic regional perfusion in cDCDs does not restore circulatory function. T. M. E. was supported, in part, by the UNC Lung Transplant Research Fund, with generous contributions from the Ferguson family and John Doherty.