Normothermic Regional Perfusion, Causes, and the Dead Donor Rule

This is the authors' abstract. We don't add key points for this paper.

The interpretation of the dead donor rule (DDR) has been central to recent debates regarding normothermic regional perfusion with controlled donation after circulatory death (NRP-cDCD). Proponents of NRPcDCD tend to understand the DDR as requiring that procurement occur only after the donor is dead. In contrast, those who believe that NRP-cDCD is morally impermissible argue that the DDR requires that procurement not cause the death of the donor. For example, in a recent exchange in CHEST, James et al. argued that: “for the purposes of organ donation, the DDR requires (1) that a patient must be declared dead before the procurement of vital organs for transplantation and (2) that the act of organ procurement cannot occur before the death of the patient” (James et al. 2022, 291). They suggest that NRP-cDCD is permissible because (among other reasons) both conditions are met. DeCamp et al. accuse them of “misapply[ing] basic ethical principles,” suggesting that the DDR requires “that organ procurement cannot cause death and that a patient’s death cannot be caused in organ procurement” (DeCamp, Snyder Sulmasy, and Fins 2022a, 292–293). Rather than defending the causal interpretation of the DDR, Nielsen Busch and Mjaaland rely on authorial authority to suggest that this is the appropriate definition. They argue, however, that NRP-cDCD is permissible even if we interpret the DDR as requiring that procurement not cause the death of the donor. In the case of standard cDCD, what causes the patient’s death is the “permanent loss of circulatory, respiratory, and brain function” from withdrawal of life sustaining treatment (Nielsen Busch and Mjaaland 2023, 9). Since this event precedes organ procurement, the organs are no longer necessary for life “because life will not persist” (Nielsen Busch and Mjaaland 2023, 9). Hence, procurement does not cause the donor’s death. However, in abdominal NRP there is an additional step beyond standard cDCD. Balloon occlusion of the aorta and/or ligation of the thoracic cavity circulatory supply prevents reperfusion of the heart, lungs, and brain. Nielsen Busch and Mjaaland argue that, for NRP-cDCD, the cause of death is still withdrawal of life sustaining treatment. NRP “merely ensures that the demise of the organism continues as it would have” (Nielsen Busch and Mjaaland 2023, 10). But to “merely ensure” is to add another step in the causal chain. In this case, what causes the donor to meet criteria for permanent loss of circulatory, respiratory, and brain function is vascular occlusion prior to procurement. More broadly, the causal interpretation of the DDR needs to be coupled with a theory of causation if it is to be coherent. Nielsen Busch and Mjaaland do not offer such a theory, perhaps understandably given the lack of consensuses on the metaphysics of causality. But take a standard counterfactual theory of what it is for c to cause e: