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Can the Dead Donor Rule be Resuscitated?

This issue of American Journal of Bioethics includes an interesting and highly charged debate about organ donation after cardiac death (DCD). Significant disagreement continues to surround the way in which we define death in connection to organ procurement. However, it might be helpful to consider other (less charged) settings in which the general bifurcated legal standard of death is applied. For example, when a patient dies in the ICU or in other medical settings unrelated to organ procurement, death is determined based on either of the two standard criteria—brain death or irreversible cessation of circulation and respiration. In practice, there seems to be variation in the “irreversibility” of death. For instance, when a patient is full code, has a fatal rhythm and circulation ceases, attempts made to resuscitate the patient—i.e., to restore circulation—may go on for an extended period. Should these efforts fail, the patient may not be declared dead for tens of minutes after circulation was discontinued. In contrast a patient who is a no-code—i.e., a patient for whom it has been decided not to attempt to restore circulation and particularly in cases where life support is withdrawn—is declared dead after it is made certain that there is no possibility of auto-resuscitation and as soon as a physician can be brought into the room, sometimes within a minute or two of cessation of circulation. Rodrı́guez-Arias and colleagues’ (2011) arguments rest on an important assumption: that the definition of death is an objective, biological fact and external contingencies, such as whether or not attempts will be made to restore circulation, are irrelevant. Common practice of declaring death outside the organ donation context clearly conflicts with this perspective. It follows from this logic that whether you are DNR or a full code would actually matter in the determination of whether you are dead or not. Intentions do matter in practice for when death is declared. This seems to support Bernat’s argument that irreversible cardiac death means will not be restored rather than could not be restored (Bernat 2008).