This paper defends an ‘opt-out’ scheme for organ procurement, by distinguishing this system from ‘presumed consent’ (which the author regards as an erroneous justification of it). It, first, stresses the moral importance of increasing the supply of organs and argues that making donation easier need not conflict with altruism. It then goes on to explore one way that donation can be increased, namely by adopting an opt-out system, in which cadaveric organs are used unless the deceased (or their family) registered (...) an objection. Such policies are often labelled ‘presumed consent’, but it is argued that critics are right to be sceptical of this idea—consent is shown to be an action, rather than a mental attitude, and thus not something that can be presumed. Either someone has consented or they have not, whatever their attitude to the use of their organs. Thankfully, an opt-out scheme need not rest on the presumption of consent. Actual consent can be given implicitly, by one's actions, so it is argued that the failure to register an objection (given certain background conditions) should itself be taken as sign of consent. Therefore, it is permissible to use the organs of someone who did not opt out, because they have—by their silence—actually consented. (shrink)

Altruism and solidarity are concepts that are closely related to organ donation for transplantation. On the one hand, they are typically used for encouraging people to donate. On the other hand, they also underpin the regulations in force in each country to different extents. They are often used indistinctly and equivocally, despite the different ethical implications of each concept. This paper aims to clarify to what extent we can speak of altruism and solidarity in the predominant models of organ donation. (...) It also raises the ethical question of whether these categories are adequate as a basis for such models, bearing in mind that organs are a scarce resource and that a shortage of them may mean that fewer lives are saved or improved. (shrink)

This collection features comprehensive overviews of the various ethical challenges in organ transplantation. International readings well-grounded in the latest developments in the life sciences are organized into systematic sections and engage with one another, offering complementary views. All core issues in the global ethical debate are covered: donating and procuring organs, allocating and receiving organs, as well as considering alternatives. Due to its systematic structure, the volume provides an excellent orientation for researchers, students, and practitioners alike to enable a deeper (...) understanding of some of the most controversial issues in modern medicine. (shrink)

I argue against various versions of the ‘attitude’ view of consent and of the ‘action’ view of consent: I show that neither an attitude nor an action is either necessary or sufficient for consent. I then put forward a different view of consent based on the idea that, given a legitimate epistemic context, absence of dissent is sufficient for consent: what is crucial is having access to dissent. In the latter part of the paper I illustrate my view of consent (...) by applying it to the case of consenting to being an organ donor. (shrink)

In this chapter, we provide an overview of the ethical considerations relevant to the use of nudges in organ donation policy. We do not defend a position on the permissibility of nudging in this context, but instead aim to clearly outline the strongest arguments on the different sides of this issue that have been presented in the English-language scholarly bioethics literature. We also highlight the questions that are in need of further investigation. In part 1, we briefly discuss nudging before (...) considering proposals to use nudges to increase the number of registered organ donors, including opt-out donor registration systems and the use of “nudge statements.” In part 2, we discuss the use of nudges to influence the decision-making of family members in circumstances where they have a veto over the donation of their loved one’s organs. (shrink)

A chief objection to opt-out organ donor registration policies is that they do not secure people's actual consent to donation, and so fail to respect their autonomy rights to decide what happens to their organs after they die. However, scholars have recently offered two powerful responses to this objection. First, Michael B Gill argues that opt-out policies do not fail to respect people's autonomy simply because they do not secure people's actual consent to donation. Second, Ben Saunders argues that opt-out (...) policies do secure people's actual—if not explicit—consent, provided that certain conditions are satisfied. I argue that Gill and Saunders’ arguments are not successful. My conclusion does not imply that jurisdictions should not implement opt-out policies—their failure to secure people's actual consent may be outweighed by other considerations. But, my conclusion does imply that Gill and Saunders are mistaken to claim that opt-out policies are respectful of people's autonomy. (shrink)

