Donation after cardiac death (DCD) entails removing a patient’s life-support in the operating room in order to facilitate organ harvest as soon as possible after death has been pronounced. Although not a new procedure, the practice of DCD is on the upswing in the U.S. in an attempt to increase the availability of organs for transplantation. The United Network for Organ Sharing (UNOS) estimates that on average 18 people die each day waiting for an organ. In order to support the push to expand the pool of possible donors, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has mandated that all accredited hospitals must have DCD policies by January 1, 2007. Currently only performed at high-volume transplant centers, the goal of UNOS and JCAHO is that DCD become a routine practice, thus significantly increasing the number of organs available. This widespread change in hospital policy towards in-hospital death warrants careful ethical consideration.This paper examines the history of organ donation and the brain death and cardiac death criteria. The ethical justifications for withdrawal of life-sustaining treatment and procurement of organs are then surveyed. The Principle of Double Effect (PDE) has been a classic argument for the moral licitness of removing or foregoing a life-sustaining intervention because it separates intentions from consequences. The argument is made that DCD is a practice on moral thin ice, as the orchestration of the death of a patient in the operating room seems to fully intend the death of that patient. Furthermore, I examine the argument made by physician-assisted suicide and euthanasia advocates that the PDE is a moral fiction and explore the tenability of maintaining the bright line between killing and “letting die.” Finally, I offer some suggestions on end-of-life care from a Christian perspective.