Author: Jordan Francke, MD, MPH
Advances in extracorporeal membrane oxygenation and organ transplantation can preserve life and increase the number of organs available for donation. However, these technologies have also created difficult ethical questions involving death, medical futility, patient autonomy, resource allocation, and the responsibilities of clinicians.
A session at the 2026 IARS and SOCCA Annual Meeting examined the ethical challenges that arise when temporary organ-support therapies become indefinite and when newer organ-recovery procedures test traditional definitions of death.
When the Bridge Becomes the Destination
Shahla Siddiqui, MBBS, MSc, discussed the concept of a “bridge to nowhere.”
In the intensive care unit, clinicians and families frequently must make urgent decisions despite incomplete information and uncertain prognoses. When a patient’s wishes are unknown, the default may be to begin aggressive treatment unless:
• A clear advance directive limits treatment
• Death is unquestionably irreversible
• The burdens and risks of treatment clearly outweigh the expected benefits
ECMO may be initiated as a temporary bridge to heart or lung transplantation. The ethical problem becomes especially difficult when the patient is later determined not to be a transplant candidate.
At that point, the therapy no longer provides a bridge to recovery or transplantation. The bridge has effectively become the patient’s destination.
Clinicians and families must then decide whether ECMO should be continued, limited, or withdrawn. These decisions can produce substantial moral distress, particularly when the patient remains awake or continues to interact meaningfully with family members.
Deciding Who Should Receive ECMO
Jai Madhok, MD, MSE, explained that decisions about ECMO eligibility vary considerably among physicians and medical centers.
Factors that may influence the decision include:
• The patient’s diagnosis and prognosis
• The severity and reversibility of organ failure
• Existing medical conditions
• Eligibility for transplantation
• The institution’s experience with ECMO
• Availability of equipment and trained personnel
• The speed of referral and cannulation
• Differences in ECMO circuits and clinical protocols
Prediction tools may help clinicians estimate outcomes. The PRESERVE mortality-risk score, for example, has shown an association with six-month survival among patients receiving ECMO for severe acute respiratory distress syndrome.
However, prognostic scores cannot resolve every ethical question, and clinical decisions remain vulnerable to bias.
Biases Affecting ECMO Decisions
Clinicians may be influenced by several cognitive biases.
Recency bias can occur when a physician remembers a recent patient who recovered after prolonged ECMO and allows that experience to influence the assessment of a different patient.
Sunk-cost bias occurs when the amount of time, effort, and resources already invested makes it emotionally difficult to stop treatment, even when the likelihood of achieving the original goal has become extremely small.
Other biases may involve a patient’s age, disability, social circumstances, perceived quality of life, or the clinician’s personal experiences.
Recognizing these biases is important because decisions should be based on the individual patient’s values, prognosis, and treatment goals rather than emotional reactions or previous cases.
Can ECMO Provide Value Without Recovery?
One of the most difficult scenarios involves a patient who cannot recover or receive a transplant but remains awake, communicates with family members, and experiences meaningful moments.
ECMO may no longer be moving the patient toward a definitive medical solution, but it may still be preserving a life that the patient considers worthwhile.
This creates several difficult questions:
• Must every life-sustaining treatment lead to recovery or transplantation?
• Can time with family be a sufficient benefit to justify continued ECMO?
• Should treatment continue until a major complication occurs?
• Who determines whether the burdens of treatment outweigh its benefits?
• How should limited medical resources be considered?
There is no simple answer. The appropriate decision requires careful communication among the patient, family, clinical team, palliative-care specialists, and ethics consultants.
Donation After Circulatory Death
Louanne Carabini, MD, MA, FASA, examined ethical concerns surrounding organ donation after circulatory death.
Thoracoabdominal normothermic regional perfusion is a developing organ-recovery technique used at some transplant centers. Following the declaration of circulatory death, the vessels supplying the brain are surgically blocked while circulation is restored to the thoracic and abdominal organs.
Restoring circulation can improve organ perfusion and potentially increase the number and quality of transplantable organs.
