We argued in a recent issue of this journal that if abortion is restricted,1 then there are parallel obligations for parents to donate body parts to their children. The strength of this obligation to donate is proportional to the strength of the abortion restrictions. If abortion is never permissible, then a parent must always donate any organ if they are a match. If abortion is sometimes permissible and sometimes not, then organ donation is sometimes obligatory and sometimes not. (...) Our argument was based on the following ideas: (a) that a fetus has full moral status, (b) that parents have special obligations to their offspring, fetus or not, and (c) that this special obligation is to protect them. The result is the conclusion that abortion restrictivists cannot also consistently deny that organ donation should be compulsory. (shrink)

Five arguments are presented in favour of the proposal that people who opt in as organ donors should receive a tax break. These arguments appeal to welfare, autonomy, fairness, distributive justice and self-ownership, respectively. Eight worries about the proposal are considered in this paper. These objections focus upon no-effect and counter-productiveness, the Titmuss concern about social meaning, exploitation of the poor, commodification, inequality and unequal status, the notion that there are better alternatives, unacceptable expense, and concerns about the veto (...) of relatives. The paper argues that none of the objections to the proposal is very telling. (shrink)

This essay, based on data referring to Brazil and Spain, addresses aspects relevant to the scenario of organ donation and transplantation, such as the relationship between supply and demand, current legislation, costs, and possible improvements to increase donation rates and performance in the transplantation process as a whole. The objective is to present current empirical data that increase the relevant empirical knowledge for the bioethical evaluation in an organized way. The two countries stand out when it comes to transplants, (...) Brazil, because it has the largest public system of organ transplants in the world; Spain, for decades the highest rate of effective donor per million inhabitants. Our initial data analyses suggest the need to deal more explicitly with the interests of those affected and with the public opinion, within a systemic articulation between legislation, evidence-based public policies, and research. (shrink)

The wishes of registered organ donors are regularly set aside when family members object to donation. This genuine overruling of the wishes of the deceased raises difficult ethical questions. A successful argument for providing the family with a veto must (a) provide reason to disregard the wishes of the dead, and (b) establish why the family should be allowed to decide. One branch of justification seeks to reconcile the family veto with important ideas about respecting property rights, preserving autonomy, (...) and preventing harm. These arguments are ultimately unsuccessful. Another branch of arguments is consequentialist, pointing out the negative consequences of removing the veto. Whether construed as concerning family distress or as a potential drop in the organs available, these arguments are unsuccessful; the first fails to recognize the tremendous distress associated with waiting for an organ, while the second has little supporting evidence. A final section considers and rejects whether combining some of the arguments just examined could justify the family veto. We should thus remove the family veto in organ donation. (shrink)

Some people oppose abortion on the grounds that fetuses have full moral status and thus a right to not be killed. We argue that special obligations that hold between mother and fetus also hold between parents and their children. We argue that if these special obligations necessitate the sacrifice of bodily autonomy in the case of abortion, then they also necessitate the sacrifice of bodily autonomy in the case of organ donation. If we accept the argument that it is (...) obligatory to override a woman’s bodily autonomy for the sake of an unborn child’s survival, we must continue to override the bodily autonomy of parents to ensure the survival of their living children, until the parent no longer has a special obligation to their child to the same degree as their special obligation to the fetus. And if the life of a child is truly more important than the bodily autonomy of its parents, as must be the case to force women to carry unwanted pregnancies to term, this should remain true until such a time that their children are no longer considered their responsibility. Thus, parity of reasoning suggests that policies compelling the gestation of a fetus should be accompanied by policies compelling organ donation. (shrink)

The dead donor rule (DDR) prohibits retrieval protocols that would be lethal to the donor. Some argue that compliance with it can be maintained by satisfying the requirements of double‐effect reasoning (DER). If successful, one could support organ donation without reference to the definition of death while being faithful to an ethic that prohibits intentionally killing innocent human life. On the contrary, I argue that DER cannot make lethal organ donation compatible with the DDR, because there are plausible (...) ways it fails DER's requirements. A key takeaway is that the theories of intention and proportionality assumed in DER matter for its plausibility as a constraint on practical reasoning. (shrink)

We explore the ethics of using motivational interviewing, an evidence-based, client-centred and directional counselling method, in conversations with next of kin about deceased solid organ donation. After briefly introducing MI and providing some context around organ transplantation and next of kin consent, we describe how MI might be implemented in this setting, with the hypothesis that MI has the potential to bring about a modest yet significant increase in next of kin consent rates. We subsequently consider the objection (...) that using MI in this context would be manipulative. Although we cannot guarantee that MI would never be used in a problematically manipulative fashion, we conclude that its use would, nevertheless, be permissible as a potential means to increase next of kin consent to deceased solid organ donation. We propose that MI be trialled in consent situations with next of kin in nations where there is widespread public support for organ donation. (shrink)

Goal: To assess public knowledge and attitudes towards the family’s role in deceased organ donation in Europe. -/- Methods: A systematic search was conducted in CINHAL, MEDLINE, PAIS Index, Scopus, PsycINFO, and Web of Science on December 15th, 2017. Eligibility criteria were socio-empirical studies conducted in Europe from 2008 to 2017 addressing either knowledge or attitudes by the public towards the consent system, including the involvement of the family in the decision-making process, for post-mortem organ retrieval. Screening and (...) data collection were performed by two or more independent reviewers for each record. -/- Results: Of the 1482 results, 467 studies were assessed in full-text form, and 33 were included in this synthesis. When the deceased has not expressed any preference, a majority of the public support the family's role as a surrogate decision-maker. When the deceased expressly consented, the respondents' answers depend on whether they see themselves as potential donors or as a deceased's next-of-kin. Answers also depend on the relationship between the deceased and the decision-maker(s) within the family, and on their ethnic or cultural background. -/- Conclusions: Public views on the authority of the family in organ donation decision-making require further research. A common conceptual framework and validated well-designed questionnaires are needed for future studies. The findings should be considered in the development of Government policy and guidance regarding the role of families in deceased organ donation. (shrink)

In this essay I argue that childbearing and various kinds of organ donation are morally analogous activities. I argue, further, that the ethos of giftgiving ought to inform our analyses of both of these forms of bodily life support. This reframing of the abortion and organ donation debates yields new insights into two relatively neglected subtopics. First, though frequently asserted, few have demonstrated why bodily life support--especially in the form of childbearing--cannot be morally required. This comparison yields insights (...) into the reasons for such an axiom. Second, while the giving of bodily life support is sometimes exhorted and almost always respected and admired, its intelligibility and political meaningfulness as a moral choice is rarely explored. This analogical wager reveals why one ought to give another bodily life support. In summary, the analogy yields insights crucial to the development of cogent arguments regarding both the grounds for and limits of the responsibility to give bodily life support. Further, the analogy displays the disparity between what has been demanded traditionally of those who are pregnant and of those men (and women) who by virtue of tissue or blood type can offer other forms of bodily life support. The analogy enables reflection on abortion (and organ donation) to develop in a context free of sexist biases. Finally, efforts are made to assess this giftgiving ethos in light of the feminist "hermeneutics of suspicion" regarding arguments which have and can sacralize victimization. (shrink)

Objectives To increase postmortem organ donation rates, several countries are adopting an opt-out (presumed consent) policy, meaning that individuals are deemed donors unless they expressly refused so. Although opt-out countries tend to have higher donation rates, there is no conclusive evidence that this is caused by the policy itself. The main objective of this study is to better assess the direct impact of consent policy defaults per se on deceased organ recovery rates when considering the role of the (...) family in the decision-making process. This study does not take into account any indirect effects of defaults, such as potential psychological and behavioural effects on individuals and their relatives. -/- Design Based on previous work regarding consent policies, we created a conceptual model of the decision-making process for deceased organ recovery that included any scenario that could be directly influenced by opt-in or opt-out policies. We then applied this model to internationally published data of the consent process to determine how frequently policy defaults could apply. -/- Main outcome measures We measure the direct impact that opt-in and opt-out policies have per se on deceased organ recovery. -/- Results Our analysis shows that opt-in and opt-out have strictly identical outcomes in eight out of nine situations. They only differ when neither the deceased nor the family have expressed a preference and defaults therefore apply. The direct impact of consent policy defaults is typically circumscribed to a range of 0%–5% of all opportunities for organ recovery. Our study also shows that the intervention of the family improves organ retrieval under opt-in but hinders it under opt-out. -/- Conclusions This study may warn policy makers that, by emphasising the need to introduce presumed consent to increase organ recovery rates, they might be overestimating the influence of the default and underestimating the power granted to families. (shrink)

Bioethical discourse on organ donation covers a wide range of topics, from informed consent procedures and scarcity issues up to ‘transplant tourism’ and ‘organ trade’. This paper presents a ‘depth ethics’ approach, notably focussing on the tensions, conflicts and ambiguities concerning the status of the human body. These will be addressed from a psychoanalytical angle. First, I will outline Lacan’s view on embodiment as such. Subsequently, I will argue that, for organ recipients, the donor organ becomes (...) what Lacan refers to as an object a, the ‘partial object’ of desire, the elusive thing we are deprived of, apparently beyond our grasp. Within the recipient’s body an empty space emerges, a kind of ‘vacuole’, once occupied by a faltering organ. This space can only be filled by a ‘gift’ from the other, by an object a. Once implanted, however, this implant becomes an ‘extimate’ object: something both ‘external’ and ‘intimate’, both ‘embedded’ and ‘foreign’, and which is bound to remain an object of concern for quite some time, if not for life. A Lacanian analysis allows us, first of all, to address the question what organ transplantation has in common with other bodily practices involving bodily parts procured from others, such as cannibalism. But it also reveals the basic difference between the two, as well as the distance between the ‘fragmented body’ of Frankenstein’s ‘monster’—as an aggregate of replaceable parts—and the multiple organ recipients of today. (shrink)

Deceased organ donation is widely considered as a case of easy rescue―that is, a case in which A may bestow considerable benefits on B while incurring negligent costs herself. Yet, the policy implications of this observation remain unclear. Drawing on Christopher H. Wellman’s samaritan account of political obligations, the paper develops a case for a so-called opt-out system, i.e., a scheme in which people are defaulted into being donors. The proposal’s key idea is that we may arrange people’s options (...) in specific ways for the sake of others. (shrink)

