you are an intensivist in an institution that performs solid organ transplantations . in an effort to provide patients and families with increased opportunities to donate their organs , the institution has recently developed a policy for donation after cardiac death ( dcd ) . with the new dcd policy , organ donation is offered to patients and their families in a controlled setting when death occurs immediately following the withdrawal of life - support . based on your understanding of organ donation , you are aware there are certain medications ( for example , inotropes to maintain tissue perfusion ) and certain management practices that may allow the donated organs to have better outcome . you wonder about the ethics of starting interventions that will have no benefit to the dying patient but will benefit the organs that are about to be donated . jason phua and tow keang lim what medications and interventions are started in potential donors before death for the sole purpose of making the organs more viable in dcd , and how do they affect organ function ? firstly , inotropes and vasopressors are crucial for the preservation of organ perfusion in patients in shock . the majority of potential donors are hypotensive before cardiac death , and hypotension worsens graft function . secondly , anticoagulants such as heparin decrease the risk of thrombosis after the circulatory arrest and the negative consequences on organ function . to maximize effectiveness , heparin thirdly , vasodilators such as phentolamine may enhance organ blood flow and lower the incidence of delayed renal graft function . more controversial practices are the administration of thrombolytics and antemortem cannulation in preparation for the administration of cold preservation solution . although rarely performed in europe , these practices are endorsed by major american and canadian transplantation and ethical guidelines [ 3,7 - 9 ] . indeed , most american dcd centres consider heparin administration at the time of withdrawal of life - sustaining treatment as the current standard of care . the acceptability of these practices should be evaluated according to beauchamp and childress ' four moral principles . as far as beneficence is concerned , none of these practices benefit the donors , at least not physically , since they will die regardless of the treatment provided . most of the opposition to these practices , however , stems from the second principle of nonmaleficence . there is concern that anticoagulants and thrombolytics may cause bleeding and that vasodilators may cause hypotension  and therefore hasten death . nevertheless , there is no evidence that heparin leads to sufficient bleeding after the withdrawal of life - sustaining therapies to cause death . the guidelines , however , do state that heparin should only be used in patients with low bleeding risks , and phentolamine should only be used in patients without significant hypotension . the most important moral principle in dcd , however , is arguably that of autonomy . if the potential donor or his / her designate gives informed consent for these organ - preserving measures with a clear understanding of their possible side effects , who are healthcare professionals to object ? critics point to the lack of large randomized controlled trials to validate these measures . as the data available are very suggestive , however , while we await these trials ( which may never be performed ) the onus is on us to institute these measures to prevent any organs from going to waste . this is all the more crucial when one considers the last moral principle of justice , and the fact that these organs are a scarce resource . to conclude , we believe that starting certain medications and interventions such as inotropes , vasopressors , heparin and phentolamine in potential donors for the sole purpose of making the organs in dcd more viable is an acceptable practice , provided they are used in patients with a low risk for side effects and that informed consent is provided . david a zygun and christopher j doig the ethical principle of the ' rule of double effect ' provides moral justification for the provision of certain forms of care at the end of life that result in death . a practical example of this principle is the use of narcotics for pain relief , although respiratory depression and death are potential consequences . application of this principle requires all four conditions to be met : the act must not belong to a category of acts considered evil ; the good effect ( for the patient ) , and not the bad effect , must be intended ; the bad effect must not be a means to the good effect ; and there must be a proportionally good reason for bringing about the bad effect . this principle has also been used to justify antemortem interventions in dcd , but do these interventions meet these necessary elements ? the benefit of dcd is primarily to organ recipients and society [ 13 - 15 ] . this is evident in the published literature , where the common justification for dcd is to increase the supply of organs . furthermore , the organ most likely to be recovered in dcd is the kidney , which will result in significant cost savings to healthcare systems by removing a patient from dialysis . although there are some data that families may gain benefit from dcd , such as avoidance of delayed regret for missing the opportunity to donate organs   or the desire that donation will ease their grief , these reasons are also not for the benefit of the patient . is there potential harm to the donor ( a hastening of death as a primary consequence ) ? most dcd donors are individuals with neurological injury , and heparin poses more than a theoretical risk of precipitating or exacerbating intracranial haemorrhage and hastening death . phentolamine , a potent vasodilator , may precariously decrease blood pressure and hasten haemodynamic collapse in any icu patient , and would be particularly harmful in a patient with impaired cerebral autoregulation . there are other interventions that might also be considered , such as intravenous fluid administration to maintain urine output ( would this be acceptable if the patient has concomitant hydrostatic pulmonary oedema ? ) . simply , none of these interventions would be reasonably provided outside the setting of dcd , all are credibly associated with potential harm to the dying patient , and the perceived benefit of dcd may be directly gained through the harm caused ( a more rapid death ) . the principle of ' double effect ' is suggested as an appropriate ethical framework to support antemortem interventions in dcd donors . the requisite elements of this principle are not met , and this principle can not be used as a moral justification . as such , antemortem interventions with a risk to harm the patient violate the moral duty to ' first do no harm ' , and should not be condoned . finally , invoking the principle of double effect places this principle in jeopardy as a reasonable justification for many appropriate interventions in palliative care treatment ; if this principle is brought into disrepute , it may be harmful to palliative care patients , society and the practice of medicine . jason phua and tow keang lim some argue that by facilitating a successful dcd such antemortem interventions benefit the donor by fulfilling his / her wishes , benefit the donor 's family by easing their grief , and benefit the recipient . we propose that instead of focusing on this doctrine , these interventions should be evaluated according to beauchamp and childress ' moral principles . we reiterate that any bad effects of heparin and phentolamine must not be exaggerated without medical evidence . these interventions benefit dcd by improving organ viability , not by causing ' a more rapid death ' . david a zygun and christopher j doig violation of the principle of beneficence has been acknowledged . with nonmaleficence , absence of evidence of harm does not equal proof of absence of harm ; the incidence of harm from heparin is credible and has not been systematically examined . a standard of practice to use heparin without good clinical evidence of benefit and lacking measurement of potential harm is not a credible argument . most potential dcd candidates are not competent to consent . families as proxy are not acting in the patient 's autonomous interest in consenting to treatment that will not benefit and may harm the patient , irrespective of benefit of family or another third party ( society , organ recipient ) . importantly , the statement ' they will die regardless of the treatment ' is not factual . finally , justice requires an equal share of not only benefits , but also of burden . given premortem intervention requires the dying patient to solely bear the burden ; justice can not be elicited to support such interventions .