In reply: The issues raised by Rady and colleagues, Tibballs, and Kennedy include claims that antemortem interventions for organ donation after cardiac death (DCD) are harmful, involve inadequate consent procedures, and require abandoning the “dead donor rule”.

To clarify, we advocate the use of antemortem heparin in people with a known desire to be organ donors; we do not advocate potentially harmful or disruptive interventions such as femoral vessel cannulation.

Rady and colleagues cite their recent article1 to support the claim that antemortem interventions are harmful. However, that article makes no reference to antemortem interventions such as heparin hastening death. In contrast, Bernat et al clearly state:

This position is supported by international evidence-based protocols that advocate the use of antemortem heparin, such as those from Britain3 and Canada.4

Rady and colleagues’ claim that antemortem interventions are criminal in the United States seems to relate to a US surgeon who was charged with murder after allegedly administering 200 mg of morphine and 80 mg of lorazepam to hasten patient death in a failed DCD case.5 These drugs are standardly used in therapeutic doses for end-of-life care. Our proposal supports best practice end-of-life care; we do not suggest this care should be delivered by the transplant surgeon. The example of one apparent rogue practitioner is not evidence that antemortem interventions are unethical.

We agree with Tibballs that the wishes of the patient constitute only one of many elements listed in the various Guardianship Acts that should be taken into account when determining best interests. However, we are aiming at the spirit of the law rather than the narrower “black letter” view, as this ignores the situation of dying patients whose physical interests are extremely limited, leaving their wishes as the final expression of their humanity.

With respect to Tibballs’ assertion that Airedale NHS Trust v Bland is not law in Australia, we acknowledge that it is not binding, but the persuasiveness of the judicial reasoning of the House of Lords has been well recognised and has provided guidance and been cited with approval in numerous decisions in Australia. Recent examples include Harriton v Stevens6 and Application of Herrington, re King.7

In relation to Kennedy’s comments about Northridge v Central Sydney Area Health Service, this difficult case (in which there was disagreement between hospital doctors and the patient’s family about treatment withdrawal) can be distinguished from our argument. We do not advocate acting contrary to the wishes of a patient’s family members. With DCD, the decision to withdraw treatment is made by the family and treating doctors independently of and before any discussions about donation. We recognise the potential psychological stresses involved in caring for patients in this situation. Clarity about what is legally and ethically acceptable, and clear separation of decisions to withdraw treatment from discussions about donation may help to alleviate some of this stress.

We do not advocate hastening or redefining death, nor do we suggest abandoning informed consent. We believe, for the reasons given in our article, that non-harmful antemortem interventions are legally and ethically justifiable.8