"Organ Donation Euthanasia": A Dangerous Proposal

E. Christian Brugger
© 2010 Culture of Life Foundation.
Reproduced with Permission
Culture of Life Foundation

Should we adopt euthanasia to maximize our supply of available organs for transplantation?

For several decades transplant medicine has suffered from a critical shortfall in the supply of organs needed for patients with organ failure. As a result thousands of patients die each year on waiting lists. Presently there are over 100,000 patients awaiting donor organs in the U.S.; in 2007 alone, 18 patients per day died waiting for deceased donor organs. The problem has given rise to significant milestones in end-of-life medicine. For example, the shift in the 1960s from diagnosing human death in terms of the cessation of heart and lung function (cardio-pulmonary death) to neurological criteria (whole brain death) was motivated by a desire to preserve more transplantable organs. Another idea that's been debated over the years is "organ conscription." This very month, lawmakers in New York introduced an "opt out" organ conscription bill that would presume that all patients are organ donors unless they explicitly opt out on their driver's license.1 Those of us whose organs are more or less healthy may not appreciate the distress that patients and their families feel knowing that their lives could be saved if only their names reach the top of the wait list.

The most recent contribution to this ongoing conversation was recently published in the prestigious journal Bioethics.2 Two medical ethicists from Oxford University, Julian Savulescu (you might recall his name from my recent piece on "Transhumanism") and Dominic Wilkinson, argue that euthanasia should be used to maximize the number and quality of organs for transplantation. Patients should be allowed to designate on their end-of-life documents their desire to donate their organs through a process that the authors call Organ Donation Euthanasia or ODE. They carefully qualify the criteria for ODE eligibility: patients must be in intensive care and dependent on life support; they must have planned for the withdrawal of life support if their prognosis is poor; their condition is such that they will die anyway within a short time of the removal of life support; and they must explicitly consent to ODE. If these conditions are met, doctors may put them under general anesthesia and harvest their organs. But intentionally removing vital organs from a living patient, especially the heart, will ordinarily kill the patient. So the procedure is euthanasia. The authors identify four benefits to be gained by introducing ODE into transplant medicine: 1) patient autonomy is maximized; 2) patients are provided the widest possible scope to donate their organs; 3) the supply of viable organs for transplantation is significantly increased; and 4) patients are less likely to suffer (because of the general anesthesia) than they would be through the ordinary withdrawal of life support.

The authors assess these benefits in the light of the concept of a "Pareto improvement," a principle used in economics to determine whether we have strong reasons to prefer some alternative. The principle - which the authors call "one of the most basic principles of rationality" - states that some proposed alternative constitutes a Pareto improvement if as a result of its implementation at least one person is better off while no person is left worse off. It follows that if some state of affairs constitutes a Pareto improvement, then we have strong reasons to adopt that alternative.

Savulescu and Wilkinson confidently assert that ODE for eligible patients constitutes a Pareto improvement. It is superior to the current practice of removing life support, waiting until patients die, and then harvesting their organs (called donation after cardiac death, or DCD); both in the case of DCD and ODE a patient dies, but with ODE "more lives are able to be saved" because more useful organs can be harvested from a living human being than from a corpse.

I went into their complicated concept of a Pareto improvement so you (our readers) might appreciate the next thing the authors say in their essay. It illustrates with startling clarity the deficiency of the utilitarian reasoning they use to justify ODE. They say: "ODE might not be regarded as a Pareto improvement if the killing of the patient were regarded as a moral harm or a rights violation. However, it is difficult to see why a patient is morally harmed or has their rights violated if they are actively killed, compared with a state of affairs where they die as a result of treatment withdrawal, assuming that they have consented to either." For our authors, and for utilitarians generally, moral harm is calculated exclusively as a function of measurable outcomes. If death promises to follow upon each of two alternatives, and one alternative promises in addition to death some measurable benefit, then - presuming informed consent in relation to both - that alternative presumptively is rationally superior. After all D + B (where D equals guaranteed and consented - to death and B some measurable benefit) must be superior to D alone.

