Introduction
In medicine, technology can refer to anything from antibiotics like penicillin used to treat everyday infections and antivirals that suppress HIV, to dialysis circuits and cardiopulmonary bypass pumps. More broadly, technology is the machinery and methods developed through scientific knowledge to solve practical problems. Organ transplant—the act of removing organs from one person’s body to restore life in another—has, since its inception, depended on technology.
The first successful kidney transplant was performed in 1954 by Dr. Joseph Murray at Brigham Hospital in Boston. Because the donor and recipient were identical twins, the challenge of immunologic compatibility was easily overcome. Yet the case raised questions about what happens when donor and recipient are not genetically identical, as well as from where organs can be obtained if not from living donors. Over the following decades, technological and medical breakthroughs transformed the field. Mechanical ventilation made it possible to maintain donors long enough for organ recovery and immunosuppressive therapies made long-term graft survival between non-genetically identical persons feasible.
Today, complex computer-based logistics systems, portable perfusion platforms, and novel preservation techniques keep organs viable across greater distances and longer spans of time than ever before. The present inflection point is that, while exciting, new technology is being innovated and applied at a dramatic pace. The implementation of new technology in transplant is not only occurring quickly, but it is doing so with little discussion or input by the lay community, and virtually no oversight or regulation.
Technology in Transplant: Expanding the Possible
Modern transplantation stands at a remarkable point in its technological evolution. Devices and practices that once seemed experimental are now routine. Among them include normothermic regional perfusion (NRP) and the use of ex vivo machine perfusion, two methods that have dramatically changed how organs are recovered, evaluated, and preserved for transport. These tools allow organs that might once have been discarded to be transplanted successfully, increasing organ availability and improving outcomes. And more recently, enzyme converting technology has been shown to alter the blood type of donor organs while in transit to their recipient.
NRP, in particular, has become a central practice for donors after circulatory death (DCD), or donors who do not meet criteria for brain death but from whom organs can still be recovered once the heart and lungs stop functioning. In its simplest form, NRP involves inserts cannulas into the major blood vessels while selectively clamping others, to control which regions of the body are re-perfused and connecting the donor’s body to an external circuit that oxygenates and circulates blood. (See figure 1.) The goal is to restore flow to certain organs—typically those in the abdomen and/or thoracic regions—to reduce ischemic injury and assess viability before transplantation.
Figure 1
In its least controversial form, abdominal NRP (A-NRP), the practice involves re-perfusing the abdominal organs for a period of time after cardiac death has been declared. In such instances, the patient is declared cardiac dead, and remains cardiac dead as the chest region—including the heart—is not re-perfused with oxygenated blood. Rather, re-perfusion is isolated to the abdomen for the recovery of the liver and kidneys. Thoraco-abdominal NRP (TA-NRP), on the other hand, extends this principle further, re-establishing perfusion not only to the abdominal but also to the thoracic organs, including the heart. This makes possible the recovery of high-quality hearts and lungs from DCD donors. Notably, is that under TA-NRP, like with A-NRP, patients are declared cardiac dead. However, the aim of TA-NRP is to intentionally restart and perfuse the heart with oxygenated blood. At the same time under TA-NRP, oxygenated blood is intentionally prevented from perfusing the brain so as to maintain a declaration of death.
Portable perfusion systems preserve, assess, and maintain organs after recovery and while in transit to their recipient’s hospital. One company, TransMedics, developed organ care systems (OCS) which enable the heart, lungs, and liver to be rehabilitated and maintained in a near-physiologic state. (See figure 2). Other biotech companies like Paragonix have focused on replacing the standard use of cold ice for storing organs, developing devices which maintain organs at a constant temperature for long periods of time. These technologies have transformed DCD organ recovery and cold storage logistics into dynamic, data-rich platforms.
Figure 2
These innovations address scarcity by “rescuing” marginal organs, reducing the time organs spend deprived of oxygen, and opening national sharing pathways that were logistically implausible a decade ago. As an example, it is not uncommon today for a patient in Philadelphia to receive lungs from an organ donor originating on the west coast of the United States. However, while doing so, they are not without controversy and objections have been raised, particularly in the case of TA-NRP.
Ethical and Philosophical Tensions
Despite the potential possibilities for technology in transplant, its power brings a perennial philosophical challenge, that of maintaining boundaries between technology that aids and technology that obscures. To aid means to serve as a tool that enhances human flourishing, respects persons, and supports clinical ends without distorting moral visibility. To obscure occurs when devices and data abstracts persons from view, donors become mere supplies of organs, the recipient a mechanical platform for graft performance, and the organ itself a fungible object in circulation.
