Was den Menschen zum Menschen macht

Normothermic Regional Perfusion

7 Min. Lesezeit

🇩🇪 Deutsche Version: Normotherme Regionale Perfusion (NRP)

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).

Normothermic regional perfusion (NRP) is a procedure used within the framework of donation after circulatory death. After determined permanent circulatory arrest, oxygen-rich blood is circulated again in the donor organism by means of ECMO (extracorporeal membrane oxygenation). The aim is to improve organ quality and to make it possible to assess organ function before retrieval.

NRP is internationally controversial. The position maintained here assigns it to the class of ethically critical medical practices: the restoration of circulation immediately annuls the condition on which the determination of death precisely still rests (no circulating blood). Whoever takes permanence as a sufficient condition for death and then nevertheless allows circulation gives up their own definition at the wrong time.

Thoracoabdominal NRP (TA-NRP)

In the thoracoabdominal variant, circulation is restored in the chest and abdominal organs, while the supra-aortic arteries — the vessels of the aortic arch that supply the brain — are surgically clamped to prevent the return of cerebral perfusion.

In substance-ontological terms, TA-NRP is especially critical. The necessity of the clamping presupposes that cerebral perfusion would otherwise return. But whoever would otherwise return was, at the moment of the clamping, not definitively gone. The clamping then appears as causally death-producing — and thus as a direct violation of the Dead Donor Rule and the Personalist Norm: the person is made the means of organ procurement, its killing the precondition of the donation.

A porcine study from 2022 showed empirically that the clamping does indeed prevent the return of cerebral activity. Proponents count this as a technical solution of the problem; critics counter that the ethical problem is thereby not removed from the world, but only its empirical presupposition confirmed: without clamping, cerebral perfusion would return.

Ontological classification

Superordinate concepts: Critical medical practice

Ontological relations:

Chapter assignment: Chapter 5: Oblivion of the Person (German), Chapter 4: Personhood (German)

International discourse

Proponents — Robert D. Truog (Hastings Center Report 2024, In Defense of Normothermic Regional Perfusion) defends NRP with the argument that after determined permanence no living subject any longer exists to whom a harm could be done. The reperfusion does not annul the permanence, because the will not to resuscitate again remains normatively binding.

Critics — James L. Bernat and Thaddeus M. Pope have, in several contributions since 2010, disputed the coherence of this interpretation: permanence is performatively annulled by the NRP, because the criterion of its determination (no circulating blood) is precisely violated by the NRP action (circulating blood). In TA-NRP the objection sharpens into a DDR violation.

Practical consequence — the United Kingdom (NHS Blood and Transplant) paused the TA-NRP practice at the end of 2020 out of precisely this concern. Other countries (Spain, USA, Belgium, the Netherlands) continue it.

Substance-ontological assessment

The ontology adopts a two-stage position:

First stage (donation after circulatory death in general): Already the practice of donation after circulatory death as a whole potentially violates the Dead Donor Rule and the Personalist Norm — because it bases its determination of death on permanence, which is substance-ontologically not sufficient for certain death. NRP is therefore not a special problem within an otherwise unproblematic practice, but a sharpening of an already substance-ontologically questionable procedure.

Second stage (NRP in addition): NRP sharpens the problem: it performatively annuls permanence, because it negates the condition of the determination of death (no circulating blood) through its action (circulating blood). NRP is thereby a second, independent violation — beyond the basic problem of donation after circulatory death.

Third stage (TA-NRP in addition): TA-NRP adds the causal killing action (aortic-arch clamping). It is thereby a direct (not merely potential) violation of the Dead Donor Rule and the Personalist Norm.

There is therefore no “unproblematic” variant of donation after circulatory death. Even controlled donation after circulatory death without NRP, with the observed five-minute rule, rests on a positing of permanence that does not hold substance-ontologically. The precautionary principle of Benedict XVI demands in this situation the stricter condition: not permanence, but irreversibility.

Sources

Sources: Generated by querying the Personhood ontology.

Defense of NRP

Critique and the justification gap

  • Bernat, James L. (2013): Controversies in defining and determining death in critical care. Nature Reviews Neurology 9(3): 164—173.
  • Joffe, Ari R.; Carcillo, Joseph; Anton, Natalie; deCaen, Allan; Han, Yong Y.; Bell, Michael J.; Maffei, Frank A.; Sullivan, John; Thomas, James; Garcia-Guerra, Gonzalo (2011): Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent. Philosophy, Ethics, and Humanities in Medicine 6: 17.
  • DeVita, Michael A.; Snyder, James V.; Grenvik, Ake (1993): History of organ donation by patients with cardiac death. Kennedy Institute of Ethics Journal 3(2): 113—129.

Thoracoabdominal NRP (TA-NRP)

  • Wang, Jasmine K.; Lopez, Diego N.; Roselli, Eric E.; Toth, Andrew J.; Joh, Anaelica; Insler, Steven R.; et al. (2025): Thoracoabdominal normothermic regional perfusion — approaches to arch vessels and options of cannulation. Annals of Cardiothoracic Surgery. https://pmc.ncbi.nlm.nih.gov/articles/PMC11811573/
  • Royo-Villanova, Mario; Miñambres, Eduardo; Pérez-Redondo, Marina; Coll, Elisabeth; Manso, Carlos; Domínguez-Gil, Beatriz (2024): Maintaining the permanence principle of death during normothermic regional perfusion in controlled donation after the circulatory determination of death: Results of a prospective clinical study. American Journal of Transplantation 24(2): 213—221. Clinical study on aortic-arch clamping.
  • Dalsgaard, Frederik F.; Moeslund, Niels; Zhang, Zhi-Long; Pedersen, Michael; Hjortdal, Vibeke E.; Erasmus, Michiel E.; Royo-Villanova, Mario (2022): Clamping of the Aortic Arch Vessels During Normothermic Regional Perfusion After Circulatory Death Prevents the Return of Brain Activity in a Porcine Model. Transplantation 106(9): 1763—1769. https://pubmed.ncbi.nlm.nih.gov/35066546/
  • 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. UK position on the TA-NRP pause.

Systematic reviews and guidelines

Pediatric application and ELPAT position

See also

Graphansicht

Backlinks