Defining Death: A Bioethical Examination of Donation by Circulatory Death (DCD) for Heart Transplantation

The definition of death carries significant implications that reach far beyond the boundaries of social convention and age-old traditions, particularly in the context of organ transplantation. Donation after circulatory death (DCD) determines death based on the permanent cessation of circulatory function, whereas donation after brain death (DBD) is established by the irreversible loss of all brain activity. Healthcare systems worldwide apply these criteria differently, reflecting ongoing efforts to expand donor eligibility and address the severe organ shortage caused by rising demand for transplantation. Normothermic regional perfusion (NRP), a recently developed technique used exclusively within DCD protocols, restores oxygenated blood flow after cardiac arrest to reverse ischemia and preserve organ viability. Its introduction has sparked considerable ethical debate, particularly over whether reinstating circulation risks violating core principles that prohibit organ procurement before death is definitively established. The persistence of these unresolved questions highlights longstanding ambiguities in how death is defined under DCD compared with DBD and challenges the ethical framework underlying heart transplantation. In an effort to shed light on this ongoing debate, this article examines the legal, ethical, and medical arguments both supporting and opposing the use of NRP in DCD heart procurement.