Medicine, Health Care and Philosophy

, Volume 16, Issue 3, pp 457–467

One or two types of death? Attitudes of health professionals towards brain death and donation after circulatory death in three countries

  • D. Rodríguez-Arias
  • J. C. Tortosa
  • C. J. Burant
  • P. Aubert
  • M. P. Aulisio
  • S. J. Youngner
Scientific Contribution


This study examined health professionals’ (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)—controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios—BD, uncontrolled DCD and controlled DCD—were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors’ loss of circulatory function could be reversed, and raises questions about “death” as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs’ discomfort must be further identified and addressed.


Attitude to death Tissue and organ procurement Ethics Attitude of health personnel Donation after circulatory death Brain death France Spain United States 


  1. Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. 1968. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA 205(6): 337–340.CrossRefGoogle Scholar
  2. Arnold, R.M., and S.J. Youngner. 1993. The dead donor rule: Should we stretch it, bend it, or abandon it? Kennedy Institute of Ethics Journal 3(2): 263–278.PubMedCrossRefGoogle Scholar
  3. Bernat, J.L. 2008. The boundaries of organ donation after circulatory death. New England Journal of Medicine 359(7): 669–671.PubMedCrossRefGoogle Scholar
  4. Bernat, J.L., C.M. Culver, and B. Gert. 1982. Defining death in theory and practice. The Hastings Center Report 12(1): 5–8.PubMedCrossRefGoogle Scholar
  5. Bernat, J.L., A.M. Capron, T.P. Bleck, S. Blosser, S.L. Bratton, J.F. Childress, et al. 2010. The circulatory-respiratory determination of death in organ donation. Critical Care Medicine 38(3): 963–970.PubMedCrossRefGoogle Scholar
  6. Borry, P., W. Van Reusel, L. Roels, and P. Schotsmans. 2008. Donation after uncontrolled cardiac death (uDCD): A review of the debate from a European perspective. The Journal of Law, Medicine & Ethics 36(4): 752–759, 610.Google Scholar
  7. Boucek, M.M., C. Mashburn, S.M. Dunn, R. Frizell, L. Edwards, B. Pietra, et al. 2008. Pediatric heart transplantation after declaration of cardiocirculatory death. New England Journal of Medicine 359(7): 709–714.PubMedCrossRefGoogle Scholar
  8. Cabrol, C. 2007. Prélèvements d’organes sur donneur à coeur arrêté. Académie Nationale de Médecine.Google Scholar
  9. Capron, A.M. 1999. The bifurcated legal standard for determining death: Does it work? In The definition of death: Contemporary controversies, ed. S.J. Youngner, R. Arnold, and R. Schapiro, 117–136. Baltimore: The Johns Hopkins University Press.Google Scholar
  10. Capron, A.M., and L.R. Kass. 1972. A statutory definition of the standards for determining human death: An appraisal and a proposal. University of Pennsylvania Law Review 121(87): 102–104.Google Scholar
  11. Council of Europe. 2009. International figures on donation and transplantation—2008. Newsletter Transplant 14(1): 26–29.Google Scholar
  12. D’Alessandro, A.M., J.W. Peltier, and J.E. Phelps. 2008. Understanding the antecedents of the acceptance of donation after cardiac death by healthcare professionals. Critical Care Medicine 36(4): 1075–1081.PubMedCrossRefGoogle Scholar
  13. Décret no. 2005-949 du 2 août .2005. Relatif aux conditions de prélèvement des organes, des tissus et des cellules et modifiant le livre II de la première partie du code de la santé publique (dispositions réglementaires), art. R1232-1. Journal Officiel de la République Française, 6 août 2005.Google Scholar
  14. DeVita, M.A., J.V. Snyder, and A. Grenvik. 1993. History of organ donation by patients with cardiac death. Kennedy Institute of Ethics Journal 3(2): 113–129.PubMedCrossRefGoogle Scholar
  15. Doig, C.J., and D.A. Zygun. 2008. (Uncontrolled) donation after cardiac determination of death: A note of caution. The Journal of Law, Medicine & Ethics 36(4): 760–765, 610.Google Scholar
