Was den Menschen zum Menschen macht

Donation after Circulatory Death

10 Min. Lesezeit

🇩🇪 Deutsche Version: Organspende nach Kreislaufstillstand

Note: The ethical judgments on this page refer exclusively to the action — never to the person who performs it. Every person possesses inalienable dignity, regardless of what they do or have done. Cf. Note on ethical judgments (German).

Donation after circulatory death (DCD) — in German-speaking countries also called Herz-Kreislauf-Spende — is a donation category in which the determination of death is bound to the final circulatory arrest of the donor. It thus stands as an alternative to donation after determined irreversible loss of brain function.

Internationally, DCD is established in many countries. In Europe, both controlled and uncontrolled DCD are practiced by Spain, France, Italy, the Netherlands, Belgium, Austria, the Czech Republic, and Switzerland; only controlled DCD by Ireland, Norway, Sweden, and the United Kingdom. Outside Europe, the USA, Canada, and Australia are established.

Spain (through the Organización Nacional de Trasplantes) runs the world’s largest uncontrolled DCD program; France launched its uncontrolled DCD program in 2006. Switzerland reintroduced DCD practice in 2011 — DCD heart donation was added as regular practice in 2023 and is currently performed in only nine countries worldwide (Australia, Belgium, Italy, the Netherlands, Austria, Spain, Switzerland, the USA, the United Kingdom).

In Germany, DCD is currently excluded under the Transplantation Act, since the law presupposes irreversible loss of brain function as the criterion of death.

Important: The legal establishment of DCD in a country does not mean that certain death in the substance-ontological sense is thereby determined beyond doubt. DCD is a clinical-legal stipulation on the basis of permanence, not an ontological identification of the moment of death with the separation of body and spiritual substance. DCD practice bases the determination of death on the concept of permanence: after observed asystole, a no-touch period of at least five minutes is observed — the five-minute observation — during which no resuscitation measure is carried out. Permanence (no further resuscitation attempt) is a weaker condition than irreversibility (anatomically impossible); whether it suffices for certain death is, in substance-ontological terms, not trivial and is answered within the precautionary principle.

The Maastricht classification

The internationally valid Maastricht classification (1995, in the Paris modification of 2013) distinguishes five donor categories:

  • Category I — Dead on arrival, no resuscitation attempt (uncontrolled).
  • Category II — Unsuccessful resuscitation of a circulatory arrest (uncontrolled; Spain’s uncontrolled DCD program is predominantly based on this category).
  • Category III — Expected circulatory arrest after planned withdrawal of treatment in the intensive care unit or operating room (controlled; the most frequent type worldwide).
  • Category IV — Circulatory arrest in a patient with already determined irreversible loss of brain function (controlled).
  • Category V — Unexpected circulatory arrest in the intensive care unit (uncontrolled; added in the 2013 Paris modification).

Ontological classification

Superordinate concepts: State of Affairs, donation category

Ontological relations:

Chapter assignment: Chapter 4: What Is Human Personhood? (German), Chapter 5: Oblivion of the Person (German)

Substance-ontological assessment

The ontology held here rejects the stipulation of DCD. The reason: permanence — the weaker condition on which DCD bases the determination of death — is in substance-ontological terms not a sufficient criterion for certain death (= separation of body and spiritual substance, end of the prote energeia). A practice that removes organs after permanent but not irreversible circulatory arrest undermines the precondition of the Dead Donor Rule and thereby potentially violates the Personalist Norm.

The assessment reads “potentially violates” and not definitively — because the ontological question of whether permanence suffices for certain death cannot be decided by empirical means. Precisely for this reason, Benedict XVI’s precautionary principle strictly demands, in this situation, the adoption of the stronger condition: “Where certainty has not been reached, the principle of precaution must prevail.”

Consequence for the DCD variants:

  • Controlled DCD (Maastricht III) — problematic under the precautionary principle; potentially violates the DDR and the Personalist Norm.
  • Uncontrolled DCD (Maastricht I, II, V) — epistemically somewhat less delicate (resuscitation exhausted), but this does not change the ontological question. Potentially violates the DDR and the Personalist Norm.
  • Maastricht category IV — additionally inherits the brain-death problem from the discussion of irreversible loss of brain function.
  • NRP — aggravates the problem: it performatively cancels permanence, because it negates the condition for determining death (no circulating blood) through its own action (circulating blood).
  • Thoracoabdominal NRP (TA-NRP) — an aggravated special case: the surgical clamping of the aortic arch vessels is causally death-producing if the person is not definitively dead. A direct (not merely potential) violation of the DDR and the Personalist Norm.

Clinically, DCD typically takes place in the intensive care unit during the terminal or dying phase — after a decision to withdraw treatment (WLST, cf. phases of dying). Within the spectrum of places of dying (hospice, hospital, intensive care unit, home), DCD is the ICU variant of a practice that links dying with organ procurement — and is therefore substance-ontologically critical.

Asymmetry paired / unpaired: the heart as the sharpest point

The DCD problem is not the same for all organs. From the medical classification (cf. living organ donation) an ethical asymmetry follows:

Organ typeExamplesLiving donation possible?DCD assessment
Pairedkidney, lungyes, low riskDCD avoidable — living donation is the less problematic alternative
Divisibleliver, pancreasyes, higher riskDCD partly avoidable
Strictly unpairedheart, whole livernoDCD structurally unavoidable — the permanence tension becomes maximal

John Paul II made this differentiation explicit in his magisterial address of 2000 before the 18th International Congress of the Transplantation Society (Rome):

“Vital organs which occur singly in the body can be removed only after death, that is from the body of someone who is certainly dead. This requirement is self-evident, since to act otherwise would mean intentionally to cause the death of the donor in disposing of his organs.”

