COMMENTARY ON FORUM
Death by Donation: Reflections on Individual Authorization, Assisted Suicide and Organ Donation Antonia J. Cronin rgan shortage means that every year thousands die waiting for a transplant. Now, expanded criteria or marginal donor organs, which fail to meet standard donor criteria and are often associated with less good transplant outcomes, are being routinely transplanted into selected recipients as a means of increasing the donor pool. On the basis of these facts, one could be forgiven for thinking that the current situation is dire. However, last year, in the United Kingdom, the lives of 4,212 patients were saved or improved by an organ transplant (1). The life-saving potential of organ transplants acts as a powerful stimulus to identify the possible ways in which donor organs can and should be made available for transplantation. A number of resourceful solutions have been implemented. In the United Kingdom, for instance, a publicly funded program of work related to a series of recommendations set out by an Organ Donation Taskforce, successfully overhauled the operational infrastructure related to organ donation, retrieval, and transplantation, and resulted in a 50% increase in the number of deceased organ donors over 5 years (2). Further public funding has now been set aside to support interventions and research aimed at increasing the number and quality of organs for transplants, particularly those donated after diagnosis and confirmation of death by circulatory criteria (DCD). Elsewhere, new laws have been introduced. In Israel, for example, the Organ Transplantation Act 2010 has enabled the development of a unique priority point system aimed at motivating individual’s to donate their organs (3). Other countries have amended existing legislation to take account of an individual’s wish to direct their donation to a family member or loved one, and so on.
O
In his article, Organ donation after assisted suicide: a potential solution to the organ scarcity problem, David Shaw investigates another potential solution: organ donation after planned assisted suicide (DAS) (4). He claims that if such a scheme were successfully implemented in Switzerland, a country that, he says, has a surprisingly low rate of deceased organ donation and allows assisted suicide, a donor organ surplus could be achieved within 1 year. In this commentary, I provide a brief analysis of the arguments Shaw sets out and highlight possible difficulties that would need to be overcome were his proposal to be implemented. I suggest that considering the possibility of DAS may be a useful way of developing our understanding on the scope and breadth of individual consent and authorization in the context of donation and end-of-life decision-making. Moreover, I posit we should not underestimate the important role such understanding may play as the potential for premortem interventions and research to increase the number and quality of donor organs, in particular DCD, gains momentum. Finally, reflecting on the principles underpinning an individual’s entitlement both to donate and to die, I consider the possibility that an individual may choose to die by donating their organs. Though improbable, I claim that any society prepared to uphold an individual’s wishes and allow them to define and choose the circumstances in which they die must also be prepared to consider the possibility that an individual may choose death by donation.
ORGAN DONATION AND ASSISTED SUICIDE IN SWITZERLAND
The research conducted for this paper was funded/supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St. Thomas’ NHS Foundation Trust and King’s College, London. The views expressed are those of the author’s and not necessarily those of the NHS, the NIHR or the Department of Health. A.J.C. is a member of the UK Donation Ethics Committee (UKDEC). The other authors declare no conflicts of interest. King’s College, London, MRC Centre for Transplantation, Guy’s Hospital, Great Maze Pond, London, United Kingdom.; Address correspondence to: King’s College, London, MRC Centre for Transplantation, 5th Floor Tower Wing, Guy’s Hospital, Great Maze Pond, London SE19RT, United Kingdom. E-mail: [email protected] Received 1 April 2014. Accepted 4 April 2014. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/983-254 DOI: 10.1097/TP.0000000000000238
The rate of deceased organ donation in Switzerland is 12 donors per million people. This low rate may be caused by sociocultural factors; however, the lack of a central organ donor registry has also been implicated. Despite efforts to promote donation, the number of people registered on the transplant waiting list is growing (4). According to Shaw, one way in which Switzerland could increase its rate of deceased organ donation is by allowing DAS. Swiss law permits its citizens and foreigners, who have gone through a rigorous procedure of safeguards, to obtain assistance in committing suicide. Although the Swiss Academy of Medical Sciences has apparently acknowledged that the practice is problematic, assisted suicide seems to be widely accepted (4). However, as Shaw explains, for practical reasons, individual’s who commit suicide with assistance are not currently able to donate their organs for transplant even though, he says, ‘‘it is likely that many of
254
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www.transplantjournal.com
& Volume 98, Number 3, August 15, 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
* 2014 Lippincott Williams & Wilkins
them wish to donate their organs.’’ This, he claims, amounts to a ‘‘massive waste of an extremely precious resource.’’ By setting out a simple calculation, Shaw demonstrates that even if only 50% of those who commit suicide with assistance donated their organs, it would substantially increase organ availability, and, he claims, Switzerland could achieve an organ surplus once the current large waiting list is reduced. He highlights three further key advantages of DAS. First, it enables advance organ matching and transplant operation scheduling; second, it maximizes patient autonomy by enabling donation; and third. it reduces the risk of family refusing to permit donation.
