Death Fiction and Taking Organs from the Living

By Julian Savulescu and Dominic Wilkinson

Imagine you could save 6 lives with a drop of your blood. Would you have a moral obligation to donate a drop of blood to save six people’s lives? It seems that if any sort of moral obligation exists, you have a moral obligation to save six lives with just a pinprick of your blood.

But every day people do far worse than failing to give a drop of blood to save 6 lives. They choose to bury or burn their organs after their death, rather than save 6 lives with these organs. And it would cost them nothing to give those organs after their death. Our failure to give our organs to those who need them is among the greatest moral failures of our lives. At zero cost to themselves, not even having to endure a pinprick, many people choose to destroy their lifesaving organs after their death.

In the UK, 1000 people per year die on the transplant waiting list. In the US, 18 patients per day die waiting. Australia’s organ donation rate is one of the lowest in the Western world. Those who choose to donate deserve a moral gold star. The most pressing ethical concern is how we can encourage more people to consent to donate their organs, and how we can make sure that those who want to donate their organs are able to.

So it is in one way surprising that a Melbourne intensive care physician, Jim Tibballs, is reported as criticising current organ donation guidelines on the grounds that donors are not actually dead at the time that organs are removed. Other doctors have called Professor Tibballs’ comments “irresponsible” on the grounds that they might cause a significant fall in organ donation rates.

Tibballs claims that current legal standards of death – either brain death or cardiac death – are not being met. He claims that organs are being taken from people who are dying rather than dead. Whether or not this is true, there is no dispute on one issue: organs are not being taken from people who would have lived if their organs had not been taken.

The ethics of organ transplantation have been dominated by one rule – that organs may only be removed from patients who are dead. – the dead donor rule. In the 1960s it was recognised that some patients could be kept ‘alive’ with machines in intensive care after all functions of their brain had been irreversibly lost. Death was redefined to enable organs to be taken from people whose brains were irreversibly and profoundly damaged, Such people were defined as “brain dead.”

What counts as the precise moment of death is arbitrarily determined. This is because death is gradual process with organs dying at different rates. And, within a certain range, it does not matter morally where we draw the line. So for this reason, death is defined differenly in different places. In Australia, the legal definition involves death of the brainstem, which is necessary for vital functions. In the US, it is death of the whole brain. The Japanese do not use the concept of brain death at all.

When we recognise the “fiction” of defining the precise moment of death, or that it is a definitional issue of drawing a line in a process for sake of some purpose, we can identify one way to increase the supply of organs. Change the definition of death again. Tibball’s concerns are legal concerns, not fundamentally ethical concerns. We could move the definitional point of death slightly earlier into the dying process to account for his worries.

But there is another more radical way to increase the supply of organs. We could abandon the dead donor rule. We could for example, allow organs to be taken from people who are not brain dead, but who have suffered such severe injury that they would be permanently unconscious, like Terry Schiavo, who would be allowed to die anyway by removal of their medical treatment.

Many will find it abhorrent to think of taking organs from a person who is still alive, even if this is to save many lives. But some would not. We would prefer our organs to be taken if we were permanently unconscious and our treatment was about to be withdrawn and we would die, once and for all. The may be others like us, who would want their organs to be taken if they had no chance of meaningful life and they were going to die soon.

Many people die in intensive care. After a critical illness some are found to have lost all function of their brain and brain stem. Life support machines are turned off. Others are alive, but have such a low chance of any meaningful recovery that their doctors, in consultation with their loved ones, remove life support and allow them to die. Both of these sorts of patients may be able to donate their organs, but at present the focus is on the question ‘are they dead?’

We believe people should be offered the choice to donate their organs before they have died. And those wishes must be respected. After all, they are the altruistic ones who are prepared to do what they should do. It would fail to respect their autonomy and wishes if we did not take their organs, if they had explicitly requested it.

We have two options – we could further revise the definition of death, though it may leave us vulnerable to the criticism that we are gerrymandering the definition to suit our purposes. Alternatively we could move away from an emphasis on death, to an emphasis on the really important moral question: is organ donation consistent with the wishes of the patient, and can it harm them to donate their organs?

A patient whose life support is being removed because their prognosis is extremely poor cannot be harmed by donating their organs (as long as it is ensured that they do not suffer). If they would have wanted to donate their organs, we should do what we can to respect their wishes.

We should do whatever we ethically can to stop people burying and burning the most valuable human resource. At very least, we should allow the morally virtuous to give their organs just as they wish.

The Paradox of Organ Donation Consent, practicalethicsnews.com

Organs Removed Before Donors Are ‘Dead’, ABC Online