Last month, I wrote about the ethical issues generated by the euphemistic and imprecise term Medical Assistance In Dying (or MAID) and the way in which the change in the law which led to the legalization of assisted suicide and euthanasia had avid supporters (whom I have labelled “optimists”) and vociferous critics (whom I labelled “pessimists”).
Both sides, I argued, are right about something: the former, that the change in the law supports autonomy and freedom of choice; the latter, that MAID presents us with a radical change in the ethos of medicine, and may lead to abuses. None of the abuses feared by the pessimists have (so far) come to pass.
This month, however, I want to consider a proposal which causes in me feelings of ethical disquiet, and try to identify why it does so. It is so radical a proposal that optimists once dismissed concerns that proposals like this would come forward if MAID was legalized as irresponsible fearmongering. Optimists assured us that such things would never, could never, be permitted.
The last time I went to renew my driver’s license, I was asked whether I wanted to be marked down as an organ donor. I said yes – if my organs can benefit someone else after my death, that clearly seems to be a good thing.
As I am sure readers know, there is a shortage of organs available for transplant. Interestingly enough, Nova Scotia recently became the first jurisdiction in North America to move to a system of presumed consent for organ donation – which means that, instead of being asked to opt in (as I was), people will have to make a choice to opt out: consequently, everyone will be presumed to be an organ donor unless they specifically refuse. While the new system will take a few months to be put in place, it is likely that this move will generate many more organs that are available for transplant, since most people will not make the effort to opt out.
While this seems to me to be a reasonable approach to addressing the organ shortage, I recently read a 2018 New England Journal of Medicine article which caused me some ethical discomfort. The article, entitled “Voluntary Euthanasia – Implications for Organ Donation,” makes the case that those individuals who have chosen MAID should be eligible to serve as organ donors. What makes the proposal so controversial was not so much that a connection was being made between those who choose to die by MAID and those who need organs, it was that the authors propose that MAID should be performed, not by the administration of a substance that causes death, but by the removal of the organs themselves. This would violate what is called “the dead donor rule” (or DDR), and it is this violation that makes this proposal so ethically troubling,
The DDR is an important ethical principle in place to ensure that organ transplantation is done in an ethically sound way. This rule requires exactly what it sounds like it does, namely, that those who have agreed to act as organ donors after they die must be dead before their organs are removed, and that the removal of the organs must not, itself, be the cause of death. It is, in fact, knowledge of the DDR that made me comfortable agreeing to be a potential organ donor: I am happy to donate my organs to someone else after I am dead, but not before.
The purpose of the DDR is two-fold. In practical terms, it increases the number of people willing to be organ donors, because it provides reassurance that their organs will not be removed until they are no longer of use to them. Even after Nova Scotia fully implements the presumed consent model, for example, it is likely that more people would go to the effort of opting out if the DDR rule were not in place.
In ethical terms, the DDR does something very important: it ensures that those who are dying, even if they have agreed to be donors, are treated as patients up until the moment of their deaths, and not simply as a source of raw materials that can be exploited to benefit others. It ensures, that is to say, they are treated as subjects, not objects.
An important technical challenge in organ donation is to keep the organs as fresh as possible as they are moved from donor to recipient. Sometimes, for various reasons, this period is too long, and the organs become unusable before they can be transplanted. The authors of the article in The New England Journal of Medicine argue that taking organs from MAID patients before they are dead would ensure that they are fresh; moreover, they assert that this approach would be a way of respecting the autonomous choice made by those MAID recipients who also want to be organ donors.
As the authors put it, in the case of voluntary euthanasia:
Since first-person consent is required, clinicians can obtain a reliable understanding of the patients’ goals and values. Although some patients may want to be sure that organ procurement won’t begin before they have been declared dead, others may want not only a rapid, peaceful, painless death, but also the option of donating as many organs as possible and in the best condition as possible. Following the dead donor rule could interfere with the ability of these patients to achieve their goals.
Kidney transplant operation. (Source: UAB Vimeo https://vimeo.com/218828790)
The authors also note that moving to this kind of procurement protocol would require a change in the Criminal Code of Canada, which states that medical assistance in dying means the administration of a substance, by a qualified provider, which causes death.
By this definition, organ retrieval is not an accepted cause of death.
If this proposal were ever accepted, it would change not only how, but also where, MAID patients die. Death at home, or in a hospital room surrounded by loved ones, would not be possible. As the authors blandly note:
The operating room is likely to be viewed as colder and more sterile than other locations, and in some cases operating room policies may preclude the presence of family during the procedure itself, forcing family members to say their final goodbyes outside the operating room.
Speaking for myself, if I had a loved one who had chosen MAID and wanted to die according to this proposed protocol, I would be unable to watch them die by having their organs removed, were I the one who had chosen MAID by this method, I wouldn’t want my loved ones’ last memory of me to be seeing physicians removing my heart, lungs, and other organs.
While I accept the need for more organs to be made available for transplantation, and recognize that MAID will be the best option for some people, causing death by removing organs in order to facilitate transplantation seems to me to take us no small distance down the slippery slope to killing people for their organs. This proposal is the stuff of horror fiction and dystopian fantasies. To see it made in a reputable medical journal is disturbing.
It should be noted that following the DDR in the case of MAID patients who have agreed to be organ donors does not mean that their organs will necessarily be unusable, any more than allowing the victim of a motorcycle accident to die before their organs are removed means that they will be unusable. (Of course, it’s quite possible that the disease which led to the request for MAID in the first place might make the person’s organs unusable – but this would apply whether those organs were removed before or after death.)
To use organs after their owners are dead is one thing; to kill someone by removing their organs is quite another.
Wolfville native Rachel Haliburton teaches philosophy at the University of Sudbury. Her latest book, The Ethical Detective: Moral Philosophy and Detective Fiction, was published in February by Lexington Books.
