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<p>Contemporary controlled donation after circulatory determination of death (cDCD) faces a widening epistemic gap: as resuscitative and perfusion technologies expand the ability to restore regional circulation, the inferential distance between the concept of death and bedside determinations becomes more salient. I defend organismic unity—the permanent loss of the organism’s capacity for integrated self-maintenance—as the most defensible biological criterion of death. Yet this criterion is underdeterminate at the bedside: it must be tracked by fallible proxies operating under time pressure and uncertainty. The central claim is modal: if irreversibility is constitutive of death, then protocols must distinguish biological impossibility from practical or policy-based non-intervention. In cDCD contexts, what is often operationally established is not biological irreversibility in the strongest sense but a form of prudential warrant under a normative frame of non-intervention (i.e., permanence). I develop (1) a taxonomy and protocol-facing hierarchy of irreversibility senses, (2) an analysis of what 5-min no-touch intervals can and cannot establish, and (3) a conceptual geography of normothermic regional perfusion (NRP) variants, including the thoracoabdominal hard case. From these epistemic limits I derive second-order safeguards-conservatism, transparency, independence, corrigibility, and public accountability-grounded both in deontic respect for the patient and in the dead donor rule (DDR)’s role as a trust-sustaining commitment device. I conclude that safeguarding the dead donor rule in the age of NRP requires neither metaphysical pretense nor DDR abandonment, but institutional integrity: taxonomic clarity about irreversibility, verifiable cerebral exclusion, and second-order safeguards that make uncertainty governable.</p>

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Safeguarding the dead donor rule in the age of normothermic regional perfusion: organismic unity, irreversibility, and epistemic responsibility

  • 期刊论文

  • 发表日期：

    2026年4月16日

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  • Ersun Augustinus Kayra

摘要

Contemporary controlled donation after circulatory determination of death (cDCD) faces a widening epistemic gap: as resuscitative and perfusion technologies expand the ability to restore regional circulation, the inferential distance between the concept of death and bedside determinations becomes more salient. I defend organismic unity—the permanent loss of the organism’s capacity for integrated self-maintenance—as the most defensible biological criterion of death. Yet this criterion is underdeterminate at the bedside: it must be tracked by fallible proxies operating under time pressure and uncertainty. The central claim is modal: if irreversibility is constitutive of death, then protocols must distinguish biological impossibility from practical or policy-based non-intervention. In cDCD contexts, what is often operationally established is not biological irreversibility in the strongest sense but a form of prudential warrant under a normative frame of non-intervention (i.e., permanence). I develop (1) a taxonomy and protocol-facing hierarchy of irreversibility senses, (2) an analysis of what 5-min no-touch intervals can and cannot establish, and (3) a conceptual geography of normothermic regional perfusion (NRP) variants, including the thoracoabdominal hard case. From these epistemic limits I derive second-order safeguards-conservatism, transparency, independence, corrigibility, and public accountability-grounded both in deontic respect for the patient and in the dead donor rule (DDR)’s role as a trust-sustaining commitment device. I conclude that safeguarding the dead donor rule in the age of NRP requires neither metaphysical pretense nor DDR abandonment, but institutional integrity: taxonomic clarity about irreversibility, verifiable cerebral exclusion, and second-order safeguards that make uncertainty governable.