Cronin
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invest in the relevant infrastructure to expand its DCD program regardless of whether the proposed DAS scheme is implemented. Labeling DAS as a more, or possibly less, ‘‘awkward DCD group,’’ as Shaw does, before understanding more fully how a DCD program would operate in Switzerland seems premature. Similarly, it is not clear that the proposal, though well intended, to designate DAS donors to a new Maastricht category VI, to distinguish aspects of their donation process is necessary. It may be sensible to defer any decision on this issue until such time as a DCD program is more established and, as set out above, we have a better understanding of the sorts of assisted deaths after which DAS could in fact take place.
PRACTICAL ISSUES Shaw considers three practical obstacles to the implementation of DAS scheme: transport to hospital, donation after cardiac death, and quality of organs. Transport to Hospital Shaw explains that the most obvious practical problem with DAS is ensuring the donated organs reach a hospital in time to be transplanted. He suggests two straightforward solutions to this. The first solution he says would be for the suicide to take place within hospital grounds. The second would be to have an ambulance booked to arrive at the time of death and transfer the deceased from their place of death to an organ retrieval hospital. If the individual who has chosen to commit suicide with assistance has also chosen to be an organ donor after their death, then these solutions seem relatively uncontroversial. However, they are linked to a more pertinent issue: Switzerland’s capacity for DCD. This would need to be addressed before the implementation of Shaw’s DAS scheme could be given serious consideration. Donation After Cardiac Death Most deceased organ donors in Switzerland donate their organs after diagnosis and confirmation of brain-stem death, so-called DBD. In contrast DAS would involve donation of organs after diagnosis and confirmation of circulatory death, so-called DCD. Shaw claims that this complicates the issue of rapid transport to hospital, because transplantation after DCD ‘‘must take place almost immediately.’’ A short time frame between diagnosis of death and organ retrieval is desirable to reduce warm ischemic time. However, successful DCD kidney transplants have been reported where organ retrieval has taken place up to 1 or 2 hr after withdrawal of life-sustaining treatment and diagnosis of death by circulatory criteria, or category III DCD. What perhaps therefore needs to be more fully understood and defined are the sorts of deaths with assistance after which DAS could in fact be realized, and the circumstances in which such deaths, and donations, ought to take place. This suggestion is not in conflict with Shaw’s overarching DAS proposal. On the contrary, it sits comfortably with his aim to ‘‘enable advance transplant operation scheduling’’ and ‘‘maximize patient autonomy by enabling donation’’ (4). The more apposite problem, which Shaw himself acknowledges, relates to the overall capacity for DCD transplantation in Switzerland. Improving this would, as Shaw says, be essential if his DAS proposal was to be adopted, particularly when we recall his calculation suggesting the possibility of an organ surplus. However, Switzerland should
Quality of Organs Shaw cites two potential objections regarding the quality of the organs retrieved from those committing suicide. First, he says, the organs could be harmed by the administration of the lethal drug, usually sodium pentobarbital. However, as Shaw himself explains, although this drug causes death, it does not normally cause any permanent damage to the organs. Moreover, organs (but not hearts) removed after euthanasia in Belgium have been transplanted successfully (5). The second objection, Shaw continues, is that cases of DAS will involve people who are seriously ill or dying. However, all potential deceased donors, whether potential DCD or DBD donors, are seriously ill, dying, or dead. As a matter of fact, being seriously ill, dying, or dead is usually necessary to meet the eligibility criteria for donation, much less an objection to it. Inevitably, there will be contraindications to donation. Cancer is just one example. On the one hand, Shaw claims that many people using assisted suicide services have cancer. On the other, he claims less than 40% of people accessing assisted suicide services in Switzerland have cancer (4). Reports vary. The point is this, where published evidence suggests a relative or absolute contraindication to using a donor organ of some sort or another, that evidence should be taken into account when deciding whether the donation goes ahead or not. This however should be the case regardless of the source of donor organ and is not something peculiar to the proposed DAS scheme. The more pressing question with regard to donor organ quality is whether, and if so to what extent, premortem interventions can and should be used to optimize successful donation? DAS may be a useful way of developing our understanding on the scope and breadth of individual consent and authorization in this context. It would of course be necessary