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Why We Must Leave Our Organs to Others

Article in The American Journal of Bioethics August 2006

DOI: 10.1080/15265160600755839 Source: PubMed

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 InFocus Article

Why We Must Leave Our Organs

to Others
D. Micah Hester, University of Arkansas for Medical Sciences

Organ procurement presents several ethical concerns (from what constitutes acceptable crite- Keywords
ria for death to issues involved in specifically designating to whom an organ can be given), but organ
none is more central than the concern for what are appropriate means for acquiring organs.
transplant
The following discussion attempts a different perspective on the issue of organ procurement
procurment
by arguing that, rather than appealing to our charitable consciences or our pocketbooks, re-
linquishing our organs after death in this day and age is, in fact, obligatory for most people. obligation

Each of us is pressed by the growing demand for our organs should we die rightly, and that respect
desperate need has risen to such a level that not to release our organs for transplantation would
constitute a serious moral wrong.

Organ procurement presents several ethical con-
cerns (from what constitutes acceptable criteria for
death to issues involved in specifically designat-
ing to whom an organ can be given), but none is
more central than the concern for what are appro-
priate means for acquiring organs. For more than
three decades now, the call to procure organs to use
in transplantation has markedly grown louder, but
supply simply has not kept up with demand. acceptable for surrogates to offer organs on behalf of
This fact is well known, and the statistics, although
often recounted, remain quite telling. According to
the United Network for Organ Sharing (UNOS)
as of May 2006, approximately 92,000 patients
are candidates for organ transplantation (e.g., more
than 66,000 for kidneys alone). This is more than
a 100% increase from 10 years ago. At the same
time, only about 28,000 transplant operations were
performed in 2005 (e.g., approximately 16,000 kid-
ney transplants), and these numbers represent only
about a 40% increase from 10 years ago (UNOS
website).
In response, various strategies have been pro-
posed to aid in the task of increasing procurement
rates. Initially focusing on suitable conditions for
the procurement of organs, groups began investi-
gating neurological standards for death to supplant
the traditional cardiopulmonary understanding. For
example, the 1968 Harvard Ad Hoc Committee
developed its well known whole-brain death cri-
teria in reaction not only to the rise of various car-
diopulmonary technologies but also to demand for a
medically, morally and legally acceptable definition
of death that would aid in supplying the nascent
need for heart transplantation (Ad Hoc Committee
1968). With the implementation of the Pittsburgh
protocol in the late 1980s, development of the non-
heart-beating criteria (i.e., donation after cardiac
death) has been gaining not uncontroversial support
in order to help with the supply of lungs, kidneys
and livers (Arnold and Younger 1993; Arnold et al.
1995). Analogously, some argue that it is morally
patients in a persistent vegetative state (Koppelman
2003).
However, while these value-laden processes may,
in fact, identify morally acceptable biological con-
ditions for procurement, that identification pro-
vides no guarantee that patients (or their fami-
lies/surrogates) will, in reality, allow organs to be
made available for transplantation. Thus, rather
than trying to identify such conditions, the most
common and public mode of addressing the pro-
curement issue has been through direct appeals to
the populace at-large, and such strategies have tra-
ditionally taken one of two lines. The most widely
accepted approach to raising the procurement rate
has been an appeal to charity (e.g., Murray 1986;
Fox and Swazey 1992), and this model undergirds
all legally sanctioned procurement in the United
States.1 Organ donation (the very term bespeaks
1. Still under a charity model, but employing a state-
sponsored incentive, in 2005 the state of Utah passed
a law giving tax credit for expenses incurred by liv-
ing donors, and had previously passed a law giv-
ing 30-day leave to state employees who donate (see
http://www.idslife.org/news-145i.php).

