Theoretical Medicine and Bioethics

, Volume 39, Issue 1, pp 1–25 | Cite as

How (not) to think of the ‘dead-donor’ rule

  • Adam OmelianchukEmail author


Although much has been written on the dead-donor rule (DDR) in the last twenty-five years, scant attention has been paid to how it should be formulated, what its rationale is, and why it was accepted. The DDR can be formulated in terms of either a Don’t Kill rule or a Death Requirement, the former being historically rooted in absolutist ethics and the latter in a prudential policy aimed at securing trust in the transplant enterprise. I contend that the moral core of the rule is the Don’t Kill rule, not the Death Requirement. This, I show, is how the DDR was understood by the transplanters of the 1960s, who sought to conform their practices to their ethics—unlike today’s critics of the DDR, who rethink their ethics in a question-begging fashion to accommodate their practices. A better discussion of the ethics of killing is needed to move the debate forward.


Transplant ethics Dead donor rule Killing Organ donation 


  1. 1.
    Anscombe, G.E.M. 1958. Modern moral philosophy. Philosophy 33: 1–19.CrossRefGoogle Scholar
  2. 2.
    Chaten, Frank. 2014. The dead donor rule: Effect on the virtuous practice of medicine. Journal of Medical Ethics 40: 496–500.CrossRefGoogle Scholar
  3. 3.
    Miller, Franklin G., and Robert D. Truog. 2008. Rethinking the ethics of vital organ donations. Hastings Center Report 38: 38–46.CrossRefGoogle Scholar
  4. 4.
    Fost, Norman. 2004. Reconsidering the dead donor rule: Is it important that organ donors be dead? Kennedy Institute of Ethics Journal 14: 249–260.CrossRefGoogle Scholar
  5. 5.
    Bernat, James L. 2008. The boundaries of organ donation after circulatory death. New England Journal of Medicine 359: 669–671.CrossRefGoogle Scholar
  6. 6.
    Coons, Christian, and Noah Levin. 2011. The dead donor rule, voluntary active euthanasia, and capital punishment. Bioethics 25: 236–243.CrossRefGoogle Scholar
  7. 7.
    Koppelman, Elysa R. 2003. The dead donor rule and the concept of death: Severing the ties that bind them. American Journal of Bioethics 3: 1–9.CrossRefGoogle Scholar
  8. 8.
    Robertson, John A. 1999. Delimiting the donor: The dead donor rule. Hastings Center Report 6: 6–14.Google Scholar
  9. 9.
    Rodríguez-Arias, David, Maxwell J. Smith, and Neil M. Lazar. 2011. Donation after circulatory death: Burying the dead donor rule. American Journal of Bioethics 11: 36–43.CrossRefGoogle Scholar
  10. 10.
    Bernat, James L. 2013. Life or death for the dead-donor rule? New England Journal of Medicine 369: 1289–1291.CrossRefGoogle Scholar
  11. 11.
    Fost, Norman. 1999. The unimportance of death. In The definition of death: Contemporary controversies, ed. Stuart J. Youngner, Robert M. Arnold, and Renie Schapiro, 161–178. Baltimore: John Hopkins University Press.Google Scholar
  12. 12.
    Khushf, George. 2010. A matter of respect: A defense of the dead donor rule and of a “whole-brain” criterion for determination of death. Journal of Medicine and Philosophy 35: 330–364.CrossRefGoogle Scholar
  13. 13.
    Levin, Noah Michael. 2013. The role of death in the moral permissibility of solid organ procurement after cardiac death and its implications. Dissertation, Bowling Green State University.
  14. 14.
    Morrissey, Paul E. 2012. The case for kidney donation before end-of-life care. American Journal of Bioethics 12: 1–8.Google Scholar
  15. 15.
    Miller, Franklin G., and Robert D. Truog. 2012. Death, dying, and organ transplantation: Reconstructing medical ethics at the end of life. New York: Oxford University Press.Google Scholar
  16. 16.
    Birch, Samuel C.M. 2013. The dead donor rule: A defense. Journal of Medicine and Philosophy 38: 426–440.CrossRefGoogle Scholar
  17. 17.
    Jensen, Steven J. 2011. Killing and letting die. In The ethics of organ transplantation, ed. Steven J. Jensen, 170–194. Washington, DC: Catholic University of America Press.Google Scholar
  18. 18.
    Wertin, Thomas M., Mohamed Y. Rady, and Joseph L. Verheijde. 2012. Antemortem donor bilateral nephrectomy: A violation of the patient’s best interests standard. American Journal of Bioethics 12: 17–20.CrossRefGoogle Scholar
  19. 19.
