To the Editor: In the recent article by Richards and Rogers, the ethical and legal arguments made to justify antemortem interventions for organ donation after cardiac death (DCD) raise some questions.1

First, do antemortem interventions harm the patient? Anticoagulants (eg, heparin) expand intracranial haemorrhage and hasten the death of potential donors with acute ischaemic or haemorrhagic strokes. Large volumes of crystalloid fluids are infused to maintain organ perfusion, while exacerbating cerebral oedema and accelerating the onset of brain stem herniation and infarction in potential donors. Vasodilators are infused for organ preservation, causing hypotension and early onset of cardiorespiratory arrest after discontinuation of mechanical ventilation. While it may be debatable whether these interventions can cause harm to a person destined to die, they certainly shorten the dying process and hasten death.2

Many cultures and societies worldwide consider the performance of interventions to shorten the dying process ethically unacceptable.3 In the United States, the intent to administer — for the sole purpose of organ viability — a medication that expedites death and shortens the warm ischaemia time in DCD is a criminally liable action.4 Regardless of the lack of evidence that dying in an operating theatre is not worse than dying in an intensive care unit, if dying in the operating theatre results in the denial of death with dignity and peace, it can result in long-lasting traumatic experiences and memories for families and relatives.5

Second, is consenting to appendicectomy the same as consenting to organ donation? The only similarity between appendicectomy and removal of organs from a donor is that both are surgical procedures performed in the operating theatre. However, consent to the former is intended to “heal and preserve life” while the latter has no such intent and can imply to “shorten life”. To draw a conclusion that consent to DCD could be viewed as consent to take all reasonable steps to ensure that the operation is successful and results in the procurement of viable organs for transplantation is only justifiable if society has decided to abandon the “dead donor rule” and sanction “physician-assisted suicide”.2