When I was a student, a trauma surgeon described how, in the early days of transplants, he had to physically restrain the transplant surgeons from “harvesting” the kidneys of potential donors. So enthusiastic were surgeons about this exhilarating technology that they were willing to sacrifice one life for another, for they tended to count a life saved by transplant as being of more than ordinary value, perhaps double; and, no doubt irrationally, I have remained mildly suspicious of them, the transplant surgeons, ever since.
There were two opposing articles in a recent edition of the New England Journal of Medicine about the ethics of transplantation. For a number of years the supply of organs for transplant has not equalled the demand, and one way of meeting it would be to relax slightly the rules governing the removal of transplantable organs from donors. At the moment the dead-donor rule (known as the DDR — an acronym that for me still brings first to mind the German Democratic Republic) prevails, according to which the donation of an organ must not kill the donor.
One of the authors suggests that the DDR is routinely violated in any case and that, in so far as it is obeyed, it limits the number of organs available for transplant and thereby allows people to die who could have been saved. But, says the author, “it is not obvious why certain living patients, such as those who are near death but on life support, should not be allowed to donate their organs, if doing so would benefit others and be consistent with their own interests. … Allegiance to the DDR … limits the procurement of transplantable organs by denying some patients the option to donate in situations in which death is imminent and donation is desired.”
I find this way of putting the matter sinister. When the authors say “donation is desired” I want to ask, “Desired by whom?” Not necessarily by the dying patient, it seems, for the authors cite a case in which “if there [had been] no requirement to comply with the DDR, the family would have been permitted to donate all the patient’s vital organs.” As to consistency with the donor patient’s own interests as judged by the transplanting doctor, one can imagine what a slippery slope that might easily lead down. One cannot but recall that delightful phrase, Lebensunwerten Lebens, life unworthy of life, and all that followed from it.
Alas, nature does not cut reality up into nice neat categories for the benefit of medical ethicists; the natural world is full of ambiguities. Even those who hold to the DDR have difficulty in deciding when death has taken place. For example, according to the DDR an organ may be removed once a dying patient has been without a heartbeat for two minutes: but it might be that he has been without a heartbeat because a decision was taken not to start it again, even though it might be possible to do so, because such an action would be futile, the person being so close to inevitable death. In other words, the two sides — those who believe in the DDR and those who do not — may in practice be less opposed than appears at first sight.
Nevertheless, there is something sinister in the language employed in their article by the opponents of the DDR (at least one of whom is affiliated to the Orwellian-sounding Fostering Improvement in End-of-Life Decision Science Program at the University of Pennsylvania). They say that the views of people who disagree with them should be respected, but there is no reason nonetheless why they should be… well, respected.