The American Journal of Bioethics, 6(4): W23W28, 2006 ajob W23

Copyright

c Taylor & Francis Group, LLC
ISSN: 1526-5161 print / 1536-0075 online
DOI: 10.1080/15265160600755839
 The American Journal of Bioethics
charity), in this sense, has been characterized as a
precious and vital gift to be made from one person to
another. It is considered, in the language of ethics, to
be supererogatorybeyond our moral obligations,
but highly laudable. The metaphor has even taken
root in public policy with the development of the
Uniform Anatomical Gift Act (19721987), to en-
courage (and protect) donors and donations.
The most vocal alternative strategy has been
one of commodificationan economic appeal or
market-based model, as it were (e.g., Lachs 1979;
Annas 1984; Gill and Sade 2002; Cherry 2005;
Kishore 2005). While not legally accepted in the
United States,2 it has been argued (primarily on
liberaleven libertarianautonomy basis) that
monetary incentives should be offered to potential
donors. Though it eventually reversed its policy,
India (as one example) has allowed for the use of
monetary incentives, but the argument has never
won the day in the United States (Wilkinson and
Garrad 1996; Cohen 2002; Goya et al. 2002). Each
side in this debate has put forth strong reasons why
the other fails as an acceptable strategy to procure
organs, but ultimately, neither puts forth sufficient
support for its own position. Both sides fundamen-
tally miss the moral point because both sides im-
plicitly and falsely accept that organ procurement
must be the result of a voluntary and supereroga-
tory act. However, as will be argued, the call to re-
linquishing organs upon our deaths begins as what
some would call a prima facie or even ordinary obli-
gation, and what has also been referred to as a de
facto obligation. As others have pointed out, charity
is morally weak, and requires little of us and others
(Caplan 1992, 156). This article, in kind, argues for
a stronger moral claim, one that becomes further
strengthened as this de facto claim quickly becomes
a de jure (i.e., moral) obligationthat is, as it be-
comes a final moral good worthy of our pursuit, in
the face of no significant and comparable obligation
or loss to ourselves on our deaths (cf. James 1891;
Dewey 1926).
The following, then, will attempt to refocus the
issue away from an appeal to our charitable con-
2. Relatedly, the South Carolina legislature passed a
law in 2004 allowing living donors a tax deduc-
tion and giving surviving family of deceased donors
a tax credit. The bill was vetoed by the gov-
ernor. (see http://www.scstatehouse.net/sess115 2003-
2004/bills/5085.htm). Further, other proposed ethical
incentives can be found in but adding what has been
called ethical incentives Delmonico et al. 2002 and
Steinberg 2004.
W24 ajob
sciences or our pocketbooks. Instead, as intimated
by Caplan (1992, 156157) and addressed directly
by Nelson (2003a), the following argues that re-
linquishing our organs after death in this day and
age is, in fact, obligatory for most people. Each of us
is pressed by the growing demand for our organs
should we die according to acceptable procurement
standards, and that desperate need has risen to such
a level that not to release our organs for transplanta-
tion (an admittedly awkward phraseLoewy 1996)
would constitute a serious moral wrong.3
The focus of this article is primarily
theoreticalby which is meant that the argument
contained herein relies on a moral logic. Whereas
many articles on organ procurement begin with a
concern about the need to increase procurement
rates (and it is agreed that this is a serious prac-
tical concern), the argument that follows does not
primarily aim to increase procurement. It may, in
fact do so, but the central purpose of the argument
is to ground our procurement practices on the surest
moral footing possible. To do so, the argument be-
gins from a basic assumption about ethical theory
and the moral lifenamely, that we are obligated
to do what we can to save seriously endangered lives
when we can do so without risking anything of sig-
nificant value to us.4 Without accepting this as-
sumption, the argument that follows will rest inse-
curely its own ethical moorings.
Granting the previous assumption about
the moral life, then, the first premise is
straightforwardnamely, saving a life is a good
which is worthy of pursuit. Unless circumstances
dictate that undue harm or potential harm (whether,
in the case of transplants, to the recipient or the per-
son from whom the organ is procured) would result
from life-saving measures, attempts at saving some-
one who would foreseeably die otherwise is a moral
good.
3. Having said this, however, I leave open the question of
public policy for further debate. The legal and strategic
questions of whether and how the state should require the
relinquishing of organs on death is importantly distinct,
and while I believe our liberal democracy rightly demands
that we allow the moral choice to be real, whatever are
the legal/strategic implications of my position, the moral
question must be answered first.
4. In fact, any viable conception of what we owe to each
other must recognize this basic obligation. Although
the phrase is from the deontologically-minded Thomas
Scanlon (2000), some version of this simple moral point
can be found in other deontologists such as Ross (2003),
utilitarians such as Mill (1975) and Singer (1972), and
even pragmatists such as James (1891), among many
others.
July/August 2006, Volume 6, Number 4

