In transplant medicine, the use of normothermic regional perfusion (NRP) in donation after circulatory determination of death raises ethical difficulties. NRP is objectionable because it restores the donor's circulation, thus invalidating a death declaration based on the permanent cessation of circulation. NRP's defenders respond with arguments that are tortuous and factually inaccurate and depend on introducing extraneous concepts into the law. However, results comparable to NRP's—more and higher‐quality organs and more efficient allocation—can be achieved by removing organs from (...) deceased donors and using normothermic machine perfusion (NMP) to support the organs outside the body, without jeopardizing confidence in transplantation's legal and ethical foundations. Given the controversy that NRP generates and the convoluted justifications made for it, we recommend a prudential approach we call “ethical parsimony,” which holds that, in the choice between competing means of achieving a result, the ethically simpler one is to be preferred. This approach makes clear that policy‐makers should favor NMP over NRP. (shrink)

This letter responds to the article “Neither Ethical nor Prudent: Why Not to Choose Normothermic Regional Perfusion,” by Adam Omelianchuk et al., in the July‐August 2024 issue of the Hastings Center Report.

Normothermic regional perfusion (NRP) is a relatively new approach to procuring organs for transplantation. After circulatory death is declared, perfusion is restored to either the thoracoabdominal organs (in TA-NRP) or abdominal organs alone (in A-NRP) using extracorporeal membrane oxygenation. Simultaneously, surgeons clamp the cerebral arteries, causing a fatal brain injury. Critics claim that clamping the arteries is the proximate cause of death in violation of the dead donor rule and that the procedure is therefore unethical. We disagree. (...) This account does not consider the myriad other factors that contribute to the death of the donor, including the presence of a fatal medical condition, the decision to withdraw life support, and the physician's actions in withdrawing life support and administering medication that may hasten death. Instead, we claim that physicians play a causative role in many of the events that lead to a patient's death and that these actions are often ethically and legally justified. We advance an “all things considered” view according to which TA-NRP may be considered ethically acceptable insofar as it avoids suffering and respects the wishes of the patient to improve the lives of others through organ donation. We conclude with a series of critical questions related to the practice of NRP and call for the development of national consensus on this issue in the United States. (shrink)

The interpretation of the dead donor rule (DDR) has been central to recent debates regarding normothermic regional perfusion with controlled donation after circulatory death (NRP-cDCD). Proponents...

This letter responds to letters by Garson Leder and by Harrison Lee in the same issue, September‐October 2024, of the Hastings Center Report.

Two of the lead articles in this issue examine the emerging practice of organ procurement by normothermic regional perfusion (NRP) in terms of whether or not these patients are “dead” at the time t...

In “Neither Ethical nor Prudent: Why Not to Choose Normothermic Regional Perfusion” Omelianchuk and colleagues offer an exceptionally clear and methodical critique of the ethical and legal permissibility of in situ normothermic regional perfusion (NRP). NRP involves, in part, the reperfusion of organs via extracorporeal membrane oxygenation (ECMO) after a declaration of death and the occlusion of the arteries supplying blood to the brain. The authors’ main conclusion is that NRP invalidates the declaration of death via (...) the standards set by the Uniform Determination of Death Act (which requires either permanent cessation of circulatory and respiratory functions or irreversible cessation of all brain functions for a determination of death) and thereby violates the Dead Donor Rule (DDR) (which, minimally, requires that organ recovery not be the cause of death). Their arguments for these points, however, are flawed. Most notably, this conclusion rests on mistaken assumptions about the role of circulation in both the UDDA and DDR. A close examination of the role of circulation in sustaining life shows that NRP is consistent with both the UDDA and the DDR. (shrink)

