The dead donor rule.

Although living persons donate kidneys, cadaveric donors are the main source of solid organs for transplantation. Yet cadaveric donations have never been sufficient to meet the needs of persons with end-stage organ disease. One factor among many that limits the availability of cadaveric organs is the dead donor rule--the ethical and legal rule that requires that donors not be killed in order to obtain their organs. Laws and norms against homicide forbid killings done for any purpose, including killings done to obtain organs to save the life of others. These laws and norms apply even if the person is unconscious, extremely debilitated, or very near death. The effect is to create the dead donor rule--the rule that states that organ retrieval itself cannot cause death. Removal of organs necessary for life prior to demise would violate the dead donor rule regardless of the condition or consent of the donor because removal of those organs would kill the donor. Removal of nonvital organs prior to death would not violate the rule, though it would implicate other laws and ethical norms. Laws and norms against killing are most clearly applicable when the person killed has not consented to the killing. But they also apply when a person requests death, whether to avoid suffering or to provide organs for transplant. The dead donor rule would thus prevent a person from committing suicide in order to provide organs to his family or others. In the short run the rule is deontologic rather than utilitarian, for it prevents the killing of one person for organs that would save the three or more lives that can be saved by a single cadaveric donor. The dead donor rule is a center piece of the social order's commitment to respect for persons and human life. It is also the ethical linchpin of a voluntary system of organ donation, and helps maintain public trust in the organ procurement system. Although it is possible that some changes in the dead donor rule could be adopted without a major reduction in protection of persons and public trust, changes in the rule should be measured by their effect on both those functions. Several recent proposals to increase the supply of cadaveric organs would create exceptions to the dead donor rule to allow donation when the donor lacks an upper brain and will imminently die (anencephalic infants) or will be executed (death row prisoners).[1] These proposals do not challenge the rule's core function of protecting persons against unwanted demise. They do not, for example, propose a "survival lottery" in which persons are picked by chance to be killed to provide organs to several others.[2] Nor would they permit competent persons to choose suicide by organ retrieval in order to save others. Instead, they would modify the rule at the margins of human life. Proposals to permit donation from anencephalic infants or condemned prisoners aim to maintain respect for the core values underlying the dead donor rule while concluding that the benefits of relaxing the rule in these marginal cases outweigh the loss in respect for life and trust in the transplant system that might result. In contrast, proposals to retrieve organs from non-heart-beating donors claim to respect the dead donor rule as such by permitting organ retrieval only after the donor has been pronounced dead on cardiopulmonary grounds. Ethical controversy arises there, however, because uncertainties in determining cardiopulmonary death create a risk that the donor will not be dead when organ retrieval occurs, but will die as a result of the retrieval itself. A closely related question concerns whether it is ethically acceptable for physicians to implement proposals that violate the dead donor rule in these marginal cases. From the time of Hippocrates, codes of medical ethics have condemned killing by physicians. This tradition continues strongly today in medical, ethical, and legal opposition to active euthanasia, physician-assisted suicide, and the participation of physicians in capital punishment and torture. …