The Ethics of Organ Donation
Introduction
If one was dying, in dire need of an organ transplant, would one be willing to have one? If so, are they not also obligated to register as an organ donor to
Organ donation is one of the most well-known medical procedures. From dramatic episodes of Grey’s Anatomy to new scientific discoveries, the philosophy of organ procurement and transplantation is a prevalent and evolving issue. Despite its popularity and capacity to save numerous lives, countless people refuse to register as organ donors for a myriad of reasons. In this essay, I will show that under Utilitarian and Kantian reasoning, everyone should sign up as an organ donor, explain why it is unethical to oppose doing so, and respond to a popular objection.
Background
Organ procurement and transplantation
To better comprehend the ethical debate, we must understand the basics definitions of key terms associated with organ donation, as well as the process of donation and transplant. An organ donor is brain dead, meaning that sophisticated medical equipment does not detect any brain wavelength activity. The donor’s consciousness is gone, and they are in a permanent coma-like state. There is a 0% chance they will recover. Donor Network West, the Organ Procurement Organization (OPO) and federal nonprofit overseeing all organ donation related activities in California and Nevada, highlights the fact that “one donor can save up to 8 lives through organ donation” and “heal up to 75 lives through tissue donation.” Anyone older than 13-years-old can register as a donor. The donor’s family makes the ultimate decision for adults that are not registered and for underage children, regardless of the minor’s registration status. Living donors can also save lives; however, I will not be discussing the ethics of living donation. Potential recipients are placed on a transplant waitlist and assigned a specific level of priority based on urgency, current health status, etc. The matching of donors and recipients is dependent on a myriad of complex factors. Due to the lack of donors and the massive volume of patients on the waitlist, healthcare professionals often struggle to pair recipients with life-saving organs and tissues.
Utilitarianism
The premise of John Stuart Mill’s Utilitarian ethical theory is the Greatest Happiness Principle, the notion that “actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness” (Dell’Olio and Simons 4). In other words, actions are considered moral based on the amount of happiness or pleasure they create, and immoral based on the amount of happiness they remove or sadness they create for the overall population. Actions that create the maximum happiness for just one individual yet unhappiness for the majority are considered selfish and immoral; moral actions should create happiness for the most people, even if that means self-sacrifice and personal pain. In other words, the happiness for a few individuals is less valuable than the happiness of more individuals, especially if the happiness of fewer individuals is at the expense of happiness for more people. The goal of our actions should be to promote the greatest happiness, thus, the greatest good, without bias or preference for one’s family, friends, etc. To streamline the decision-making process one can, abide by the general moral rules. These moral rules are the very basic ideas of what is considered right and wrong, such as it is immoral to steal, chat, lie, intentionally harm others, etc. Mill believes that no moral rule is breakable, and we must abide by them to promote the greater good. Mill recognizes the fact that it is impossible to be 100% satisfied and achieve maximum happiness, thus, compromises may be necessary. However, this should not deter one from pursuing the greatest happiness. The overall goal of Utilitarianism is to reduce the amount of pain and suffering to a minimum and maximize the amount of pleasure and happiness, both in quantity and quality.
The trolly problem is a popular philosophical exercise that demonstrates Utilitarian ethics. A train is about to slaughter five people standing on one train tracks. On another train track, only one person is standing. There is not enough time to warn the people or help them get off the tracks. One has the power to pull a lever to change the direction of the train; instead of killing five people, it will only kill one person. Utilitarianism argues that it is moral to change the direction of the track because the death of one person promotes less unhappiness than the death of five people. In other words, the survival of five people is more valuable and promotes more happiness than the survival of only one person. The same concept would apply if one had to sacrifice themselves to save the other five people. In another version, pushing a person off a bridge to stop the train would also be considered moral. Some objectors believe it is moral to pull the lever yet immoral to do the later, because doing so would actively participate in and cause someone’s death. Utilitarians would refute this claim, explaining that both result in the death of one person (who would have otherwise survived) to save five people. Therefore, by the Greatest Happiness Principle, both scenarios are moral; the action that causes the least pain and sacrifice, or the action that promotes the most happiness, is the most moral action. Arguably, the ends justify the means.
Kantian Ethics
Immanuel Kant’s ethical theory revolves around the definition of goodwill, duty, and the categorical imperative. Goodwill, a foundational concept determining morality, can be defined as the proper motivations for actions that fulfill moral duties and obligations. Kant argues that “we can readily distinguish whether [an] action which agrees with duty is done from duty, or from a selfish view,” to determine if our actions enhance the notion of goodwill (Dell’Olio and Simons 214). The categorical imperative is a “test” that determines if the action itself is moral. It begs the question if we would want to live in a world where everyone would, when placed in our exact situation and presented with the same options, would act as we would. This concept is very similar to the “treat others the way you wanted to be treated” golden rule.
