When "Dead Enough" Becomes a Metric

How Performance Metrics Are Corrupting Medicine's Most Sacred Threshold

The heart monitor flatlines. The family weeps. The doctors wait exactly 75 seconds—then restart the procedure. In the world of organ transplants, "dead enough" has become a moving target.

The New York Times just reported something most people aren't ready to hear: in the rush to expand organ transplants, procurement teams have sometimes started too early. Not after death—before it was fully established.

This isn't just investigative journalism anymore—it's official. In July, the U.S. Department of Health and Human Services released the results of a federal investigation into the transplant system. Their words, not mine: "Hospitals allowed the organ procurement process to begin when patients showed signs of life, and this is horrifying," declared HHS Secretary Robert F. Kennedy, Jr. The federal report found at least 28 patients may not have been dead when organ removal began.

This is happening under a protocol called donation after circulatory death (DCD). It's fundamentally different from the more established practice of donation after brain death, where patients have irreversibly lost all brain function and are kept on machines only to maintain their organs. DCD patients still have some brain activity—they're dying, but not yet dead. Doctors determine they're near death and won't recover, but that's a medical judgment call, not biological certainty.

DCD used to be rare. Now it accounts for a huge and growing share of transplants. Every day, 13 people perish waiting for organs that never come. That urgency is real, and it explains why the system feels pressure to expand every possible avenue for donation. But saving lives by potentially taking them prematurely isn't salvation—it's a different kind of death sentence.

This is not a debate about whether transplants save lives—they do. It's about something more fundamental: the line between life and death being treated as a flexible scheduling variable.

The Sacred Threshold

Death has always been humanity's most profound mystery—the ultimate divide between being and non-being, consciousness and void. Modern medicine promised precision: neurological death, cardiac arrest, clinical criteria that could mark the exact moment when a person becomes a body.

But when death becomes a protocol instead of an ontological reality, something essential is lost. As philosopher Ivan Illich argued, when a culture medicalizes every boundary—birth, death, even meaning—it loses its ability to navigate those distinctions without institutional permission.

We're talking about the moment a human being ceases to exist as a conscious entity and becomes, in the system's calculus, a collection of harvestable parts.

The problem runs deeper than protocols. As bioethicist Charles Camosy observes, contemporary medicine finds itself in "an intellectually embarrassing place: medics and others who haven't thought these matters through and have virtually no training in serious philosophy/theology are making up their moral anthropology as they go to achieve the desired organ outcome." When institutions start optimizing fundamental principles, they lose any coherent framework for understanding what they're actually doing.

When Reflexes Become "Meaningless"

If the definition of "dead enough" becomes negotiable, we've already lost the plot. The donor designation on your driver's license represents more than medical consent—it's a spiritual contract about what happens to the vessel that carried your consciousness through life.

One patient pulled his knees to his chest while being prepped for organ removal, only to have medical staff dismiss it as "meaningless reflexes." In Alabama, Misty Hawkins was wheeled into surgery after being declared dead, but when surgeons made their first incision, they found her heart moving, her chest rising and falling with "gasping respirations." They were slicing into her while she was alive.

Meaningless to whom? In that gesture—that involuntary pulling inward, in that beating heart discovered too late—lies the fundamental question: What if something essential still inhabits that body? What if the divide between life and death isn't a clean line but a liminal space we're rushing through too quickly?

The Incentive Machine

Follow the incentives, but also follow the metaphysics. When hospitals are graded on "conversion rates"—a term that would make both a used car salesman and a theologian blush—they're measuring how efficiently they transform dying humans into spare parts. OPOs have federal contracts to keep, their performance judged on throughput.

The numbers tell the story: donation after circulatory death has tripled since Trump's 2019 executive order. Nearly 20% of organs now skip the official waiting list entirely, up from 3% in 2020. Fifty-five medical workers across 19 states have witnessed disturbing cases. In Kentucky alone, federal investigators found 73 patients with "neurological signs incompatible with organ donation" who were still being prepared for harvesting.

