Living Organ Donation and Transplantation: Principlism or Charity?

1.2.4 The Application of the Principle of Justice

The moral demand for justice has wide implications for living organ donation and transplantation in the context of a fair distribution of its benefits and harms. This raises the question of how to respect people's rights, especially the rights of the donors and potential recipients in the context of living organ donation and transplantation.101 In other words, how can we justify the risks and the benefits both of donors and recipients.

In the view of D. Bakker, when looking at the principle of justice in connection with the reception, it is clear that an individual can avoid being kept on the waiting list by accepting a kidney from a living related or unrelated donor. Can we say that this is fair? Does this provide equal opportunity for everyone in need? Of course, we can argue that it is not fair. But, on the other hand, not many transplant surgeons would put a patient on the waiting list when a living related or living unrelated donor is ready to donate his/her organs.102

One of the most pressing problems of justice in the medical profession is in allocating organs for transplant.103 The allocation of human organs and tissues for transplantation consists in the specific application of ethical norms to its social practice. The main problems of allocation do not usually concern living donors since most transplanted organs are taken from cadavers. However, questions of justice arise both about procedures for contributing organs and about procedures of allocating organs on hand. The questions about procedures for contributing organs are limited to the provision of live organs for transplant. One is not treated unfairly when his/her own voluntary choices are achieved, and there is no reason to believe that highly altruistic and compassionate choices cannot be fully voluntary. The question whether it can be fair to compel persons to donate one of their paired organs in times of short supply and sudden need is more difficult to address.

In order to clarify distributive justice, let us discuss the age-based allocation in organ donation and transplantation. For instance, due to their age, many end-stage kidney recipients are not included for transplantation. Age is one of the important considerations in medicine for choosing recipients for transplantation. Success of transplantation is higher in younger patients than in older patients. Sometimes age-based rationing is justified because of scarcity. However, some philosophers justify arguments in favour of age-based allocation.104 For example, Norman Daniels says that we should make a "prudential individual decision about the health care from the perspective of an entire lifetime rather than a particular moment in time."105 According to UNOS, organ allocation is done on the basis of "priority to urgency of need and then to length of time on the list."106

There are other issues of injustice in living organ donation and transplantation. In the case of kidney donation, what should be the criterion to select two potential donors? For example, a woman needs a kidney for transplantation and there are two possible donors: one is the woman's fourteen-year-old daughter and the other is her thirty five-year-old mentally disabled brother. Many would choose taking the kidney from the mentally retarded person. This also highlights the issues of justice in living organ donation and transplantation.

Another ethical problem is equality and social justice in paid donations. Social justice demands equality in distributing organs and prohibits private sale. The Transplantation Society states that paid donations for transplantation will increase inequality in health care:

If wealthy individuals from other countries are placed on transplant lists - they compete with local patients for scarce cadaver kidney - private hospitals in Europe now perform kidney transplants for foreigners who can afford the substantial fees… The unacceptable consequences of this is that kidneys go only to patients who can pay.107

Hence, poor people cannot get organs because they cannot pay.108 And paid donation creates an opportunity for the rich to exploit the poor.109 Rosamond Rhodes notes that even though poor people donate their organs and encourage transplantation experimentation, they do not get organs for transplantation. In his opinion, we should give adequate emphasis to the rights of each person.110 Transplantation seems to be unattainable by poor people.111 Again, Arthur L. Caplan and Beth Virnig observe the injustice that prevails in America: "If you are rich, you can get a transplant; if you are rich or poor you can donate organs and tissues to be transplanted to others. This situation is not fair, and the American people know it."112 The same can be seen in India. Poor people cannot afford transplantation. Subsequently, they face death. This situation shows the violation of justice.113 Other victims of injustice are the poor donors (for example, in India) who are exploited by the middlemen and professionals.114 Without being given sufficient information about the transplantation, these donors are exploited; this happens especially in the case of women and children.

Furthermore, there are clear contrasts in the practices of organ donation and transplantation in different countries like India and North America. In many western countries, organ donation takes place with a high standard of social and distributive justice. There is health care insurance. But in India one does not have medical insurance.115 In this context, T. Koch observes that "the failure to assure equal access to medical care creates divisions and inequalities denying equality among citizens. This in turn affects the supply of transplantable contributions integral to the just sharing between members of a community."116

There are other ethical problems of injustice in the paired indirect kidney exchange programme or cross over renal transplantation on the basis of ABO-incompatibility and the impact on potential O recipients. There is some kind of disproportionality to certain group of recipients. Some persons can benefit while others have to suffer. Certain groups of persons have to wait for a long time, especially recipients in the O blood group. The reason is that the majority of ABO incompatible "donor-recipient pairs involve a potential" O blood group receiver. Hence, the waiting time of O recipients is lengthened by the ABO incompatible indirect exchange programmes.117 This is an injustice to this vulnerable group.