Thoracoabdominal normothermic regional perfusion (TA-NRP), a new method of controlled donation after circulatory death, seems to provide more and better organs for patients on organ transplant waiting lists compared to standard controlled donation after circulatory death. Despite its benefits, the ethical permissibility of TA-NRP is currently a highly debated issue. The recent statement published by the American College of Physicians (ACP) highlights the reasons for these debates. Critics’ main concern is that TA-NRP violates the Dead Donor Rule. This (...) paper presents an ethical analysis of the objections raised by the ACP against TA-NRP and argues that TA-NRP is not only morally permissible but also morally required where it is financially and technically feasible. To support this conclusion, the concepts of ‘resuscitation,’ ‘intention,’ ‘irreversibility,’ ‘permanence,’ ‘impossibility,’ and ‘respect’ in the context of TA-NRP are explored. Additionally, the ethical permissibility of this procedure is evaluated through the lenses of Utilitarianism, Kantianism, the core principles of bioethics, and the Doctrine of Double Effect. This ethical analysis demonstrates why the ACP’s objection lacks a solid moral foundation and conflates moral and legal considerations. This paper also argues that extra measures are needed to ensure the moral permissibility of TA-NRP, emphasizing the importance of informed consent, additional brain blood flow and activity monitoring, and a contingency plan to abort the organ procurement process if a sign of morally relevant brain activity is detected. (shrink)

The current issue of the American Journal of Bioethics illustrates the scope of disagreement among professionals about normothermic regional perfusion (NRP). A similar range of opinions has been de...

Normothermic Regional Perfusion, or NRP, is a method of donated organ reperfusion using cardiopulmonary bypass or a modified extracorporeal membrane oxygenation (ECMO) circuit after circulatory death while leaving organs in the dead donor’s corpse. Despite its potential, several key ethical issues remain unaddressed by this technology.

Donation after circulatory determination of death (DCDD) is an accepted practice in the United States, but heart procurement under these circumstances has been debated. Although the practice is experiencing a resurgence due to the recently completed trials using ex vivo perfusion systems, interest in thoracoabdominal normothermic regional perfusion (TA-NRP), wherein the organs are reanimated in situ prior to procurement, has raised many ethical questions. We outline practical, ethical, and equity considerations to ensure transplant programs make well-informed decisions (...) about TA-NRP. We present a multidisciplinary analysis of the relevant ethical issues arising from DCDD-NRP heart procurement, including application of the Dead Donor Rule and the Uniform Definition of Death Act, and provide recommendations to facilitate ethical analysis and input from all interested parties. We also recommend informed consent, as distinct from typical “authorization,” for cadaveric organ donation using TA-NRP. (shrink)

The implementation of the thoracoabdominal normothermic regional perfusion in organ donation after circulatory determination of death (TANRP-DCDD) protocol is garnering increasing attention and pre...

An adult university hospital ethics committee evaluated a proposed TA-NRP protocol in the fall of 2018. The protocol raised ethical concerns about violation of the Uniform Determination of Death Act and the prohibition known as the Dead Donor Rule, with potential resultant legal consequences. An additional concern was the potential for increased mistrust by the community of organ donation and transplantation. The ethics committee evaluated the responses to these concerns as unable to surmount the ethical and legal boundaries and the (...) ethics committee declined to endorse the procedure. These concerns endure. (shrink)

At the conclusion of their 1968 report, the Harvard Ad Hoc Committee argued that “responsible medical opinion” was ready to accept severe and permanent neurologic injury as a new criterion for deat...

Why is there still debate about definitions of death in medicine and bioethics? Is it because of existential uncertainty and philosophical curiosity about when a person has died so the person’s dea...

Old habits die hard; so, it seems, do old arguments. Proponents of thoracoabdominal normothermic regional perfusion (TA-NRP, but more commonly referred to as NRP) continue to proffer arguments and...