    DeVita, Michael A., and James V. Snyder. 1993. Development of the University of Pittsburgh Medical Center policy for the care of terminally ill patients who may become organ donors after death following the removal of life support. Kennedy Institute of Ethics Journal 3: 131–143.CrossRefGoogle Scholar
  20. 20.
    Beauchamp, Tom L., and James F. Childress. 2013. Principles of biomedical ethics, 7th ed. New York: Oxford University Press.Google Scholar
  21. 21.
    Cochrane, Thomas I. 2011. Allow the dying to donate: Replace the dead donor rule. In The ethics of organ transplantation, ed. Steven J. Jensen, 135–154. Washington, DC: Catholic University of America Press.Google Scholar
  22. 22.
    Chen, Yen-Yuan, and Wen-Je Ko. 2011. Further deliberating burying the dead donor rule in donation after circulatory death. American Journal of Bioethics 11: 58–59.CrossRefGoogle Scholar
  23. 23.
    Collins, Mike. 2010. Reevaluating the dead donor rule. Journal of Medicine and Philosophy 35: 1–26.CrossRefGoogle Scholar
  24. 24.
    Miller, Franklin G., Robert D. Truog, and Dan W. Brock. 2010. The dead donor rule: Can it withstand critical scrutiny? Journal of Medicine and Philosophy 35: 299–312.CrossRefGoogle Scholar
  25. 25.
    Sade, Robert M. 2011. Brain death, cardiac death, and the dead donor rule. Journal of the South Carolina Medical Association 107: 146–149.Google Scholar
  26. 26.
    Shafer-Landau, Russ. 2015. The fundamentals of ethics, 3rd ed. New York: Oxford University Press.Google Scholar
  27. 27.
    Choper, Jesse H. 1982. Defining “religion” in the first amendment. University of Illinois Law Review 1982: 579–613.Google Scholar
  28. 28.
    Nussbaum, Martha C. 2012. The new religious intolerance: Overcoming the politics of fear in an anxious age. Cambridge: Harvard University Press.CrossRefGoogle Scholar
  29. 29.
    Pellegrino, Edmund D. 2002. Professionalism, profession and the virtues of the good physician. Mount Sinai Journal of Medicine 69: 378–384.Google Scholar
  30. 30.
    Ramsey, Paul. 1970. The patient as person: Explorations in medical ethics. New Haven: Yale University Press.Google Scholar
  31. 31.
    Fletcher, Joseph F. 1954. Morals and medicine: The moral problems of the patient’s right to know the truth, contraception, artificial insemination, sterilization, euthanasia. Princeton: Princeton University Press.Google Scholar
  32. 32.
    Williams, Glanville L. 1957. The sanctity of life and the criminal law. New York: Alfred A. Knopf.Google Scholar
  33. 33.
    Scribner, Belding H. 1964. Ethical problems of using artificial organs to sustain human life. Transactions of American Society for Artificial Internal Organs 10: 209–212.Google Scholar
  34. 34.
    Murray, J.E., J.H. Harrison, and J.P. Merrill. 1956. Renal homotransplantation in identical twins. Surgical Forum 6: 432–436.Google Scholar
  35. 35.
    Barry, John M., and Joseph E. Murray. 2006. The first human renal transplants. Journal of Urology 176: 888–890.CrossRefGoogle Scholar
  36. 36.
    Starzl, Thomas E. 1992. The puzzle people: Memoirs of a transplant surgeon. Pittsburgh: University of Pittsburgh Press.CrossRefGoogle Scholar
  37. 37.
    Daube, David. 2008. The jottings of David Daube: Reflections from the 20th century by one of its foremost legal minds, ed. Calum Carmichael. New York: YBK Publishers.Google Scholar
  38. 38.
    Murray, Joseph E., John P. Merrill, Gustave J. Dammin, J. Hartwell Harrison, Edward B. Hager, and Richard E. Wilson. 1964. Current evaluation of human kidney transplantation. Annals of the New York Academy of Sciences 120: 545–557.CrossRefGoogle Scholar
  39. 39.
    Starzl, Thomas E. 1967. Ethical problems in organ transplantation: A clinician’s point of view. Annals of Internal Medicine 67: 32–36.CrossRefGoogle Scholar
  40. 40.
    Wolstenholme, G.E.W., and Maeve O’Connor (eds.). 1966. Ethics in medical progress: With special reference to transplantation. London: Churchill.Google Scholar
  41. 41.