In short, the principle of justice is very significant in the case of living organ donation and transplantation. We need an adequate method for assuring justice in cases where donation is made by the mentally disabled persons, since injustice prevails in this field. Another question is whether society should concentrate on rescue strategies such as dialysis, kidney transplantation, and artificial heart transplantation, or whether the society should concentrate on the prevention of disease and disability?118 Is organ transplantation only for rich people? In this context, what should be the basic norms to ensure justice? All these questions remind us of the relevance of addressing justice in health care.

1.3 Critical Evaluation

We have seen the application of the four principles separately in the case of living organ donation and transplantation. Regarding the four traditional principles of medical ethics and living organ donation, one has to take all the principles together. Principlism is not against living organ donation and transplantation.119 David Lamb points out that "in practice these principles are not held absolutely and one of the tasks of the ethicist is to seek harmony between them and determine where to draw the line when principles apparently conflict."120 The living donor programme is the achievement of harmony between the principles of non-maleficence and beneficence, on the one hand, and the principle of respect for autonomy, on the other hand.121 From a positive point of view, principlism is very good for solving problems in clinical practice. In the case of living organ donation and transplantation, the principle of non-maleficence prohibits a higher risk to the donor. The principle of beneficence promotes doing good to others. For example, the donor helps the recipient. Here respect for the autonomy of the donor and the recipient is important. The principle of autonomy does not allow for moral pressure on the potential donor. Justice deals with the rights of the donor and the recipient. However, it is observed that in the opinion of some scholars, these principles are not absolute in themselves: we have to establish harmony between them so that there is no contradiction between these principles.

From a critical point of view, according to R. Gillon, the four principles of principlism are the deontological norms for transplantation.122 Robert A. Sells notes that there is serious conflict among these principles. For instance, harm is inevitable during the operation, which may lead to benefit. Here we find a combination of risk and benefit, which is a clear enigma in principlism. In the deontological approach, for example, one would not compare the benefits and the risks of the donor.123

Moreover, M. G. de Ortúzar, C. Soratti, and I. Velez in analysing principlism, observe that the physician can apply the principle of beneficence, the principle of non-maleficence, and the principle of autonomy. The donor may use the principle of beneficence and the principle of autonomy. But, one does not find any principles for the protection of the recipient.124 They say that against the principle of non-maleficence to the donor, the principles of autonomy and beneficence to the recipient make organ donation and transplantation justifiable. But, sometimes, if the risk is very high, then non-maleficence prohibits donation even though it is a good service to the recipient.125 Another problem is that the principle of autonomy is not always reliable since a person's decision can be influenced by emotional factors. This does not make for a sound informed consent. The principle of justice may clash with other principles, for instance, when doing some favour to a patient which might lead to an unfair advantage to others in the allocation of resources. Measures to achieve harmony among ethical principles may differ from country to country.126

Regarding the donor, he/she is not morally obliged by the principle of beneficence. Donation is based on a supererogatory concept, and is not binding.127 So, if one gives importance to beneficence, then there are no objective criteria to judge the risks taken by the donor. Another problem is that if we consider only the principle of non-maleficence, transplantation is not possible because of the harm done to the donor. Concerning the application of principlism to living organ donation and transplantation, one has to confront an ethical conflict. The main duty of the physician is to do good to the patient (recipient) and not 'harm' the donor. But it is very difficult to meet "both demands."128

Beauchamp and Childress formulated principlism from different ethical theories, especially deontological and utilitarian theories, that are useful in many medical issues. Respect for autonomy is important in principlism. Autonomy is seen in combination with the principles of non-maleficence, beneficence, and justice. Regarding living organ donation and transplantation, we observe that the principle of autonomy and genuine consent is very relevant. However, there are clashes between normative and radical interpretations of autonomy. The radical interpretation of autonomy does not give an adequate justification for living organ donation and transplantation. It allows paid donations. And the limited view of body in the normative concept of autonomy is also not apt for living organ donation. In this sense, principlism includes only a limited expression of the value of and the attention for the relational aspect,129 which is very important for living organ donation and transplantation. As well, a strict application of the principle of non-maleficence is a hindrance to living organ donation.

