80 | CO NTRO VERSIES IN THE D ETERMINATIO N O F D EATH

A key challenge to procuring organs from non-heart-beating cadav-

ers is posed by warm ischemic damage, caused by the lack of blood
perfusion while the organs are still in the body of the newly de-
ceased donor. To prevent or limit this damage, the time between
the cessation of circulation (“effective asystole”) and the procure-
ment of organs must be minimized. For this purpose, the final
cardiac contractions must be controlled: In the moments following
asystole, the body must be prepared for surgeons either to remove
the organs promptly or to maintain their viability for transplantation
in the ensuing hours. For the moment of cardiac arrest to be con-
trolled in this way, the prospective organ donor must be a patient
from whom a ventilator and perhaps other forms of life-sustaining
treatment will be withdrawn, either in accordance with the patient’s
wishes or the wishes of a surrogate. In other words, a potential non-
heart-beating donor, in the vast majority of cases, is an individual
who is ventilator-dependent but not yet deceased according to to-
day’s neurological standard.* The ventilator is then removed, the
patient is watched and kept comfortable until the heart stops circu-
lating blood through the body, a waiting period is observed (usually
two to five minutes), and then the surgical procurement of organs
begins.

Procuring organs in this way was very rare until the early 1990s— in
most transplant centers throughout the United States, only heart-

Intensive C are M ed 18, no. 4 (2003): 189-97. In addition to kidney transplantations

from such cadavers in the 1950s and 1960s, the first liver transplantation in 1963
and the first heart transplant in 1967 were performed by taking the organ from a
patient after life-support had been removed and the patient had become asystolic.
* Many candidates for controlled D CD are patients who are “very close to brain

dead”— i.e., who are tested for total brain failure but show minimal signs of brain
function that are nonetheless sufficient to preclude such a diagnosis. There are
other candidates for controlled D CD , however, who are dependent on a life-
sustaining technology for reasons other than a traumatic brain injury, e.g., pa-
tients with a high-spinal cord injury or patients at the end-stage of a
neurodegenerative disease such as amyotrophic lateral sclerosis (ALS). For a case
study of a fully conscious patient who chose to become a controlled D CD donor
upon removal of the ventilator, see J. Spike, “Controlled NHBD Protocol for a
Fully Conscious Person: When D eath Is Intended as an End in Itself and It Has
Its O wn End,” J C lin E thics 11, no. 1 (2000): 73-7.
 CHAPTER SIX | 81

beating organ donors were used.* This restriction meant that some
individuals who had suffered accidents or injuries that left them
with little hope of recovery were not eligible to become donors,
even if a responsible decision to remove life-sustaining interven-
tions was made. In some cases, families who knew that their
relatives wanted to be donors in the event of an accident were dis-
appointed to find out that making this gift was not possible. This
fact— along with concerns about the general shortage of available
organs compared to the growing need among potential recipients—
led some pioneering institutions to develop and implement non-
heart-beating donor protocols.† These protocols codified the insti-
tutional practices for managing the withdrawal of treatment and for
optimizing the conditions for organ procurement. The early con-
trolled D CD protocols included both logistical procedures and
ethical safeguards.

The work of these first institutions raised concerns among some

ethicists, health care professionals, and members of the general
public. For the purposes of this report, these concerns can be di-
vided into two categories: concerns about the care of the dying
patient at the end of life, and concerns about initiating organ pro-
curement before the patient is dead. The second set of concerns is
treated at length in Part II of this chapter. Regarding the first set of
concerns, we shall address the principal points here while encourag-
ing the interested reader to consult the companion volume to this
white paper, O rgan T ransplantation: A n E thical Inquiry by the President’s
C ouncil on Bioethics; in Chapter Three of that report, the Council of-
fers a more thorough investigation of these concerns about care of
the dying patient in the context of organ transplantation.

* O ne exception is the University of Wisconsin Hospital, where controlled D CD

has been performed continuously since 1974. See J. Lewis, et al., “D evelopment
of the University of Wisconsin D onation after Cardiac D eath Evaluation Tool,”
Prog T ransplant 13, no. 4 (2003): 265-73.
† The first modern controlled D CD protocol was instituted at the University of

Pittsburgh Medical Center in 1992. For details, see M. A. D eVita, J. V. Snyder,

and A. G renvik, “History of O rgan D onation by Patients with Cardiac D eath,”
K ennedy Inst E thics J 3, no. 2 (1993): 113-29.