Authors: Joseph M. Eble, John A. Di Camillo, Peter J. Colosi. --- NEWS RELEASE For Immediate Release February 27, 2024 Contact: Joseph M. Eble, MD Corresponding author 919-667-5206 -/- The statement, Catholics United on Brain Death and Organ Donation: A Call to Action (HTML), was published on February 27, 2024. It was prepared by Joseph Eble, a physician and President of the Tulsa Guild of the Catholic Medical Association; John Di Camillo, an ethicist of The National Catholic Bioethics Center; (...) and Peter Colosi, a philosophy professor at Salve Regina University. -/- Catholic United explains that the criteria for brain death establish only partial loss of brain function. This is now abundantly clear based on scientific studies, a recent effort to lower the legal standard for death, and updated brain death guidelines issued in October 2023. -/- Catholics United bridges a divide among faithful Catholics about whether the concept of brain death aligns with Church teaching. Some Catholics hold that brain death represents true death when there is complete and irreversible cessation of all brain activity, often called whole brain death. Others hold that brain death does not represent true death. Since the existing criteria establish only partial loss of brain function, all the endorsers—whether they accept or reject whole brain death as true death—agree that “the current brain death criteria in widespread use do not provide moral (prudential) certainty of death.” -/- Catholics United calls on health care professionals and institutions to cease organ harvesting that relies on the inadequate criteria, noting that 70% of all donors are declared dead using brain death criteria. “Given the lack of moral certainty of death whenever the current brain death criteria are used,” the statement affirms, “a clear majority of vital organ donors can be presumed alive at the time of organ harvesting.” Since the Catholic Church forbids removing vital organs when this would kill the patient, “it is therefore wrong to remove organs from patients declared dead using these inadequate criteria.” . (shrink)

In the beginning of the COVID pandemic, researchers and bioethicists called for human challenge trials to hasten the development of a vaccine for COVID. However, the fact that we lacked a specific, highly effective treatment for COVID led many to argue that a COVID challenge trial would be unethical and we ought to pursue traditional phase III testing instead. These ethical objections to challenge trials may have slowed the progress of a COVID vaccine, so it is important to evaluate their (...) merit. One common way of doing so is to make an analogy to other social practices that are relevantly similar and which we currently sanction. We submit that non-directed live organ donation (NDLOD) is a promising analogy. After arguing that the risks to volunteers for each activity appear similar, we explore potential disanalogies that would undermine the comparison. We note that there are differences in both the kind and certainty of benefit secured by NDLOD compared to challenge trials. We conclude these differences are insufficient to make NDLOD permissible and challenge trials impermissible. Ultimately, if we think the risks associated with NDLOD are ethically permissible, then we should think the same of the risks associated with COVID challenge trials. (shrink)

Background: Several countries have recently changed their model of consent for organ donation from opt-in to opt-out. We undertook a systematic review to determine public knowledge and attitudes towards these models in Europe. Methods: Six databases were explored between 1 January 2008 and 15 December 2017. We selected empirical studies addressing either knowledge or attitudes towards the systems of consent for deceased organ donation by lay people in Europe, including students. Study selection, data extraction, and quality assessment were (...) conducted by two or more reviewers independently. Findings: Awareness of the consent model was lower in opt-out countries than in opt-in countries. A majority of the public agrees with opt-in, regardless of the law in their own country. There are ambivalent attitudes regarding the opt-out system. The public tend to prefer opt-in and mandatory choice over opt-out when several options are offered. Interpretation: The assumption that people in opt-out countries are aware of the legal requirements to be excluded from the pool of potential donors is not supported by the results of this review. This is a concern, since ignorance hinders people's autonomy regarding organ donation decision-making. Higher awareness of consent model in opt-in countries may reflect greater efforts to inform the public through campaigns to motivate donation. Legal moves towards opt-out are at odds with people's expressed preferences. Main limitations of this review are the lack of data from some countries, study population heterogeneity, and methodological shortcomings. (shrink)

I aim to understand how the act of becoming an organ donor impacts whether it is permissible for a family veto to override an individual’s wish to donate. I argue that a Consent Model does not capture the right understanding of donor autonomy. I then assess a Gift Model and a Promise Model, arguing that both fail to capture important data about the ability to revoke one’s donor status. I then propose a Promise Acceptance Model, which construes becoming an (...) organ donor as accepting a promise the state makes to you to use your organs. This model, which implies that family vetoes are impermissible, captures the data other models struggle to accommodate. (shrink)

This descriptive study explores the views of resident physicians working in intensive care units (ICUs) concerning deceased organ donation and examines the various ethical issues surrounding organ donation encountered by residents. This was a qualitative, descriptive study utilizing solo interviews with participants together with focus group discussions. The participants' experiences and views were elicited via interviews and focus group discussions covering the following topics: ethical thoughts about deceased organ donation, barriers that impede or prevent organ donation, (...) its effect on the next of kin, and its relationship with futile treatment. The discussions were reviewed using qualitative content analysis. The residents commented that deceased organ donation is a complex and stressful process for the family of the potential donor as well as the transplant team, and still lacks wide acceptance in Turkish society. The opt-in system requires informed consent, thus creating a major barrier for both the patient’s family and the ICU team to overcome. The participants stated that new legal, ethical, and medical arrangements are needed to increase organ donation rates in Turkey. In order to increase rates of deceased organ donation and reduce cases of futile treatment, improved communication between the ICU, transplant team, and patient relatives is critical to ensure that ethical issues are properly managed. On a societal level, the subject of deceased organ donation needs to receive greater attention from public health authorities to increase public awareness. Residents can make valuable contributions to the deceased organ donation process as physicians and as psychosocial support for patients and their families. (shrink)

