is open to a stronger and weaker interpretation. on the stronger interpretation "irreversibility" means that spontaneous cardiocirculation "cannot be restored no matter what intervention is done, including cpr." on the weaker interpretation it means that spontaneous cardiocirculation "cannot be restored because cpr efforts have been refused by the patient (as a dnr order in an advance directive), by a surrogate decision-maker or by the medical team because it is not medically indicated." thus the person need not be in a physically irreversible state, but only in a morally or legally irreversible state. on the weaker interpretation, persons declared dead by dcd cardiocirculatory criteria cannot be known to be dead, as it is not always physically impossible to restore circulation by vigorous cpr. the weaker interpretation, however, does allow persons declared dead by dcd criteria to be counted as dead. it is often objected that this interpretation does not accord with the everyday meaning of death. ordinarily we do not think that persons are dead when we have reasons not to revive them, but only when they cannot physically be revived. nonetheless, declaring persons dead for purposes of transplantation by dcd criteria is "accepted medical practice" in many parts of the world, and where it is (as in canada, for example) the legal standard for declaring death is met. the upshot is that we cannot straightforwardly say whether dcd violates the ddr. whether it does or not depends on whether we think this requires that people be dead in the ordinary sense of the word or in a legal or some other understanding of it, and writers are lined up on both sides of this issue. pain and suffering controlled dcd may involve interventions such as vessel cannulation before life-sustaining therapy is withdrawn and death is declared, and may also involve post-mortem interventions such as in situ preservation. uncontrolled dcd may additionally involve chest compressions and mechanical ventilation both before and after consent for dcd is obtained and typically requires the withdrawal of life-sustaining treatment. we know that all of these interventions cause distress to conscious patients who are not taking palliative medications. thus, because patients who are candidates for dcd are not known to be brain dead either before or shortly after they are declared dead by cardiocirculatory criteria, the possibility that they may experience distress must be considered. there are three approaches that have been taken to this possibility of pain and suffering: (1) provide palliative medications where there are physical signs compatible with distress; (2) withhold all such medications on the ground that even if signs of distress are occurring, the patient does not have sufficient cognition to interpret any sensations as noxious; or (3) provide palliative medications prophylactically to prevent any possible distress. whichever approach is adopted, worries have been expressed over whether patients can be guaranteed not to experience any distress. re: (1) providing medication only on signs compatible with distress does not prevent the possibility of distress. re: (2), since patients declared dead by cardiocirculatory criteria cannot be known to be brain dead, dismissing signs compatible with distress as not being distress again does not prevent the possibility of distress. re: (3) physicians may inappropriately withhold sufficient sedative or analgesic medication to avoid the appearance of euthanasia or in order to improve organ viability. there is also the question of whether dcd patients receive compromised end of life (eol) care. the president's council for bioethics has warned that dcd can transform eol care from a "peaceful dignified death" into a profanely "high-tech death" experience for donors and donor's families. icus are not typically set up to provide optimum palliative care. the process of obtaining donation consent and subsequent donor management protocols for dcd deviate from some of the quality indicators recommended for optimal eol care. organ-focused behaviour by professionals requesting consent for organ donation and ambivalent decision making by family members increase the risk of relatives of deceased donors subsequently developing traumatic memories and stress disorders. the processes required for the successful accomplishment of donation consent and subsequent organ recovery can interfere with many of the interventions that lessen the burden of bereavement of relatives of icu decedents. informed consent the standard consent for dcd goes like this. patients or families are told that they will have a chance to say their goodbyes, the patient will then be taken to the operating room, life support will be removed, and after 2–10 minutes of continuously observed absence of pulse, blood pressure, and respiration, death will be declared and the removal of organs begin. consent to this is taken to be consent to organ donation at death determined by cardiocirculatory criteria, i.e., to dcd. the problem is that death is commonly understood as an irreversible state in the strong sense. the commonsense understanding of death is that it is a permanent state, and that if a person has truly died then life cannot be restored to the individual. death understood as an irreversible state in the weak sense—as one that will not be, or ought not to be, or cannot legally or morally be reversed—is on this view a revisionist account of how death can be best conceived rather than an accurate descriptive account of how it actually is commonly understood. given this, when donors consent to donation at death they can only be presumed to be consenting to organ donation when their loved one is in a physically irreversible state. since, however, death determined by cardiocirculatory criteria is not necessarily a physically irreversible state, consent to organ donation at death is not consent to organ donation at death determined by cardiocirculatory criteria. menikoff criticizes the iom for not routinely disclosing to prospective donors and families that and how death determined by cardiocirculatory criteria differs from death in the ordinary sense. in particular, he faults the iom for not telling them that donors will be declared dead before brain death is known to have occurred, and hence they may have their organs removed when portions of the brain (including the higher brain) are still functional. potts et al. on behalf of the iom reply that informed consent does not require