The new surgical procedure makes us question what it means to be alive

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The writer is a scientific commentator

It’s not quite a “partial resurrection,” as some have dramatically dubbed it, but the new technique involves restarting restricted blood circulation in organ donors who have just been pronounced dead. The procedure, which props up organs inside the body rather than on external machines, has garnered global interest in recent years because it can dramatically increase the supply of transplantable organs.

But, as Science magazine points out this month, the practice also has its critics. Doctors, ethicists and lawyers have wondered if you blur the line between life and death; violates US law; it flouts a key principle of giving; and, despite the protections, it unknowingly triggers brain activity, perhaps even consciousness.

The ongoing debate, which has prompted some in the UK and abroad to noticeably halt work while data is being collected, is strangely reassuring: the history of medicine is filled with innovations such as in vitro fertilization, vaccination and transplantation. who have met opposition on the way to acceptance. Controversy is the price we pay for progress.

Transplantation has been a reliable model in that regard, from the first ever transplant of a kidney in 1954, to the first pig heart transplant into a human patient in 2022. However, a deliberate break in the new technique to allay swirling concerns may ultimately purpose to serve the cause of organ donation, an institution built on public trust.

“Science should never precede ethics,” insists Marat Slessarev, a critical care physician at Western University in Ontario who is starting a study in Canada to look for brain activity in dead donors.

In many countries, donated organs come mainly from patients kept alive who have already been declared brain dead. They are called “donors after brain death”.

This new technique, called thoracoabdominal normothermic regional perfusion (taNRP, sometimes abbreviated to NRP), instead begins with donors who are typically unconscious and have no prospect of significant recovery, but are not yet brain dead. With the proper consent, life support is removed, circulation is stopped, and after confirmation of death, machines are used to restart the restricted circulation while organs such as the heart, liver and kidneys are still in situ. Basically in NRP, surgeons block off some vessels before restoring circulation, to prevent blood from reaching the brain.

Opposition, including from the American College of Physicians, has taken hold since the first operations at the heart of the PNR, in the United Kingdom, were reported in 2016 (the procedure then spread to Spain, Belgium, the Netherlands and the United States, with a March paper outlining the results of 157 such transplants).

In Chest magazine last year, bioethicists argued that the technique was “decidedly ethically problematic” because restarting circulation violates US standards for reporting death, which requires the “irreversible cessation of circulatory and respiratory function” and violates the rule that a death cannot be caused by procuring an organ. Furthermore, taking steps to block blood flow to the brain could be read as an implicit acknowledgment that a patient may not be brain dead, opening the door to lawsuits. NRP advocates counter that restarting restricted circulation does not equate to resuscitation.

Stephen Large, a consultant cardiothoracic surgeon at the Royal Papworth Hospital in Cambridge, whose team carried out those pioneering early operations but are not involved in organ retrieval, considers himself a proponent but has suspended such transplants while studies, including at Papworth, investigate further. Sounds wise, if frustrating, given the urgent need for more organs.

The Global Observatory on Donation and Transplantation recorded about 8,400 heart transplants globally in 2021, but nearly 22,000 people are on a waiting list for one. NRP, big estimates, could increase supply of hearts by 30 percent. He also points out that the procedure can help those who want to leave a life-saving legacy. “I would like to see a national programme[of taNRP]. . . to fulfill that particular individual’s ultimate wish, which is to be a wonderful multiple organ donor,” Large told me.

The science to watch will be studies like Slessarev’s, looking for neurological signals in NRP donors. The tricky question is whether, if activity is detected, it can be interpreted as sensitivity or pain. “The patient is alive now,” Slessarev asks. “Do we give anesthetics? We just don’t know.

This is uncharted territory with so much at stake: promising new science that not only saves lives but, along the way, may also help redefine life itself.