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...

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...

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)

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)

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)

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...

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...

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...

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...

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...

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)

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)

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...

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)

The present study examined deep gray matter perfusion in neonates with congenital heart disease (CHD) with arterial spin labeling magnetic resonance imaging preoperatively. We found that neonates with cyanotic CHD showed lower right thalamus compared with controls and lower right basal ganglia perfusion compared with acyanotic CHD. When the CHD group was assessed as a whole, it showed slightly decreased left thalamus perfusion compared with controls. The results suggest that cardiac physiology plays a crucial part in changes (...) in regional cerebral perfusion. Perfusion with arterial spin labeling may be a useful marker of high risk for impaired cerebral blood flow auto-regulation and cerebral hypoperfusion in neonates with CHD. (shrink)

Computerized relaxation training has been suggested as an effective and easily accessible intervention for individuals with psychological distress. To better elucidate the neural mechanism that underpins the effects of relaxation training, we investigated whether a 10-session computerized relaxation training program changed prefrontal gamma-aminobutyric acid levels and cerebral blood flow in women with psychological distress. We specifically focused on women since they were reported to be more vulnerable to develop stress-related disorders than men. Nineteen women with psychological distress but without a (...) diagnosis of psychiatric disorders received the 10-day computerized relaxation training program that consisted of 30-min cognitive-relaxation training and 10-min breathing-relaxation training per day. At baseline and post-intervention, perceived stress levels, anxiety, fatigue, and sleep quality were assessed by self-report questionnaires. Brain magnetic resonance spectroscopy and arterial spin labeling scans were also performed before and after the intervention to evaluate GABA levels and relative CBF in the prefrontal region. Levels of perceived stress, anxiety, fatigue, and sleep quality improved following 10 sessions of computerized relaxation training, resulting in a significant relief in composite scores of stress-related symptoms. The prefrontal GABA levels decreased, while relative CBF increased after the intervention. In addition, a greater increase in relative prefrontal CBF was associated with better composite scores of stress-related symptoms following the intervention. The current findings suggest that computerized relaxation training may improve stress-related symptoms through modulating the prefrontal GABA levels and CBF in women with psychological distress. (shrink)

Background: There is increasing evidence to support the efficacy of transcranial direct current stimulation applications in cognitive augmentation and rehabilitation. Neuromodulation achieved with tDCS may further regulate regional cerebral perfusion affiliated through the neurovascular unit; however, components of cerebral perfusion decrease across aging. A novel neuroimaging approach, functional near-infrared spectroscopy, can aid in quantifying these regional perfusional changes. To date, the interaction of the effects of tDCS on cognitive performance across the lifespan and obtained fNIRS hemodynamic (...) responses remain unknown.Objective: This review aims to examine the effects of tDCS on cognitive performance and fNIRS hemodynamic responses within the context of cognitive aging.Methods: Six databases were searched for studies. Quality appraisal and data extraction were conducted by two independent reviewers. Meta-analysis was carried out to determine overall and subgroup effect sizes.Results: Eight studies met inclusion criteria. The overall effect size demonstrates that tDCS can alter cognitive performance and fNIRS signals, with aging being a potential intermediary in tDCS efficacy.Conclusion: From the studies included, the effects of tDCS on cognitive performance and fNIRS metrics are most prominent in young healthy adults and appear to become less robust with increasing age. Given the small number of studies included in this review further investigation is recommended. (shrink)

Is age discrimination ethically objectionable? One puzzle is that we sometimes assume that the target of both age discrimination and ageism must be older people, yet in poorer nations, older people are generally shown more respect. This article explores the ethical question. It looks first at ethical arguments favoring age discrimination toward younger people in low‐income, less industrialized countries of the global South, using sub‐Saharan Africa as an illustration. It contrasts these with arguments favoring age discrimination toward older people in (...) high‐income, more industrialized countries of the global North, particularly the United States and United Kingdom. Finally, it considers what role, if any, differences in life expectancy, infant and child mortality, and prospects for healthy lives should play in the moral embrace of a particular view by a community. It argues that there can be reasons to favor different types of discrimination in different parts of the world. (shrink)

In seeking to explain the evolution of social cooperation, many scholars are using increasingly complex game-theoretic models. These complexities often model readily observable features of human and animal populations. In the case of previous games analyzed in the literature, these modifications have had radical effects on the stability and efficiency properties of the models. We will analyze the effect of adding spatial structure to two communication games: the Lewis Sender-Receiver game and a modified Stag Hunt game. For the Stag Hunt, (...) we find that the results depart strikingly from previous models. In all cases, the departures increase the explanatory value of the models for social phenomena. (shrink)

The COVID-19 pandemic cropping up at the end of 2019 started to pose a threat to millions of people’s health and life after a few weeks. Nevertheless, the COVID-19 pandemic gave rise to social and economic problems that have changed the progress steps of individuals and the whole nation. In this study, the work conditions for employees from Taiwan, Malaysia, and the Chinese mainland are explored and compared, and the relationship between support mechanisms and innovation behaviors is evaluated with a (...) view of the social cognitive career theory. This study adopts the cross-sectional survey and purposive sampling to collect questionnaires. A total of 623 copies of a questionnaire from Taiwanese, 440 copies from Malaysians, and 513 copies from mainlanders were collected in this study to compare the three groups in developing employees’ IBs. Smart-partial least squares for partial least squares structural equation modeling was applied in the structural model to conduct a verification of the hypotheses and comparative analysis in this study. According to the findings, compared with employees from the Chinese mainland, the Taiwanese and Malaysian samples show more significant paths regarding employee employability, IB, prior knowledge, perceived organizational support, self-efficacy, and job performance. Our results will offer more insights and advice concerning theories of human resource. (shrink)