to develop a robust defence of any such interventions. Among other things, assisted suicide is only legal in cases where the assister(s) will not benefit from the death. Simply proceeding on the basis that such interventions are not related to the assisted suicide per se is likely to invoke criticism. Nevertheless, the process of informed consent may provide valuable insight into the factors affecting an individual’s endof-life decision-making process and the perceived acceptability of premortem interventions, instrumentalization, and so on, aimed at optimizing successful donation at that time. Such understanding could usefully be applied more generally to DCD. It may even come to occupy an important role as the potential for premortem interventions and research to increase the number and quality of donor organs gains momentum.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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ETHICAL ISSUES The Burden Argument Shaw says it might be argued that people who would otherwise not opt for assisted suicide might choose to die to donate their organs and help other people. This, he says, is a variation of the ‘‘burden argument’’ against assisted suicide in general. Shaw provides a swift rebuttal to this argument. First, he clarifies that there are specific criteria for assisted suicide in Switzerland, only terminally ill and those experiencing extreme suffering are eligible. Second, he explains that the decision about suitability for assisted suicide must be kept entirely separate from the decision to donate. Finally, he says, the sick in receipt of life-sustaining treatment can choose to refuse treatment even if it will result in their death, without invoking the burden argument. Implicit in Shaw’s rebuttal however seems to be the assumption that an individual, who does choose to die to donate their organs and help others, is somehow mistaken or wrong. The separation Shaw describes may well be attractive on a pragmatic level. However, it does not provide a satisfactory answer to the question, which asks, if we are prepared to use the organs of those who have chosen to refuse life-saving or lifesustaining treatments, why do we not consider using the organs of those who have chosen to die to, or even in such a way that, saves the lives of others? It might well be the case, as Shaw suggests, that for some, organ donation ‘‘simply provides an additional minor reason for choosing to die I that is unlikely to be decisive.’’ However, it is not clear that this is always, under all circumstances, going to be the case. Creating an association here, as Shaw seems to, with those who have died in the tragic circumstances of ‘‘violent unassisted suicide’’ does not shed more light on the issue. Death by Donation The principle of autonomy underpinning an individual’s entitlement to choose the circumstances in which they die is, rightly or wrongly, the same principle upon which most, if not all, societies have chosen to model deceased donation. It loosely follows therefore that any society that permits deceased organ donation and is also prepared to uphold an individual’s wishes and allow them to define and choose the circumstances in which they die, must also be prepared, at the very least, to consider the possibility that an individual may choose death by donation. This has been described elsewhere as ‘‘organ retrieval euthanasia’’ (4). Harrowing and improbable, as this choice may seem to many of us, and contrary to the long established so-called dead donor rule, it is not clear why the perceived tension between causing death and saving lives should preclude an individual’s wishes to be upheld in these circumstances. It may well be desirable, indeed necessary, to impose limitations on such individual entitlements and models of deceased donation within a framework of positive law. However, it is nevertheless important to provide coherent reasons for rejecting an individual’s choice and their donation, especially when we consider the potential benefits that may, as an inevitable consequence, be lost. In
Transplantation
& Volume 98, Number 3, August 15, 2014
Switzerland, as Shaw explains, upholding such a state of affairs would require the legalization of euthanasia and, he suggests, could even ‘‘alienate potential AS donors.’’ Others have suggested extending the concept of living kidney donation in relation to imminent death of a potential DCD donor (6). Scheduling such a living donation immediately before obtaining assistance with committing suicide is hardly likely to go unnoticed. Once again, it brings into focus the assertion that ‘assisted suicide is only legal in cases where the assister(s) will not benefit from the death’, and will inevitably raise a few eyebrows. Whether this concept would alienate or attract AS donors is open to debate. Either way, it lends support to the view, set out above, that understanding and defining the sorts of deaths with assistance after which DAS could in fact be realized, and the circumstances in which such deaths, and donations, ought to take place, is a priority. Taking account of professional concerns, conscientious objections, and the law must be an integral part of any such deliberation.