The introduction of normothermic regional perfusion (NRP) in controlled donation after circulatory determination of death (cDCDD) protocols is by some regarded as controversial and ethically troublesome. One of the main concerns that opponents have about introducing NRP in cDCDD protocols is that reestablishing circulation will negate the determination of death by circulatory criteria, potentially resuscitating the donor. In this article, I argue that this is not the case. If we take a closer look at the concept of death (...) underlying the circulatory criterion for determination of death, we find that the purpose of the criterion is to show whether the organism as a whole has died. I argue that this purpose is fulfilled by the circulatory criterion in cDCDD protocols, and that applying NRP does not negate the determination of death or resuscitate the donor. (shrink)

Normothermic Regional Perfusion (NRP) is increasingly being adopted as an intervention designed to improve organ utilization from donors after circulatory death because of the efficiency with which...

Use of normothermic regional perfusion (NRP) for organ recovery in donation after circulatory death (DCD) raises two crucial, and intertwined, ethical questions. The first is whether the use of NRP...

Does normothermic regional perfusion (NRP) resurrect the dead? That was the question I asked in one of the target articles published in the special issue of The American Journal of Bioethics (AJOB)...

Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation (...) that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act. (shrink)

The articles by Bernat, Busch, Dudzinski et al., and Derse illustrate the difficulties with reconciling normothermic regional perfusion (NRP) with the dead donor rule (DDR) (Bernat forthcoming; Busch forthcoming; Dudzinski et al. forthcoming; Derse forthcoming). I appreciate their arguments because they help illuminate the issues that generate a dilemma: either reject NRP or the DDR. I am convinced that the dilemma is unavoidable because the procurement team is involved with determining and securing the death of the donor when (...) circulation restarts. Evidence for this is found in the reasons and recommendations given for blocking blood flow to the brain, both of which betray a lack of certainty over the donor’s vital status. The surgical activity in NRP therefore conflicts with the values the DDR protects: respect for the donor’s life and avoidance of conflict of interest. (shrink)

Nielsen Busch and Mjaaland argue that controlled donation after circulatory death (DCD), and normothermic regional perfusion (NRP) do not violate the dead donor rule (DDR) (Nielsen Busch and Mjaala...

Other than the ligation of the aortic arch vessels, extracorporeal cardiopulmonary resuscitation (ECPR) and thoraco-abdominal normothermic regional ­perfusion (TA-NRP) in donation after circulatory...

While much of the debate around the practice of normothermic regional perfusion (NRP) is focused on the potential violation of the dead donor rule (DDR), another concern is whether allowing this pr...

Background: Ethical frameworks for organ donation following circulatory death (DCD) were established >20 years ago. However, considerable variation exists among these, indicating consensus has not been reached on all issues. Additionally, advances such as cardiac DCD transplants and normothermic regional perfusion (NRP) may have reignited old debates.Methods: We reviewed the English-language literature addressing ethical issues in DCD from 1993 to 2022, examining changes in frequency with which ethical principles and their sub-themes identified within each, were addressed.Results: Non-maleficence was (...) the most frequently addressed principle (192 of 199 articles), as well as the most varied, with 9 subthemes (versus 2-4 within each of the other bioethical principles).Conclusions: There were several changes in the terminology used to refer to DCD over time, and substantial interest in cardiac DCD and NRP in recent publications, arising in 11 and 19 of the 30 publications from 2018 to 2022. (shrink)

Deemed consent legislation for deceased organ donation was introduced in England in 2020, and is considered a vital part of the new UK NHS Blood and Transplant’s 10-year strategy to increase consent for organ donation. Despite the legislation containing safeguards to protect the public, the introduction of deemed consent creates ethical, psychological and social un/certainties for healthcare professionals in their practice. In this paper, we offer insights into healthcare professionals’ perspectives on deemed consent, drawn from interview data with 24 healthcare (...) professionals in an NHS Trust in England, prior to the introduction of the legislation. Whilst participants supported deemed consent in principle, they were concerned that it would present a threat to the nature of donation as a ‘gift’; the notion of informed consent (or non-consent); and the autonomy of donors, their relatives, and their own roles as health professionals, posing dilemmas for practice. We argue that healthcare professionals present themselves as guardians of potential (non)donors and thus as having ethics and integrity in their own practice. We draw conclusions around the values and principles that matter to healthcare professionals when contemplating consent in deceased donation which will be useful for organ donation committees and ethics forums. (shrink)

