Should we allow organ donation euthanasia? alternatives for maximizing the number and quality of organs for transplantation

Bioethics

Volumn 26, Issue 1, 2012, Pages 32-48

  Wilkinson, Dominic ^a   Savulescu, Julian ^a  

^a UNIVERSITY OF OXFORD   (United Kingdom)

Author keywords

Euthanasia; Medical ethics; Organ transplantation ethics; Tissue and organ procurement ethics; Tissue donors supply distribution

Indexed keywords

ACTIVE EUTHANASIA; ARTICLE; BRAIN DEATH; ETHICS; HUMAN; LIVING WILL; TRANSPLANTATION; TREATMENT WITHDRAWAL;

ADVANCE DIRECTIVE ADHERENCE; BRAIN DEATH; EUTHANASIA, ACTIVE; HUMANS; TISSUE AND ORGAN PROCUREMENT; WITHHOLDING TREATMENT;

EID: 83655193537     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2010.01811.x     Document Type: Article

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47. The order of principles here is not meant to convey any lexical priority of different principles.
48. One heart, two lungs, two kidneys, split liver (one adult, one child recipient), one pancreas and one intestine.
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50. Truog refers to this principle as 'respect for persons'.
51. For organ donation the concept of patient autonomy is somewhat different from autonomy in other contexts since the patient is (often) deceased, and the question is whether their previous wishes should be respected.
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54. So for example, the British Transplant Society guidelines for DCD stipulates that sufficient time has elapsed after cardiac arrest for hypoxic injury to the brain and brain-stem to have occurred. British Transplant Society. Guidelines Relating to Solid Organ Transplants from Non-Heart Beating Donors. London: BTS. After all brain function has been irreversibly lost we can be confident that they have no further need for their organs. By contrast, the influential US Institute of Medicine paper on DCD argued that it was irreversibility and not brain damage that was relevant to the definition of death on cardiopulmonary criteria. Herdman & Potts We acknowledge that there is substantial overlap between Principles 5 and 6.2005
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56. There are, however good reasons to think that withdrawal of life-sustaining treatment should be classified as an act of killing. F.G. Miller, R.D. Truog & D.W. Brock. Moral Fictions and Medical Ethics. Bioethics 2009
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62. It is arguable whether dead people can be used as a mere means in the same way as we use live people as a mere means. They are dead, have no ongoing interests and are incapable of consenting.
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64. The UK organ donation taskforce rejected evidence of possible increases in donor numbers and recently released a report advising against the adoption of opt-out consent in the UK. Organ Donation Taskforce. 2007. The potential impact of an opt out system for organ donation in the UK: an independent report from the Organ Donation Taskforce. London, UK. Available at: [Accessed 07 Jan2009].
65. We are grateful to an anonymous reviewer for encouraging us to investigate this alternative. Combinations of these measures are possible. For example an opt-out organ donation consent system could be introduced without permitting family members to veto donation. This is sometimes referred to as a 'hard opt-out' form of organ donation (ibid:12). It is not possible from UK figures to estimate what effect this would have on overall organ supply.
66. This depends whether the organs made available were of the right sort and tissue type to meet the needs of those currently dying while waiting for a transplant. It may not be enough to provide organs for those patients who at present are arbitrarily excluded from waiting lists (see note 8).
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72. Truog's justification for ODE is different from that presented here. He argues that current concepts of brain death and the dead-donor rule are incoherent, and he proposes an alternative based upon the principles of autonomy and non-maleficence. We find Truog's arguments compelling. Our paper can be seen as providing a complementary argument in favour of ODE. Truog favours a narrow definition for the group of patients who may consent to this procedure: only those who will die within minutes of withdrawal of life support, or who are permanently unconscious. Our definition of LSW donors overlaps with Truog's, but includes the larger group of patients from whom it is permissible to withdraw life support in intensive care, and whose death is highly likely to ensue (though not necessarily instantly).
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77. In the Belgian case 10 minutes elapsed after the circulation ceased before organ retrieval commenced. Only the liver and kidneys were transplanted. (Ibid.)
78. Absent kidney, liver or pancreatic function can lead to death - but not usually in a short time frame (days or weeks rather than hours). Thus if death were predicted within this time frame, organ donation prior to treatment withdrawal would be unlikely to affect the timing of death.
79. It may be possible to reduce the chance of this - for example with the use of epidural anaesthesia.
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81. If the interval were shortened to less than one minute it would not be possible to distinguish extreme bradycardia from periods of asystole.
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84. Although organ donation after brief asystole might lead to death sooner than would otherwise occur, it would not be likely to lead to death in patients who would have survived had organ donation not taken place. (see note 18) Even if the heart restarts in this setting, without further resuscitation the death of the patient is likely to follow within a fairly short interval9.
85. Except option 1c - increased efficiency of obtaining consent.
86. Indeed, some may have concerns that even the discussion of such options may negatively impact on organ donation rates.
87. In a similar vein some some have supported the idea that individuals should be permitted to opt-in to alternative criteria for death. K. Zeiler. Deadly pluralism? Why death concept, death definition, death criterion and death test pluralism should be allowed, even though it creates some problems. Bioethics 2009; 23450-459
88. A. Bagheri. Individual Choice in the Definition of Death. J Med Ethics 2007; 33: 146-149
89. Veatch. Abandon the Dead Donor Rule or Change the Definition of Death
90. Indeed, many current donors might not be aware of all available means of organ donation (for example DCD). Our proposal would increase autonomy by providing patients with a range of options and allowing them to choose those they wished to apply to themselves.
91. In the case of Ruben Navarro there was a break-down in this normal separation.
92. A requirement for independent confirmation of prognosis for LSW donors would potentially delay treatment withdrawal. But at present treatment withdrawal is sometimes delayed to allow transplant teams to prepare. There would be a strong incentive to ensure that confirmation of prognosis was able to occur expeditiously. If this were not able to take place within a reasonable time frame life support might still be able to be withdrawn, but organ donation could not proceed.
93. J. Bourke. 2006. Fear A Cultural History. London: Virago: 317.
94. As noted earlier (note 61), there is a relatively high level of community support for the latter, though it has not been adopted in any jurisdiction. We are grateful to an anonymous reviewer for highlighting this objection.
95. Organ Donation Euthanasia would potentially be a Pareto improvement in jurisdictions where voluntary active euthanasia is permitted and a patient has consented to euthanasia (for reasons other than the donation of their organs), Coons & Levin
96. UK Potential Donor Audit 1 April 2008-31 March 2009 (personal communication 27 Nov 2009).