Organ donation procedure violates the dead donor rule

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

On October 20, 2022, I wrote an article entitled: New Organ transplant procedure violates the dead donor rule where I explain why Normothermic Regional Perfusion organ donation violates the dead donor rule. 

On June 2, 2023 the Journal of the American Medical Association published an article by Troug et al, explaining how Normothermic Regional Perfusion works, why there are ethical objections to it, yet heralding this new organ donation technique as possibly  "The Next Frontier in Organ Donation".

Robert Troug, the lead author of this article, is a long-time proponent of dropping the dead donor rule for organ donation. (Article 1) (Article 2) (Article 3)

The article explains how Normothermic Regional Perfusion is done:

The donation after circulatory death–normothermic regional perfusion method differs from standard donation after circulatory death in that perfusion to the organs is restored in situ before they are removed. In normothermic regional perfusion, immediately after death is declared, surgeons perform a sternotomy, place cannulas into the right atrium and the descending aorta, clamp the brachiocephalic arteries to occlude blood flow to the brain, and use an extracorporeal membrane oxygenation (ECMO) machine to initiate warm perfusion to all of the organs. Once ECMO perfusion is established, the perfused organs typically start to regain function inside the donor’s body: the heart beats, the liver makes bile and clears lactate, the kidneys produce urine, and the donor may even be weaned off ECMO. This procedure allows time for the organs to be monitored and optimized before removal and transplant.

This means that once the heart stops beating for 5 minutes and the person is declared dead, the organ donation team will then block the blood flow to the brain and restart the heart to enable normal organ function. 

These people are being intentionally made 'brain dead' in order to be used as organ donors.

Troug states that those who support Normothermic Regional Perfusion believe that they are fulfilling the circulatory death protocol, with the only difference being that after the person is declared dead, the heart is restarted to ensure that the organs remain healthy.

Troug explains that those who oppose Normothermic Regional Perfusion argue that the only reason the person is not resuscitated in the first place is that the person has agreed to be an organ donor. Troug explains:

Critics insist that restoring circulation with ECMO does indeed reverse the very criteria by which the patient was declared to be dead and that once supported on ECMO, patients no longer fulfill the circulatory criteria for death. Proponents disagree, noting that cerebral circulation had ceased for 5 minutes during the hands-off period and was prevented from being restored by the clamping of the brachiocephalic vessels, inevitably leading to a state of brain death. Yet this response has been criticized because (1) it seems to switch the criteria by which death is determined from circulatory to neurological, and (2) the determination of death by neurological criteria requires a number of specific examinations and tests that cannot be completed within the timeframe of donation after circulatory death-normothermic regional perfusion.

Troug opposes the dead donor rule and he supports Normothermic Regional Perfusion. Troug does repeat the concerns with the new organ donation technique, but he states:

The donation after circulatory death–normothermic regional perfusion procedure offers an unprecedented opportunity to improve both the number and quality of organs procured from donation after circulatory death. Faced with a growing waiting list, a commitment to saving as many lives as possible, and increasing scrutiny and regulatory pressures, many in the transplant community are eager to embrace normothermic regional perfusion.

Normothermic Regional Perfusion bi-passes the dead donor rule by allowing an organ donor to die, even though the person may have been able to live, in order to harvest healthy organs. It is not that death first occurs, rather death is made to occur, for the purpose of organ donation.

The dead donor rule is being circumvented in order to provide more organs for donation.