The ability of very wealthy individuals (or, as I will call them, the ‘super-rich’) to turn their economic power into political power has been—and remains—an important cause of political inequality. In response, this paper advocates an original solution. Rather than solving the problem through implementing a comprehensive conception of political equality, or through enforcing complex rules about financial disclosure etc., I argue that we should impose a choice on the super-rich. The super-rich must choose between (i) forfeiting the things that (...) make them super-rich, i.e., pay a 100 % tax on their wealth above a certain level, or, (ii) they must forfeit some of their political rights. These rights include entitlements to fund political parties; to stand for office; and to work or volunteer for political parties. The right to vote, though, is not limited. I defend my proposal against non-consequentialist and consequentialist objections. I also argue that it avoids two problems that many attempts to reduce political inequality face; these are the political egalitarian’s dilemma and the problem of political equality’s relative moral importance. (shrink)

This article, taking a social semiotic approach, analyses two pieces of music written, shared and exalted by two pre-1945 European fascist movements – the German NSDAP and the British Union of Fascists. These movements, both political and cultural, employed mythologies of unity, common identity and purpose in order to elide the realities of social distinction and political–economic inequalities between bourgeois and proletarian groups in capitalist societies. Visually and inter-personally, the fascist cultural project communicated a machine-like certainty about a vision (...) for a new society based on discipline, conformity and the might of the nation. In this article, we are interested in the ways that these very same discourses are also communicated through sound and music in two songs: The Horst Wessel Lied and the BUF marching song, two songs that used the same melody. We analyse the discourses communicated by the semiotic choices made in melody, arrangements, sound qualities, rhythms as well as in lyrics. The article first identifies some of the underlying semiotic resources for meaning making in sound and then shows how these are used in order to communicate specific ideas, values and attitudes. (shrink)

This book explores that question in unprecedented detail, drawing on empirical evidence from an impressive array of sources.

The diagnosis of a new geological epoch, The ‘Anthropocene’, has implications far beyond geological science. If human activity has disrupted the planet, then this diagnosis potentially disrupts socio-political conventions. This article assesses the implications the Anthropocene has for democratic politics, by delineating three challenges: challenges of knowledge, time and boundary. In contrast to the claim that democratic institutions are unable to adequately respond to these challenges, I suggest that they might be strengthened through an engagement with them. Following an ‘agonistic’ (...) understanding of politics, I argue that the contestation instigated by the challenges of the Anthropocene is key to democratic renewal. Just as democracy in the Anthropocene can be enhanced through an agonistic approach, agonistic theory can be enriched through an engagement with the Anthropocene. (shrink)

This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, (...) existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals. (shrink)

In this article, we carry out a Multimodal Critical Discourse Analysis of a sample from a larger corpus of Romanian news articles that covered the controversial camp evictions and repatriation of Romanian Roma migrants from France that began in 2010 and continue to the time of writing in 2017. These French government policies have been highly criticized both within France and by international political and aid organizations. However, the analysis shows how these brutal, anti-humanitarian events became recontextualized in the Romanian (...) Press to represent the French government’s actions as peaceful and consensual. In addition, the demonization of the Roma in the press serves as a strategy to continuously disassociate them from their Romanian counterparts. While there is a long history of discrimination against the Roma in Romania, these particular recontextualizations can be understood in the context of the Romanian government’s need to gloss over its failure to comply with the Schengen accession requirements and acquire full European Union membership. (shrink)

Democracy can be a means to independently valuable ends and/or it can be intrinsically (or non-instrumentally) valuable. One powerful non-instrumental defence of democracy is based on the idea that only it can publicly justify political authority. I contend that this is an argument about the reasonable acceptability of political authority and about the requirements of publicity and that satisfying these requirements has nothing to do with whether a society is democratic or not. Democracy, then, plays no role in publicly justifying (...) political authority. I also show that any non-instrumental defence of democracy must make claims about what justice requires and make several further claims that require substantial justification. (shrink)