From this it follows for the DCD discussion: in paired donation (kidney, lung), living donation is the ethically less problematic path — permissible under the principle of totality (Pius XII, 1956), without DDR tension. In strictly unpaired donation — especially of the heart — living donation is structurally impossible. The entire ethical burden thus falls on the permanence stipulation of postmortem donation. Donation of the heart after circulatory death, introduced as regular practice in Switzerland in 2023 and already established in the USA in 2025 with 24 percent of heart donations, is therefore the paradigmatically problematic case of the entire DCD discussion.

In substance-ontological terms: the violation of permanence acts more sharply where the practice has no alternative. The asymmetry is not merely descriptive, but normative.

The United Kingdom paused TA-NRP at the end of 2020 out of this concern. The position held here goes further: not only TA-NRP, but the stipulation of DCD as a whole is, in the substance-ontological sense, untenable as long as permanence rather than irreversibility is made the basis of the determination of death.

International discourse

Robert D. Truog (Hastings Center Report 2024) defends NRP with the argument that after determined permanence there no longer exists a living subject to whom harm could be done. James L. Bernat and Thaddeus M. Pope counter that the restoration of circulation cancels exactly the condition on which the determination of death had just rested — a performative undoing of death a few minutes after its determination.

The empirical basis of the five-minute rule is the study by Dhanani et al. (NEJM 2021; systematic review CJA 2023): the longest documented case of a spontaneous return of cardiocirculatory function — of autoresuscitation — is at 4 minutes 20 seconds. Five minutes are thus empirically sufficient to exclude spontaneous return, without answering the stronger question of irreversibility.

Benedict XVI formulates the precautionary principle in his address before the International Congress on Organ Donation (Rome, 7 November 2008): where certainty has not been reached in the determination of death, the principle of precaution must prevail. The statement goes back to Pius XII (1957, address to anesthesiologists): death must be determined before organ removal; the definition of the moment of death is a matter for medicine within the limits of natural morality.

Organ donation itself is, according to Catholic teaching, legitimate and potentially meritorious as a sign of love and free self-giving — bound solely to the safeguarding of the donor’s dignity.

Sources

Sources: Generated by querying the Personhood ontology.

Further sources:

Maastricht classification and DCD practice

  • Thuong, Maud; Ruiz, Angel; Evrard, Patrick; Kuiper, Mike; Boffa, Catherine; Akhtar, Mohammed Z.; Neuberger, James; Ploeg, Rutger (2016): New classification of donation after circulatory death donors definitions and terminology. Transplant International 29(7): 749—759. Paris modification of the Maastricht classification.
  • Domínguez-Gil, Beatriz; Duranteau, Jacques; Mateos, Antonio; Núñez, Jose Ramón; Cheisson, Gaëlle; Corral, Esther; De Jongh, Walter; Antoine, Corinne; Pleskovic, Aljosa; Haase-Kromwijk, Bernadette; Procaccio, Francesco (2016): Uncontrolled donation after circulatory death: European practices and recommendations for the development and optimization of an effective programme. Transplant International 29(8): 842—859.
  • NHS Blood and Transplant: Donation after circulatory death. https://www.odt.nhs.uk/deceased-donation/best-practice-guidance/donation-after-circulatory-death/
  • Swisstransplant: Donation after Circulatory Determination of Death.

Permanence, autoresuscitation, Dead Donor Rule

  • Dhanani, Sonny; Hornby, Laura; Ward, Roxanne; et al. (2021): Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures. New England Journal of Medicine 384(4): 345—352. Source of the longest documented autoresuscitation interval.
  • Hornby, Karen; Hornby, Laura; Shemie, Sam D. (2010): A systematic review of autoresuscitation after cardiac arrest. Critical Care Medicine 38(5): 1246—1253.
  • 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.
  • Bernat, James L. (2013): Controversies in defining and determining death in critical care. Nature Reviews Neurology 9(3): 164—173.

International practice

  • Lomero, Mar; Gardiner, Dale; Coll, Elisabeth; Haase-Kromwijk, Bernadette; Procaccio, Francesco; Immer, Franz; et al. (2020): Donation after circulatory death today: an updated overview of the European landscape. Transplant International 33(1): 76—88.
  • Immer, Franz F. (2015): Organ donation after circulatory death in Switzerland: slow but constant progress. Swiss Medical Weekly 145: w14062.
  • Ruiz, Angel (2018): Uncontrolled DCD: The Spanish Experience.
  • Antoine, Corinne; Mourey, Frédéric; Prada-Bordenave, Emmanuelle; Steering committee on DCD program (2014): How France launched its donation after cardiac death program. Annales Françaises d’Anesthésie et de Réanimation 33(2): 138—143.
  • Foss, Stein; Nordheim, Espen; Sørensen, Dag W.; et al. (2018): First Scandinavian Protocol for Controlled Donation After Circulatory Death Using Normothermic Regional Perfusion. Transplantation Direct 4(7): e366.
  • Joshi, Yashutosh; Wang, Katherine; MacLean, Campbell; et al. (2024): The Rapidly Evolving Landscape of DCD Heart Transplantation. Current Cardiology Reports 26: 1499—1507.
  • Global Observatory on Donation and Transplantation (GODT): International Report on Organ Donation and Transplantation Activities, Executive Summary 2023.

Catholic position

NRP ethics

  • Truog, Robert D. (2024): In Defense of Normothermic Regional Perfusion. Hastings Center Report 54(4): 24—31.
  • Murphy, Nicholas B.; Slessarev, Marat; Basmaji, John; et al. (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.

See also

Generated by querying the Personhood ontology.

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