The Not-So-Tell-Tale Heart

To the Editor: Before using brain criteria, pronouncing death in humans was based on irreversible loss of something vaguely thought of as respiration or circulation or cardiac function. We have always known the loss had to be irreversible. We have also long known that "irreversible" was ambiguous. In his article ("Are DCD Donors Dead?" May-June 2010), Don Marquis captures this ambiguity when he contrasts irreversibility and permanence. Defenders of cardiocirculatory criteria have known that, in some cases, these functions physiologically could be reversed, but won't be because advance directives or surrogate refusal would make intervention illegal and immoral. When intervening is illegal and immoral, we claim the stoppage is "irreversible" because intervening is normatively impermissible. Marquis challenges this leap, insisting that "permanent" differs from "irreversible" and that stoppages that won't be reversed for normative reasons should be called permanent, but not irreversible.

I have long felt squeamish about calling such stoppages of the cardiocirculatory system "irreversible" (thus permitting organ procurement under the dead donor rule) but have endorsed the prevalent consensus justifying donation after cardiac death of all organs except the heart. The heart cannot be included because reversing heart stoppage would upset the fragile claim that cardiocirculatory function has been lost irreversibly. Contrary to Marquis, I suggested that, in the Boucek cases of successful transplant of pediatric hearts, the surrogates have not exactly refused resuscitation since they clearly have consented to the restarting of the infants' hearts (albeit after those hearts are removed from their original bodies).

Marquis's point is different. He rejects the normative use of the term "irreversible" and thus claims those who are the source of DCD organs are not dead regardless of whether hearts were restarted. If the heart has merely permanently, but not irreversibly, stopped, then, he claims, death has not occurred and no organs can be procured without violating the dead donor rule. My immediate concern is not the normative use of the concept of irreversibility, but the fact that cardiac function has actually been restored, thus making the permanence claim controversial.

The really interesting development is that cases such as Boucek's force even greater refinement of our views about whether and when people can be declared dead by cardiac or circulatory criteria. Assuming that what Marquis calls the normative use of irreversible can be defended (as most apparently still believe), we now must know much more precisely what it is that cannot (legally) be reversed.

Defenders of Boucek's procurements have claimed that the infants were really dead because circulation rather than heart function is critical. Boucek restored heart function but not circulation—at least not in those pronounced dead. If the circulatory part of cardiocirculatory function is really what is critical, then the restarting of the heart is as irrelevant as the restarting of the liver or kidneys following DCD. Thus, if objections to normative determinations of irreversibility can be overcome and circulation is definitive, Boucek's patients really are dead based on circulatory criteria. (That case still requires that we confirm the empirical claim that circulation was indeed irreversibly lost after the mere seventy-five seconds before pronouncing death. It also requires that we accept the slippery normative use of the term "irreversible.")

There is a problem, however. Others are simultaneously developing protocols for what is called "uncontrolled donation after cardiac death." Some of these protocols incorporate chest compressions or extracorporeal membrane oxygenation, which restore some elements of circulation following death pronouncement. They are defended as cases consistent with the dead donor rule because the individuals are deceased based on irreversible cardiac function loss, even though circulation is in some sense restored.

The problem becomes apparent even if Marquis's criticism of the normative use of "irreversibility" can be overcome. Some DCD protocols, such as Boucek's, pronounce death even though heart function will be restored. They do so on the grounds that circulation is what counts. Others pronounce death even though circulatory function will be restored, and do so on the grounds that cardiac function is what counts. Clearly, one cannot have it both ways.

Now the deeper problem is apparent: we have never before...