  16. Esteban, A., F. Gordo, J.F. Solsona, I. Alia, J. Caballero, C. Bouza, et al. 2001. Withdrawing and withholding life support in the intensive care unit: A Spanish prospective multi-centre observational study. Intensive Care Medicine 27(11): 1744–1749.PubMedCrossRefGoogle Scholar
  17. Feinberg, J. 1985. The mistreatment of dead bodies. The Hastings Center Report 15(1): 31–37.PubMedCrossRefGoogle Scholar
  18. Ferrand, E., R. Robert, P. Ingrand, and F. Lemaire. 2001. Withholding and withdrawal of life support in intensive-care units in France: A prospective survey. French LATAREA Group. Lancet 357(9249): 9–14.PubMedCrossRefGoogle Scholar
  19. Fondevila, C., A.J. Hessheimer, A. Ruiz, D. Calatayud, J. Ferrer, R. Charco, et al. 2007. Liver transplant using donors after unexpected cardiac death: Novel preservation protocol and acceptance criteria. American Journal of Transplantation 7(7): 1849–1855.PubMedCrossRefGoogle Scholar
  20. Gardiner, D., and R. Sparrow. 2010. Not dead yet: Controlled non-heart-beating organ donation, consent, and the dead donor rule. Cambridge Quarterly of Healthcare Ethics 19(1): 17–26.PubMedCrossRefGoogle Scholar
  21. Glannon, W. 2011. Donation, death, and harm. The American Journal of Bioethics 11(8): 48–49.PubMedCrossRefGoogle Scholar
  22. Hester, D.M., and J. Green. 2011. It’s all about the brain. The American Journal of Bioethics 11(8): 44–45.PubMedCrossRefGoogle Scholar
  23. Hornby, K., L. Hornby, and S.D. Shemie. 2010. A systematic review of autoresuscitation after cardiac arrest. Critical Care Medicine 38(5): 1246–1253.PubMedGoogle Scholar
  24. Institute of Medicine. 1999. Non-heart-beating transplantation II: The scientific and ethical basis for practice and protocols. Washington, DC.Google Scholar
  25. Institute of Medicine. 2006. Opportunities for action. Washington, DC: National Academies Press.Google Scholar
  26. Joffe, A.R. 2007. The ethics of donation and transplantation: Are definitions of death being distorted for organ transplantation? Philosophy, Ethics, and Humanities in Medicine 2: 28.PubMedCrossRefGoogle Scholar
  27. Marquis, D. 2010. Are DCD donors dead? Hastings Center Report 40(3): 24–31.Google Scholar
  28. Matesanz, R. 1996. Documento de consenso español sobre extracción de órganos de donantes en asistolia. Nefrologia XVI(suppl. 2): 48–53.Google Scholar
  29. Mathur, M., S. Taylor, K. Tiras, M. Wilson, and S. Abd-Allah. 2008. Pediatric critical care nurses’ perceptions, knowledge, and attitudes regarding organ donation after cardiac death. Pediatric Critical Care Medicine 9(3): 261–269.PubMedCrossRefGoogle Scholar
  30. McMahan, J. 2006. An alternative to brain death. The Journal of Law, Medicine & Ethics 34(1): 44–48, 43.Google Scholar
  31. Menikoff, J. 1998. Doubts about death: The silence of the Institute of Medicine. The Journal of Law, Medicine & Ethics 26(2): 157–165.CrossRefGoogle Scholar
  32. Miller, F.G., R.D. Truog, and D.W. Brock. 2010. The dead donor rule: Can it withstand critical scrutiny? Journal of Medicine and Philosophy 35(3): 299–312.PubMedCrossRefGoogle Scholar
  33. Molina, A., D. Rodríguez-Arias, and S.J. Youngner. 2008. Should individuals choose their definition of death? Journal of Medical Ethics 34(9): 688–689.PubMedCrossRefGoogle Scholar
  34. Nelson, J.E., D.C. Angus, L.A. Weissfeld, K.A. Puntillo, M. Danis, D. Deal, et al. 2006. End-of-life care for the critically ill: A national intensive care unit survey. Critical Care Medicine 34(10): 2547–2553.PubMedGoogle Scholar
  35. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1981. Defining death: Medical, legal and ethical issues in the determination of death. Washington, DC: Government Printing Office.Google Scholar
  36. Rady, M.Y., J.L. Verheijde, and J. McGregor. 2008. Organ procurement after cardiocirculatory death: A critical analysis. Journal of Intensive Care Medicine 23(5): 303–312.PubMedCrossRefGoogle Scholar
  37. Rodriguez-Arias, D., L. Wright, and D. Paredes. 2010. Success factors and ethical challenges of the Spanish model of organ donation. Lancet 376(9746): 1109–1112.PubMedCrossRefGoogle Scholar