This descriptive study explores the views of resident physicians working in intensive care units (ICUs) concerning deceased organ donation and examines the various ethical issues surrounding organ donation encountered by residents. This was a qualitative, descriptive study utilizing solo interviews with participants together with focus group discussions. The participants' experiences and views were elicited via interviews and focus group discussions covering the following topics: ethical thoughts about deceased organ donation, barriers that impede or prevent organ donation, (...) its effect on the next of kin, and its relationship with futile treatment. The discussions were reviewed using qualitative content analysis. The residents commented that deceased organ donation is a complex and stressful process for the family of the potential donor as well as the transplant team, and still lacks wide acceptance in Turkish society. The opt-in system requires informed consent, thus creating a major barrier for both the patient’s family and the ICU team to overcome. The participants stated that new legal, ethical, and medical arrangements are needed to increase organ donation rates in Turkey. In order to increase rates of deceased organ donation and reduce cases of futile treatment, improved communication between the ICU, transplant team, and patient relatives is critical to ensure that ethical issues are properly managed. On a societal level, the subject of deceased organ donation needs to receive greater attention from public health authorities to increase public awareness. Residents can make valuable contributions to the deceased organ donation process as physicians and as psychosocial support for patients and their families. (shrink)

An effective method to increase the number of potential cadaveric organ donors is to make people donors by default with the option to opt out. This non-coercive public policy tool to influence people’s choices is often justified on the basis of the as-judged-by-themselves principle: people are nudged into choosing what they themselves truly want. We review three often hypothesized reasons for why defaults work and argue that the as-judged-by-themselves principle may hold only in two of these cases. We specify (...) further conditions for when the principle can hold in these cases and show that whether those conditions are met is often unclear. We recommend ways to expand nationwide surveys to identify the actual reasons for why defaults work and discuss mandated choice policy as a viable solution to many arising conundrums. (shrink)

Bioethical discourse on organ donation and transplantation medicine covers a wide range of topics, from informed consent procedures and scarcity issues up to transplant tourism and organ trade. Over the past decades, this discourse evolved into a stream of documents of bewildering proportions, encompassing thousands of books, papers, conferences, blogs, consensus meetings, policy reports, media debates and other outlets. Beneath the manifest level of discourse, however, a more latent dimension can be discerned, revolving around issues of embodiment, the (...) moral status of the human body and the concept of bodily integrity. This publication aims to bring these “deeper” questions to the fore. What is envisioned is a “depth” ethics (the moral equivalent of a depth psychology) focussing on the tensions, conflicts and ambiguities at work in bioethical deliberations on organ transplantation, fuelling the viewpoints articulated on the more manifest levels of discourse. Organ donation reopens the question of the status of the body as something which we have, but at the same time are, and as something which constitutes a whole, while at the same time being a set of replaceable elements or parts. (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)

MacKay and Robinson (2016) claim that some legal procedures that regulate organ donations (VAC, opt-in, opt-out) bypass people's rational capacities and thus are “potentially morally worse than MAC”, which only employs a very mild form of coercion. We provide a critique of their argumentation and defend the opposite thesis: MAC is potentially morally worse than the three other options.

Is it possible to donate unpaired vital organs, foreseeing but not intending one's own death? We argue that this is indeed psychologically possible, and thus far agree with Charles Camosy and Joseph Vukov in their recent paper on 'double effect donation.' Where we disagree with these authors is that we see double effect donation not as a morally praiseworthy act akin to martyrdom but as a morally impermissible act that necessarily disrespects human bodily integrity. Respect for bodily integrity goes beyond (...) avoiding the aim to kill: not all side effects of deliberate bodily interventions can be outweighed by intended benefits for another even if the subject fully consents. It is not any necessary intention to kill or harm another or oneself that makes lethal donation/harvesting illicit but the more immediate intention to accept or perform surgery on an (innocent) person combined with the foresight of lethal harm and no health-related good for him or her. Double effect donation falls foul of the first condition of double effect reasoning in that the immediate act is wrong in itself. We argue further that the wider effects of such donation would be socially disastrous and corrupting of the medical profession: doctors should retain a sense of nonnegotiable respect for bodily integrity even when they intervene on willing subjects for the benefit of others. (shrink)

