Donating Hearts after Cardiac Death — Reversing the Irreversible

Organ Donation after Cardiac DeathIn this issue of the Journal, Boucek et al. (pages 709–714) report on three cases of heart transplantation from infants who were pronounced dead on the basis of cardiac criteria. The three Perspective articles and a video roundtable discussion at www.nejm.org address key ethical aspects of organ donation after cardiac death. Bernat and Veatch comment on the cases described by Boucek et al.; Truog and Miller raise a fundamental question about the dead donor rule. In a related Perspective roundtable, moderator Atul Gawande, of Harvard Medical School, is joined by George Annas, of the Boston University School of Public Health; Arthur Caplan, of the University of Pennsylvania; and Robert Truog. Watch the roundtable online at www.nejm.org.Once, all transplantable organs were procured after a donor's heart had stopped irreversibly. Assuming that one accepted the dead donor rule, irreversible heart stoppage triggered organ procurement. Around 1970, the law gradually began to accept the declaration of death on the basis of irreversible loss of brain function. Today, physicians in all U.S. states may pronounce death and procure organs when brain function is determined to be permanently lost. Nevertheless, the more traditional heart-based pronouncement is accepted as an alternative.The application of either brain- or heart-based criteria for pronouncing death is somewhat more complicated for infants and small children. . . .