It has been recently demonstrated that yeast cells are able to partially regress chromosome segregation in telophase as a response to DNA double‐strand breaks (DSBs), likely to find a donor sequence for homology‐directed repair (HDR). This regression challenges the traditional concept that establishes anaphase events as irreversible, hence opening a new field of research in cell biology. Here, the nature of this new behavior in yeast is summarized and the underlying mechanisms are speculated about. It is also discussed whether it (...) can be reproduced in other eukaryotes. Overall, this work brings forwards the need of understanding how cells attempt to repair DSBs when transiting the latest stages of mitosis, i.e., anaphase and telophase. (shrink)

There has been criticism of how Fair-Trade products represent workers in remote parts of the world where packaging offers an encounter with distant others which romanticizes and homogenizes them as a pre-modern form of ethnicity. Such workers are shown as always engaged in authentic, simple, honest decontextualized manual labor. And they are depicted as highly appreciative of, and empowered by, the act of ethical shopping. This paper shows that a close social semiotic analysis of Fair-Trade packaging reveals a different set (...) of meanings which sit alongside the decontextualized ones. Designs integrate these workers into more contemporary kinds of modernist, rational, design chic, which communicates its own kind of honesty and authenticity. We consider how this, too, shapes how such consumers encounter distant others and its consequence for the meaning of the act of ethical shopping, where consumers can buy into moral alignment offered by products. (shrink)

Clinical ethics can be viewed as a practical discipline that provides a structured approach to assist healthcare practitioners in identifying, analysing and resolving ethical issues that arise in practice. Clinical ethics can therefore promote ethically sound clinical and organisational practices and decision-making, thereby contributing to health organisation and system quality improvement. In order to develop students’ decision-making skills, as well as prepare them for practice, we decided to introduce a clinical ethics strand within an undergraduate medical curriculum. We designed a (...) programme of clinical ethics activities for teaching and assessment purposes that involved using ethical frameworks to analyse hypothetical and real-life cases in uni- and inter- professional groups. In this paper, we draw on medical student feedback collected over 6 years to illustrate the appeal to students of learning clinical ethics. We also outline the range of benefits for students, healthcare organisations, and the field of clinical ethics arising from tomorrow’s doctors experiencing clinical ethics early in their training. We conclude by briefly reflecting on how including clinical ethics within tomorrow’s doctors curricular can secure and continue future engagement in clinical ethics support services in the UK, alongside the dangers of preparing students for organisational cultures that might not exist. We anticipate the findings presented in the paper will contribute to wider debates examining the impact of ethics teaching, and its ability to inform future doctors’ practice. (shrink)

While there has been extensive work on the textual realizations of climate change in the media, there has been little on the way such discourses are realized and promoted visually. This article addresses this using Multimodal Critical Discourse Analysis to examine a new collection of images from the globally operating Getty Images intended for use in promotions, advertisements and editorials. Getty is promoting this collection in terms of Green Issues being a `marketing opportunity'. In this article we consider the results (...) of these issues being recontextualized through this process, where they are shaped to fit the culture of branding. Analysis is of the images and the search terms where Getty lay out what can be said with the images. (shrink)

Researchers engaged in studies about ‘hidden social groups’ are likely to face several ethical challenges. Using a study with undocumented Chinese migrants in the UK, challenges involved in obtaining approval by a university research ethics committee are explored. General guidance about how to resolve potential research ethics issues, with particular reference to ‘hidden social groups’, prior to submission to a research ethics committee is presented.