Immanuel Kant’s deontological (meaning duty focused) ethical theory focuses on goodwill and duty, and is supported by the Categorical Imperative and the Humanity Principle. Most aspects of Kantian ethics are the polar opposite of Utilitarianism. Goodwill, a foundational concept determining morality, can be defined as the proper motivations for actions that fulfill moral duties and obligations. Kant argues that “we can readily distinguish whether [an] action which agrees with duty is done from duty, or from a selfish view,” to determine if our actions enhance the notion of goodwill (Dell’Olio and Simons 214). This can be broken down into two critical parts: the motivations behind an action must be morally correct and the action itself must also be moral. For example, if the intent behind an action and the action itself is moral but the outcome is negative or immoral, the overall act is morally correct because the goodwill fueling the action was pure, and sometimes the outcomes of our actions are beyond our control. The purpose of goodwill, including moral actions, is to serve our moral duties and obligations. Goodwill is the only thing that is good in it of itself, thus, we must utilize it to execute moral obligations. In Kantian ethics, there are two tests to determine if actions conform to moral law: The Categorical Imperative and the Humanity Principle.
The Categorical Imperative asks if everyone can live on the principle we are to act on. In other words, it begs the question if we would want to live in a world where everyone, if placed in our exact same situation and presented with the same options, would act as we would. If we would want to live in such a world, it is likely that the action is moral. If not, the action is likely immoral. This the foundational idea of the grade school golden rule-- “treat others the way you want to be treated.” Truth is considered a keystone categorical imperative because most people do not want to live in a world where everyone lies. This can be observed in Kant’s popular axeman example. A man with an axe is looking for our friend. Kant argues that it would immoral to lie about the friend’s whereabouts, because there is no way to definitively know the axeman’s intentions. If we tell the truth and the man kills our friend, their death is not our responsibility because we served our duty, checked it with the categorical imperative, and did not actually kill our friend. We simply told the truth. The responsibility of our friend’s death falls solely on the shoulders of the axeman. Similarly, if we lied about our friend’s whereabouts and the axeman ran into our friend (who unbeknownst to us was trying to escape) and killed them, we would be responsible for our friend’s murder. If we had told the truth, our friend would have safely escaped and the axeman would have left. Some objectors contend that this scenario does not accurately convey the categorical imperative. If the axeman was looking for us and our friend was the in same position as us, we would hope that our friend lies about our location because it decreases the change of death. Telling the truth results in our death, thus, we would want to live in a world where our friend lies about our location. However, Kant argues that it is not our moral obligation or duty to get involved in scenarios any more than requested or required. In this situation, we simply have to do what is requested of us—to tell the truth.
In another example of the categorical imperative, a student that is considering cheating on a test should ask themselves if they would want to live in a world where everyone cheated on exams (if placed in the student’s exact scenario). Most likely, the student would not want to live in such a world, because that diminishes the purpose of taking exams and is unfair to other students. As such, according to the categorical imperative, it is immoral to cheat on a test.
The Humanity Principle highlights the idea that we should always treat humans as the end and never the means to an end. Since we have an immeasurable number of motivations, definitions of individual goals, hopes, dreams, etc. humans have an incalculable amount of intrinsic value. Treating other humans as objects to fulfill a need or a small aspect in a larger plan is considered immoral. Instead, the Humanity Principle argues that humans are valuable solely for existing; our value is not determined by the job we fulfill, money we make, connections we have, etc. Treating each human as a person solely for existing is pivotal to the Humanity Principle. Arguably, this idea stretches to all rational living beings, because each living being has a hope, dream, need, etc. Although humans have the most complex intrinsic value, all conscious beings hold different amounts of intrinsic value.
Utilitarian Reasoning
From a Utilitarian approach, everyone should register as an organ donor because it enhances the greater good. Patients on the waitlist suffer a slow painful death, and their only hope for survival is a life-saving transplant. United Network of Organ Sharing (UNOS), the national organization overseeing all OPOs, notes that “68,480 people are on the national waitlist” and “109,683 people [are] in need of a life-saving organ transplant.” The national non-profit leading registration efforts, Donate Life America, clarifies that “22 people die each day because the organ they needed is not donated in time.” The lack of brain dead people is not the driving force for these statistics. Instead, it is a lack of registered donors. Without organ donors, transplants cannot happen; thus, the number of preventable fatalities will escalate. Those that are not registered are directly causing the death of patients on the waitlist. As such, unregistered persons are actively supporting the opposite of the Greatest Happiness Principle, because they are contributing to more despair and avoidable casualties.
