Was den Menschen zum Menschen macht

Dead Donor Rule

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🇩🇪 Deutsche Version: Dead Donor Rule

The Dead Donor Rule (DDR) is a clinical-ethical foundational principle of transplantation medicine, given in two formulations:

  1. Vital organs may be procured only from the dead.
  2. The procurement of organs must not cause the death of the donor.

Both propositions belong together: the first protects the precondition of donation (a dead person is present), the second protects the causality of donation (procurement must not become a killing). The DDR is an expression of the Personalist Norm in the context of organ donation: the person must not be treated as a means for obtaining a donor organ — the person is to be affirmed for his or her own sake.

The DDR is a normative posit. Its application depends decisively on two prior questions: first, what death means; second, what to cause means. Both questions are philosophically non-trivial.

Relation to the Definition of Death

The DDR renders the ontological problem of the definition of death relevant to practice. Whoever equates death with the irreversible loss of brain function can declare donation after irreversible loss of brain function to be DDR-compliant; whoever, with the position defended here, distinguishes irreversible loss of brain function from certain death takes the DDR more strictly. Whoever holds the permanence of circulatory arrest to be sufficient will count donation after circulatory death as DDR-compliant; whoever demands irreversibility sees a violation.

The ontology defended here follows the second line: permanence is, in terms of substance ontology, not sufficient for certain death. Thus the practice of donation after circulatory death potentially violates the DDR — not only in its most acute form (TA-NRP), but already in the positing of permanence itself. The ontology therefore marks donation after circulatory death, in its controlled and uncontrolled forms, as a potential violation of both the Dead Donor Rule and the Personalist Norm.

The precautionary principle of Benedict XVI supports this assessment: where the definition of death is contested, the DDR is to be construed in the stricter sense — and this means: not permanence, but irreversibility as the criterion.

Violation through Causality

The second proposition of the DDR — that procurement must not cause death — becomes especially acute in the debate over normothermic regional perfusion. In the thoracoabdominal NRP variant with surgical clamping of the aortic arch vessels the question arises: if the person is not definitively dead at the moment of clamping (but only displays permanent circulatory arrest), is the clamping itself then the cause of death?

James L. Bernat and Thaddeus M. Pope have argued that the necessity of the clamping anticipates the answer: one clamps because otherwise cerebral perfusion would return. But whoever would otherwise return was, at the moment of clamping, not definitively gone. Along this line, TA-NRP is a causal act of killing — and thus a direct violation of the DDR. Robert D. Truog (Hastings Center Report 2024) counters that, after established permanence, no subject any longer exists that could be killed; the normative will not to resuscitate again renders permanence sufficient.

The ontology defended here follows the line of Bernat and Pope: TA-NRP is problematic in terms of substance ontology; the United Kingdom paused the practice at the end of 2020 for precisely this reason.

Ontological Classification

Superordinate concepts: Normative Justification, Norm

Ontological relations:

Chapter assignment: Chapter 4: What is human personhood?, Chapter 5: Oblivion of the Person

Sources

Sources: Generated by querying the Personhood ontology.

Further sources:

Classical Formulation and Discussion

  • Robertson, John A. (1999): Delimiting the Donor: The Dead Donor Rule. Hastings Center Report 29(6): 6—14. Classical account and first systematic defense.
  • Bernat, James L. (2006): Are organ donors after cardiac death really dead? Journal of Clinical Ethics 17(2): 122—132.
  • Bernat, James L. (2013): Controversies in defining and determining death in critical care. Nature Reviews Neurology 9(3): 164—173.
  • Truog, Robert D.; Robinson, Walter M. (2003): Role of brain death and the dead-donor rule in the ethics of organ transplantation. Critical Care Medicine 31(9): 2391—2396.

Permanence versus Irreversibility

  • Bernat, James L.; Capron, Alexander M.; Bleck, Thomas P.; Blosser, Sandralee; Bratton, Susan L.; Childress, James F.; et al. (2010): The circulatory-respiratory determination of death in organ donation. Critical Care Medicine 38(3): 963—970.
  • Zorko, David J.; Shemie, Sam D.; Hornby, Laura; et al. (2023): Autoresuscitation after circulatory arrest: an updated systematic review. Canadian Journal of Anesthesia 70(4): 699—712.

NRP and Potential DDR Violation

  • Truog, Robert D. (2024): In Defense of Normothermic Regional Perfusion. Hastings Center Report 54(4): 24—31.
  • Manara, Alex et al. (2020): Maintaining the permanence principle for death during in situ normothermic regional perfusion for donation after circulatory death organ recovery: A United Kingdom and Canadian proposal. American Journal of Transplantation 20(8): 2017—2025.
  • Murphy, Nicholas B.; Slessarev, Marat; Basmaji, John; Blackstock, Lucia; Blaszak, Marlena; Brahmania, Mayur; Chandler, Jennifer A.; Dhanani, Sonny; Gaulton, Maya; Gross, Jeffrey A.; Healey, Andrew; Lingard, Lorelei; Ott, Michael; Shemie, Sam D.; Weijer, Charles (2025): Ethical Issues in Normothermic Regional Perfusion in Controlled Organ Donation After Determination of Death by Circulatory Criteria: A Scoping Review. Transplantation 109(4): 597—609.

Magisterial Support for the Position

  • Pius XII (1957): Le Dr. Bruno Haid — Address of 24 November 1957. AAS 49: 1027—1033.
  • Benedict XVI (2008): Address to the International Congress on Organ Donation, Rome, 7 November 2008.

Guidelines

See also

Graphansicht

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