Last week I posted two criticisms of the NEJM article advocating the dismantling of the dead donor rule (here and here) that requires death before the taking of vital organs. I got some backstage blowback that I painted with too broad a brush about the kind of support such proposals have within bioethics. I don’t think I did that, given that the attempt to kill the dead donor rule is being mounted in the most Establishment medical and bioethics journals by some of the most respected thinkers in their fields, but there is no question that “killing for organs” is far from the unanimous view–for example Art Caplan’s good work in this area–a point that I could perhaps have made more clear. (The URL for the NEJM article is also now available, which can be accessed here.)
Still, it seems to me that the issue is gaining traction, particularly within the field of organ transplant medicine, in part because the idea has been “in play” for some time. This was perhaps most vividly illustrated in a very disturbing article written by Robert M. Arnold and Stuart J. Youngner in the prestigious Kennedy Institute of Ethics Journal way back in June 1993, “The Dead Donor Rule: Should we Stretch It, Bend It, or Abandon It?” (no link). They claim in the piece that “the production of body parts will increasingly be linked to the intentional ending of some lives with the salvaging of others.” And they give a hypothetical that would seem to be the product of a nightmare:
Machine dependent patients could give consent for organ removal before they are dead. For example, a ventilator-dependent ALS patient could request life support to be removed at 5:00 p.m., but that at 9:00 a.m. the same day he be taken to the operating room, put under general anesthesia, and his kidneys, liver, and pancreas removed. Bleeding vessels would be tied off or cauterized. The patient’s heart would not be removed and would continue to beat throughout the surgery, perfusing the other organs with warm, oxygen-and nutrient rich blood until they were removed. The heart would stop, and the patient would be pronounced dead only after the ventilator was removed at 5:00 p.m, according to plan, and long before the patient could die from renal, hepatic, or pancreatic failure.
If “choice” becomes the issue in organ donation instead of being dead, how do we avoid ultimately sinking to that scenario? Indeed, the authors seem to support moving in that direction–while using the usual “on one hand, on the other” hedge that is a hallmark of bioethical discourse, writing:
Given the difficulties our society is likely to experience in trying to openly adjudicate these disparate views [pro and con dead donor], why not simply go along with the quieter strategy of policy creep. It seems to be getting us where we seem to want to go, albeit slowly. Besides, total candor is not always compatible with the moral compromises that inevitably accompany the formulation of public policy.
Calling a spade a spade has at least one advantage however. By framing our choice in stark rather than obfuscated terms, we may be able to choose our path more clearly and be less surprised where it takes us.
This is precisely how I see my role: I strive to bring these controversies out of the ivory tower and into the public square in ways that prevent the obfuscation that leads to stealth policy creep.
And on this issue, the stakes could not be more stark. We turn our heads away and let “the experts” sort it all out at society’s peril.