Going in Circles about ‘Circulation’: A Defense of Normothermic Regional Perfusion

Abstract: There is a significant amount of confusion regarding the ethical/legal permissibility of thoracoabdominal normothermic regional perfusion (TA-NRP). Much of this confusion is rooted in a persistent misunderstanding of the role ‘circulation’ plays in the determination of death. The UDDA identifies two criteria to determine death: either (1) permanent cessation of circulatory and respiratory functions (the circulatory criterion) or (2) irreversible cessation of all brain functions (the neurological criterion). TA-NRP involves the reperfusion of the thoracoabdominal organs after the declaration of death via the circulatory criterion. Critics of the use of TA-NRP have argued that since TA-NRP restores circulation to the body, it therefore invalidates the standard by which death was declared (i.e., the circulatory criterion), and thus violates the dead donor rule (which, minimally, requires that organ recover not be the cause of death). This talk argues that this criticism rests on a mistaken assumption about what ‘circulation’ is necessary for life. If the UDDA is to remain logically consistent, then there is a direct entailment relationship between the two criteria regarding the scope of the circulatory criterion. Specifically, the neurological criterion entails that that the minimal threshold of circulatory functioning necessary for life be circulation that perfuses a functioning brain (since neurological death can be determined while circulatory functions persist). TA-NRP, which involves the occlusion of cerebral arteries, does not restart the kind of circulation necessary for life (if cerebral blood flow is indeed stopped). This talk diagnoses the source of this confusion and shows a way towards consensus.

Keywords: Normothermic regional perfusion, Uniform Determination of Death Act (UDDA), The Dead Donor Rule