The first question I discuss in this paper is whether we have a duty of rescue to make our organs available for transplantation after our death, a duty we owe to patients suffering from organ failure. The second question is whether political obligations, in particular the obligation to obey the law, can be derived from natural duties, possibly duties of beneficence. Such duties are normally seen as merely imperfect duties, not owed to anyone. The duty of rescue, however, is a (...) perfect one, mainly because it applies to us when we are in a unique position to provide urgent help to a person in need. The basic idea of a natural duty account of political obligation is that such unique positions can be artificially created by institutionalized coordination schemes. The remaining problem is how any particular coordination scheme could claim our allegiance rather than any other. This problem can be solved in different ways in the organ donation case, and in respect to a limited set of political obligations, mainly negative ones. A natural duty account is best seen as a constitutive part of a multiple principle theory of political obligation. (shrink)

Background Posthumous organ procurement is hindered by the consenting process. Several consenting systems have been proposed. There is limited information on public relative attitudes towards various consenting systems, especially in Middle Eastern/Islamic countries. Methods We surveyed 698 Saudi Adults attending outpatient clinics at a tertiary care hospital. Preference and perception of norm regarding consenting options for posthumous organ donation were explored. Participants ranked (1, most agreeable) the following, randomly-presented, options from 1 to 11: no-organ-donation, presumed consent, informed consent by donor-only, (...) informed consent by donor-or-surrogate, and mandatory choice; the last three options ± medical or financial incentive. Results Mean(SD) age was 32(9) year, 27% were males, 50% were patients’ companions, 60% had ≥ college education, and 20% and 32%, respectively, knew an organ donor or recipient. Mandated choice was among the top three choices for preference of 54% of respondents, with an overall median[25%,75%] ranking score of 3[2,6], and was preferred over donor-or-surrogate informed consent (4[2,7], p vs. 11[6,11], respectively, p = 0.002). Compared to females, males more perceived donor-or-surrogate informed consent as the norm (3[1,6] vs. 5[3,7], p vs. 8[4,9], p vs. 5[2,7], p Conclusions We conclude that: 1) most respondents were in favor of posthumous organ donation, 2) mandated choice system was the most preferred and presumed consent system was the least preferred, 3) there was no difference between preference and perception of norm in consenting systems ranking, and 4) financial (especially in females) and medical (especially in males) incentives reduced preference. (shrink)

In recent years, the principle of informed consent has come under significant pressure with the rise of biobanks and data infrastructures for medical research. Study-specific consent is unfeasible in the context of biobank and data infrastructure research; and while broad consent facilitates research, it has been criticised as being insufficient to secure a truly informed consent. Dynamic consent has been promoted as a promising alternative approach that could help patients and research participants regain control over the use of their biospecimen (...) and health data in medical research. Critical voices have focused mainly on concerns around its implementation; but little has been said about the argument that dynamic consent is morally superior to broad consent as a way to respect people’s individual autonomy. In this paper, we identify two versions of this argument—an information-focused version and a control-focused version—and then argue that both fail to establish the moral superiority of dynamic over broad consent. In particular, we argue that since autonomous choices are a certain species of choices, it is neither obvious that dynamic consent would meaningfully enhance people’s autonomy, nor that it is morally justifiable to act on every kind of consent choice enabled by dynamic consent. (shrink)

Access to human biospecimens is widely regarded as essential to the progress of medical research, and in particular, to the success of “personalized medicine.” Understanding the influence of genetic variation on human health and disease requires that researchers conduct genetic and other studies on thousands of human specimens. Over the past decade, human “biobanks” — vast collections of human biospecimens — have proliferated both in the United States and internationally. These biobanks are subject to a heterogeneous mix of standards that (...) govern the collection and use of biospecimens. (shrink)