  38. Rodriguez-Arias, D., M.J. Smith, and N.M. Lazar. 2011. Donation after circulatory death: Burying the dead donor rule. The American Journal of Bioethics 11(8): 36–43.PubMedCrossRefGoogle Scholar
  39. Roels, L., B. Cohen, and C. Gachet. 2007. Countries’ donation performance in perspective: Time for more accurate comparative methodologies. American Journal of Transplantation 7(6): 1439–1441.PubMedCrossRefGoogle Scholar
  40. Shemie, S.D. 2007. Clarifying the paradigm for the ethics of donation and transplantation: Was ‘dead’ really so clear before organ donation? Philosophy, Ethics, and Humanities in Medicine 2: 18.PubMedCrossRefGoogle Scholar
  41. Shemie, S.D., A.J. Baker, G. Knoll, W. Wall, G. Rocker, D. Howes, et al. 2006. National recommendations for donation after cardiocirculatory death in Canada: Donation after cardiocirculatory death in Canada. CMAJ 175(8): S1.PubMedGoogle Scholar
  42. Shewmon, A.D., and E.S. Shewmon. 2004. The semiotics of death and its medical implications. In Brain death and disorders of consciousness. Proceedings of the IV international symposium on coma and death, held March 912, 2004, in Havana, Cuba, eds. C. Machado, and A.D. Shewmon, 89–114. New York: Kluwer/Plenum.Google Scholar
  43. Steinbrook, R. 2007. Organ donation after cardiac death. New England Journal of Medicine 357(3): 209–213.PubMedCrossRefGoogle Scholar
  44. UNOS. 2007. Annual report, OPTN data. Accessed 28 Nov 2011.
  45. UNOS. 2008. Annual report, OPTN data. Accessed 28 Nov 2011.
  46. Veatch, R.M. 1989. Death, dying and the biological revolution. New York: Yale University Press.Google Scholar
  47. Veatch, R.M. 2010. Transplanting hearts after death measured by cardiac criteria: The challenge to the dead donor rule. Journal of Medicine and Philosophy 35(3): 313–329.PubMedCrossRefGoogle Scholar
  48. Verheijde, J.L., M.Y. Rady, and J. McGregor. 2007. Recovery of transplantable organs after cardiac or circulatory death: Transforming the paradigm for the ethics of organ donation. Philosophy, Ethics, and Humanities in Medicine 2: 8.PubMedCrossRefGoogle Scholar
  49. Volk, M.L., G.J. Warren, R.R. Anspach, M.P. Couper, R.M. Merion, and P.A. Ubel. 2010. Attitudes of the American public toward organ donation after uncontrolled (sudden) cardiac death. American Journal of Transplantation 10(3): 675–680.PubMedCrossRefGoogle Scholar
  50. Wagner, H., C.J. Terkelsen, H. Friberg, J. Harnek, K. Kern, J.F. Lassen, et al. 2010. Cardiac arrest in the catheterisation laboratory: A 5-year experience of using mechanical chest compressions to facilitate PCI during prolonged resuscitation efforts. Resuscitation 81(4): 383–387.PubMedCrossRefGoogle Scholar
  51. Wall, S.P., B.J. Kaufman, A.J. Gilbert, Y. Yushkov, M. Goldstein, J.E. Rivera, et al. 2011. Derivation of the uncontrolled donation after circulatory determination of death protocol for New York City. American Journal of Transplantation 11(7): 1417–1426.PubMedCrossRefGoogle Scholar
  52. Youngner, S.J., C.S. Landefeld, C.J. Coulton, B.W. Juknialis, and M. Leary. 1989. ‘Brain death’ and organ retrieval. A cross-sectional survey of knowledge and concepts among health professionals. JAMA 261(15): 2205–2210.PubMedCrossRefGoogle Scholar
  53. Youngner, S.J., R.M. Arnold, and M.A. DeVita. 1999. When is “dead”? The Hastings Center Report 29(6): 14–21.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  • D. Rodríguez-Arias
    • 1
    • 3
  • J. C. Tortosa
    • 2
    • 3
  • C. J. Burant
    • 4
    • 5
  • P. Aubert
    • 6
    • 7
  • M. P. Aulisio
    • 6
  • S. J. Youngner
    • 6
  1. 1.Institute of Philosophy, CCHSSpanish National Research Council, CSICMadridSpain
  2. 2.Anesthésie RéanimationHôpital Saint CamilleBry sur MarneFrance
  3. 3.Laboratoire d’Éthique MédicaleUniversité Paris-DescartesParisFrance
  4. 4.Frances Payne Bolton School of NursingCase Western Reserve UniversityClevelandUSA
  5. 5.Geriatric Research, Education, and Clinical CenterLouis Stokes Cleveland VA Medical CenterClevelandUSA
  6. 6.Department of BioethicsCase Western Reserve UniversityClevelandUSA
  7. 7.National Institutes of HealthBethesdaUSA

Personalised recommendations