When you measure the system that way, "more and faster" becomes a worldview that redefines the threshold between life and death for operational efficiency. Incentives that start as life-saving quickly metastasize into production quotas.

The Human Cost

As one surgical technician told The New York Times after watching a crying, responsive patient sedated and removed from life support: "I felt like if she had been given more time on the ventilator, she could have pulled through. I felt like I was part of killing someone." She quit her job afterward, traumatized by participating in what felt like institutional murder disguised as medical protocol.

The risk isn't hypothetical—it's ontological. First the protocol says two minutes without a pulse. Then it's 75 seconds. Then it's "sufficiently non-responsive." Each time we shave seconds off the waiting period, we're not just adjusting medical protocols—we're redefining what it means to be dead. We're treating the mystery of consciousness as if it were a software bug to be optimized away.

This isn't just a transplant problem—it's the operating system of modern institutions. We saw it during COVID, when case definitions for hospitalizations varied dramatically based on different criteria, generating wildly different case counts depending on which metrics institutions chose to emphasize. We saw it in nursing homes, where Medicare payment rules force families to choose between skilled nursing care and hospice services, pushing life-and-death decisions toward the most administratively convenient outcome. We see it in pharmaceutical approvals, where the FDA's accelerated approval pathway has come under fire for approving drugs based on surrogate endpoints rather than proven clinical benefit, with confirmatory trials often delayed and some drugs later proven ineffective.

The Erosion of Trust

Trust isn't built by press releases. It's built by honoring the profound weight of what we're asking families to navigate. Once the public believes this divide—this boundary between metrics and meaning—is being handled cavalierly, they'll stop signing up as donors. In Arkansas, organ donation advocates are already suing to block a new law that requires family authorization even when someone is a registered donor—a sign that public trust is already fracturing.

Without trust in the sanctity of the process, the system designed to save lives collapses under the weight of its own utilitarian shortcuts. That makes everyone worse off: the people who might have received those organs, the doctors who follow the rules, the families who might have chosen donation under circumstances that respected both the clinical and metaphysical dimensions of death.

What This Reveals

These aren't problems that can be solved within the current system because the current system is the problem. Once you've created institutions that measure "conversion rates" for human death, you've already crossed a line that can't be uncrossed through regulation.

Such reverence can't be bureaucratized back into existence. You can't write protocols that restore the mystery of consciousness or create metrics that honor the metaphysical weight of mortality. The corruption isn't in the implementation—it's in the very idea that this division can be standardized, optimized, and administered by institutions with performance targets.

What we're witnessing isn't a series of medical errors to be corrected, but evidence of a civilizational shift that's already happened. We've moved from a culture that approached mortality with awe and uncertainty to one that treats it as an operational challenge to be managed efficiently. The countdown isn't just starting—we're already deep into it.

Body Sovereignty as Spiritual Sovereignty

At its core, this isn't about transplant science. It's about sovereignty over the body and soul at the most vulnerable moment of all. The legitimacy of the transplant apparatus rests entirely on the public's belief that determinations of mortality honor both biological reality and metaphysical mystery—that the moment of transition is marked with precision, consistency, and zero institutional self-interest.

Every donor registry signature represents a final act of trust—that medicine will honor both life and death with equal reverence, that the frontier between existence and non-existence will be treated as inviolable rather than convenient. Break that trust, and no number of procurement reforms will solve the organ shortage. It will be solved by empty registries and closed caskets.

That legitimacy is fragile because it touches something deeper than healthcare—our fundamental beliefs about consciousness, identity, and what it means to be human. It can't be bought with PR. It can only be earned through transparency, accountability, and an unflinching commitment to honoring the mystery we're navigating.

If "dead enough" becomes a metric, the countdown has already started—not just for the patient, but for our collective faith in medicine's ability to serve something higher than its own efficiency. Because once we accept dying as a managerial decision rather than a spiritual reality, we're no longer just optimizing a framework—we're reprogramming the moral code of civilization itself.

Civilizations don't survive long when they forget what matters most—and when they do, the harvest always comes. First for the body, then for the soul.

When the sacred is subordinated to the schedule, it's not only bodies that are harvested.