Background Consent policies for post-mortem organ procurement (OP) vary throughout Europe, and yet no studies have empirically evaluated the ethical implications of contrasting consent models. To fill this gap, we introduce a novel indicator of governance quality based on the ideal of informed support, and examine national differences on this measure through a quantitative survey of OP policy informedness and preferences in seven European countries. -/- Methods Between 2017–2019, we conducted a convenience sample survey of students (n = 2006) (...) in Austria (AT), Belgium (BE), Denmark (DK), Germany (DE), Greece (GR), Slovenia (SI) and Spain (ES), asking participants about their donation preferences, as well as their beliefs and views about the policy in place. From these measures, we computed indices of informedness, policy support, and fulfilment of unexpressed preferences, which we compared across countries and consent systems. -/- Results Our study introduces a tool for analyzing policy governance in the context of OP. Wide variation in policy awareness was observed: Most respondents in DK, DE, AT and BE correctly identified the policy in place, while those in SI, GR and ES did not. Respondents in opt-out countries (AT, BE, ES and GR) tended to support the policy in place (with one exception, i.e., SI), whereas those in opt-in countries (DE and DK) overwhelmingly opposed it. These results reveal stark differences in governance quality across countries and consent policies: We found a preponderance of informed opposition in opt-in countries and a general tendency towards support–either informed or uninformed–in opt-out countries. We also found informed divergence in opt-in countries and a tendency for convergence–either informed or uninformed–among opt-out countries. -/- Conclusion Our study offers a novel tool for analyzing governance quality and illustrates, in the context of OP, how the strengths and weaknesses of different policy implementations can be estimated and compared using quantitative survey data. (shrink)

There is a libertarian argument for live donor organ markets, according to which live donor organ markets would be permitted if we simply refrained from imposing any substantive and controversial moral assumptions on people who reasonably disagree about morality and justice. I argue that, to the contrary, this endorsement of live donor organ markets depends upon the libertarians’ adoption of a substantive and deeply controversial conception of strong, extensive property rights. This is shown by the fact that (...) these rights would prevent states intervening in cases of preventable and intuitively impermissible wronging of others that can arise when free individuals engage in voluntary offers and exchanges. I outline two forms of such wronging: discrimination and disrespectful demands. I argue that although these types of acts are morally impermissible, the policy question of whether and how they should be regulated by states is non-trivial. I then argue that there is good reason to think that organ markets would rely on disrespectful demands. This may help explain the widespread moral repugnance people feel toward organ trading. It also provides a prima facie, though not decisive, case for states to prohibit such markets. (shrink)

Several European countries are approving legislative reforms moving to a presumed consent system in order to increase organ donation rates. Nevertheless, irrespective of the consent system in force, family's decisional capacity probably causes a greater impact on such rates. In this contribution we have developed a systematic methodology in order to analyse and compare European organ procurement laws, and we clarify the weight given by each European law to relatives' decisional capacity over individual's preferences (expressed or not while (...) alive) regarding the destination of his or her organs after death. In this sense, the results constitute the first comprehensive and comparative legislative mapping on European transplantation laws. (shrink)

This article argues that personal medical data should be made available for scientific research, by enabling and encouraging individuals to donate their medical records once deceased, similar to the way in which they can already donate organs or bodies. This research is part of a project on posthumous medical data donation developed by the Digital Ethics Lab at the Oxford Internet Institute at the University of Oxford. Ten arguments are provided to support the need to foster posthumous medical data donation. (...) Two major risks are also identified—harm to others, and lack of control over the use of data—which could follow from unregulated donation of medical data. The argument that record-based medical research should proceed without the need to secure informed consent is rejected, and instead a voluntary and participatory approach to using personal medical data should be followed. The analysis concludes by stressing the need to develop an ethical code for data donation to minimise the risks, and offers five foundational principles for ethical medical data donation suggested as a draft code. (shrink)

This article argues that personal medical data should be made available for scientific research, by enabling and encouraging individuals to donate their medical records once deceased, in a way similar to how they can already donate organs or bodies. This research is part of a project on posthumous medical data donation developed by the Digital Ethics Lab at the Oxford Internet Institute. Ten arguments are provided to support the need to foster posthumous medical data donation. Two major risks are also (...) identified—harm to others, and lack of control over the use of data—which could follow from unregulated donation of medical data. The argument that record-based medical research should proceed without the need to ask for informed consent is rejected, and it instead a voluntary and participatory approach to using personal medical data should be followed. The analysis concludes by stressing the need to develop an ethical code for data donation to minimise the risks providing five foundational principles for ethical medical data donation; and suggesting a draft for such a code. (shrink)

Due to the shortage of organs, it has been proposed that the ban on organ sales is lifted and a market-based procurement system introduced. This paper assesses four prominent proposals for how such a market could be arranged: unregulated current market, regulated current market, payment-for-consent futures market, and the family-reward futures market. These are assessed in terms of how applicable prominent concerns with organ sales are for each model. The concerns evaluated are that organ markets will crowd (...) out altruistic donation, that consent to sell organs is invalid, that sellers will be harmed, and that commodification of organs will affect human relationships in a negative way. The paper concludes that the family-reward futures market fares best in this comparison but also that it provides the weakest incentive to potential buyers. There is an inverse relationship between how applicable prominent critiques are to organ market models and the increase in available organs they can be expected to provide. (shrink)

We present evidence from a pre-registered experiment indicating that a philosophical argument––a type of rational appeal––can persuade people to make charitable donations. The rational appeal we used follows Singer’s well-known “shallow pond” argument (1972), while incorporating an evolutionary debunking argument (Paxton, Ungar, & Greene 2012) against favoring nearby victims over distant ones. The effectiveness of this rational appeal did not differ significantly from that of a well-tested emotional appeal involving an image of a single child in need (Small, Loewenstein, (...) and Slovic 2007). This is a surprising result, given evidence that emotions are the primary drivers of moral action, a view that has been very influential in the work of development organizations. We did not find support for our pre-registered hypothesis that combining our rational and emotional appeals would have a significantly stronger effect than either appeal in isolation. However, our finding that both kinds of appeal can increase charitable donations is cause for optimism, especially concerning the potential efficacy of well-designed rational appeals. We consider the significance of these findings for moral psychology, ethics, and the work of organizations aiming to alleviate severe poverty. (shrink)