This article argues against the claim that democracy is a necessary condition of political legitimacy. Instead, I propose a weaker set of conditions. First, I explain the case for the necessity of democracy. This is that only democracy can address the ‘egalitarian challenge’, i.e. ‘if we are all equal, why should only some of us wield political power?’. I show that if democracy really is a necessary condition of political legitimacy, then (what I label) the problems of domestic justice and (...) of international legitimacy become intractable. I then argue that the egalitarian challenge is addressed where the requirements of (1) horizontal equality, (2) acceptable vertical inequality, and (3) publicity, are met and where (4) citizens have some institutionalized opportunity for a voice in decisions. I show that these conditions can be realized in non-democratic form and conclude by explaining how the four conditions can be employed to make the problems of domestic justice and of international legitimacy more tractable. Overall, my ambitions are limited. I do not offer an all-things-considered case against democracy but I do show that (some) forms of non-democratic government are permissible. (shrink)

Radical democratic thinking is becoming intrigued by the material situatedness of its political agents and by the role of nonhuman participants in political interaction. At stake here is the displacement of narrow anthropocentrism that currently guides democratic theory and practice, and its repositioning into what we call ‘the nonhuman condition’. This Critical Exchange explores the nonhuman condition. It asks: What are the implications of decentering the human subject via a new materialist reading of radical democracy? Does this reading dilute political (...) agency? Or should this be seen, on the contrary, as an invitation for new voices and demands to enter into democratic assemblages? How might engagement with the more-than-human disrupt or extend theories of radical democracy? Hans Asenbaum and Amanda Machin discuss the human democratic subject both through radical democratic and new materialist lenses. They suggest that a new materialist decentred subject does not lose agency but further gains political responsibility in radical democracy. Jean-Paul Gagnon highlights the possibility of becoming through loss. In losing our anthropocentric arrogance—our understanding of being other and better than animal—we become more connected and discover our place in human-nonhuman assemblages. Melissa Orlie agrees that something can be gained through renouncing dominant human fantasies and presents a ‘radical democratic naturalism’. By renouncing land violence and acknowledging nature’s subjectivity, we can further nonexploitative radical democratic politics. This is where the notion of ‘tidalectic’ processes introduced by James L. Smith is helpful. Focusing on water and the Indigenous knowledges around rivers, he considers how democracy and community can be reimagined as plural, cyclical and attentive to the nonhuman with which the human is inevitably entangled. Diana Leong offers a different approach. Considering the nonhuman from the perspective of Black Studies demands an awareness to how blackness has long been constituted as non- or partially human. (shrink)

The United Nations ‘Transforming our world: the 2030 Agenda for Sustainable Development’ lays out 17 Sustainable Development Goals to address a range of global issues related to the future of the planet and human well-being. Critics, however, argue that the Agenda, a complex product of multi-stakeholder governance, in its drive to accommodate many competing voices, is overloaded with weakly defined, overlapping and contradictory issues, concepts and buzzwords. These serve to gloss over actual concrete global problems and forces, concealing an underlying (...) free-trade ideology. In this paper, using Multimodal Critical Discourse Analysis, we draw attention to the nature of the documents used to communicate the Agenda. These documents comprise an edifice of self-referential texts that rely heavily on infographics, bullet points, charts and tables. Such formats appear to helpfully simplify, distil information and break things down into workable components. But, we show, through the affordances of these formats, the the vagueness of buzzwords, contradictions and lack of clear causalities can be glossed over, presenting the Agenda as a highly technical, engaging, and above all moral process. These formats are important, therefore, for the legitimization and rhetorical power of the Agenda, necessary for its take-up by governments and organizations around the world. (shrink)

Researchers engaged in studies about ‘hidden social groups’ are likely to face several ethical challenges. Using a study with undocumented Chinese migrants in the UK, challenges involved in obtaining approval by a university research ethics committee are explored. General guidance about how to resolve potential research ethics issues, with particular reference to ‘hidden social groups’, prior to submission to a research ethics committee is presented.

Name der Zeitschrift: Semiotica - Journal of the International Association for Semiotic Studies / Revue de l'Association Internationale de Sémiotique Jahrgang: 2013 Heft: 197 Seiten: 119-140.