Determination of death in donation after circulatory death: an ethical propriety

The recently developed donation after circulatory death (DCD) heart transplant technique, pioneered by Papworth Hospital in the UK, involves the use of extra-corporeal perfusion technologies to restart the donor heart in situ and thereby restore the donor’s own circulation, after first isolating the donor’s cerebral circulation. By restoring the circulation in the deceased donor, even if the cerebral circulation is excluded, the Papworth technique challenges the acceptability of death determination in DCD. This paper uses as its exemplar case the Papworth DCD heart technique to review and make wider comment about death determination in DCD. We seek to answer three challenges to ethical propriety raised by the Papworth technique: 1) Death determination using the permanence standard (common to all DCD practice); 2) Restoration of heart contractility and circulation in the body; and 3) Active prevention of the restoration of brain circulation by use of a cross clamp to isolate the cerebral circulation. We conclude that the Papworth technique for heart DCD does not compromise the permanence standard for declaring death and therefore respects the dead donor rule in the UK, but perhaps elsewhere the law would need to change to refer to the cessation of circulation in the brain