Over the last few years, policies have been introduced in the UK that identify and treat patients as potential organ donors before death. Patients incapacitated due to catastrophic brain injury may now undergo intensive ante-mortem interventions to improve the chances of successfully transplanting their organs into third parties after death. The most significant ethical and legal problem with these policies is that they are not based on the individual’s specific wishes in the circumstances. Policy-makers appear reluctant to inform potential registrants (...) on the Organ Donor Register about ante-mortem donor optimisation procedures and to provide an opportunity to record specific wishes in advance. They are reliant on blind trust in the organ donation programme, which as I argue in this paper, presents significant risks for the achievement of its aim of securing an adequate supply of organs for transplantation. I argue that informed trust, based on accurate information about the future consequences of registra... (shrink)

The demand for organs prompted the first use of elective ventilation in the UK in the 1990s. Recently the shortfall in supply of organs has once again prompted calls for elective ventilation to be instituted even in patients who are not brain dead. This paper proposes that the term ‘elective’ ventilation is a misnomer and the term non-therapeutic ventilation (NTV) should be used instead. It is further argued that the practice of NTV in cases of severe stroke is unethical and (...) has the potential of causing a variety of harms to the patient, their relatives, the healthcare professionals working in transplant teams and this may result in a backlash of reductions in the number of organ donations. (shrink)

Elective ventilation (EV) is ventilation—not to save a patient's life, but with the expectation that s/he will die—in the hope that organs can be retrieved in the best possible state. The arguments for doing such a thing rest on the value of the lives being saved by the donated organs, maximally honouring the donor's wishes where the patient can be reasonably thought to wish to donate, and a general principle in favour of organ donation where possible as an expression of (...) human solidarity. Arguments against include difficulties surrounding the patient's consent to donation (including the risk of them surviving in an unacceptably bad state), the possibility of changing our perception of organ donation and care in dying, and the moral distress potentially caused to intensive care unit (ICU) staff involved in EV. EV can occur before or after the patient is declared dead and it is EV before the declaration of death (EVb) that occasions the ethical worries. I argue that when we acknowledge the tragedy involved, attend sensitively to the grief proper to human death, and ensure that we are not working in an ethical and legal climate that increases the likelihood of inadvertent survival in an unacceptably bad state, EVb is ethically defensible. (shrink)

One of the most controversial aspects in uncontrolled donation of organs after circulatory death is the initiation of preservation measures before death. I argue that in so-called opting-out systems only under very stringent conditions we might presume consent to the instauration of those measures. Given its current legal framework, I claim that this is not the case of Spain, a well-known country in which consent is presumed—albeit only formally—and where uDCD is currently practiced.

This essay comments on the British Medical Association's recent suggestion that protocols for Elective Ventilation (EV) might be revived in order to increase the number of viable organs available for transplant. I suggest that the proposed revival results, at least in part, from developments in the contemporary political landscape, notably the decreasing likelihood of an opt-out system for the UK's Organ Donor Register. I go on to suggest that EV is unavoidably situated within complex debates surrounding the epistemology and ontology (...) of death. Such questions cannot be settled a priori by medical science, bioethics or philosophical reflection. As Radcliffe-Richards suggests, the determination of death has become a moral question, and therefore, now extends into the political arena. I argue for the conclusion that EV, and wider debates about organ donation and the constitution of the organ donation register, are matters of ‘biocitizenship’ and must, therefore, be addressed as ‘biopolitical’ questions. (shrink)

In this paper we defend that elective ventilation (EV), even if conceived as the instrument to maximise the chances of organ recovery, is mainly the means to provide the patient who is dying with a dignified death in several ways, one of them being the possibility of becoming an organ donor. Because EV does not harm the patient and permits the medical team a better assessment of the patient's clinical trajectory and a better management of the dying process by the (...) family, EV does not violate the principle of non-beneficence nor the principle of autonomy if we restrict the initiation of EV to those cases in which it is not known what the previous wishes of the patient were as regards to his or her care at the end of life. (shrink)

Current organ procurement policies in the UK include ante-mortem interventions to facilitate organ donation. However, a clear and unambiguous legal framework for these procedures does not currently exist. The Human Tissue Act 2004 does not provide authority for donor optimisation procedures before death, and there are a number of difficulties in encompassing these procedures within the Mental Capacity Act 2005 provisions on best interests. This article proposes a system of specific advance consent to enable best interests to take on its (...) ascribed role as the legal justification for donor optimisation procedures. (shrink)