CONCLUSION Organ DAS would be permissible by Swiss law and is one potential solution to the organ shortage crisis in that country. David Shaw’s article provides a comprehensive, insightful account of the practical obstacles to implementing such a scheme, and the relevant ethical and legal arguments. If Shaw’s proposed DAS scheme were successfully implemented in Switzerland, it would represent a landmark change in organ donation policy. Although enhancing our understanding on the scope of individual autonomy, such a scheme may also provide valuable insight into the factors affecting an individual’s end-of-life decision-making process and the perceived acceptability of premortem interventions aimed at optimizing successful donation. Two key outstanding hurdles need to be addressed before such a scheme can be considered further. First, Switzerland must invest in the operational infrastructure necessary to develop its DCD program. Second, a better understanding of the sorts of deaths with assistance after which DAS could be realized and the circumstances in which such deaths, and donations, ought to take place, must be developed. REFERENCES 1.
2.
3. 4. 5. 6.
NHSBT. Transplant activity in the UKVactivity report 2012Y13. http:// www.organdonation.nhs.uk/ukt/statistics/transplant_activity_report/ archive_activity_reports/pdf/ukt/activity_ report_2010_13.pdf (accessed 04 March 2014). The recommendations are set out the Report Organs for Transplants http://webarchive.nationalarchives.gov.uk/20130107105354/http://www. dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ documents/digitalasset/dh_082120.pdf (accessed 04 March 2014). Cronin AJ. Points mean prizes: priority points preferential status and directed organ donation in Israel. Isr J Health Policy Res 2014; 3: 3. Shaw D. Organ donation after assisted suicide: a potential solution to the organ scarcity problem. Transplantation 2014. Ysebaert D, Van Beeumen G, De Greef K. Organ procurement after euthanasia: Belgian experience. Transplant Proc 2009; 41: 585. Morrissey PE, Monaco AP. Donation after circulatory death: current practices, ongoing challenges and potential improvements. Transplantation 2014; 97: 258.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Death by Donation: Reflections on Individual Authorization, Assisted Suicide and Organ Donation Antonia J. Cronin rgan shortage means that every year thousands die waiting for a transplant. Now, expanded criteria or marginal donor organs, which fail to meet standard donor criteria and are often associated with less good transplant outcomes, are being routinely transplanted into selected recipients as a means of increasing the donor pool. On the basis of these facts, one could be forgiven for thinking that the current situation is dire. However, last year, in the United Kingdom, the lives of 4,212 patients were saved or improved by an organ transplant (1). The life-saving potential of organ transplants acts as a powerful stimulus to identify the possible ways in which donor organs can and should be made available for transplantation. A number of resourceful solutions have been implemented. In the United Kingdom, for instance, a publicly funded program of work related to a series of recommendations set out by an Organ Donation Taskforce, successfully overhauled the operational infrastructure related to organ donation, retrieval, and transplantation, and resulted in a 50% increase in the number of deceased organ donors over 5 years (2). Further public funding has now been set aside to support interventions and research aimed at increasing the number and quality of organs for transplants, particularly those donated after diagnosis and confirmation of death by circulatory criteria (DCD). Elsewhere, new laws have been introduced. In Israel, for example, the Organ Transplantation Act 2010 has enabled the development of a unique priority point system aimed at motivating individual’s to donate their organs (3). Other countries have amended existing legislation to take account of an individual’s wish to direct their donation to a family member or loved one, and so on.
O
In his article, Organ donation after assisted suicide: a potential solution to the organ scarcity problem, David Shaw investigates another potential solution: organ donation after planned assisted suicide (DAS) (4). He claims that if such a scheme were successfully implemented in Switzerland, a country that, he says, has a surprisingly low rate of deceased organ donation and allows assisted suicide, a donor organ surplus could be achieved within 1 year. In this commentary, I provide a brief analysis of the arguments Shaw sets out and highlight possible difficulties that would need to be overcome were his proposal to be implemented. I suggest that considering the possibility of DAS may be a useful way of developing our understanding on the scope and breadth of individual consent and authorization in the context of donation and end-of-life decision-making. Moreover, I posit we should not underestimate the important role such understanding may play as the potential for premortem interventions and research to increase the number and quality of donor organs, in particular DCD, gains momentum. Finally, reflecting on the principles underpinning an individual’s entitlement both to donate and to die, I consider the possibility that an individual may choose to die by donating their organs. Though improbable, I claim that any society prepared to uphold an individual’s wishes and allow them to define and choose the circumstances in which they die must also be prepared to consider the possibility that an individual may choose death by donation.