However, the procedure raises questions about whether restoring circulation is consistent with the declaration that circulatory function has irreversibly ceased.
Potential Restoration of Cerebral Blood Flow
During thoracoabdominal normothermic regional perfusion, the major blood vessels supplying the brain are ligated to prevent the restoration of cerebral circulation.
Nevertheless, critics argue that collateral arterial blood flow to the brain cannot always be excluded with complete certainty. This creates concern about whether the procedure could partially restore circulation after death has already been declared.
The ethical debate therefore centers not only on whether the major cerebral vessels have been blocked, but also on whether the determination of death remains valid after circulation is restored elsewhere in the body.
The Uniform Determination of Death Act
The Uniform Determination of Death Act recognizes death based on either:
• Irreversible cessation of circulatory and respiratory functions
• Irreversible cessation of all functions of the entire brain, including the brainstem
Thoracoabdominal normothermic regional perfusion raises questions about what “irreversible” means.
Some argue that circulatory function is not truly irreversible if clinicians intentionally restore it after death is declared. Others distinguish between circulation within the donor’s body as a whole and circulation to the brain, which remains intentionally interrupted.
This distinction remains an area of ethical, legal, and professional debate.
The Dead Donor Rule
The Dead Donor Rule is frequently described as requiring that organ donation occur only after death.
Dr. Carabini emphasized a more precise interpretation: the organ-procurement process must not cause the donor’s death.
This distinction is important. The ethical concern is not simply the timing of organ recovery but whether the donor was already dead according to accepted medical and legal standards and whether procurement contributed to the death.
Maintaining Public Trust
Novel transplantation procedures may be misunderstood by patients, families, clinicians, and the general public.
Media reports describing the restoration of circulation after death may create the impression that death declarations are being reversed or that organs are being removed before death has been firmly established.
Even when these descriptions are medically inaccurate or incomplete, they can damage confidence in the transplant system and cause people to remove themselves from organ-donor registries.
Maintaining trust requires complete transparency. Hospitals and transplant programs should clearly explain:
• How death is determined
• How long clinicians wait before beginning organ recovery
• Which blood vessels are blocked
• Why circulation is restored to selected organs
• What safeguards prevent blood flow to the brain
• Who declares death
• Who participates in organ procurement
• How conflicts of interest are prevented
Consent discussions should use language understandable to patients and families rather than relying on technical terminology.
Protecting Clinicians From Moral Injury
Some clinicians may believe that participation in thoracoabdominal normothermic regional perfusion conflicts with their professional or personal understanding of death.
Departments should provide education before introducing these procedures and should establish clear policies permitting clinicians to decline participation when feasible.
An opt-out process may help prevent moral injury while ensuring that patient care and organ-donation services remain appropriately staffed.
Clinicians who decline should not be punished or stigmatized, provided that patient safety and continuity of care are protected.
The Need for Early Goals-of-Care Discussions
Many “bridge to nowhere” situations could potentially be reduced through earlier and more explicit discussions about the goals and limits of treatment.
Before initiating ECMO, clinicians should discuss:
• The intended purpose of the therapy
• The criteria for determining whether it is working
• Whether transplantation is realistically available
• The circumstances under which treatment would be discontinued
• The patient’s preferences regarding prolonged technological support
• The possibility that the patient may survive without recovering sufficiently for transplantation
These discussions do not eliminate uncertainty, but they may prevent families from believing that ECMO guarantees recovery or transplantation.
The Central Ethical Challenge
Technological capability does not automatically establish an ethical obligation to use or continue a treatment.
ECMO and novel organ-recovery procedures can save lives, but they can also create circumstances in which traditional distinctions between life, death, treatment, and organ preservation become less clear.
Ethically responsible care requires transparent consent, careful prognosis, recognition of bias, respect for patient values, institutional oversight, and honest communication about uncertainty.
The challenge is to use these technologies without allowing the ability to support organs or restore regional circulation to replace thoughtful consideration of the patient’s goals, dignity, and best interests.
Thank you to The Daily Dose and the International Anesthesia Research Society for allowing us to summarize this important session.