Commentary
A recent New England Journal of Medicine (NEJM) article made headlines by suggesting “death by donation”—the idea that people should be allowed to be killed by organ donation if they so choose.
Many people found this idea of overt euthanasia via organ harvesting shocking, but few understood that this proposal was based on the fact that our current organ transplantation system is already removing vital organs from people who are still biologically alive.
The article argues that we have been redefining the idea of death for years in order to obtain viable organs: stretching our definitions of death in order to meet the requirements of the Dead Donor Rule (DDR) through sleight of hand.
The DDR is an ethical standard that is supposed to maintain public trust in organ donation. It states that people must be dead before their organs are removed and that patients may not be killed by organ procurement.
The article posits that the DDR is not a moral absolute, but rather has been subjected to ongoing interpretation and adaptation.
“Though the DDR is considered the ‘ethical linchpin’ of transplantation, it has thus functioned less as a moral absolute than as a moral anchor, whose application requires ongoing interpretation and adaptation,” it reads.
For example, the NEJM authors point out that brain-dead people aren’t biologically dead, demonstrating that we have already changed the definition of death to suit our needs. They write:
“Despite philosophical and biological uncertainty, brain death was adopted into law and medical practice with the 1981 enactment of the Uniform Determination of Death Act, which defined death as the irreversible cessation of all brain functions.
“Accumulating clinical experience, however, exposed inconsistencies in this integrative concept of brain death. [Dr. Allan] Shewmon reported many cases of prolonged biological survival after the determination of brain death. These patients were able to grow, assimilate nutrition and eliminate waste, recover from infections and wounds, even gestate a fetus.
“Amid uncertainty, organ donation continued, revealing a deeper conceptual pivot. The DDR shifted the determination of death away from strictly biological criteria toward adherence to diagnostic criteria that were enumerated and endorsed by a definitional authority. The Death Requirement and trust in the organ-donation system were not violated if the new concept of death was accepted in social and legal standards. Such contextualization rendered the DDR a flexible moral safeguard, upholding the commitment not to take organs from living people, even as the meaning of ‘death’ itself was revised.”
Of course, shifting the determination of death away from strictly biological criteria and substituting criteria decreed by a definitional authority most certainly does violate public trust—because the public has never been informed that this shift has occurred.
Most people registering as organ donors believe that they will be biologically dead at the time their organs are removed and have no idea that “the meaning of ‘death’ itself” has been revised.
The NEJM article also discusses the fact that organ donors after controlled circulatory death (donation after circulatory death or “DCD” donors) are not known to be dead at the time that their organs are procured. This is because DCD surgery begins after just two to five minutes of pulselessness: a timeframe during which resuscitation is routinely possible. The University of Alberta’s Dr. Ari Joffe has documented that people have self-resuscitated and fully recovered after as many as 10 minutes of cardiac arrest. Thus, DCD donors do not meet the U.S. legal standard for death under the Uniform Determination of Death Act, which requires the irreversible loss of circulatory and respiratory function.
Doctors get around this by substituting the term permanent, which means that function is not expected to resume spontaneously and will not be restored through intervention. According to the NEJM article:
“Debate persists over whether DCD practices truly uphold the DDR, particularly in that permanence is not necessarily equivalent to irreversibility. In DCD, death occurs not because resuscitation is impossible, but because it is intentionally withheld, in accordance with patient values, placing patients on a trajectory toward death, which is considered ‘irreversible’ because it will not be reversed. This shift from a biologic to a procedural conception of death again contextualized the DDR, aligning it with general social and ethical understandings rather than empirical finality.”
Again, most people registering in good faith to become organ donors still think that death is an empirical finality and are not being told that, in the context of organ harvesting, hospitals have switched from a biological to a procedural conception of death.
Physician and bioethicist Robert Truog has said for years that ‘brain dead’ donors remain alive and that donors declared dead according to circulatory-respiratory criteria are not known to be dead at the time that their organs are procured.
And according to the NEJM article, the fact that we have already redefined death for the sake of organ procurement now justifies direct killing via organ harvesting.
“Although death by organ donation may be viewed as a departure from the DDR … we interpret it as consistent with a historical pattern of recontextualization,” it reads.
In a 2009 article, Joseph Verheijde, Mohamed Rady, and Joan McGregor frame our current dilemma very clearly.
“Heart-beating [brain-dead] or non-heart-beating [DCD] organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients,” they write.
Given the perceived need for a greater supply of transplantable organs, the authors write, “Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness.”
Instead of continuing our current concealed practice of physician-assisted death for the sake of organ transplantation, we need to return to recognizing death as a biological reality. People with organ failure deserve ethical options.
Views expressed in this article are the opinions of the author and do not necessarily reflect the views of The Epoch Times.