ORGAN DONATION AND ASSISTED SUICIDE IN SWITZERLAND
The research conducted for this paper was funded/supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St. Thomas’ NHS Foundation Trust and King’s College, London. The views expressed are those of the author’s and not necessarily those of the NHS, the NIHR or the Department of Health. A.J.C. is a member of the UK Donation Ethics Committee (UKDEC). The other authors declare no conflicts of interest. King’s College, London, MRC Centre for Transplantation, Guy’s Hospital, Great Maze Pond, London, United Kingdom.; Address correspondence to: King’s College, London, MRC Centre for Transplantation, 5th Floor Tower Wing, Guy’s Hospital, Great Maze Pond, London SE19RT, United Kingdom. E-mail: [email protected] Received 1 April 2014. Accepted 4 April 2014. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/983-254 DOI: 10.1097/TP.0000000000000238
The rate of deceased organ donation in Switzerland is 12 donors per million people. This low rate may be caused by sociocultural factors; however, the lack of a central organ donor registry has also been implicated. Despite efforts to promote donation, the number of people registered on the transplant waiting list is growing (4). According to Shaw, one way in which Switzerland could increase its rate of deceased organ donation is by allowing DAS. Swiss law permits its citizens and foreigners, who have gone through a rigorous procedure of safeguards, to obtain assistance in committing suicide. Although the Swiss Academy of Medical Sciences has apparently acknowledged that the practice is problematic, assisted suicide seems to be widely accepted (4). However, as Shaw explains, for practical reasons, individual’s who commit suicide with assistance are not currently able to donate their organs for transplant even though, he says, ‘‘it is likely that many of
254
Transplantation
www.transplantjournal.com
& Volume 98, Number 3, August 15, 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
* 2014 Lippincott Williams & Wilkins
them wish to donate their organs.’’ This, he claims, amounts to a ‘‘massive waste of an extremely precious resource.’’ By setting out a simple calculation, Shaw demonstrates that even if only 50% of those who commit suicide with assistance donated their organs, it would substantially increase organ availability, and, he claims, Switzerland could achieve an organ surplus once the current large waiting list is reduced. He highlights three further key advantages of DAS. First, it enables advance organ matching and transplant operation scheduling; second, it maximizes patient autonomy by enabling donation; and third. it reduces the risk of family refusing to permit donation.
Cronin
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invest in the relevant infrastructure to expand its DCD program regardless of whether the proposed DAS scheme is implemented. Labeling DAS as a more, or possibly less, ‘‘awkward DCD group,’’ as Shaw does, before understanding more fully how a DCD program would operate in Switzerland seems premature. Similarly, it is not clear that the proposal, though well intended, to designate DAS donors to a new Maastricht category VI, to distinguish aspects of their donation process is necessary. It may be sensible to defer any decision on this issue until such time as a DCD program is more established and, as set out above, we have a better understanding of the sorts of assisted deaths after which DAS could in fact take place.
