Ben Saunders

Opt-out organ donation without presumptions

This paper defends an ‘opt-out’ scheme for organ procurement, by distinguishing this system from ‘presumed consent’ (which the author regards as an erroneous justification of it). It, first, stresses the moral importance of increasing the supply of organs and argues that making donation easier need not conflict with altruism. It then goes on to explore one way that donation can be increased, namely by adopting an opt-out system, in which cadaveric organs are used unless the deceased (or their family) registered an objection. Such policies are often labelled ‘presumed consent’, but it is argued that critics are right to be sceptical of this idea—consent is shown to be an action, rather than a mental attitude, and thus not something that can be presumed. Either someone has consented or they have not, whatever their attitude to the use of their organs. Thankfully, an opt-out scheme need not rest on the presumption of consent. Actual consent can be given implicitly, by ones actions, so it is argued that the failure to register an objection (given certain background conditions) should itself be taken as sign of consent. Therefore, it is permissible to use the organs of someone who did not opt out, because they have—by their silence—actually consented.

ALTRUISM OR SOLIDARITY? THE MOTIVES FOR ORGAN DONATION AND TWO PROPOSALS

Proposals for increasing organ donation are often rejected as incompatible with altruistic motivation on the part of donors. This paper questions, on conceptual grounds, whether most organ donors really are altruistic. If we distinguish between altruism and solidarity--a more restricted form of other-concern, limited to members of a particular group--then most organ donors exhibit solidarity, rather than altruism. If organ donation really must be altruistic, then we have reasons to worry about the motives of existing donors. However, I argue that altruism is not necessary, because organ donation supplies important goods, whatever the motivation, and we can reject certain dubious motivations, such as financial profit, without insisting on altruism. Once solidaristic donation is accepted, certain reforms for increasing donation rates seem permissible. This paper considers two proposals. Firstly, it has been suggested that registered donors should receive priority for transplants. While this proposal appears based on a solidaristic norm of reciprocity, it is argued that such a scheme would be undesirable, since non-donors may contribute to society in other ways. The second proposal is that donors should be able to direct their organs towards recipients that they feel solidarity with. This is often held to be inconsistent with altruistic motivation, but most donation is not entirely undirected in the first place (for instance, donor organs usually go to co-nationals). While allowing directed donation would create a number of practical problems, such as preventing discrimination, there appears to be no reason in principle to reject it.

Normative consent and opt-out organ donation

One way of increasing the supply of organs available for transplant would be to switch to an opt-out system of donor registration. This is typically assumed to operate on the basis of presumed consent, but this faces the objection that not all of those who fail to opt out would actually consent to the use of their cadaveric organs. This paper defuses this objection, arguing that peoples actual, explicit or implicit, consent to use their organs is not needed. It borrows David Estlunds notion of ‘normative consent’ from the justification of political authority and applies it to the case of organ donation. According to this idea, when it is wrong to withhold consent to something, the moral force of that lack of consent may be null and void. If it is wrong of a person to refuse to donate their cadaveric organs to others, then it may be that their actual consent is not needed. This supports an opt-out system, which provides protection for those who have genuine reasons to refuse donation, and spares the worries as to what the deceased would actually have wanted.

Democracy, Political Equality, and Majority Rule*

Democracy is commonly associated with political equality and/or majority rule. This essay shows that these three ideas are conceptually separate, so the transition from any one to another stands in need of further substantive argument, which is not always adequately given. It does this by offering an alternative decision-making mechanism, called lottery voting, in which all individuals cast votes for their preferred options but, instead of these being counted, one is randomly selected and that vote determines the outcome. This procedure is democratic and egalitarian, since all have an equal chance to influence outcomes, but obviously not majoritarian.

Increasing Turnout: A Compelling Case?

Recently several thinkers have endorsed compulsion or other measures to increase turnout and revitalise democracy. This article argues that such measures are misguided, because lower turnout (even if unequal across social groups) is not necessarily undemocratic – indeed, it may serve democratic values by, for example, making it more likely that decisions really are made by the relevant constituency, with those most affected getting more say. