Ethical Issues in Organ Donation

My last post was on Organ Donation. Encouraging responses and comments I received from the readers, especially from my professors and friends of Alfonsiana, gave confidence to me to reflect and learn more about this issue. This post is one of the results of my further research in this field.

Since organ transplantation is now an established part of medical practice, we need to think about the ethical issues in this regard. The decision to donate an organ is an ethical decision, one which involves thinking about the ethical issues from different perspectives. As we know, from the stand point of the donor, organ donations are of two different categories: Donation of organs by a living donor and donation of organs by a dead donor (cadaver). The goal of this article is to provide a discussion which will help us to think through the ethical issues related to organ donation and transplantation. 

Catholic Church on the Ethical Issues Related to Organ Donation

While admiring Organ Donation as a beautiful and noble act expressing the culture of life, Blessed Pope John Paul II reminds us that it must be “performed in an ethically acceptable manner, with a view to offering a chance of health and even of life itself to the sick who sometimes have no other hope” (Evangelium Vitae, No. 86). The Catechism of the Catholic Church teaches that, they are in conformity with the moral law, if the physical and psychological dangers and risks incurred by the donor are proportionate to the good sought for the recipient (No. 2296). Pope John Paul II in his address to the First International Congress of the Society of Organ Sharing, in 1991, said: "This splendid development is not of course without its dark side. There is still much to be learned through research and clinical experience, and there are many questions of an ethical, legal and social nature which need to be more deeply and widely investigated".

The Ethical and Religious Directives for Catholic Health Care Services (ERDs) has similar teaching on organ donations from the living, specifying however that the donation will not sacrifice or seriously impair and essential functioning of the donor. It offers some important specifics on such procedures from the dead, e.g., only competent medical authorities ought to determine that a person has died, to avoid conflicts of interest the physician determining death ought not be a member of the transplant team (Directives, 62. 64). 

We discuss: 

1. Is it morally allowed to donate and transplant an organ to another? (We consider here both living and cadaver donors) 

2. Issues connected with donor 

3. Issues connected with recipient 


1. Is it Morally Allowed to Donate and Transplant an Organ to Another? 

The moral principle of totality points to the duty of a person to preserve intact the physical component of that integrated whole. A simple expression of the principle of totality means, that the parts of the physical entity, as parts, are ordained to the good of the physical whole. From the medical perspective, the principle of totality would mean that “all the parts of the human body, as parts, are meant to exist and function for the good of the whole body, and are thus naturally subordinated to the good of the whole body” So the principle of totality demands the moral obligation of a person to preserve his ‘bodily integrity’. Any indiscriminate removal, disposal or mutilation is against this principle. This principle seems to prohibit any donation of organs by a living donor. But theologians interpret ‘bodily integrity’ distinguishing between anatomical and functional integrity, maintaining that only the latter is essential for bodily and personal integrity. 

Theologians Benedict Ashley and Kevin O’Rourke opine that the concept of functional integrity is the key factor in addressing the morality of transplants between living persons. They acknowledge that the donor runs a risk in giving an organ, but this is acceptable if it does not impair his own functional integrity (e.g., if he donates one kidney, his functional integrity is not impaired because he still has a functioning kidney). The transplant would be immoral if the organ’s removal were to impair the donor’s functional integrity. In this context donation and transplantation, according Gerald Kelly, is justified by the principle of fraternal charity or love when doing so is of great benefit to the recipient, with the proviso that the harm suffered by the donor is limited and morally acceptable. 

According to moral theologians, for example Germain Grisez, organ transplants from the living can be justified by the principle of double effect. According to this principle an action having two effects, one good, the other bad, is morally good provided that the action is not morally wrong for other reasons, that the evil is not intended, that the evil is not the means to the good, and that there is a ‘proportionate reason’ for tolerating or accepting the bad effect. 

2. Ethical Issues Regarding the Donor 

2.1 Living Donors 

2.1.1 Consider it as an Act of Charity 

The magisterium of the Catholic Church and moral theologians agree that organ donation and transplants from living donors are morally justified and are indeed noble and good actions so long as certain criteria are met. According to Pope Benedict XVI, "organ donation is a unique testimony of charity" (Address to the participants of the International Congress 'A Gift for Life: Considerations on Organ Donation' on 7 Nov 2008).
People choose to be living donors, or choose not to be, for different kinds of reasons or for a mixture of reasons. In many cases the desire to donate an organ may be based on the wish to save the life or improve the health of a relative with whom there are already bonds of affection and love. In other cases, a person may wish to do something to save the life or improve the health of an unknown person in the community, based on more impersonal ideas of helping others or giving to the community. Such donors may consider that the potential personal disadvantages or discomforts of donating are more than outweighed by the potential benefits to the person needing a transplant. So, here donation may be considered as an opportunity to give of one’s self to another human being, even a stranger. On this view, organ donation can represent the highest capacity of human giving: the gift of life itself. Such giving benefits not only the receiver but also the giver and the society as a whole. 

2.1.2 Free and Informed Consent 

Free and informed consent is required when the transplant is from a living donor. Pope John Paul II teaches: "transplantation presupposes a prior, explicit, free and conscious decision on the part of the donor" (Address to the First International Congress of the Society of Organ Sharing). Pope Benedict XVI reminds: "In these cases, informed consent is a precondition of freedom so that the transplant can be characterized as being a gift and not interpreted as a coercive or abusive act". Voluntary and expressed consent involves a person making known his/her free offer to donate one or more of their organs and/or bodily tissue. Informed consent means that the donor must be clearly informed about the risks involved, health problems, if any etc. by a professional. 

2.1.3 The Functional Integrity of the Body

The body of a human being can never be considered as a mere object (cf. Deus Caritas Est, No. 5); to do otherwise would impose on it the logic of the market. The body of each person, together with the spirit that is given to each one individually, constitutes an inseparable unity upon which is impressed the image of God himself. It is necessary, then, that priority must be given to respect for the dignity of the human person and the protection of individual identity (Benedict XVI, A Gift for Life: Considerations on Organ Donation). The functional integrity of the donor must not be impaired by the donation, even if anatomical integrity is weakened. The burden or risk taken by the donor must be proportionate to the benefit received by the recipient.

2.1.4 Avoid Commercialism 

Donating organs for financial gain must be avoided. The World Health Organization has expressly argued against the practice. Paying for organs can constitute unjust moral pressure on the donor. It could invalidate any free consent or a contract. World Health Organization demands its member states to take appropriate measures to prevent the purchase and sale of human organs for transplantation. (Nos. 62-3 and 202-3) The Catholic Church clearly teaches that “economic advantages should not accrue to the donor” (The Ethical and Religious Directives for Catholic Health Care Services, 30). Pope John Paul II reminds: "The human body is always a personal body, the body of a person. The body cannot be treated as a merely physical or biological entity, nor can its organs and tissues ever be used as items for sale or exchange. Such a reductive materialist conception would lead to a merely instrumental use of the body, and therefore of the person. In such a perspective, organ transplantation and the grafting of tissue would no longer correspond to an act of donation but would amount to the dispossession or plundering of a body"(Address to the First International Congress of the Society of Organ Sharing). Pope Benedict XVI teaches: "Any reasons for the buying and selling of organs, or the adoption of utilitarian and discriminatory criteria, would clash in such a way with the meaning of gift that they would be invalidated, qualifying them as illicit moral acts. Abuses in transplants and organ trafficking, which frequently affect innocent persons, such as children, must find the scientific and medical community united in a joint refusal. They should be decidedly condemned as abominable"(A Gift for Life: Considerations on Organ Donation). The Catholic Health Association of Canada (CHAC) holds that the buying and selling of human organs, tissues and blood “contradicts the principle of charity which is part of the necessary justification for such transplantations” (Procurement and Transfer of Human Tissues and Organs, Working Paper 66). 

