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On the ethical permissibility of in situ reperfusion in cardiac transplantation after the declaration of circulatory death
  1. Karola Veronika Kreitmair
  1. Medical History and Bioethics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
  1. Correspondence to Professor Karola Veronika Kreitmair, Medical History and Bioethics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA; kreitmair{at}


Transplant surgeons in the USA have begun performing a novel organ procurement protocol in the setting of circulatory death. Unlike traditional donation after circulatory death (DCD) protocols, in situ normothermic perfusion DCD involves reperfusing organs, including the heart, while still contained in the donor body. Some commentators, including the American College of Physicians, have claimed that in situ reperfusion after circulatory death violates the widely accepted Dead Donor Rule (DDR) and conclude that in situ reperfusion is ethically impermissible. In this paper I argue that, in terms of respecting the DDR, in situ reperfusion cardiac transplantation does not differ from traditional DCD cardiac transplantation. I do this by introducing and defending a refined conception of circulatory death, namely vegetative state function permanentism. I also argue against the controversial brain occlusion feature of the in situ reperfusion DCD protocol, on the basis that it is ethically unnecessary and generates the problematic appearance of ethical dubiousness.

  • Death
  • Ethics- Medical
  • Philosophy
  • Transplantation

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  • Presented at An initial version of this paper was presented at the 2022 annual American Society for Bioethics and Humanities (ASBH) meeting in Portland, Oregon.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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