Registered organ donors boost happiness in various ways. First and foremost, it is less stressful (in a context that requires family permission) for a donor family to consent, if their loved one has specified a decision beforehand. A donor family can easily honor their loved one by fulfilling their last wish. Doing so provides a sense of comfort during a melancholy time. Signing up beforehand also encourages the donor's family to approve procurement because they can easily honor their loved one's last wish. Consequently, more organs are available to save more patients on the waitlist. Before transplants even occur, merely registering as a donor already contributes to the Greatest Happiness Principle. Those who do not register to donate often cause or amplify psychological tribulations and misery for their family members because it is difficult to make a critical decision for an incapacitated loved one who has not specified their wishes. This uncertainty also seeds hesitation regarding donation. Many donor families decide not to consent because it is "safer" than complying with something that the donor may not want. As a result, the number of organs available for transplant decreases; more patients on the waitlist are significantly susceptible to premature death.
The most obvious point is that organ donors save numerous lives, increasing the capacity to contribute to the Greatest Happiness Principle. Many recipients return to activities that they have not been able to participate in for many years. The gift of life frees them from the waitlist's shackles, establishing a better quality of life. An often-overlooked benefit of this phenomenon is that it also boosts the happiness of the recipient's loved ones. Their family and friends do not have to experience the treachery of watching a relative die. The Greatest Happiness Principle, in the context of transplantation, transcends beyond solely saving the recipient. It is a chain reaction that promotes happiness for everyone close to the recipient and donor. Not registering as an organ donor and inducing the death of a patient on the waitlist directly contributes to their family members' unhappiness. As such, this chain reaction reduces the overall amount of happiness in the world and actively reverses the Greatest Happiness Principle.
Kantian Reasoning
Despite being the polar opposite of Mill’s Utilitarianism, Kantian ethics can also support organ donation ethics. To comply with the categorical imperative, those that do not designate as organ donors (or donor families questioning consent to do so) should attempt to empathize with those on the transplant waitlist. Since the categorical imperative revolves around the “golden rule,” one should ask themselves if they would hope that a stranger would generously provide the “gift of life” if they were in dire need of an organ transplant. If one is willing to receive a transplant, one is obligated sign up as an organ donor because it implies that they do not want to live in a world where everyone does not register or donate when possible. Instead, their frame of mind suggests that they want to live in a world where the probability of receiving a life-saving transplant is higher, thus, the number of organs available for transplantation is also much higher. Since one has the potential to save someone else’s life, one is obligated to enroll in the organ donor registry. Not doing so is contradictory of previous convictions and presents hypocritical and selfish attitudes-- the definition of unethical behavior under Kantian principles. If donating organs and receiving organs is considered ethical under the categorical imperative, then it is vital that one signs up as an organ donor.
The concept of goodwill is also relevant. If, according to the categorical imperative, one is obligated to register as an organ donor, registering becomes a fundamental aspect of their duty, because it is part of enhancing goodwill. In this sense, donation is a categorized as a moral action conforming to moral (as tested and confirmed by the categorical imperative and humanity principle), thus it one’s duty requires that they have goodwill by donating organs.
Similarly, the Humanity Principle also applies. As stated before, the main idea of the Humanity Principle is that we should always treat humans as the end and never the means to an end. By signing up as organ donor, one is following the Humanity Principle because they are treating the patients on the waitlist as the ultimate end. The ultimate good and purpose of organ donation directly saves the lives of those on the waitlist. As such, they become the ultimate end because they benefit from the actions corresponding to the ultimate good.
Common Objection
The most popular counter-argument is that one continues to have autonomy over their body after death. Objectors contend that they have control over their body because their genetic composition is unique, and is something that solely and wholly belong to them. One owns their body (including their organs), thus, one has jurisdiction over what happens to their body after one dies. For example, one has the right to refuse medical treatment, get tattoos and piercing, etc. when alive. They have complete control over their body. If one has the liberty and control over their body (including organs) when alive, why don’t such principles apply after death? Just as control over monetary property and funds transcends death, control over one’s body and organs (another type of property) also transcends death. It is considered immoral for a family member to take control of an estate, bank account, etc. after a loved one’s death, if such control was not explicitly specified in the will. How is organ donation any different? Why is it not considered immoral for a family member to have authority over their loved one’s organs, after their death? As such, organ donation in the case of minors and adults who have not signed up as organ donors (meaning, organ donation where donor family consent is required) is unethical because the family is taking control over their loved one’s body, a portion of their property, after death. Doing so is a violation of the Humanity Principle, because the family is infringing on their loved one’s rights by treating them as a means to an end, regardless of the fact that the end results in saving many lives. For example, if a 25-year-old male is eligible to become an organ donor, but did not sign up to do so in the past, the man’s family would violate the Humanity Principle by donating his organs because there is no definitive way to know if that was the man’s wish. Consenting donation strips the man of his rights, his control and autonomy over his body after death. His life becomes a means to an end to save other people. To consider another scenario, it is immoral for a family to donate the organs of a 6-year-old family member because she is likely too young to understand what organ donation means, thus, cannot have a definitive opinion about it. If she is too young to decide, her family should not donate at all because there is no way to know if she would support or oppose organ donation as an adult. Making a decision for a minor, who (because they are too young to have developed adequate intellect or reasoning to decide) did not express an opinion about organ donation is a violation of the Humanity Principle because it treats the child as a means to an end. Although the end contributes to a greater good and promotes the Greatest Happiness Principle, violating the Humanity Principle to achieve this goal makes the overall act of organ donation and transplantation immoral.
