Non–Heart-Beating Donation: Ethical Aspects J.L. Vincent and S. Brimioulle ABSTRACT Non– heart-beating donation (NHBD) is under considerable ethical debate including concerns that the donor is not really dead when organs are procured and that withdrawing therapy may be expedited to harvest needed organs. We suggest a two-step process to NHBD based largely on the ethical principle of beneficence. First, once a decision has been made that there is no reasonable hope of survival for the patient and that active treatment is of no further benefit and should be withdrawn, NHBD can be suggested. Second, once the decision for NHBD has been made, there is no reason for further delay and withdrawal of treatment should be implemented as rapidly as possible to ensure that the quality of the donated organs remains optimal for the maximal benefit of the organ recipient. R EPORTS OF CONSIDERATION of organ transplan- tation date back as far as the ninth century BC, but it was only in the 1960s that any real progress in solid organ transplantation began to be made. Although initially organs were retrieved from patients immediately after cardiorespi- ratory arrest, since the report on the definition of brain death by the Harvard Medical Committee in 1968 1 and the subsequent widespread introduction of brainstem testing in the 1970s, most organs are now retrieved from patients certified as brain dead. However, with advances in surgi- cal techniques, anesthesia, organ preservation, and anti- rejection medication, the good results of organ transplan- tation have led to an increase in demand for organs, and demand is now continuously greater than supply. For example, in the United Kingdom in March 2006, 6698 patients were on the waiting list for solid organ trans- plantation. 2 Between March 2006 and March 2007, 3087 transplantation procedures were performed, and 459 patients died while waiting for an organ. In an attempt to improve organ supply, non– heart-beating donation (NHBD), in which patients declared dead according to cardiac criteria but who do not fulfill brainstem death criteria can be donors, has been reintroduced in some centers. Medical staff and the public are still, however, relatively unfamiliar with this newer technique, and it remains a sensitive area with concern that the donor is not really dead when organs are procured and that withdrawing therapy may be expedited in some cases to harvest needed organs. Nevertheless, NHBD can provide a valuable source of life-saving organs, and patients and relatives need to be aware of its existence and the possibility that they or their loved one can donate organs using this technique. Ethical Issues There are four primary bioethical principles in the NHBD process. The first is autonomy. This principle must be respected for the donor; however, it is irrelevant to the recipient. Second is beneficence. To the donor, this is no longer relevant; however, it is very relevant to the recipient. Third is nonmaleficence. Again, this principle must be respected for the donor; however, this principle is irrelevant to the recipient. Fourth is distributive justice, which is very relevant to both the donor and the recipient. With the sensitive nature of all organ donations, NHBD must be considered and discussed openly and honestly to avert raising unnecessary concern or suspicion among the public. Thus, when discussing the possibility of NHBD, we believe a two-step process based on the ethical principle of beneficence must be completed. Step 1: No Further Benefit for the Patient The first rule of NHBD is that it cannot be considered unless there is absolutely no reasonable hope of survival for the patient; further active treatment is, therefore, futile; and death is inevitable and expected. Once this prognosis is From the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium. Address reprint requests to J.L. Vincent, Department of Inten- sive Care, Erasme Hospital, Route de Lennik 808, 1070 Brux- elles, Belgium. E-mail: jlvincen@ulb.ac.be 0041-1345/09/$–see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.transproceed.2008.12.023 360 Park Avenue South, New York, NY 10010-1710 576 Transplantation Proceedings, 41, 576 –578 (2009)