The Australian Federal Government has announced a two-year trial scheme to compensate living organ donors. The compensation will be the equivalent of six weeks paid leave at the rate of the national minimum wage. In this article I analyse the ethics of compensating living organ donors taking the Australian scheme as a reference point. Considering the long waiting lists for organ transplantations and the related costs on the healthcare system of treating patients waiting for an organ, (...) the 1.3 million AUD the Australian Government has committed might represent a very worthwhile investment. I argue that a scheme like the Australian one is sufficiently well designed to avoid all the ethical problems traditionally associated with attaching a monetary value to the human body or to parts of it, namely commodification, inducement, exploitation, and equality issues. Therefore, I suggest that the Australian scheme, if cost-effective, should represent a model for other countries to follow. Nonetheless, although I endorse this scheme, I will also argue that this kind of scheme raises issues of justice in regard to the distribution of organs. Thus, I propose that other policies would be needed to supplement the scheme in order to guarantee not only a higher number of organs available, but also a fair distribution. (shrink)

Families play an essential role in deceased organ procurement. As the person cannot directly communicate his or her wishes regarding donation, the family is often the only source of information regarding consent or refusal. We provide a systematic description and analysis of the different roles the family can play, and actions the family can take, in the organ procurement process across different jurisdictions and consent systems. First, families can inform or update healthcare professionals about a person’s donation wishes. (...) Second, families can authorize organ procurement in the absence of deceased’s preferences and the default is not to remove organs, and oppose donation where there is no evidence of preference but the default is to presume consent; in both cases, the decision could be based on their own wishes or what they think the deceased would have wanted. Finally, families can overrule the known wishes of the deceased, which can mean preventing donation, or permitting donation when the deceased refused it. We propose a schema of 4 levels on which to map these possible family roles: no role, witness, surrogate, and full decisional authority. We conclude by mapping different jurisdictions onto this schema to provide a more comprehensive understanding of the consent system for organ donation and some important nuances about the role of families. This classificatory model aims to account for the majority of the world’s consent systems. It provides conceptual and methodological guidance that can be useful to researchers, professionals, and policymakers involved in organ procurement. (shrink)

If a person requires an organ or tissue donation to survive, many philosophers argue that whatever moral responsibility a biological relative may have to donate to the person in need will be grounded at least partially, if not entirely, in biological relations the potential donor bears to the recipient. We contend that such views ignore the role that a potential donor's unique ability to help the person in need plays in underwriting such judgments. If, for example, a sperm donor (...) is judged to have a significant moral responsibility to donate tissue to a child conceived with his sperm, we think this will not be due to the fact that the donor stands in a close biological relationship to the recipient. Rather, we think such judgments will largely be grounded in the presumed unique ability of the sperm donor to help the child due to the compatibility of his tissues and organs with those of the recipient. In this paper, we report the results of two studies designed to investigate the comparative roles that biological relatedness and unique ability play in generating judgments of moral responsibility in tissue donation cases. We found that biologically related individuals are deemed to have a significant moral responsibility to donate tissue only when they are one of a small number of people who have the capacity to help. (shrink)

The federal system for allocating donated livers in the United States is often criticized for allowing geographic disparities in access to livers. Critics argue that such disparities are unfair on the grounds that where one lives is morally arbitrary and so should not influence one's access to donated livers. They argue instead that livers should be allocated in accordance with the equal opportunity principle, according to which US residents who are equally sick should have the same opportunity to receive a (...) liver, regardless of where they live. In this paper, we examine a central premise of the argument for the equal opportunity principle, namely, that geographic location is a morally arbitrary basis for allocating livers. We raise some serious doubts regarding the truth of this premise, arguing that under certain conditions, factors closely associated with geographic location are relevant to the allocation of livers, and so that candidates' geographic location is sometimes a morally non-arbitrary basis for allocating livers. Geographic location is morally non-arbitrary, we suggest, since by taking it into account, the UNOS may better fulfill its central goals of facilitating the effective and efficient placement of organs for transplantation and increasing organ donation. (shrink)

Cet article propose une évaluation éthique des institutions qui organisent la transplantation avec donneurs décédés, au travers du rôle qu’elles accordent à la famille survivante. Son objectif est double. Il s’agit, premièrement, de montrer que la famille possède un pouvoir de décision considérable en matière de prélèvement posthume bien que les législations soient habituellement décrites comme fondées sur le consentement ou l’opposition des personnes concernées. Deuxièmement, il s’agit de montrer que les politiques qui octroient un tel pouvoir aux familles manquent (...) à un devoir d’équité, en négligeant les intérêts à la fois des personnes concernées et des malades en attente de greffe. (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 (...) class='Hi'>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)