    Woodruff, M.F.A. 1966. Transplantation: The clinical problem. In Ethics in medical progress: With special reference to transplantation, ed. G.E.W. Wolstenholme, and Maeve O’Connor, 6–23. Boston: Little, Brown.Google Scholar
  42. 42.
    Schreiner, G.E. 1966. Dialysis and transplantation: Ethical problems. In Ethics in medical progress: With special reference to transplantation, ed. G.E.W. Wolstenholme, and Maeve O’Connor, 126–133. Boston: Little, Brown.Google Scholar
  43. 43.
    Hamburger, J. 1966. Some general considerations. In Ethics in medical progress: With special reference to transplantation, ed. G.E.W. Wolstenholme, and Maeve O’Connor, 134–138. Boston: Little, Brown.Google Scholar
  44. 44.
    Cortesini, R. 1966. Outlines of a legislation on transplantation. In Ethics in medical progress: With special reference to transplantation, ed. G.E.W. Wolstenholme, and Maeve O’Connor, 171–181. Boston: Little, Brown.Google Scholar
  45. 45.
    Daube, David. 1966. Transplantation: Acceptability of procedures and the required legal sanctions. In Ethics in medical progress: With special reference to transplantation, ed. G.E.W. Wolstenholme, and Maeve O’Connor, 188–201. Boston: Little, Brown.Google Scholar
  46. 46.
    Ethical guidelines for organ transplantation. 1968. JAMA 205: 341–342.Google Scholar
  47. 47.
    Halley, M. Martin, and William F. Harvey. 1968. Medical vs. legal definitions of death. JAMA 204: 423–425.CrossRefGoogle Scholar
  48. 48.
    Elliot, D.W. 1964. Editorial: When is the moment of death? Medicine, Science and the Law 4: 77–80.CrossRefGoogle Scholar
  49. 49.
    Baker, Jeffrey C. 1968. Liability and the heart transplant. Houston Law Review 6: 85–112.Google Scholar
  50. 50.
    Redefinding death. 1968. Newsweek, May 20.Google Scholar
  51. 51.
    Jentzen, Jeffrey M. 2009. Death investigation in America: Coroners, medical examiners, and the pursuit of medical certainty. Cambridge: Harvard University Press.CrossRefGoogle Scholar
  52. 52.
    Marrison, Benjamin. 1988. Did doctors act to soon in harvest of organs in Pamela James case? The Blade, March 6.Google Scholar
  53. 53.
    Munson, Ronald. 2002. Raising the dead: Organ transplants, ethics, and society. New York: Oxford University Press.Google Scholar
  54. 54.
    Capron, Alexander Morgan, and Leon R. Kass. 1972. Statutory definition of the standards for determining human death: An appraisal and a proposal. University of Pennsylvania Law Review 121: 87–118.CrossRefGoogle Scholar
  55. 55.
    Berman, Emile. 1968. The legal problems of organ transplantation. Villanova Law Review 13: 751–758.Google Scholar
  56. 56.
    Kutner, Luis. 1969. Due process of human transplants: A proposal. University of Miami Law Review 24: 782–807.Google Scholar
  57. 57.
    Woodside, Frank C. 1970. Organ transplantation: The doctor’s dilemma and the lawyer’s responsibility. Ohio State Law Journal 31: 66–109.Google Scholar
  58. 58.
    Murray, Joseph E. 2001. Surgery of the soul: Reflections on a curious career. Canton, MA: Science History Publications.Google Scholar
  59. 59.
    Fost, Norman. 1983. The new body snatchers: On Scott’s the body as property. Law and Social Inquiry 8: 718–732.Google Scholar
  60. 60.
    Giertz, G.B. 1966. Ethical problems in medical procedures in Sweden. In Ethics in medical progress: With special reference to transplantation, ed. G.E.W. Wolstenholme, and Maeve O’Connor, 139–148. Boston: Little, Brown.Google Scholar
  61. 61.
    Bishop, Jeffrey Paul. 2011. The anticipatory corpse: Medicine, power, and the care of the dying. South Bend: University of Notre Dame Press.Google Scholar
  62. 62.
    Hamilton, David. 2012. A history of organ transplantation: Ancient legends to modern practice. Pittsburgh: University of Pittsburgh Press.CrossRefGoogle Scholar
  63. 63.
    Murray, Joseph E. 1964. Moral and ethical reflection on human organ transplantation. Linacre Quarterly 31: 54–56.Google Scholar
  64. 64.