Second, the use of organ transplantation is a
medically and ethically appropriate means to saving
a life. On the whole transplants have proven to be
relatively safe surgeries that extend the lives of those
who have them, and transplants do so without grave
harm to either the transplant patients themselves or
to others. As such transplantation has demonstrated
that it is not simply a case of the technological im-
perative running amok, but a socially positive use
of ingenuity and technology in medicine.
Similarly, my third premise should be easily
accepted: Namely, those who await organ trans-
plantation must rely on othersphysicians, nurses,
benefactors, and most importantly, donors. It may
seem trivial, but it is worth emphasizing that trans-
plant patients cannot fulfill their needs without
someone else coming through for them. Also, in most
cases, patients find themselves in need of a trans-
plant through no moral failing of their own. It
cannot be denied that nutrition, lifestyle and per-
sonal choice can lead to heart disease, cirrhosis and
other organ-compromising disease. As such, some
imply (if not claim outright) that, for example, al-
coholics require liver transplants because of their
moral failure to stop excessive drinking (Moss and
Siegler 1991; Kluge 1994). Of course, the impor-
tance of volition implied here cannot be minimized.
It seems false to say that eating habits are strictly
willful acts or that excessive drinking is primar-
ily a chosen avocation. There is ample evidence,
for example, that many, if not most, alcoholics de-
velop as a consequence of genetic and environmen-
tal factors beyond their own decisive control; also,
diets routinely fail even in the face of willful deter-
mination. Even if psychological and moral factors
can be brought to bear to pronounce negatively on
some potential recipients, surely the medical situa-
tions many patients find themselves in do not con-
tain such morally questionable circumstances and,
even when they do, genetic and biological factors at
least mitigate some degree of moral responsibility.
Further, many of these concerns would affect allo-
cation, rather than procurement, decisions. Fourth,
it is clear that the demand for organs is high, and
those organs are vital to the patients who need them.
Transplantation fulfills a basic and important good
to those who receive the organs. Every year, approx-
imately over 6,000 people on the UNOS waiting
list die still waiting for a transplant. Many others
wait in various stages of deteriorating health for up-
wards of 5 years or more. At the same time tens of
thousands of kidney patients, in particular, must
go through dialysis, which not only produces its
July/August 2006, Volume 6, Number 4
Why We Must Leave Our Organs
own negative side-effectsboth physiological and
psychological (Brown and Parfrey 1999)but also
reduces transplant success rates as well (Mange et al.
2001).
Fifth, the most complex premise remains: Dead
persons have no embodied countervailing interests
that could trump the vital interests of potential
transplant patients. Bodies, although significant
symbols of the life once inhabiting them, have no
need for the organs that remain after death. The
question raised, then, is what harm could be done
to now-dead persons if organs are taken without di-
rect consent? Aristotle and others have noted that
it is still possible to be harmed after ones death.
The question, then, is whether any potential harms
could be serious enough to affect the powerful obli-
gation to save a life. Nelson (2003a), for one, does
not think so, which follows from both beneficence
and what Nelson calls the easy rescue (118120).
In a brief commentary, Nelson notes that fastid-
iousness about ones dignity, which might pre-
clude them from consenting to life-saving acts, is
not morally supportablehis argument turning on
the virtually costless nature of certain kinds of
life saving acts like organ release over-and-against
the clearly beneficial nature of organ transplantation
(2003b, 14).
Of course, some groups believe that the removal
of organs from a dead person can itself be a form of
disrespect. These claims are often made in light of
larger value-systems, such as religious beliefs. For
example, though most religious organizations ac-
cept donation as charitable, none require it (e.g.,
Kunin 2005); at the same time some groups, such as
the orthodox Jews, strict Jehovahs Witnesses, some
Amish, and Confucians (cf. Lam and McCullough
2000), have particular reluctances, and still others
such as the Shinto in Japan find the dead body im-
pure and thus find procurement and transplantation
inherently troubling (Cooper and Taylor 2000).
Such claims, however, seem difficult to support,
even for long-standing religious institutions, in the
face of deep moral concerns for potentially dying
persons. The extent to which the body is symbolic
of the person should not be discounted, but even a
well-established belief system that claims that only
whole-bodied persons can gain glory in an after-
life must address the question of what shape a
body must be in and why. Does heart disease, for
example, constitute an unclean bodily form, and if
not, which cellular and functional apparatus must
be present and which need not be? Of course, it
could be claimed that even raising the question
ajob W25
 The American Journal of Bioethics
against such belief systems employs a kind of a
category error that reduces bodily integrity merely
to biological processes rather than utilizing spiri-
tual language and concepts. Of course, there is a
stronger argument to be madenamely, any spir-
itual or philosophical value system that leads to
failure of ethical duties to others in your society
should be help accountable for the moral weak-
nesses that follow. Respect and disrespect are paid
to persons/moral agents, not to bodies per se. In
the face of the need for healthy organs for living
human beings, spiritual concepts that champion a
spiritual notion of bodily integrity over helping oth-
ers survive seems misguided. Instead, procurement