PRACTICAL ISSUES Shaw considers three practical obstacles to the implementation of DAS scheme: transport to hospital, donation after cardiac death, and quality of organs. Transport to Hospital Shaw explains that the most obvious practical problem with DAS is ensuring the donated organs reach a hospital in time to be transplanted. He suggests two straightforward solutions to this. The first solution he says would be for the suicide to take place within hospital grounds. The second would be to have an ambulance booked to arrive at the time of death and transfer the deceased from their place of death to an organ retrieval hospital. If the individual who has chosen to commit suicide with assistance has also chosen to be an organ donor after their death, then these solutions seem relatively uncontroversial. However, they are linked to a more pertinent issue: Switzerland’s capacity for DCD. This would need to be addressed before the implementation of Shaw’s DAS scheme could be given serious consideration. Donation After Cardiac Death Most deceased organ donors in Switzerland donate their organs after diagnosis and confirmation of brain-stem death, so-called DBD. In contrast DAS would involve donation of organs after diagnosis and confirmation of circulatory death, so-called DCD. Shaw claims that this complicates the issue of rapid transport to hospital, because transplantation after DCD ‘‘must take place almost immediately.’’ A short time frame between diagnosis of death and organ retrieval is desirable to reduce warm ischemic time. However, successful DCD kidney transplants have been reported where organ retrieval has taken place up to 1 or 2 hr after withdrawal of life-sustaining treatment and diagnosis of death by circulatory criteria, or category III DCD. What perhaps therefore needs to be more fully understood and defined are the sorts of deaths with assistance after which DAS could in fact be realized, and the circumstances in which such deaths, and donations, ought to take place. This suggestion is not in conflict with Shaw’s overarching DAS proposal. On the contrary, it sits comfortably with his aim to ‘‘enable advance transplant operation scheduling’’ and ‘‘maximize patient autonomy by enabling donation’’ (4). The more apposite problem, which Shaw himself acknowledges, relates to the overall capacity for DCD transplantation in Switzerland. Improving this would, as Shaw says, be essential if his DAS proposal was to be adopted, particularly when we recall his calculation suggesting the possibility of an organ surplus. However, Switzerland should
Quality of Organs Shaw cites two potential objections regarding the quality of the organs retrieved from those committing suicide. First, he says, the organs could be harmed by the administration of the lethal drug, usually sodium pentobarbital. However, as Shaw himself explains, although this drug causes death, it does not normally cause any permanent damage to the organs. Moreover, organs (but not hearts) removed after euthanasia in Belgium have been transplanted successfully (5). The second objection, Shaw continues, is that cases of DAS will involve people who are seriously ill or dying. However, all potential deceased donors, whether potential DCD or DBD donors, are seriously ill, dying, or dead. As a matter of fact, being seriously ill, dying, or dead is usually necessary to meet the eligibility criteria for donation, much less an objection to it. Inevitably, there will be contraindications to donation. Cancer is just one example. On the one hand, Shaw claims that many people using assisted suicide services have cancer. On the other, he claims less than 40% of people accessing assisted suicide services in Switzerland have cancer (4). Reports vary. The point is this, where published evidence suggests a relative or absolute contraindication to using a donor organ of some sort or another, that evidence should be taken into account when deciding whether the donation goes ahead or not. This however should be the case regardless of the source of donor organ and is not something peculiar to the proposed DAS scheme. The more pressing question with regard to donor organ quality is whether, and if so to what extent, premortem interventions can and should be used to optimize successful donation? DAS may be a useful way of developing our understanding on the scope and breadth of individual consent and authorization in this context. It would of course be necessary to develop a robust defence of any such interventions. Among other things, assisted suicide is only legal in cases where the assister(s) will not benefit from the death. Simply proceeding on the basis that such interventions are not related to the assisted suicide per se is likely to invoke criticism. Nevertheless, the process of informed consent may provide valuable insight into the factors affecting an individual’s endof-life decision-making process and the perceived acceptability of premortem interventions, instrumentalization, and so on, aimed at optimizing successful donation at that time. Such understanding could usefully be applied more generally to DCD. It may even come to occupy an important role as the potential for premortem interventions and research to increase the number and quality of donor organs gains momentum.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
256
www.transplantjournal.com