Jessica Flanigan argues that individuals have the right to self-medicate. Flanigan presents two arguments in defense of this right. The first she calls the epistemic argument and the second she calls the rights-based argument. I argue that the right to self-medicate hangs and falls on the rights-based argument. This is because for the epistemic argument to be sound agents must be assumed to be epistemically competent. But, Flanigan’s argument for a constitutionally mandated right to self-medicate models agents as epistemically incompetent. (...) For Flanigan, agents are different at the pharmacy than they are at the polls. I identify this behavioral asymmetry and advocate a symmetric and realistic behavioral postulate for both arguments. The result, however, is that the success of the epistemic argument becomes contingent which fails to justify a constitutionally mandated right. I proceed to raise skepticism about the rights-based argument as well. I conclude that there is reason to be skeptical that these arguments can justify a constitutionally mandated right to self-medicate. Ultimately, a bottom-up approach to pharmaceutical ethics is preferable. (shrink)

This article explores the meaning and moral significance of presumed consent with particular reference to an opt-out policy for postmortem organ donation. It does so under two general categories: circumstances where we believe consent to have been given and those where we have no reason to believe that it has either been given or been refused. In the context of an opt-out policy, the first category would relate to the idea of tacit consent. It is argued both that substituting the (...) term ‘presumed consent’ would be misleading and that it is unlikely that the conditions for tacit consent would be met in practice. Regarding the second category, where the claim would be one regarding counterfactual consent, two main points are made: that claims about consent are unwarranted, and also that they are unnecessary to moral argument, given that the moral work is done by reasons other than any supposedly provided by a presumption of consent. (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.

In this reply to Wilkinson and De Wispelaere, I argue that an opt-out donation system can be regarded as tacit consent. I first separate the opt-in/opt-out issue from that of the role that the family ought to play. I then argue that what De Wispelaere calls minimal approval-tracking is not obviously necessary and that, even if it were, opt-out schemes can satisfy this requirement.

Although transplantation surgeries are relatively successful and save the lives of many, only few are willing to donate organs. In order to better understand the reasons for donation or refusing donation and their implications on and influence by public policy, we conducted a survey examining public views on this issue in Israel. Between January and June 2010, an anonymous questionnaire based on published literature was distributed among random and selected parts of Israeli society and included organ recipients, organ donors, soldiers, (...) university and high school students, and the general population. The analysis of 799 questionnaires revealed that, although 74.7 percent have not signed a donor card, 60.8 percent of participants consider doing so. Additionally, 54.3 percent of respondents objected to giving or receiving compensation for donation, and, if at all, priority in transplantation care is the most desired form of such compensation. The health status of the donor and knowing that donation saves lives or that there exists a shortage of organs for transplantation are the two factors most affecting motivation to donate. Lack of information, relatives’ views on donation, and type of organ involved in donation are factors most inhibiting donation. Willingness to donate is significantly affected by the proximity of the recipient to the donor. With regard to most organs, their contribution to one’s sense of “self” and its symbolic role strongly affects motivation to donate, except for donation to relatives. Compensation for organ donation has little effect on motivation to donate during life and after death. Our findings suggest new ways to construct a more effective public policy on this issue. (shrink)

Ben Saunders claims that actual consent is not necessary for organ donation due to ‘normative consent’, a concept he borrows from David Estlund. Combining normative consent with Peter Singer's ‘greater moral evil principle’, Saunders argues that it is immoral for an individual to refuse consent to donate his or her organs. If a presumed consent policy were thus adopted, it would be morally legitimate to remove organs from individuals whose wishes concerning donation are not known. This paper disputes Saunders' arguments. (...) First, if death caused by the absence of organ transplant is the operational premise, then, there is nothing of comparable moral precedence under which a person is not obligated to donate. Saunders' use of Singer's principle produces a duty to donate in almost all circumstances. However, this premise is based on a flawed interpretation of cause and effect between organ availability and death. Second, given growing moral and scientific agreement that the organ donors in heart-beating and non-heart-beating procurement protocols are not dead when their organs are surgically removed, it is not at all clear that people have a duty to consent to their lives being taken for their organs. Third, Saunders' claim that there can be good reasons for refusing consent clashes with his claim that there is a moral obligation for everyone to donate their organs. Saunders' argument is more consistent with a conclusion of ‘mandatory consent’. Finally, it is argued that Saunders' policy, if put into place, would be totalitarian in scope and would therefore be inconsistent with the freedom required for a democratic society. (shrink)