Selgelid and Koplin’s article ‘Kidney Sales and the Burden of Proof’ (K&S 2019) presents a series of detailed and persuasive arguments, intended to demolish my own arguments against the prohibition of organ selling. And perhaps they might succeed, if the case described by the authors were anything like the one I actually make. However, notwithstanding the extensive quotations and the detailed explanations of the way I supposedly argue, this account of my position comprehensively mistakes both the conclusions I reach (...) and the arguments I give for them. -/- I know that there are around many misconceptions about my views on this subject, but I have always hoped they could not survive a reading of what I had actually written. I have just—after a gap of many years—looked again at the two most recent of the texts Koplin and Selgelid refer to, and it goes without saying that I can see various things I could now do better; but I do still find these misinterpretations hard to understand. And since anyone with nothing to go on but this article would reasonably conclude that the original texts were not worth reading, I am grateful to the editors for the opportunity to try to set the record straight. -/- I presume not many readers would be interested in a detailed comparative commentary on the texts, showing where this account gets my intentions wrong. I shall try instead to explain how what I do mean—and what I think I say—diverges from what is said here, and then go on to a brief outline of what my arguments and conclusions really are. I hope this may also give some sense of why, for all the opposition I have encountered since I was first drawn into this debate, I persist in thinking that the work I have been doing is important not only for this topic but for analysis in practical ethics more generally. (shrink)

After a long search, Jonathan has finally found someone willing to donate a kidney to him and thereby free him from dialysis. Meredith is Jonathan's second cousin, and she considers herself a generous person, so although she barely knows Jonathan, she is willing to help. However, as Meredith learns more about the donation process, she begins to ask questions about Jonathan: “Is he HIV positive? I heard he got it using drugs. Has he been in jail? He's already had one (...) live donor, so what happened to the first kidney? Did he forget to take his drugs or something?” The transplant center must, then, decide if Meredith is, in fact, entitled to answers to these kinds of questions. According to the Consensus Statement on the Live Organ Donor, “It is incumbent on the transplant center to provide full and accurate disclosure to potential donors of all pertinent information regarding risk and benefit to the donor and recipient.” But whether answers to the Meredith's questions count as “pertinent information regarding the risk and benefit” is the issue at hand. (shrink)

In December 2015, Wales became the first country in the UK to move away from an opt-in system in organ procurement. The new legislation introduces the concept of deemed consent whereby a person who neither opt in nor opt out is deemed to have consented to donation. The data released by the National Health Service in July 2017 provide an excellent opportunity to assess this legislation in light of concerns that it would decrease procurement rates for living and deceased (...) donation, as well as sparking an increase in family refusals. None of these concerns have come to pass, with Wales experiencing more registered donors, fewer family refusals and more living donations. However, as the number of actual donors has dropped slightly from a high level, the situation must be monitored closely in the years to come. (shrink)

A number of bioethicists have been critical of the power of the family to “veto” a patient’s decision to posthumously donate her organs within opt-in systems of organ procurement. One major objection directed at the family veto is that when families veto the decision of their deceased family member, they do something wrong by violating or failing to respect the autonomy of that deceased family member. The goal of this paper is to make progress on answering this objection. I (...) do this in two stages. First, I argue that the most plausible interpretation of what happens when a person registers as an organ donor in an opt-in system is that she gives her consent to the state to posthumously remove her organs for transplantation purposes. Call this the Authorization Account. Second, given the Authorization Account, I argue by analogy that when families veto an individual’s decision to donate and the individual’s organs are not in the end removed, neither the doctors nor the family violate the individual’s autonomy in any morally objectionable sense. Call this the Nonremoval Thesis. I argue that since the Nonremoval Thesis is true, we do not violate or fail to respect the autonomy of registered donors when we fail to remove their organs because their family has objected. (shrink)

This chapter reviews fundamental ethical controversy surrounding the ongoing effort to revise the Uniform Determination of Death Act in the United States. Instead of focusing on the process of the revision itself, the chapter explores the underlying ethical debate over brain death that has been ongoing for many decades and finally culminated in this revision. Three issues are focused: the requirement for consent and personal exemptions before applying brain death for the diagnosis of death; redefining the areas of the brain (...) that have ceased to function in the definition of brain death; and codifying the American Academy of Neurology as the authority to issue the standards of the diagnosis of brain death. The chapter concludes that allowing the personal choice of death determination gives a pragmatic compromise to the disputed definition and practice of diagnosing brain death. So long as all risks and imperfections of the diagnosis are accepted through the consenting process, there is nothing ethically objectionable to continuing the current practice of diagnosing brain death as a successful tool to facilitate heart-beating organ donation without violating the dead-donor rule. By contrast, precluding personal choice and imposing legal restrictions to consent and exemptions would further erode public trust. (shrink)

In Canada, there are currently no guidelines at either the federal or provincial level regarding the provision of kidney transplantation services to foreign nationals (FN). Renal transplant centres have, in the past, agreed to put refugee claimants and other FNs on the renal transplant waiting list, in part, because these patients (refugee claimants) had health insurance through the Interim Federal Health Programme to cover the costs of medication and hospital care. However, severe cuts recently made to this programme have forced (...) clinicians to question whether they should continue with transplants for FNs, for financial and ethical reasons. This paper first examines different national policies (eg, in Canada, USA, France and the UK) to map the diversity of approaches regarding transplantation for FNs, and then works through different considerations commonly used to support or oppose the provision of organs to these patients: (1) the organ shortage; (2) the free-rider problem; (3) the risk of becoming a transplant destination; (4) the impact on organ donation rates; (5) physicians’ duties; (6) economic concerns; (7) vulnerability. Using a Canadian case as a focus, and generalising through a review of various national policies, we analyse the arguments for and against transplantation for FNs with a view to bringing clarity to what is a sensitive political and clinical management issue. Our aim is to help transplant centres, clinicians and ethicists reflect on the merits of possible options, and the rationales behind them. (shrink)