    Beecher, Henry K., R.D. Adams, and A. Clifford Barger. 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: 337–340.CrossRefGoogle Scholar
  65. 65.
    Singer, Peter. 1994. Rethinking life and death: The collapse of our traditional ethics, 2nd ed. New York: St. Martin’s Press.Google Scholar
  66. 66.
    Giacomini, Mita. 1997. A change of heart and a change of mind? Technology and the redefinition of death in 1968. Social Science and Medicine 44: 1465–1482.CrossRefGoogle Scholar
  67. 67.
    Oderberg, David S. 2000. Applied ethics: A non-consequentialist approach. Oxford: Blackwell.Google Scholar
  68. 68.
    Koch, Tom. 2012. Thieves of virtue: When bioethics stole medicine. Cambridge: MIT Press.Google Scholar
  69. 69.
    Belkin, Gary. 2014. Death before dying: History, medicine, and brain death. Oxford: Oxford University Press.Google Scholar
  70. 70.
    Siminoff, Laura A., Christopher Burant, and Stuart J. Youngner. 2004. Death and organ procurement: Public beliefs and attitudes. Social Science and Medicine 59: 2325–2334.CrossRefGoogle Scholar
  71. 71.
    President’s Council on Bioethics. 2008. Controversies in the determination of death: A white paper of the President’s Council on Bioethics. Washington, DC: President’s Council on Bioethics.
  72. 72.
    Rachels, James. 1975. Active and passive euthanasia. New England Journal of Medicine 292: 78–80.CrossRefGoogle Scholar
  73. 73.
    Rachels, James. 1986. The end of life: Euthanasia and morality. Oxford: Oxford University Press.Google Scholar
  74. 74.
    Brock, Dan W. 1992. Voluntary active euthanasia. Hastings Center Report 22: 10–22.CrossRefGoogle Scholar
  75. 75.
    Smith, Wesley J. 2001. Culture of death: The assault on medical ethics in America. San Francisco: Encounter Books.Google Scholar
  76. 76.
    Truog, Robert D. 1997. Is it time to abandon brain death? Hastings Center Report 27: 29–37.CrossRefGoogle Scholar
  77. 77.
    Riley, Lauren J. 2011. A call to reject the neurological standard in the determination of death and abandon the dead donor rule. Notre Dame Law Review 87: 1749–1795.Google Scholar
  78. 78.
    Sade, Robert M., and Andrea Boan. 2014. The paradox of the dead donor rule: Increasing death on the waiting list. American Journal of Bioethics 14: 21–23.CrossRefGoogle Scholar
  79. 79.
    Shewmon, D. Alan. 1997. Recovery from “brain death”: A neurologist’s apologia. The Linacre Quarterly 64: 30–96.CrossRefGoogle Scholar
  80. 80.
    Shewmon, D. Alan. 1998. “Brainstem death,” “brain death” and death: A critical re-evaluation of the purported equivalence. Issues in Law and Medicine 14: 125–145.Google Scholar
  81. 81.
    Shewmon, D. Alan. 2001. The brain and somatic integration: Insights into the standard biological rationale for equating “brain death” with death. Journal of Medicine and Philosophy 26: 457–478.Google Scholar
  82. 82.
    Shewmon, D. Alan. 2004. The dead donor rule: Lessons from linguistics. Kennedy Institute of Ethics Journal 14: 277–300.CrossRefGoogle Scholar
  83. 83.
    Veatch, Robert M. 1975. The whole-brain-oriented concept of death: An outmoded philosophical formulation. Journal of Thanatology 3: 13–30.Google Scholar
  84. 84.
    Veatch, Robert M. 1993. The impending collapse of the whole-brain definition of death. Hastings Center Report 23: 18–24.CrossRefGoogle Scholar
  85. 85.
    Bernat, James L. 1998. A defense of the whole-brain concept of death. Hastings Center Report 28: 14–23.CrossRefGoogle Scholar
  86. 86.
    Jox, Ralf J. 2014. Sketching the alternative to brain death: Dying through organ donation. American Journal of Bioethics 14: 37–39.CrossRefGoogle Scholar
  87. 87.
    Nair-Collins, Michael, and Franklin G. Miller. 2016. Is heart transplantation after circulatory death compatible with the dead donor rule? Journal of Medical Ethics 42: 319–320.CrossRefGoogle Scholar
  88. 88.
    Arnold, Robert M., and Stuart J. Youngner. 1993. The dead donor rule: Should we stretch it, bend it, or abandon it? Kennedy Institute of Ethics Journal 3: 263–278.CrossRefGoogle Scholar
  89. 89.
