The permanence thesis is the position that permanence is sufficient as a surrogate indicator for irreversibility — because it immediately and inevitably precedes it. The thesis underpins the international practice of donation after circulatory death and is the counter-position to the irreversibility thesis.
Proponents
- James L. Bernat — the canonical source: “How the Distinction between Irreversible and Permanent Illuminates Circulatory-Respiratory Death Determination” (Journal of Medicine and Philosophy 35, 2010, pp. 242—255). Deepened in “Conceptual Issues in DCDD Donor Death Determination” (Hastings Center Report 48 Suppl 4, 2018).
- David M. Greer and the World Brain Death Project — Greer et al. (JAMA 324, 2020, pp. 1078—1097) use the formulation “permanent loss of function with no possibility of recovery” — a shift away from “irreversible.”
- Dale Gardiner and Andrew McGee — “Permanent: The UDDA Revision Series” (Neurology 2023) — a defense of the switch to permanence at the legal level.
- Swiss Academy of Medical Sciences (SAMW) — 2025 consultation on the revision of the guidelines “Determination of death with regard to organ transplantation”: for the first time in a national guideline, the explicit proposal to replace “irreversible” with “permanent.”
The argument
Bernat’s key distinction: “irreversible” means “cannot reverse” (anatomically-physiologically impossible), “permanent” means “will not reverse” (no attempt is made). The thesis claims that permanence is a “perfect surrogate indicator” for irreversibility — because after the onset of permanence, irreversibility follows anyway within a few minutes.
Practical scope
The permanence thesis is not merely a theoretical position — it is the normative basis of international DCD practice. The five-minute observation after asystole operationalizes exactly the permanence stipulation: after five minutes without a resuscitation attempt, the circulatory arrest is taken to be permanent — and on this basis death is determined and organ removal begun.
Empirical challenge: NRP
Normothermic regional perfusion (NRP) shows empirically that circulation can be restored after determined permanence — which exposes permanence as a purely performative stipulation (see performative permanence). Truog/Miller and Omelianchuk argue: if reactivation is possible, the state was not irreversible — and the Dead Donor Rule is violated.
Position of the ontology
The present ontology problematizes the permanence thesis in light of the precautionary principle. Where permanence is performatively reversible (NRP, aortic-arch clamping in TA-NRP), only a weak form of non-return obtains — in substance-ontological terms not sufficient for identification with certain death. The ontology records the assessment “problematic under the precautionary principle” for the permanence thesis.
Ontological classification
Superordinate class: Position
Counter-position: Irreversibility Thesis
Connected with: Permanence, Performative Permanence, Five-Minute Observation, Donation after Circulatory Death, Precautionary Principle
Sources: Generated by querying the Personhood ontology.
Further sources:
- 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.
- Bernat, James L. (2018): Conceptual Issues in DCDD Donor Death Determination. Hastings Center Report 48 Suppl 4: S26—S28.
- Greer, David M. et al. (2020): Determination of Brain Death/Death by Neurologic Criteria. The World Brain Death Project. JAMA 324(11): 1078—1097.
- McGee, Andrew & Gardiner, Dale (2023): Should the Criterion for Brain Death Require Irreversible or Permanent Cessation of Function? Permanent: The UDDA Revision Series. Neurology 101(4): 184—186.
- Swiss Academy of Medical Sciences (SAMW) (2025): Determination of death with regard to organ transplantation — consultation version.
Generated by querying the Personhood ontology.