Again, critics say that there are disadvantages in Anglo-American principlism. The principle of non-maleficence and the principle of beneficence do not go together. The principle of non-maleficence does not promote any harm done to the donor and the principle of beneficence supports the recipient. In the principle of autonomy, we find deontological and utilitarian approaches. Individual makes a decision from his/her own perspective. In addition, since justice includes many theories, it is difficult to come to any agreement about the allocation of human organs. Moreover, principlism is more concerned with clinically oriented cases only. One cannot find a fully relational and social approach in Anglo-American principlism. Going beyond principlism, we suggest that another assessment is needed in living organ donation and transplantation. In this context, we search for another approach for the justification of living organ donation and transplantation, namely the virtue of charity.

2. Virtue of Charity: An Adequate Ethical Model for Living Organ Donation and Transplantation

Principlism is inadequate in dealing with living organ donation and transplantation. One cannot find a combination of virtues in it. E. D. Pellegrino observes that the virtue of charity has a role in medical moral decision making.130 Albert Pl also shows that rules, duties, and principles can be formed by charity.131 In this context, in our opinion the ethical approach of charity can be fully expressed in living organ donation and transplantation.

1). In many cases, patients with organ failures are confronted with the choice between transplantation and death. A patient in a critical stage symbolises the real face of the other. In such situations, we have to promote basic ethical care for the other. Many theologians justify living organ donation and transplantation from the perspective of charity. Pius XII's address to ophthalmologists in 1956 argues that acts of donation cannot be viewed as a duty or as obligatory.132 Such acts are supererogatory and not obligatory. Hence, concern for the common good and love of neighbour symbolize genuine self-giving for others.133 In the opinion of F. T. Rapaport, the Catholic Church holds "organ donation as the Christian's holiest sacrament, and it is clear that most of transplantation continues to depend on benevolent donation."134 In short, one may rightly observe that in the Catholic Church organ donation is justified by the virtue of charity. Furthermore, we note that other religions also justify living organ donation on the ground of charity or love. Many religions support living organ donation and transplantation even if their point of emphasis is slightly different.

My observation is that care for the other and altruism are the secular terms that we can find in the literature on living organ donation and transplantation. Even if many use these terms, the basic idea behind them is charity. Here, care for the other or altruism in living organ donation is not a self-sacrifice alone, but there is sufficient self-concern for one's own self. Many scholars justify organ donation on the basis of altruism, charity, love or care for the other.

2) The virtue of charity gives adequate emphasis to the autonomy of the donor and the recipient. The donor should give genuine consent. The intention or motive behind donation is a free and autonomous choice. The intention of the donor is directed by gift-giving to the recipients. This is appreciated because it has to do with helping another person. The patient should be a needy person. The patient needs the help of the donor because there are no other possibilities for treatments. This approach prohibits serious risk to the donor and at the same time does not allow the personality change of the donor and the recipient.

A radical interpretation of autonomy, especially in the utilitarian approach, sometimes allows paid donations. However, the approach of charity includes both the personal freedom and the social responsibility of the person. It does not favour this radical interpretation of autonomy, especially regarding paid donations. The reason is that the dignity of the person is neglected in such cases. For instance, selling body parts for money reduces the value of the person. There should be no material profit in charitable or altruistic organ donation.135 At the World Congress of the Transplantation Society (Rome-2000), John Paul II said that "any procedure which tends to commercialize human organs or to consider them as items of exchange or trade must be considered morally unacceptable, because to use the body as an "object" is to violate the dignity of the human person."136 Paid organ donation spoils the spirit of altruism.137 In paid organ donation, one does not fully respect the other.138 E. Eyskens says that living organ donation "is a gift by the living, freely, without material reward of any sort, being informed about the expected results and possible risks."139

3) There are unjust practices that prevail in the field of organ donation and transplantation. An ethical approach of charity respects the dignity of the donor and the recipient, especially the organ donations of women, and children. This approach can eliminate donations out of poverty, can offer transplantation both for the rich and the poor, and avoids discrimination between recipients.

