To the Editor, As a former medical director of lung transplantation and ICU physician for 30 years, I know, firsthand, the importance of maximizing organ donation for dying patients. This must always be done with utmost respect for the life of the donor. I believe some of the arguments and assertions made by Parent et al.1Parent B Caplan A Moazami N Montgomery RA. Response to American College of Physician’s statement on the ethics of transplant after normothermic regional perfusion.Am J Transplant. 2022; (10.1111/ajt.16947): 1-4Google Scholar on normothermic regional perfusion (NRP) are worthy of scrutiny and deeper conversation. The authors challenge the “statement of concern” regarding NRP published in 2021 by the American College of Physicians (ACP).2American College of Physicians Ethics, determination of death, and organ transplantation in normothermic regional perfusion (NRP) with controlled donation after circulatory determination of death (cDCD): American College of Physicians Statement of Concern. https://www.acponline.org/acp_policy/policies/ethics_determination_of_death_and_organ_transplantation_in_nrp_2021.pdf. Published 2021. Accessed February 12, 2022.Google Scholar The authors explain that the practice of controlled Donation after Circulatory Determination of Death using NRP (cDCD NRP) is well established in many countries. Yet the ethical boundaries of this practice must be considered in the context of each country’s legal definition of death and the dead donor rule. Confusion, in my opinion, revolves around the ambiguity of the use of the terms circulation and resuscitation. Generally, when we use extracorporeal membrane oxygenation (ECMO) to supply the human body with systemic circulation, it is for the purpose of resuscitation and sustaining life. In the circumstances of use of ECMO for NRP, are these two practices suddenly completely distinct? The crux of the authors’ argument is that the person has been declared dead, and, therefore, the re-establishment of systemic circulation is only to preserve the organs and save them from warm ischemic injury. Yet part of the procedure is to add the unique intervention of occlusion of cerebral circulation to prevent the possibility of neuronal activity in the brain, which would obviously create (as the authors write) “questions around the circulatory determination of death.” Precisely. The dead donor rule (DDR) states that a patient cannot be killed by, or for, organ procurement. To justify this added procedure of clamping circulation to the brain itself, the authors feel compelled to explain: “The brain remains a ‘black box’ and the degree or extent of neuronal death cannot be ascertained.” The clamping of circulation is obviously to ensure brain death, yet the authors repeatedly state the DDR is not violated because the patient has been declared dead. Because brain death is, by definition, the cessation of all brain activity, is not this “circulatory” logic? A tautology? Is the re-establishment of circulation a violation of the donor’s DNR order? Indeed, one could argue that with systemic circulation re-established and a question of ongoing neuronal activity (as posed by the authors), the donor could at that point even be sent back to the ICU to determine brain activity over the next 24 to 48 h, as is common practice when we are attempting to establish brain death. Do the authors believe that a procedure to clamp cerebral circulation to cut-off flow to a human brain is worthy of a great deal more consideration before we “update the legal definition of death?” The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.