The global shortage of organs for transplantation and the development of new and better medical technologies for organ preservation have resulted in a renewed interest in non-heart-beating donation (NHBD). This article discusses ethical questions related to controlled and uncontrolled NHBD. It argues that certain preparative measures, such as giving anticoagulants, should be acceptable before patients are dead, but when they have passed a point where further curative treatment is futile, they are in the process of dying and they are unconscious. Furthermore, the article discusses consequences of technological developments based on improvement of a chest compression apparatus used today to make mechanical heart resuscitation. Such technological development can be used to transform cases of non-controlled NHBD to controlled NHBD. In our view, this is a step forward since the ethical difficulties related to controlled NHBD are easier to solve than those related to non-controlled NHBD. However, such technological developments also evoke other ethical questions.
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↵i It should also be noted that a brain-stem concept of death is used in the United Kingdom.
↵ii During hypothermia, the human brain is able to withstand much longer periods of circulation arrest. See for example Litasova et al.20
↵iii Since most (but not all) countries have accepted the whole-brain death definition as the legally valid definition, we will allow ourselves not to discuss death definitions in this article. Furthermore, we will argue as if the whole-brain death definition was the legally accepted version. See21 for a death declaration law that accepts not only the whole-brain death definition as legal, but also the traditional heart-lung death definition.
↵iv If one holds the view that all the functions of the entire brain, including the brain stem, should be irreversibly lost, this may result in a longer necessary time-span than if one holds the view that it is the irreversible loss of higher brain functions that matters. A higher-brain-death definition implies that death is defined as the irreversible loss of higher cognitive functions.
↵v Obviously, if the patient is conscious, the rules of informed consent apply.
↵vi In a recent EU opinion poll, a majority of the Swedish population (74%) stated that they would like to donate their own organs after death.22
↵vii One more ethical argument can support our view of the acceptability of organ-preserving treatment after the point of no return. The doctrine of double effect can be applied to this specific scenario. Even though giving a large amount of heparin could cause further haemorrhage in patients with brain injuries and thereby hasten death, this act meets the requirements of the double effect principle. The act is performed for the sake of something good: to ensure fulfilment of the patients’ wishes. The intention is not to hasten the patient’s death. Furthermore, the risk of death due to heparin is not a means to achieve organ viability. And, the patient is already in the process of dying.
↵viii However, it should also be noted that this lung was first rejected as non-acceptable by the Scandinavian transplant centres; later it was accepted for transplantation.
↵ix Of course, it could be argued that this is an expensive way of obtaining organs for donation and that living organ donation, as one example, is much less expensive. This, however, presumes that there are living organ donors that want to donate organs. This is not always the case.
Competing interests: None.
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