Since 1968, the irreversible loss of functioning of the whole brain, called brain death, is assimilated to individual’s death. The almost universal acceptance of this neurological criterion of death had decisive consequences for the contemporary medicine, such as the withdrawal of mechanical ventilation in these patients and organ retrieval for transplantation. The new criterion was successfully accepted in part because the assimilation of brain death state to death was presented by medicine --and acritically assumed by most of societies-- as (...) a scientific and objective fact. Nevertheless, many people do not think that the patients suffering brain death are actually dead. We show here that those people are not necessarily wrong. It can be argued that, in fact, the justification of the neurological criterion is not scientific but moral. We outline the thesis that the problem surrounding the vital status of brain dead patients is due to a confusion between factual and normative questions. Furthermore, we claim that the donation of organs and the withdrawal of life-support could be ethically acceptable even if the patients suffering brain death are considered as alive. As an alternative to the dead donor rule, we propose a justification for organ donation of brain-dead patients based on the (moral) concepts of harm and consent : what truly justifies the procurement of organs on those patients is not that they are dead, but that they wish to donate their organs and that, since they have irreversibly lost their brain, they cannot be harmed. (shrink)

We are developing the Neurological Disease Ontology (ND) to provide a framework to enable representation of aspects of neurological diseases that are relevant to their treatment and study. ND is a representational tool that addresses the need for unambiguous annotation, storage, and retrieval of data associated with the treatment and study of neurological diseases. ND is being developed in compliance with the Open Biomedical Ontology Foundry principles and builds upon the paradigm established by the Ontology for General Medical Science (OGMS) (...) for the representation of entities in the domain of disease and medical practice. Initial applications of ND will include the annotation and analysis of large data sets and patient records for Alzheimer’s disease, multiple sclerosis, and stroke. (shrink)

This paper analyses the arguments for and against what we have called automatic organ procurement model in relation to the organs of the deceased. For this purpose, this work provides empirical evidence to assess the potential impact of this model on donation rates and on public opinion. Specifically, we examine first the reasons supporting this model, with special reference to utilitarian and justice arguments. On the other hand, we analyse both the approaches based on the violation of pre mortem (...) and post mortem interests opposing this theoretical model and the rejection the model would generate in the population. Finally, we point out the aspects that, in our opinion, should be exhaustively regulated if this model were implemented. In particular, we refer to the legal status of the human body, the treatments for end-of-life patients, the incentives for health professionals and the recognition of the right to conscientious objection. (shrink)

As the debate over an English opt-out policy for organ procurement intensifies, assessing existing experiences becomes even more important. The Welsh introduction of opt-out legislation provides one important point of reference. With the introduction of deemed consent in December 2015, Wales became the first part of the UK to introduce an opt-out system in organ procurement. My article ‘Deemed consent: assessing the new opt-out approach to organ procurement in Wales’ conducted an early assessment of this.1 Taking its (...) starting point in important concerns often raised in discussion over opt-out legislation, it identified four key parameters to assess the effects. These are living donor rates, deceased donor rates, donor registrations and family refusals. My article compares these indicators before and after the enactment of the Welsh legislation employing a different-in-different design. In his reply to my article ‘Deemed consent: assessing the new opt-out approach to organ procurement in Wales’, Jordan Alexander Parsons offers two interesting critiques. The first pertains to the choice of indicators. Parsons prefer a narrower focus on the effect on deceased donor rates. The second pertains to the choice of data, Parsons preferring a time series of Wales to my different-in-different design. Parsons refers mainly to the official Welsh evaluation,2 a report I also cited in supplement to the NHS Activity Report data I employed. …. (shrink)

The dead donor rule justifies current practice in organ procurement for transplantation and states that organ donors must be dead prior to donation. The majority of organ donors are diagnosed as having suffered brain death and hence are declared dead by neurological criteria. However, a significant amount of unrest in both the philosophical and the medical literature has surfaced since this practice began forty years ago. I argue that, first, declaring death by neurological criteria is both unreliable (...) and unjustified but further, the ethical principles which themselves justify the dead donor rule are better served by abandoning that rule and instead allowing individuals who have suffered severe and irreversible brain damage to become organ donors, even though they are not yet dead and even though the removal of their organs would be the proximal cause of death. (shrink)

In this paper, I claim that live uterus donors ought to be considered for the possibility of compensation. I support my claim on the basis of comparable arguments which have already been applied to gamete donation, surrogacy, and other kinds of organ donation. However, I acknowledge that there are specificities associated with uterus donation, which make the issue of incentive and reward a harder ethical case relative to gamete donation, surrogacy, and other kinds of organ donation. Ultimately, I (...) contend that while reimbursement for the costs incurred by live uterus donors should be treated as a necessary ethical minimum, how much further we ought to remunerate uterus donations remains an open question. (shrink)