The transplantation program in the US is an altruistic program based on the premise that organ donation is a gift, and relying on ethical principles of autonomy, respect for persons (beneficence, nonmaleficence), and justice. Organ donation after cardiac death (DCD) is controversial because it combines two ethically complex events: withdrawal of life-supportive therapies as part of end-of-life care of the dying patient, and the altruistic gift of organ donation. Firewalls should separate the three key decisions involved in DCD: the decision to forgo resuscitation, the decision to withdraw life-sustaining therapies, and the decision to donate organs after death. The dead donor rule presents ethical problems for expansions of DCD, and some legislative and practice changes to counteract these limitations may have presented even greater ethical problems than the dead donor rule itself. Resolving conflicts in the DCD process may require revisiting the dead donor rule.