    Veatch, Robert M. 2008. Donating hearts after cardiac death–Reversing the irreversible. New England Journal Of Medicine 359: 672–673.CrossRefGoogle Scholar
  90. 90.
    Veatch, Robert M. 2010. Transplanting hearts after death measured by cardiac criteria: The challenge to the dead donor rule. Journal of Medicine and Philosophy 35: 313–329.CrossRefGoogle Scholar
  91. 91.
    Marquis, Don. 2010. Are DCD donors dead? Hastings Center Report 40: 24–31.CrossRefGoogle Scholar
  92. 92.
    Marquis, Don. 2014. Death as a legal fiction. American Journal of Bioethics 14: 28–29.CrossRefGoogle Scholar
  93. 93.
    Joffe, Ari R., Joe Carcillo, Natalie Anton, Allan deCaen, Yong Y. Han, Michael J. Bell, Frank A. Maffei, John Sullivan, James Thomas, and Gonzalo Garcia-Guerra. 2011. Donation after cardiocirculatory death: A call for a moratorium pending full public disclosure and fully informed consent. Philosophy, Ethics, and Humanities in Medicine 6: 1–20.CrossRefGoogle Scholar
  94. 94.
    Shewmon, D. Alan. 2010. Constructing the death elephant: A synthetic paradigm shift for the definition, criteria, and tests for death. Journal of Medicine and Philosophy 35: 256–298.CrossRefGoogle Scholar
  95. 95.
    Tomlinson, Tom. 1993. The irreversibility of death: Reply to Cole. Kennedy Institute of Ethics Journal 3: 157–165.CrossRefGoogle Scholar
  96. 96.
    Wilkinson, Dominic, and Julian Savulescu. 2012. Should we allow organ donation euthanasia? Alternatives for maximizing the number and quality of organs for transplantation. Bioethics 26: 32–48.CrossRefGoogle Scholar
  97. 97.
    Miller, Franklin G., and Robert D. Truog. 2012. Going all the way: Ethical clarity and ethical progress. American Journal of Bioethics 12: 10–11.CrossRefGoogle Scholar
  98. 98.
    Sulmasy, Daniel P. 1998. Killing and allowing to die: Another look. Journal of Law, Medicine and Ethics 26: 55–64.CrossRefGoogle Scholar
  99. 99.
    Tollefsen, Christopher. 2008. Ten errors regarding end of life issues, and especially artificial nutrition and hydration. In Artificial nutrition and hydration, ed. Christopher Tollefsen, 213–226. Philosophy and Medicine 93. Dordrecht: Springer.Google Scholar
  100. 100.
    Fox, Renée C. 1993. “An ignoble form of cannibalism”: Reflections on the Pittsburgh Protocol for procuring organs from non-heart-beating cadavers. Kennedy Institute of Ethics Journal 3: 231–239.Google Scholar
  101. 101.
    Fox, Renée C., and Judith P. Swazey. 2013. Spare parts: Organ replacement in American society, 2nd ed. New Brunswick: Transaction Publishers.Google Scholar
  102. 102.
    Lee, Patrick. 2016. Total brain death and the integration of the body required of a human being. Journal of Medicine and Philosophy 41: 300–314.CrossRefGoogle Scholar
  103. 103.
    Condic, Maureen L. 2016. Determination of death: A scientific perspective on biological integration. Journal of Medicine and Philosophy 41: 257–278.CrossRefGoogle Scholar
  104. 104.
    Moschella, Melissa. 2016. Integrated but not whole? Applying an ontological account of human organismal unity to the brain death debate. Bioethics 30: 550–556.CrossRefGoogle Scholar
  105. 105.
    DuBois, James, and Emily Anderson. 2006. Attitudes toward death criteria and organ donation among healthcare personnel and the general public. Progress in Transplantation 16: 65–73.CrossRefGoogle Scholar
  106. 106.
    Sinnott-Armstrong, Walter, and Franklin G. Miller. 2013. What makes killing wrong? Journal of Medical Ethics 39: 3–7.CrossRefGoogle Scholar
  107. 107.
    Omelianchuk, Adam. 2015. ‘Total disability’ and the wrongness of killing. Journal of Medical Ethics 41: 661–662.CrossRefGoogle Scholar
  108. 108.
    Jonsen, Albert R. 2001. Beating up bioethics. Hastings Center Report 31: 40–45.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  1. 1.The University of South CarolinaColumbiaUSA

Personalised recommendations