Transplantation Ethics

April 12, 2010 • Posted in Book Reviews

As professor of medical ethics at Georgetown University’s Kennedy Institute of Ethics, Robert M. Veatch is an able dissector of the ethical principles involved in the arena of human organ transplantation.  As a member of the United Network for Organ Sharing (UNOS) Ethics Committee, and formerly chair of its Organ Allocation Subcommittee, Veatch has practical experience with many of the issues involved in the distribution of organs for transplantation.  As chair of a local Organ-Procurement Organization (OPO) Task Force on Directed Donation, he has particular insight into procurement.  While Transplantation Ethics is certainly a reference, it is more an exposition of the current state of affairs in organ transplantation for this country.  A thorough read of this tome is essential, for details often ooze from the pages like blood components from leaky capillaries.

Following an introduction of religious and cultural perspectives and a short primer on ethical theory, the book is divided into three sections:  “Defining Death,” “Procuring Organs,” and “Allocating Organs.”  In “Defining Death,” Veatch begins the discussion with the compelling case of Bruce Tucker, whose death and organ harvesting in 1968 brought to light a number of ethical questions.  The author then considers the three primary options for defining death:  heart/lung criteria, whole-brain, and higher-brain concepts of death.  Veatch clearly interprets the first and second as inadequate, and makes his case for the third, albeit with modification.  He rightly avers that the debate regarding the definition of death is really about the “moral status of human beings” and further states that the “choice of who is alive . . . is fundamentally a moral, philosophical, or religious choice, not a scientific one.” (p. 111).  He argues for the acceptance of a higher-brain concept of death; in light of the pluralistic world in which we live, he also feels that the inclusion of a conscience clause allowing for the use of heart/lung criteria is necessary.

Veatch addresses organ procurement in the second section, beginning with whether the process represents gift or salvage.  He exposes “presumed consent” for what it is – “taking the organs without consent” (p. 160) – and calls for veracity in language.  He explains that the dead donor rule requires that the organ donor must be dead before the organs are procured.  He then proposes several groups of living donors as sources – specifically non-heart-beating donors, anencephalic infants, and PVS patients. (pp. 184-5)  One of the more troubling passages in this text is Veatch’s description of where this leads when he states,

. . . It appears that the more accurate account of these proposals would be that their advocates, among whom I include myself, really are putting forward a proposal for further modification of the definition of death.  They are proposing a higher-brain concept of death in which permanently vegetative individuals — who, by definition, can never again be conscious — would be treated as deceased.  Of course, if they are dead, then organ procurement would not violate the dead donor rule.  I think all the cases I have discussed so far — non-heart-beating donor, anencephalic infants, and permanently unconscious individuals — are (or should be) really proposals to apply the dead donor rule curatively, pressing the limits of the borders between life and death. (p.185)

To advocate the removal of organs from these populations is no small matter.  “Non-heart-beating donors” is a recent, and not uniformly accepted, addition to the list of potential donors.  Procurement of organs from anencephalic infants and the permanently unconscious is of concern.  Indeed, these are all vulnerable populations among us and the reader may well wonder who will be next.  Is the definition of death being altered so that the rest of the living can get on with their lives, some with parts from the newly “dead”?

The third section of the book deals with the difficult task of allocating available organs which are always in short supply.  While doing a good job of description, an organizational chart would help, for the myriad of entities and jurisdictions involved in the procurement and allocation of organs is complicated by layers of political boundaries.  He attacks the concept of justice in allocation from the somewhat surprising perspective of directed donation.  His conclusion — that the experts of technology (professionals involved with transplantation) should not be charged with the allocation of organs — is correct and for the reasons he states.  He calls the choices “fundamentally moral and philosophical,” and says that they “cannot be made on the basis of technical knowledge alone.” (p. 372).

Overall, Veatch has done an admirable job of assembling a compendium of difficult issues involved in organ transplantation into one text.  His discussion of the differing types of transplants, their sources, and the allocation of same not only invites, but fairly demands, the reader wrestle with these issues.  He repeatedly calls for wide public debate about the various proposals he presents; indeed, to passively accept these would be a grave error.   Transplantation Ethics is a great springboard for the discussions in which our society needs to engage.  Throughout the book, Veatch asks in various formats:  “When, and how, shall we treat a body as dead?”  In our culture, this is a question to be answered by all.

Robert M. Veatch.  Washington, D.C.:  Georgetown University Press, 2000.  ISBN 0-8784-0811-8, 427 pp., hardcover.

Reviewed by D. Joy Riley, MD, MA (Bioethics) who serves as Executive Director of the Tennessee Center for Bioethics & Culture.

Originally published Spring 2007

Reprinted with kind permission of Ethics & Medicine: An International Journal of Bioethics