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Fans of Monty Python and the Holy Grail may smile when they hear that familiar dull clank, accompanied by the plaintive cry: bring out your dead!

But not everybody is laughing, particularly those on the front lines of donation after cardiocirculatory death (DCD), a practice whereby medical teams remove organs for transplantation from individuals who have recently died.

Of course, this is all well and good – unless the donor is not quite dead.

In a recent article in Philosophy, Ethics, and Humanities, the authors cite many troubling problems with DCD, including unreliable “consensus statements” supporting the practice, unjustifiable premortum procedures that do not benefit the donor, misleading assertions that DCD conforms to current medical procedure and to the law, and conflicts of interest in the DCD process itself. But the most disturbing of the paper’s assertions is that DCD donors may not, in fact, be dead at all.

In his evaluation of the article, F1000 Faculty Member Tom Woodcock writes,

The law’s Dead Donor Rule necessitates some gerrymandering of the definition of death in societies committed to lawful organ donation, and, while other contributors to this debate have called for the rule to be abandoned {1}, Joffe and colleagues take the strict Kantian position that the rule must be observed and veracity demanded of the transplant team, even if this results in fewer donations.

The dead donor rule, write the authors, “claims that humans must be dead before vital organs can be taken, and is intended to prevent the following: patients killed by organ retrieval, harm or exploitation of the weak/vulnerable, mistrust of doctors and transplantation, and treating a patient merely as a means to organs.”

Again, all well and good. However, it’s apparently harder to determine if someone is dead than one might guess.

Let’s consider a person who has given their informed consent to be a DCD donor. It all starts out innocently enough, when, having determined that the time has come, someone pulls the plug on our donor’s life support. If circulation stops within two hours, the individual can be a donor, after which the next two to ten minutes become a frenzy of ambiguity. That’s because death can be declared during this time period, although whether the transplant team uses the two- or the ten-minute rule, or something in between, varies from clinic to clinic. Similarly, the tools and procedures used to confirm death are not standardized between countries or even hospitals.

Then there is the problem of whether the person will stay dead. Irreversibility is one of the prerequisites of declaring death by absent circulation. That said, the authors take pains to distinguish “permanence” from “irreversibility.” Perhaps they capture the dilemma most vividly with this metaphor:

Is a drowning man dead because no one will swim out to save him? Or is he merely going to die?

And let’s not even talk about the Lazarus phenomenon, where previously dead patients come back to life – eerie.

The authors conclude,

…honesty requires that we face these problems instead of avoiding them. Until the concerns we describe are seriously considered, full public disclosure occurs, and fully informed consent is obtained from donors, there should be a moratorium on the practice of DCD.

In other words, don’t bring out your dead. Leave them in there for a while: we may need to rethink our policies.

In lively Socratic repartee, evaluator Tom Woodcock begs to disagree with a strict Kantian approach:

At the altar of the Categorical Imperative and the fully autonomous agent, Kant was also able to justify infanticide, duelling and lethal medical research on convicted criminals. In more modern times, the utilitarian philosopher Peter Singer of Monash and Princeton Universities has argued cogently for medical researchers to use demented humans in preference to sentient great apes {2}. Outlandish conclusions are not incompatible with academic philosophical discourse.