from dead bodies should be championed as no vio-
lation of what respect is due to formerly embodied
persons, but instead the fulfillment of ones moral
duty.
Lastly, it may be useful to emphasize the pre-
vailing limiting factor employed throughout this
articlenamely, while some demands on us would
require the loss of a significant good in order to be
fulfilled, relinquishing cadaveric organs requires no
such loss. The previous argument, thus, is delim-
ited by a practical factnamely, the current dangers
of surgery and the vital character of our organs to
our own well being, weaken the force of both the
second and fifth premises, leaving live donations as
a supererogatory act. Further, as Truog (2005) has
argued, cadaveric organs should be regarded as a
societal resource, not as personal property. Nelson
concurs, We ought to move closer toward seeing
such organs as communal resources, and hence, as
routinely retrievable (Nelson 2005, 26). And while
living donor organs may become societal resources,
there is no debate that living individuals must con-
sent to make them available to the pool of potential
recipients. At the same time, though, these facts are
deeply contextual, and continual protections and
techniques of surgery for live donations as well as
further development of the socioethical landscape
may, in the future, raise the moral stakes to the level
of obligation even for procurement from living in-
dividuals. Either way, concerns for surgical and gen-
eral health risks, as well as legitimate morally-based
property claims, do not apply in cadavers, creating
a heightened moral requirement.
Thus, without need to draw out the logical con-
clusion, given the basic moral assumption as well
as the stated premises and conditions concerning
organ transplantation and procurement, each of us
has a moral obligation to relinquish our organs for
transplantation on our deaths.
W26 ajob
The previous argument above makes a strong
moral claim, one typically avoided (if not dispar-
aged) in the transplantation ethics literature. How-
ever, one remaining practical matter concerns the
very real existence of fear that organ procurement al-
ready occurs under questionable circumstance, and
that the medical establishment supports the has-
tening of death in order to procure organs. Soci-
ological research has already shown that such a
fear exists within the current system. In particu-
lar, African-American physicians have long argued
that organ conscription or even presumed consent
policies would heighten an already complex atti-
tude of distrust (cf. Jacob Arriola 2005) within the
African-American community towards medicine
(Robeznieks 2004). The particularly strong moral
stance of the previous argument could be seen as
ratcheting up the conditions that lead to such fear
all the more with the view that if organ removal is
morally required, then coercive measures to har-
vest organs might be more common, such as inap-
propriately withholding treatment in order to se-
cure death sooner.
This concern, along with concerns of those who
hold that organ retrieval after death is spiritually
disrespectful, will strike many as a significant prob-
lem for the argument on practical/policy grounds,
primarily because this societys liberal democratic
valuing of autonomy and personal safety requires
the use of a certain level of decisional latitude in
decisions that affect usincluding our bodies. Of
course, strict moral logic might require a very strong
policy, but important social values such as auton-
omy and safety might mitigate against strong pol-
icy precisely to leave room for those persons who
hold the kinds of beliefs that would problemati-
cally pit organ procurement against other strongly
held values. This raises the relationship between
moral argument and public policy. Theory devoid
of practical concerns is bound to fail, whereas a
practical decisions without moral grounding risk
being unethical. The given argument provides care-
ful moral reasoning concerning organ procurement;
what must be taken up next is how such moral find-
ings would be implemented given cultural condi-
tions operative in the United States.
Thus, while the argument morally grounds the
obligation to relinquish our organs after death, the
concerns of those who find organ removal after death
disrespectful have implications for how to deal with
this moral obligation in public policy. In other
words, it might seem to follow that because organ
release has been shown to be an ethical obligation,
July/August 2006, Volume 6, Number 4

we should write our laws in such a way that each of
us is legally required to donate, thus matching law
with morality (cf. Spital 2005; Kreis 2005). How-
ever, that such laws should be developed is not an
implication to be drawn by necessity.5
And yet, while practical concerns like these are
not to be ignored (and, in fact, are central to crafting
ethically and medically successful public policy),
the issue in this article is simply whether a moral
case for obligatory removal can be made. Certainly,
if there is a strong case for the obligation to give or-
gans on death, then to develop ethically appropriate
means to the implications of such an argument, there
would have to be careful attention paid to the details
of implementation. However, the difficulty of those
details cannot be allowed to settle (by precluding)
the question of whether we are morally obligated
to give our organs. Thus, the moral argument for
releasing our organs on death remains strong and
valuable.

ACKNOWLEDGMENTS
Given the tightly structured nature of the argu-
ment, I take full responsibility for its possible fail-
ure. However, its success is due to the aid of Drs.
Chris Hackler (University of Arkansas for Medi-
cal Sciences), Wayne Shelton (Albany College of
Medicine), and Robert Talisse (Vanderbilt Univer-
sity) as well as comments of the anonymous re-
viewers. I would also like to thank my institution,
University of Arkansas for Medical Sciences, for its
support of my scholarship.
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