ETHICAL ISSUES The Burden Argument Shaw says it might be argued that people who would otherwise not opt for assisted suicide might choose to die to donate their organs and help other people. This, he says, is a variation of the ‘‘burden argument’’ against assisted suicide in general. Shaw provides a swift rebuttal to this argument. First, he clarifies that there are specific criteria for assisted suicide in Switzerland, only terminally ill and those experiencing extreme suffering are eligible. Second, he explains that the decision about suitability for assisted suicide must be kept entirely separate from the decision to donate. Finally, he says, the sick in receipt of life-sustaining treatment can choose to refuse treatment even if it will result in their death, without invoking the burden argument. Implicit in Shaw’s rebuttal however seems to be the assumption that an individual, who does choose to die to donate their organs and help others, is somehow mistaken or wrong. The separation Shaw describes may well be attractive on a pragmatic level. However, it does not provide a satisfactory answer to the question, which asks, if we are prepared to use the organs of those who have chosen to refuse life-saving or lifesustaining treatments, why do we not consider using the organs of those who have chosen to die to, or even in such a way that, saves the lives of others? It might well be the case, as Shaw suggests, that for some, organ donation ‘‘simply provides an additional minor reason for choosing to die I that is unlikely to be decisive.’’ However, it is not clear that this is always, under all circumstances, going to be the case. Creating an association here, as Shaw seems to, with those who have died in the tragic circumstances of ‘‘violent unassisted suicide’’ does not shed more light on the issue. Death by Donation The principle of autonomy underpinning an individual’s entitlement to choose the circumstances in which they die is, rightly or wrongly, the same principle upon which most, if not all, societies have chosen to model deceased donation. It loosely follows therefore that any society that permits deceased organ donation and is also prepared to uphold an individual’s wishes and allow them to define and choose the circumstances in which they die, must also be prepared, at the very least, to consider the possibility that an individual may choose death by donation. This has been described elsewhere as ‘‘organ retrieval euthanasia’’ (4). Harrowing and improbable, as this choice may seem to many of us, and contrary to the long established so-called dead donor rule, it is not clear why the perceived tension between causing death and saving lives should preclude an individual’s wishes to be upheld in these circumstances. It may well be desirable, indeed necessary, to impose limitations on such individual entitlements and models of deceased donation within a framework of positive law. However, it is nevertheless important to provide coherent reasons for rejecting an individual’s choice and their donation, especially when we consider the potential benefits that may, as an inevitable consequence, be lost. In
Transplantation
& Volume 98, Number 3, August 15, 2014
Switzerland, as Shaw explains, upholding such a state of affairs would require the legalization of euthanasia and, he suggests, could even ‘‘alienate potential AS donors.’’ Others have suggested extending the concept of living kidney donation in relation to imminent death of a potential DCD donor (6). Scheduling such a living donation immediately before obtaining assistance with committing suicide is hardly likely to go unnoticed. Once again, it brings into focus the assertion that ‘assisted suicide is only legal in cases where the assister(s) will not benefit from the death’, and will inevitably raise a few eyebrows. Whether this concept would alienate or attract AS donors is open to debate. Either way, it lends support to the view, set out above, that understanding and defining the sorts of deaths with assistance after which DAS could in fact be realized, and the circumstances in which such deaths, and donations, ought to take place, is a priority. Taking account of professional concerns, conscientious objections, and the law must be an integral part of any such deliberation.
CONCLUSION Organ DAS would be permissible by Swiss law and is one potential solution to the organ shortage crisis in that country. David Shaw’s article provides a comprehensive, insightful account of the practical obstacles to implementing such a scheme, and the relevant ethical and legal arguments. If Shaw’s proposed DAS scheme were successfully implemented in Switzerland, it would represent a landmark change in organ donation policy. Although enhancing our understanding on the scope of individual autonomy, such a scheme may also provide valuable insight into the factors affecting an individual’s end-of-life decision-making process and the perceived acceptability of premortem interventions aimed at optimizing successful donation. Two key outstanding hurdles need to be addressed before such a scheme can be considered further. First, Switzerland must invest in the operational infrastructure necessary to develop its DCD program. Second, a better understanding of the sorts of deaths with assistance after which DAS could be realized and the circumstances in which such deaths, and donations, ought to take place, must be developed. REFERENCES 1.
2.
3. 4. 5. 6.
NHSBT. Transplant activity in the UKVactivity report 2012Y13. http:// www.organdonation.nhs.uk/ukt/statistics/transplant_activity_report/ archive_activity_reports/pdf/ukt/activity_ report_2010_13.pdf (accessed 04 March 2014). The recommendations are set out the Report Organs for Transplants http://webarchive.nationalarchives.gov.uk/20130107105354/http://www. dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ documents/digitalasset/dh_082120.pdf (accessed 04 March 2014). Cronin AJ. Points mean prizes: priority points preferential status and directed organ donation in Israel. Isr J Health Policy Res 2014; 3: 3. Shaw D. Organ donation after assisted suicide: a potential solution to the organ scarcity problem. Transplantation 2014. Ysebaert D, Van Beeumen G, De Greef K. Organ procurement after euthanasia: Belgian experience. Transplant Proc 2009; 41: 585. Morrissey PE, Monaco AP. Donation after circulatory death: current practices, ongoing challenges and potential improvements. Transplantation 2014; 97: 258.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