4) The ethical approach of charity changes the emphasis on the physical nature of the human person into the promotion of the total good of the human person. The total personal good of the person is an important element in this approach. This is very clear in the case of living organ donation and transplantation. For instance, even if the donor takes a physical risk, he/she gets a psychological or spiritual benefit. This highlights the total good of the donor.140 Rosamond Rhodes writes that living organ donation gives "[a] psychological benefit to a donor from saving a loved one, or significantly improving a beloved's quality of life, or avoiding the guilt of not trying to help."141 Aaron Spital, too, speaks of the benefits received by the living donors. For instance, helping a sick or dying patient is a positive experience for the living donor.142

5) Deontological, utilitarian, and principlist approaches do not give sufficient emphasis to the relational and the social dimensions of the human person. The approach of charity brings adequate significance to this aspect. The person is always a person-in-relation. We can see this essentially in the relational philosophy of Martin Buber and Emmanuel Levinas. Their ideas on the relational dimension are important for the ethical approach of charity.143

This inter-human relationship is very clear in the case of living organ donation and transplantation, which is expressed in the relation between donor and the recipient. It is not an "I-It" relationship, but a I-Thou relationship. This means the donor is touched by the face of the other (recipient) who is in a critical stage, who is helpless. The deep relationship shows the empathy with the other.144 For instance, the French philosopher Merleau-Ponty writes: "1) There is an essential relationship between body and consciousness such that the body is never - even throughout transplant surgery - just a body, but rather a perceiving entity, that is to say animate. 2) Every body receives its specificity and becomes animate through the perception of another."145 Cornelius J. Van Der Poel holds that transplantation clearly expresses this inter-human relationship. Transplantation is not one single act, it is a whole human act; since it is a whole human act, it is "the 'exteriorization' of inter-human relationship. This implies various steps on the physical level - here in particular, 'excision' and 'grafting' are important."146 Similarly, Augustine Regan and John Gallagher note the justification of living organ donation on the basis of interpersonal relationship.147 There is an argument that the "paradigm of sharing is inherently relational. It signifies the transfer of a corporeal, spiritual, or social entity and it implies a necessary connection between two persons - to share something is to create a situation of 'joint custody.'"148 A. S. Daar says that unrelated living organ donation is "ethically justified when there was an enduring bond (relationship) between the donor and the recipient."149 Our assessments of this approach clearly show the relevance of this relational dimension in living organ donation and transplantation.

6) The virtue of charity gives emphasis to the relevance of the social dimension, which is important for living organ donation and transplantation. The human person is a social being related to other human persons. A man/woman lives in a society that includes appropriate structures and institutions. Gaudium et Spes states: "we must live in society (GS, 23-32). We need structures and institutions worthy of man (GS, 25, 29), e. g., political structures- (GS, 73-76) and international co-operation (GS, 77-90)." This explains that one has to consider the other person as "another self" (GS 27). In addition, article 55 of GS reminds us that human persons are "authors of the culture of their community."150

Organ donation also highlights the value of solidarity in society, especially in medicine. In the case of living organ donation, this approach points to a social dimension where donors and the recipients are part of the society. The social aspect is also one of the elements that assists in making decisions in living organ donation and transplantation. The value of solidarity encourages the donors and recipients, and others who participate in transplantation, to make responsible decisions. Moreover, in the present situation where we are facing a crisis of organ shortage, helping patients who are in a critical stage, really shows the social character of the human person.

In my opinion, charity can be expressed in a responsible way. Virtue stands at the middle. One can do charity in living organ donation, basing on the physical, psychological, social, and economical condition of the donor.


To conclude this paper, I acknowledge that there are other perspectives that may lead to different conclusions about living organ donation and transplantation. The issues of living organ donation and transplantation are complex. I have taken my own approach in order to come to this conclusion. The virtue of charity surpasses principlism, especially in its application to living organ donation and transplantation. The virtue of charity can, therefore, be called our ethical model for living organ donation and transplantation. The virtue of charity can be seen in different forms in religious and secular levels. In the virtue of charity, one is in no way obliged to donate one's organs and if any body does so, it is purely a virtuous act. Charity allows the living donor to make a proper personal decision, which is a combination of self-sacrifice and self-concern. The promotion of donation based on the virtue of charity will be an important element in increasing living organ donation. Autonomy of the donor is clearly maintained in charity. Therefore it can be rightly concluded that the virtue of charity should be the motive/intention for the living person to donate his/her organs to a patient, than the notions of principlism. Without the virtue of charity, living organ donation may be a mere selling of body parts.

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