2.2 Cadaver Donor 

2.2.1 Criteria for Death 

Cadaveric organ donation requires that death must be declared by a competent authority before removing any organs for transplantation. In these cases respect for the life of the donor should be assumed as the primary criterion, in such a way so that the extraction of the organs only take place after having ascertained the patient's true death (cf. Compendium of the Catechism of the Catholic Church, No. 476). The U.S. bishops’ ERDs make it clear that only competent medical authorities have the right to determine that a person has died. Blessed John Paul II several times declared that the responsibility to provide the criteria for determining that a human person had died was within the competence of medical doctors and scientists. He accepted the scientific community’s position that the criteria for determining this are (1) spontaneous cardiac and respiratory functioning and (2) the irreversible cessation of all functioning of the brain, including the brain stem, what he called the ‘neurological’ criterion (International Conference of Organ Transplant Specialists in August 2000). (However in recent years there has been a serious debate among scientists regarding the validity of the ‘neurological’ criterion. Several serious challenges, supported by evidence, have been leveled against it. This debate is continuing, but as of now the magisterium accepts the ‘neurological criterion’ as providing moral certainty that a human person has died) 

2.2.2 A Voluntary and Expressed Previous Consent 

A voluntary and expressed previous consent of the person is required, making known his/her free offer to donate one or more of their organs and/or bodily tissue, after death. Concerning cadaver donation, a person can express their wishes by some form of advanced directives. They do it in writing in the presence of two witnesses at least one of whom is a near relative. In case of no such consent or donor pledge form was filled before death, then the authority to give consent for organ donation lies with the person lawfully in possession of the dead body. 

3. Ethical Issues Regarding the Recipient 

3.1 Accept as a Gift 

The recipients of organ transplants should not "forget that they are receiving a unique gift from someone else: the gift of self made by the donor, a gift which is certainly to be considered an authentic form of human and Christian solidarity; says Pope John Paul II in hi address to the First International Congress of the Society of Organ Sharing. A joint document by the German Bishops’ Conference and the Council of the German Evangelical Church (1988), ‘Christians and the Ethics of Organ Transplants’, says: “...nobody i.e., no potential recipient, has a claim on organs or tissue of any person, living or dead. The sick should thus accept the tissue and organs freely offered by others as a gift (German Bishops’ Conference and the Council of the German Evangelical Church (1988), “Christians and the Ethics of Organ Transplants”, Catholic International, 15-30 April 1991, 373. This position is widely accepted. 

3.2 Free and Informed Consent 

Another moral issue involving the recipient is free and informed consent. A competent person who could possibly benefit from receiving a transplant should be adequately informed regarding the expected benefits, risks, burdens and costs of the transplant and aftercare, and of other possible alternatives. So, should the guardian(s) of an incompetent person. No unfair influence should be put on someone to be a transplant recipient. 

3.3 Consider as Extraordinary Means 

A potential transplant recipient and/or their guardian(s) should also consider their decision as extraordinary means of preserving life and should be sought as a last resort to save life. 

Conclusion 

There is a need for education of the general public and many health care professionals concerning the whole area of organ and tissue transplants. Many people are not well informed of the needs, the shortage of organs and tissues, and the great potential benefit of many people for transplants. Many have unfounded fears or reservations or are confused about some of the issues of being a donor. Health care professionals also need to be educated about the meaning of organ and tissue donation (CHAC, 43). Some have unfounded reservations about approaching individuals or families to consider organ and tissue donation. 

Organ donation, carried out under proper conditions, is a beautiful and noble expression of Christian charity: it gives dignity to the person who in death becomes a life-support for another; it shows noble concern for the respect of the life of others; and it implies a sense of communion with humanity. Pope Benedict XVI teaches: "Organ transplants that are in line with ethic of giving require the commitment of all sides to invest every possible effort in formation and information, so as to increasingly awaken consciences to a problem that directly affects the lives of so many. It would be necessary, then, to overcome prejudices and misunderstanding, dispel suspicions and fears and substitute them with certainties and guarantees, so as to create in all people an awareness, ever more widespread, of the great gift of life".
The Gospel proclaims that there is no greater love than to give one’s life for another (Jn 15:13). Jesus welcomes the good done to another as though it were done to himself (Matt 25).