"The dead donor rule and organ transplantation"

Dr. Robert D. Truog is a professor of medical ethics and anesthesia (pediatrics) in the Departments of Anesthesia and Social Medicine at Harvard Medical School and the Division of Critical Care Medicine at Children’s Hospital Boston — both in Boston. In August 2008, Dr. Truog has conducted a reflexion about the dead donor rule in the context of vital organ(s) removal or grafting: should we be rethinking the dead donor rule and why? (Source: New England Journal of Medicine, Aug. 14, 2008)

Robert D. Truog, M.D., and Franklin G. Miller, Ph.D.: "The Dead Donor Rule and Organ Transplantation" (NEJM, Aug. 14/2008):



"The dead donor rule says we take organs, vital organs, only from those who’ve been clearly, unequivocally pronounced dead. So nothing will happen in terms of procurement, requests, anything, until you’ve got a team that establishes death. (...) And dead people, who are not persons anymore, have no Constitutional rights, no rights at all. And that’s — that’s always been the rule."

"And so I think that the solution [the dead donor rule] to that [transplantation and its ethical justification] has been exactly the wrong way to go. The solution that medicine and society have taken is to continue to tweak and manipulate the definition of death, so that we can progressively include different kinds of patients under that umbrella. And, you know, to me, it seems that that’s the problem. And that, what we really ought to be going back to is, what’s the patient’s prognosis? What’s the neurological condition ? What are the preferences of the patient and the family? And we should respect those. And the dead donor rule, for all of its historical significance, really misses the point." (source)

"Since its inception, organ transplantation has been guided by the overarching ethical requirement known as the dead donor rule, which simply states that patients must be declared dead before the removal of any vital organs for transplantation. Before the development of modern critical care, the diagnosis of death was relatively straightforward: patients were dead when they were cold, blue, and stiff. Unfortunately, organs from these traditional cadavers cannot be used for transplantation. Forty years ago, an ad hoc committee at Harvard Medical School, chaired by Henry Beecher, suggested revising the definition of death in a way that would make some patients with devastating neurologic injury suitable for organ transplantation under the dead donor rule. The concept of brain death has served us well and has been the ethical and legal justification for thousands of lifesaving donations and transplantations. Even so, there have been persistent questions about whether patients with massive brain injury, apnea, and loss of brain-stem reflexes are really dead. After all, when the injury is entirely intracranial, these patients look very much alive: they are warm and pink; they digest and metabolize food, excrete waste, undergo sexual maturation, and can even reproduce. To a casual observer, they look just like patients who are receiving longterm artificial ventilation and are asleep. The arguments about why these patients should be considered dead have never been fully convincing. (...) The uncomfortable conclusion to be drawn from this [scientific] literature is that although it may be perfectly ethical to remove vital organs for transplantation from patients who satisfy the diagnostic criteria of brain death, the reason it is ethical cannot be that we are convinced they are really dead." (source)