this level of disclosure: "reviewing with interested family members that all brain activity may not have ceased at the exact moment that death is pronounced may be appropriate in some circumstances, but, for many families confronted with such overwhelming emotional matters, knowledge that death has been pronounced is what is paramount. the sensitivity and skill of the physicians and nurses to the individual needs of families is the key factor whether or not organ donation is involved." behind this disagreement on what disclosure is required is a larger one that brock has characterized as a choice between "truth or consequences". in brock's view, public policy cannot centre in on the unqualified and unconstrained search for the truth without concern for the consequences of that search. on some occasions "the likely effects on the well-being and rights of the public of exposing the full complexity, ambiguity, uncertainty, and controversy surrounding a particular public policy could be sufficiently adverse and serious to justify not exposing them and presenting the issue in misleading or oversimplified terms instead." brock concludes that "no general answer can be given to truth-or-consequences choices that will hold for all cases. in any particular instance of this choice, we must instead weigh the policy gains against the moral and political risks, and how that balances out will often be empirically uncertain and morally controversial." on the issue at hand, menikoff and brock think that the importance of informed consent should put us on the "truth" side of the question. menikoff writes: "deceiving prospective organ donors about relevant truths concerning their condition is likely, ultimately, to lead to diminished public confidence and to fewer organ donations. but even if it did not reduce the number of donated organs, in a system that is allegedly based on freely given consent, we must recognize that obtaining such consent by telling less than the truth is fundamentally wrong." and brock contends that in a democratic state there is a presumption that the citizens will be informed about all relevant information of public policy, and thinks that dcd involves such a radical change in the timing of death from what people ordinarily think, that it is something that they should be informed about. by contrast, the iom took itself to have the task of addressing the question: "given a potential donor in an end-of-life situation, what are the alternative medical approaches that can be used to maximize the availability of organs from that donor without violating prevailing ethical norms regarding the rights and welfare of donors?" and it replied: "our goal was to support both the interests of patients and families regarding nature and time of death and the public's interests in increased organ procurement. in striking the balance, the expert panel strictly adhered to widely endorsed principles of ethics and established legal and legal guidelines." in thus balancing what is disclosed to the family against what is in the interest of organ procurement, the iom comes down on the "consequences" side of the "truth or consequences" debate. dcd and the future dcd is a procedure that operates in an area set by two rules. the first is the ddr, which says that no vital organs can be taken before the patient is dead. the second, a corollary of this, prohibits killing patients by or for organ procurement. it is not, however, always clear how procedures that are beneficial to transplantation can be fit under those rules. for example, providing ecmo (extra corporeal membrane oxygenation) to donors immediately after death is declared by cardiocirculatory criteria can keep organs in their freshest possible condition. if, however, ecmo provides circulation and oxygenation to the entire body, can the donor really be declared dead by those criteria? the rules can also generate other puzzle cases. if a donor is declared dead by cardiocirculatory criteria, can the heart be transplanted, or does the fact that the heart is started in another negate the determination of death in the first? further such problems are bound to arise in the future. to handle them bernat recommends that a committee be set up: "a consensus-driven oversight process should determine whether investigational protocols reflect appropriate medical treatment and whether their translation into accepted clinical practice is sound public policy. leaders of the critical care, neurology, and transplantation communities need to jointly draft practice guidelines for organ donation after circulatory death that establish acceptable boundaries of practice. these boundaries should be based on scientific data and accepted principles and should be demarcated conservatively to maintain public confidence in the integrity of the transplantation enterprise." others, however, argue that rather than having to either provide answers to these problems that square with the rules in question or forgo advantageous procedures, it would be best to reject those rules. instead of making the question "when is the patient dead?" the central question to trigger organ retrieval, the proposal is to shift the focus to obtaining valid consent from patients or surrogates and the principle of nonmaleficence. as truog explains the proposal: "on this view, policies could be changed such that organ procurement would be permitted only with the consent of the donor or appropriate surrogate and only when doing so would not harm the donor. individuals who could not be harmed by the procedure would include those who are permanently and irreversibly unconscious (patients in a persistent vegetative state or newborns with anencephaly) and those who are imminently and irreversibly dying. qualified individuals who had given their consent could simply have their organs removed under general anesthesia without first undergoing an orchestrated withdrawal of life support. anencephalic newborns whose parents requested organ donation could likewise have the organs removed under general anesthesia without the need to wait for the diagnosis of brain death." this approach has conceptual and pragmatic advantages. on the conceptual side, securing organs at optimum times does not require us to constantly redefine death and when it occurs so that persons who are alive may have their organs taken. it would also allow us to say that when a physician removes life-support and the patient dies that the physician caused patient's death. many think this is more