Was den Menschen zum Menschen macht

Permanence

5 Min. Lesezeit

🇩🇪 Deutsche Version: Permanenz und Irreversibilität

Permanence and irreversibility are two different strengths of the non-return of a state. The distinction is decisive for the definition of death in transplantation medicine — especially for donation after circulatory death.

Permanence obtains when a state is not spontaneously reversible and no restorative measure is initiated. Permanence excludes return because no further intervention is made — not because an intervention would be anatomically impossible.

Irreversibility obtains when the reversal of a state is anatomically and physiologically excluded — regardless of whether an intervention is attempted.

The difference can be shown by an example: an asystole can be permanent five minutes after onset — because the treatment team has decided not to resuscitate — and at the same time not irreversible — because a resuscitation attempt would theoretically still have a chance. Permanence depends on the will, irreversibility on anatomy.

Application to DCD practice

International DCD practice bases the determination of death on permanence, not on irreversibility. 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. Empirically the interval is sufficient to exclude spontaneous return (see autoresuscitation): the longest documented case is at 4 minutes 20 seconds (Dhanani et al., NEJM 2021).

The permanence interpretation is defended by Bernat and Pope: a person who will not be resuscitated is not left behind — the normative will not to intervene any longer is medically and ethically binding. Truog (Hastings Center Report 2024) sharpens the argument: after determined permanence, no subject exists any longer.

Substance-ontological position: permanence does not suffice

From the substance-ontological position held here, permanence is not a sufficient criterion for certain death — that is, for the separation of body and spiritual substance, the end of the prote energeia. Sufficient would only be irreversibility: a state that can no longer be undone, not merely one in which intervention is no longer made.

The reason is not clinical-empirical, but ontological: what is permanent can — in principle — still be reversible if an intervention were made. NRP practice shows this empirically: it restores circulation that, by the permanence definition, “does not return.” Precisely this empirical evidence undermines the claim that permanence and certain death can be identified.

Consequence: a practice that bases its determination of death on permanence and removes organs on that basis — such as DCD practice — undermines the precondition of the Dead Donor Rule and potentially violates the Personalist Norm.

Benedict XVI’s precautionary principle is the normative answer to this ontological situation: where it is not clear whether the person is definitively dead, the stricter condition holds. The ontology records the assessment “potentially violates” for DCD practice, not “definitively violates” — because the ontological question is not epistemically closed, but the precautionary principle requires adopting the stricter interpretation in case of doubt.

Ontological classification

Superordinate concepts: State of Affairs, concept

Ontological relations:

Chapter assignment: Chapter 4: What Is Human Personhood? (German)

Sources

Sources: Generated by querying the Personhood ontology.

Further sources:

Conceptual differentiation permanence/irreversibility

  • Bernat, James L.; Capron, Alexander M.; Bleck, Thomas P.; et al. (2010): The circulatory-respiratory determination of death in organ donation. Critical Care Medicine 38(3): 963—970. Standard article on the permanence interpretation.
  • Bernat, James L. (2010): How the distinction between “irreversible” and “permanent” illuminates circulatory-respiratory death determination. Journal of Medicine and Philosophy 35(3): 242—255. Conceptual clarification.
  • Marquis, Don (2010): Are DCD donors dead? Hastings Center Report 40(3): 24—31. Critical position on the permanence interpretation.

Empirical basis of the five-minute 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. First systematic review.
  • 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. Updated data.
  • Hornby, Laura; Dhanani, Sonny; Shemie, Sam D. (2018): Update of a systematic review of autoresuscitation after cardiac arrest. Critical Care Medicine 46(3): e268—e272.

Substance-ontological position

  • Shewmon, D. Alan (2001): The brain and somatic integration: insights into the standard biological rationale for equating “brain death” with death. Journal of Medicine and Philosophy 26(5): 457—478.
  • Bexten, Raphael E. (2017): Was ist menschliches Personsein? Eichstätt-Ingolstadt, doctoral dissertation. Certain death as an ontological, not clinical, event.

Magisterial support

See also

Generated by querying the Personhood ontology.

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