The recent widespread use of NRP in DCD donation has renewed long-standing debates about the moral and conceptual foundations of death determination. In standard DCD protocols, the irreversible cessation of circulation and respiratory function marks the legal and ethical threshold for death. NRP, however, deliberately restores circulation to selection regions of the donor’s body through ex vivo circuitry after death has been declared, in order to perfuse organs and improve their viability. While increasing the potential of organs from DCD donors for transplant, it also intensifies the moral tension brought on by NRP. Once circulation and oxygenation are restored under TA-NRP, even if vessels leading to the brain are clamped to prevent cerebral reperfusion, the body appears physiologically “alive” on the basis of a beating heart. For clinicians and families alike, the visual and tactile experience of a beating heart within a “cardiac death” donor body destabilizes the ordinary boundaries between life and death.
The practice of TA-NRP raises several difficult, interconnected philosophical and moral questions. Ontologically, it asks whether in the setting of circulatory death the restoration of circulation, even with the exclusion of the brain, can undermine the claim that death is irreversible. Or whether the person’s death is secure so long as consciousness and integrated brain function cannot return. Epistemically, TA-NRP asks if clinicians can confidently assert that death remains irreversible when extracorporeal circulation is re-initiated. It would seem that under current conceptions of death, TA-NRP blurs the distinction between biological activity and personal life. Morally speaking, TA-NRP asks whether such practices respect the dignity of the donor, or whether it risks instrumentalizing the body as a means for organ recovery.
Proponents of NRP argue that it simply restores regional perfusion to organs that would otherwise deteriorate, that the person has already died, and that cerebral exclusion guarantees that no recovery of personhood is possible. Critics, however, see the act of re-animating the thoraco-abdominal circulation as a symbolic and practical violation of the dead donor rule (DDR), or the principle that vital organs should only be taken from patients who are already dead. The worry that the procedural complexity and visible animation of the donor’s body risk confusing families, eroding trust, and transforming the human body into an experimental substrate; and this worry is real. In my own personal experience, hospital staff are reporting a moral distress about TA-NRP. Several have said they feel pressured by OPOs to participate in procedures that they do not fully understand or morally endorse. This discomfort is not about a lack of compassion for those awaiting transplant, but instead reflects a deeper unease with how far technology can stretch the boundaries of human meaning.
Philosophically, TA-NRP exposes what might be called technological moral ambiguity. It clearly aids transplantation by improving graft quality and saving more lives, yet it also risks obscuring the moral reality of death and personhood. The danger is not only in what it does but also in its suggesting that human life can be paused, partitioned, and restarted regionally, that personhood is divisible into organ systems, and that technology can seesaw between states of life and death as though they were adjustable settings of a machine.
The Moral Biography of Organs
One way to clarify this boundary can be adopted from anthropology. Igor Kopytoff’s idea of the cultural biography of things and related notions on the “promiscuity” of objects reminds us that artifacts, including human organs, carry histories as they move across social worlds.[v] Organs, though biological, are also profoundly social. They originate from the life of one person, pass through the institutional and technical systems that make organ donation and transplantation possible, and come to sustain the life of another person.
A donor organ is never inert cargo. Human organs donated for transplant bear their donor’s story, the conditions of their death, the consent process, and the hopes and grief of their family. It embodies the labor of the organ procurement organization, the logistical choreography of preservation and transport, and the clinical skill of the transplant team. When transplanted, it becomes part of the recipient’s biological and personal identity, an experience that can be perceived by recipients as both gift and burden; as self and other.
To say that organs have histories is to acknowledge that transplant is not merely an exchange of biological parts but a deeply meaningful relational act. Organs traverse moral, emotional, and institutional domains, accumulating meanings at each stage. They link the lives of donor and recipient, family and clinician, and of medicine and society. Technologies like TA-NRP and machine perfusion make these passages longer, more complex, and more visible, but they also risk objectifying the organ by reducing its biography to a data set of perfusion pressures, flow rates, and ischemic times.
Toward a Balanced Future
Transplant, at its best, exemplifies both the promise and peril of modern medicine. It is a domain where technological mastery meets moral vulnerability; where lives are saved through the death of others, and where the body’s boundaries are continually reimagined.
A just and ethically grounded future in transplant will require attention to both sides of the equation, both the technological and the human. The field should adopt a person-first test for new technologies that asks not only whether an innovation works, but whether it preserves dignity, transparency, and trust. Donor-side advances like NRP and machine perfusion should be balanced with recipient-side innovation like improving support for highly immunologically-sensitized patients, reducing the toxicities of immunosuppressant medications, and using predictive technologies to enhance post-transplant quality of life.
When technology threatens to render the organ anonymous, reflection on its moral biography can restore the human story that gives transplant its ethical meaning. Organs are not merely biological materials, they are vessels of continuity that carry human relationships across the boundaries of death. If we can hold onto that awareness, then the technological future of transplant will not only save more lives but continue to also honor them.
