Can You Restart the Heart and Still Call It Death? TA-NRP and 'Irreversibility'

Thoraco-abdominal normothermic regional perfusion (TA-NRP) is a technique used in organ donation after circulatory death. After death has been declared and a five-minute observation period has lapsed, blood flow is recirculated to the organs in the chest and abdomen to improve their condition for transplantation. Although medically promising, the procedure raises a fundamental question: if circulation can be restored after death has been declared, was its cessation truly irreversible?

What Australian Law Says

In Australia, death is defined by statute, and the definitions are state and territory based. In Queensland, s 45 of the Transplantation and Anatomy Act 1979 (Qld) establishes death on two criteria: the irreversible cessation of blood circulation or all function brain. Other jurisdictions use materially similar language, for example s 33 of the Human Tissue Act 1983 (NSW).

The key word is “irreversible”. The legislation does not ask whether circulation will not be restored. It asks whether it cannot be. That is exactly where TA-NRP creates legal tension: if physicians can recirculate blood flow after death has been declared, it is hard to say the earlier cessation was irreversible in the strict sense the statute uses. The procedure therefore challenges how the legal definition of death should be understood when circulation is restarted. 

Irreversible vs Permanent

Irreversibility asks whether circulation could physically be restored. Permanence asks whether it will in fact be restored, because a settled decision has been made not to attempt it.  Bernat argues that permanence can work as proxy to irreversibility. Take a patient whose life-sustaining treatment is withdrawn and whose heart stops. CPR could technically restart it, but if a decision has already been made not to resuscitate, circulation will not return. On this view the cessation is permanent even though it remains biologically reversible.

This opens a path for defending TA-NRP. Restoring blood to selected organs does not automatically undo the earlier determination of death, provided the condition on which that determination rested stays permanent. The further question is therefore what that condition must include.

Why the Brain Matters 

If TA-NRP sent oxygenated blood to the brain, some cerebral function might return, and that would threaten the basis on which death was declared based on the cerebral criteria. This is not a purely theoretical concern. A 2019 study restored circulation to pig brains four hours after death and found cellular, metabolic and vascular function returning, although the organised electrical activity associated with consciousness did not appear. The study does not show that a human donor could be revived, but it does undercut the assumption that restoring blood to a dead brain is biologically meaningless.

So cerebral occlusion becomes the linchpin. In TA-NRP, the vessels supplying the brain are clamped so that restored circulation cannot reach it. Manara and colleagues argue that regional circulation is consistent with the permanence principle as long as cerebral perfusion stays excluded. On this view the clamp does not establish death. It preserves the condition on which death had already been determined.

Does Clamping Cause or Maintain Death?

Critics respond that the clamp is an active intervention. Without it, blood might reach the brain and some function might return, so physicians appear to be causing the absence of cerebral function rather than merely observing it.

Defenders offer a few replies. Courtwright distinguishes between causing a death and failing to prevent one that was going to occur anyway. If resuscitation had already been independently ruled out, the brain would never have been reperfused even if TA-NRP had not existed, and the clamp prevents a biological possibility rather than withholding treatment that would otherwise have been given. Truog and Doernberg add an analogy with ex situ perfusion, where organs removed from a deceased donor are perfused on a machine without anyone describing it as resuscitating the donor. Restoring biological activity to organs is not the same as restoring the person as a functioning organism, and an organ’s location inside the body does not change that.

Torts case law prove useful here. In Royall v The Queen, the High Court declined to treat causation as a purely “but for” inquiry and asked instead whether the conduct was a substantial or operating cause of the outcome. Applied to TA-NRP, it is not enough to ask whether the brain could have received blood without the clamp. We have to look at the whole chain of events. If death was validly determined independently of organ donation, the clamp appears less like the operating cause of death.

The Limits of Intention

It is tempting to rest the defence on intention: the physicians intend to preserve organs, not to cause death. Parent make a version of this argument, stressing that the decision not to resuscitate is separate from the later decision to recover organs.

I think intention carries less weight than it first appears. An intention to preserve organs cannot change the physical effect of preventing blood from reaching the brain, and critics rightly point out that the argument works only if the separation between withdrawal and donation is genuine. A physician’s statement of purpose does not prove that independence. Where alternatives such as ex situ machine perfusion can preserve organs without these concerns, critics add that there is a reason to prefer them. Intention does not settle whether the clamp causes death. Its real role is to help establish the circumstances in which the stronger causation argument becomes available.

The Circularity Trap

Everything turns on one condition: that the decision to withdraw treatment and not resuscitate was truly independent of organ donation. If that decision was influenced by the prospect of TA-NRP, the argument becomes circular. Physicians would be relying on the decision not to resuscitate to establish permanence, then relying on permanence to justify the clamp. Omelianchuk and others press exactly this point, and it is a definitely a strong point.

That is why a workable defence of TA-NRP depends on safeguards rather than philosophy alone. These include separating the treating and procurement teams, making treatment decisions before donation is considered, and keeping a clear sequence between the determination of death and the start of TA-NRP. Where these conditions are met, there is a principled basis for saying the clamp maintains a death already determined. Where they are not, the claim that physicians merely “maintain” death becomes much harder to defend.

What Remains Uncertain

Even with cerebral perfusion excluded, uncertainty remains. Evidence that cellular and metabolic functions can return after prolonged circulatory arrest raises questions about what we can infer from restored biological activity elsewhere in the body. And whether permanence is enough under statutes like Queensland’s, which demand “irreversible” cessation, is a separate question that this analysis does not answer.

In my view, the permanence approach, offers a plausible framework rather than a final resolution. It explains how TA-NRP may coexist with a valid determination of death, but only under demanding conditions: the brain stays unperfused, and the decision not to resuscitate is genuinely independent of transplantation. Whether those conditions can be reliably met in practice is the question that law, medicine and ethics still need to be explored and answered. 

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