Counter Arguments
Such arguments are preposterous because objectors only present these convictions in the case of brain death. If someone experiences a “regular” demise, no one contends that they have autonomy over their body. The person is gone. No one argues that the dead person should plan their own funeral. Although will writings and other forms of communication before death can specify the wishes of the dead person, those that remain ultimately determine what happens to one's body after death. "Brain death is death," Donor Network West explains. The donor is dead before the procurement of organs and the transplantation process. Their consciousness is gone. So why do objectors believe that autonomy in the case brain death and natural death are different? Perhaps, misinformation or deficient comprehension of the definition of brain death are some reasons blame. Some claim it is due to religious reasons. However, “all major religions support donation as a final act of compassion,” or they leave the decision up to the individual (Donate Life America). Total autonomy over one’s body does not transcend death. Realistically, one only has a limited amount of power over their assets after death because it is impossible for living people to contact the dead and ask what they want, and it is impossible for dead people to contact the living. Since pre-written communication is the primary way for one to specify their wishes and continue to have control over one’s body, one has all the more reasons to sign up as an organ donor. Nevertheless, autonomy is already limited in “regular” demise with will writings, and organ donation is no different.
Furthermore, organ donation does not have the capacity to treat the donor as a “means to an end.” Saving the donor’s life is prioritized. It is only when healthcare professionals have exhausted every resource to a save someone when donation is considered. Because the donor is dead before the process of transplantation, organ donation does not have the capacity to violate the Humanity Principle. Kant’s examples of the violation of the Humanity Principle only pertain to those that actively suffer loss or experience bad things when they are alive, or actions that lead up to their death. It is impossible to treat someone who is already dead as a “means to an end” because their consciousness doesn’t exist anymore, thus, they cannot and do not suffer. Organ donation does not involve the active suffering or a donor, because the donor is already dead.
The objection in the cause of minors is equally preposterous. Adults already control a minor’s life; their consent is required for nearly every aspect of a child’s life, from roller coasters to surgery. If a child needs specific medical treatment, wants to go on a field trip, get a tattoo or piercing, etc., the permission of a family member, an adult parent or guardian, is required. No one disputes this idea because they argue that the minor is too young to know what is good for them. Their brain is still developing, and they probably have fewer “real-life experiences”, thus, they cannot make adequate decisions about what they want or what is good for them. No one argues that child should have control over their body when they are alive, because this would result in chaos. This idea is the foundation of why laws that restrict minors from drinking, getting tattoos, consuming drugs, etc. exist and place responsibility on the adult in their life. How is organ donation any different? Regardless of the fact if a minor expressed their decision regarding organ donation, the adult’s in their life make the ultimate decision because might be too young or naïve to understand what transplantation really means. If it is considered moral for adults to have control over a minor’s life when they are alive, it is also moral during death. This is not a violation of the Humanity Principle, because the adult has authority over deeming which choices will benefit the child the most, thus, cannot be twisted into treating the minor as a means to an end. It is impossible because the adults have authority to make good decisions for those that are too young to do so for themselves.
Works Cited:
Dell'Olio, Andrew J. and Caroline J. Simon. Introduction to Ethics: A Reader. Rowman & Littlefield, 2010.
Donate Life America. Statistics and Data. July 2020. 23 July 2020. <https://www.donatelife.net/>.
Donor Network West. Organ Donation Facts And Statistics. n.d. 16 July 2020. <https://www.donornetworkwest.org/organ-donation-facts-statistics/>.
United Network of Organ Sharing (UNOS). Transplant Trends: UNOS. 22 July 202. 22 July 2020. <https://unos.org/data/transplant-trends/>.
Image Credit:
http://www.worldkidneyday.org/wp-content/uploads/2017/10/donation.jpg