Their argument that ODE causes no moral harm to patients - and by implication to anyone else - is weak, even by utilitarian standards. Does not the doctor who kills his patient harm himself? Forbidding practitioners under any circumstance to kill their patients imposes a salutary restraint upon everyone involved in the delivery of health care. It says that human life is a unique good whose respect deserves every possible safeguard. Is not the erosion of one's respect for the inviolability of the good of life a serious harm? Isn't it likely that having consented to the killing of patients for the sake of promised benefits, a practitioner will begin to prefer Organ Donation Euthanasia to donation governed by the traditional dead donor rule? And will not the profession generally begin to favor euthanasia as the 'optimal alternative' for maximizing the acquisition of organs? Does not acceptance of ODE violate the time-honored principle of medical ethics, "Do No Harm?" Who can calculate the long-term harm to the medical profession and to patients as our community's collective inhibition against doctors killing patients is relaxed 'in this one case'? And as our community grows comfortable with ODE, will not this erode our moral inhibitions against other forms of euthanasia? Pareto improvements soon will be discovered in the simple killing of patients at their autonomous requests. The authors have already told us they believe that maximizing patient autonomy by permitting them to choose ODE is itself a great good. The ODE patient then, according to the authors' own "rational principle," is better off for having his autonomous will respected than if his request is denied; and his death, since it followed from patient autonomy, could hardly be seen to leave him worse off.

Will not harms also come to families and communities as conflicts arise between patients who desire ODE and spouses, children, siblings and in-laws who reasonably judge that killing, even for a good end, is wrong? Will not violence be done to the moral sensibilities of, say, a child, as her parent's euthanasia is forced upon her? How should the community respond? "Get over it, honey. Can't you see that assisted-suicide in this case is okay!" Do not our authors consider the cultural divisiveness that their proposal will certainly precipitate a harm at least worth acknowledging? The tectonic shift that took place in the West's ethical sensibilities when abortion become legal has inflicted an irreconcilable division on our community. In the U.S., States are blue or red according to whether or not the region supports killing the unborn, and the moral identity of our political parties are largely defined by their abortion platform. Killing for organs will be just one more knife slicing deeper into this cultural divide. Moreover, the Catholic Church runs over 270 hospitals in the US, a considerable percent of the overall medical care in the country. Those hospitals will refuse to honor an advanced directive that orders ODE. This means that the Savulescu proposal promises to precipitate profound dysfunction in the delivery of health care, at least in the US. Finally, for the hundreds of millions of persons who believe that the norm against killing is backed not only by reason, but by divine sanction, there is to consider also the grave spiritual harm to the patient, the patient's killer, and all who wrongfully support the killing.

The authors' judgment that no one will be morally harmed by introducing euthanasia into transplant medicine is profoundly nave. The erosion of the moral sensibilities against killing of doctors, the medical profession and the wider community; the deepening division sown into the fabric of our community; the dysfunction introduced into the delivery of healthcare, all testify against their proposal.

The fact that a reputable journal such as Bioethics would feature an article promoting ODE illustrates how deeply our moral sensibilities against killing have already eroded. They eroded as a result of past proposals to make 'exceptions' to the norm against killing in the delivery of health care. Travelling further down this same road by sanctioning ODE may profit us in the short run by gaining us a few extra organs to transplant; but the moral cost to our community will be very dear indeed.


1 See discussion in the New York Times from May 2, 2010; http://roomfordebate.blogs.nytimes.com/2010/05/02/should-laws-encourage-organ-donation/ [Back]

2 See their essay "Should We Allow Organ Donation Euthanasia?" at: http://www3.interscience.wiley.com/cgi-bin/fulltext/123413671/main.html,ftx_abs?CRETRY=1&SRETRY=0 [Back]