Modern science’s ability to produce, store, and analyze big datasets is changing the way that scientific research is practiced. Philosophers have only begun to comprehend the changed nature of scientific reasoning in this age of “big data.” We analyze data-focused practices in biology and climate modeling, identifying distinct species of data-centric science: phenomena-laden in biology and phenomena-agnostic in climate modeling, each better suited for its own domain of application, though each entail trade-offs. We argue that data-centric practices in science are (...) not monolithic because the opportunities and challenges presented by big data vary across scientific domains. (shrink)

Two conundrums puzzle COVID‐19 investigators: 1) morbidity and mortality is rare among infants and young children and 2) rates of morbidity and mortality exhibit large variances across nations, locales, and even within cities. It is found that the higher the rate of pneumococcal vaccination in a nation (or city) the lower the COVID‐19 morbidity and mortality. Vaccination rates with Bacillus Calmette–Guerin, poliovirus, and other vaccines do not correlate with COVID‐19 risks, nor do COVID‐19 case or death rates correlate with number (...) of people in the population with diabetes, obesity, or adults over 65. Infant protection may be due to maternal antibodies and antiviral proteins in milk such as lactoferrin that are known to protect against coronavirus infections. Subsequent protection might then be conferred (and correlate with) rates of Haemophilus influenzae type B (Hib) (universal in infants) and pneumococcal vaccination, the latter varying widely by geography among infants, at‐risk adults, and the elderly. Also see the video abstract here https://youtu.be/GODBYRbPL00. (shrink)

Since the proclamation of the Universal Declaration of Human Rights, over 165 countries have incorporated human rights standards into their legal systems: the resulting jurisprudence from diverse cultural traditions creates new dimensions to concepts first articulated in 1948. In this revised second edition, Nihal Jayawickrama draws on extensive sources to encapsulate the judicial interpretation of human rights law in one comprehensive volume. Jayawickrama covers the case law of the superior courts of 103 countries in America, Europe, Africa, Asia, the Caribbean (...) and the Pacific, as well as jurisprudence of human rights monitoring bodies. He analyses the judicial application of human rights law to demonstrate empirically the universality of contemporary human rights norms. This definitive volume is essential for legal practitioners, and government and non-governmental officials, as well as academics and students of both constitutional law and the international law of human rights. (shrink)

As conceptual and theoretical discussions on environmental valuation approaches have advanced there is growing interest in the impact that valuation has on decision making. The perceived legitimacy of the outputs of valuation studies is seen as one factor influencing their impact on policy decisions. One element of this is ensuring that participants of valuation processes see the results as legitimate and would be willing to accept decisions based on these findings. Here, we test the perceived legitimacy to participants of two (...) approaches to deliberative monetary valuation, deliberated preferences and Deliberative Democratic Monetary Valuation, in the context of marine planning in the Clyde estuary in Scotland. We compare and contrast deliberated preference and deliberative democratic monetary valuation and track their emergence as responses to critiques of conventional stated preference approaches. We then present the results of our case study where we found that deliberative democratic monetary valuation produced valuations that were perceived as more legitimate that deliberated preference as the basis for decision making by those involved in the valuation process. (shrink)

Background While most countries that allow abortion on women’s request also grant physicians a right to conscientious objection (CO), this has proven to constitute a potential barrier to abortion access. Conscientious objection is regarded as an understudied phenomenon the effects of which have not yet been examined in Germany. Based on expert interviews, this study aims to exemplarily reconstruct the processes of abortion in a mid-sized city in Germany, and to identify potential effects of conscientious objection. Methods Five semi-structured interviews (...) with experts from all instances involved have been conducted in April 2020. The experts gave an insight into the medical care structures with regard to abortion procedures, the application and manifestations of conscientious objection in medical practice, and its impact on the care of pregnant women. A content analysis of the transcribed interviews was performed. Results Both the procedural processes and the effects of conscientious objection are reported to differ significantly between early abortions performed before the 12th week of pregnancy and late abortions performed at the second and third trimester. Conscientious objection shows structural consequences as it is experienced to further reduce the number of possible providers, especially for early abortions. On the individual level of the doctor-patient relationship, the experts confirmed the neutrality and patient-orientation of the vast majority of doctors. Still, it is especially late abortions that seem to be vulnerable to barriers imposed by conscientious objection in individual medical encounters. Conclusion Our findings indicate that conscientious objection possibly imposes barriers to both early and late abortion provision and especially in the last procedural steps, which from an ethical point of view is especially problematic. To oblige hospitals to partake in abortion provision in Germany has the potential to prevent negative impacts of conscientious objection on women’s rights on an individual as well as on a structural level. (shrink)

El artículo realiza una exploración inicial acerca de las políticas archivísticas en la provincia de La Pampa, que –en el periodo considerado– guardan una estrecha relación con las políticas culturales. En primer lugar se repasan los conceptos de política cultural y política archivística; en segundo lugar se presentan rápidamente algunas características de las políticas culturales en la provincia de La Pampa y en tercer lugar nos detenemos en las instancias referidas a las prácticas, disposiciones e iniciativas en relación al Archivo (...) Histórico Provincial, principal espacio de desarrollo de las escasas políticas existentes en la materia en la provincia. Se sostiene que en general la gestión del AHP surgió en vinculación a políticas culturales que a principios de la década de 1970 adherían a una noción antropológica de la cultura y se asociaron a una serie de prácticas y políticas destinadas a desarrollar investigaciones para identificar procesos históricos específicos y supuestos rasgos que caracterizarían a la identidad regional, o pampeanidad. En la provincia, las prácticas y políticas archivísticas han permanecido asociadas a esa mirada y con cada vez menor cantidad de recursos para su funcionamiento. (shrink)