Bioethics has entered a new era: as many commentators have noted, the familiar mantra of autonomy, beneficence, nonmaleficence, and justice has proven to be an overly simplistic framework for understanding problems that arise in modern medicine, particularly at the intersection of public policy and individual preferences. A tradition of liberal pluralism grounds respect for individual preferences and affirmation of competing conceptions of the good. But we struggle to maintain (or at times explicitly reject) this tradition in the face of individual (...) preferences that we find distasteful, suspect, or even repugnant, especially where the broader social good or respect for equality is at stake. Directed donation presents us with such a dilemma: can we uphold the right of self-determination through respect of individual preferences regarding disposition of transplantable organs while at the same time maintaining an allocation system that reflects values of equity and justice claimed to underlie the socially negotiated practice of transplantation? Or are some preferences simply to be deemed unethical and not respected, even if that leads to a reduction in the number of transplantable organs available and to an apparent disregard for the autonomous decisions of the recently deceased? (shrink)

It is common to interpret Rawls's maximin theory of justice as egalitarian. Compared to utilitarian theories, this may be true. However, in special cases practices that distribute resources so as to benefit the worst off actually increase the inequality between the worst off and some who are better off. In these cases the Rawlsian maximin parts company with what is here called true egalitarianism. A policy question requiring a distinction between maximin and "true egalitarian" allocations has arisen in the arena (...) of organ transplantation. This case is examined here as a venue for differentiating maximin and true egalitarian theories. Directed donation is the name given to donations of organs restricted to a particular social group. For example, the family of a member of the Ku Klux Klan donated his organs on the provision that they go only to members of the Caucasian race. While such donations appear to be discriminatory, if certain plausible assumptions are made, they satisfy the maximin criterion. They selectively advantage the recipient of the organs without harming anyone. Moreover, everyone who is lower on the waiting list is advantaged by moving up on the waiting list. This paper examines how maximin and more truly egalitarian theories handle this case arguing that, to the extent that directed donation is unethical, the best account of that conclusion is that an egalitarian principle of justice is to be preferred to the maximin. (shrink)

The difficulty in finding well‐matched kidneys for transplantation into black Americans is compounded by the disproportionately low rate of black donation. A program of directed donation that privileged black‐to‐black transplant could ease the chronic shortage of organs.

In wrongful life litigation a congenitally impaired child brings suit against those, usually physicians, whose negligence caused him to be born into his suffering existence. A key conceptual question is whether we can predicate harm in such cases. While a few courts have permitted it, many courts deny that we can, and thus have refused these children standing to sue. In this article the author examines the wrongful life cases and literature enroute to a broader consideration of harm. This literature, (...) and philosophical discussions of harm generally, rely on a definition which ascribes harm by comparing an individual's current condition with that in which he would otherwise have been, but for the allegedly harmful event. The author shows this definition to be conceptually and morally flawed. A superior general definition is offered which, when then applied to wrongful life cases, shows that we can easily ascribe harm in these cases and can find clear potential for tort liability. (shrink)

For patients suffering from renal failure, cadaveric donor kidneys are a scarce and valuable good. In 1996, the Eurotransplant International Foundation implemented a new kidney allocation. system. The aim of this paper is to identify and discuss issues of distributive justice in kidney allocation, with an emphasis on the basic features of the new Eurotransplant system. Particular consideration is given to waiting time and medical success.

The difficulty in finding well‐matched kidneys for transplantation into black Americans is compounded by the disproportionately low rate of black donation. A program of directed donation that privileged black‐to‐black transplant could ease the chronic shortage of organs.

Scientific developments of the last 20 years have made the transplantation of cadaveric solid organs a viable and expected treatment alternative for patients suffering from various forms of End Stage Organ Disease. Of the number of organs that could be utilized for this, only a small percentage of them are actually made available. North American legislation explicitly categorizes the transfer of cadaveric organs as an anatomical or tissue “gift”. The concept of the gift is mediated by transculturally consistent unwritten, but (...) powerfully felt, rules of conduct. Among the most profound elements of the concept is the obligatory gift-exchange which is central to the gift-relationship. Obviously, neither of these are permitted by the organ transplant scenario. As a result, dissonance is created within the thought process of the individual which cannot be easily resolved, paralyzing many into inaction. We maintain that the present legal framework, designed to facilitate the transfer of organs, clashes with the human phenomenon of giving, and may actually prevent organs from being made available. In a search for a solution to this gift-relationship dilemma, giving organs is contrasted with taking organs as a basis upon which to ground ethically sound public policy. Liberty-limiting principles and the concept of harm are considered within this context. (shrink)

In a well known British case, the relatives of a dead man consented to the use of his organs for transplant on the condition that they were transplanted only into white people. The British government condemned the acceptance of racist offers and the panel they set up to report on the case condemned all conditional offers of donation. The panel appealed to a principle of altruism and meeting the greatest need. This paper criticises their reasoning. The panel’s argument does not (...) show that conditional donation is always wrong and anyway overlooks a crucial distinction between making an offer and accepting it. But even the most charitable reinterpretation of the panel’s argument does not reject selective acceptance of conditional offers. The panel’s reasoning has no merit. (shrink)

Public appeals for organ donation to an identified individual raise serious ethical questions about the role of the media, the physician, the prospective recipient, and the donor in the procurement process.