and the responses they have engendered are identified and addressed later in this report on the medical and ethical issues in procuring organs for transplantation. They are also the ones that have occupied the biomedical and ethics communities in clinical and research efforts to solve them. These issues are particularly salient in the NHBD because interventions in the heart-beating donor occur in a brain-dead cadaver, and the living donor involves an autonomous, consenting person for whom every effort in his or her care is addressed toward a healthy, medically uncompromised survival.

There is a relentlessly increasing need for organs for patients with life-threatening organ failures that requires the recruitment of donors and timely intervention to obtain the donated organs in the best possible transplantable condition. Delay because of insufficient organ supply proves fatal to one-third of waiting heart and liver recipients. The total number of waiting list deaths now exceeds 4,000 each year, and for all those waiting, morbidity, pain, depression, and economic costs are a constant part of their lives (Perkins, 1987; UNOS, 1996; Youngner and Arnold, 1993).

At the same time, persons who have been or may be designated as donors have, during a final illness, rights to health care that meets appropriate, prevailing medical and ethical standards (Sadler et al., 1968). This care must promote the individual's welfare and provide the best chance for recovery, no matter how small, or for a death with as much comfort and dignity as possible. Any exceptions to the principle that decisions about, and the administration of, health care should be separate from, and uninfluenced by, any considerations of transplantation must be explicit, ethical, and subject to informed consent. Donor patients must not be killed or their death hastened by the taking of organs (the "dead donor rule," which operationally has meant that donors must be dead before donation). Furthermore, their welfare and care must not be compromised by preparation for organ retrieval, and the sensitivity and grief of family and friends must be respected. These considerations and principles apply to all kinds of cadaver donors, and they must be preserved in the face of the interventions desirable to obtain organs in the best transplantable condition. The best organs are those that are perfused by warm, oxygenated blood up to the very moment of their removal from the donor's body. These conditions are met only in heart-beating—that is, living and brain-dead—donors. Attempts to approach or simulate these ideal conditions for recovery of organs from NHBDs, therefore, pose challenges that are complex and in certain respects different from those of other donors.

The preferred NHBD in the United States is the "controlled" NHBD. Those caring for and carrying out transplantation from controlled NHBDs must manage patients with severe injury or disease, usually involving the brain, who do not meet the legal test for death by neurologic criteria and whose cardiopulmonary function has been resuscitated or is being supported through medical technology. Physicians must maintain as normal as possible blood and oxygen supply



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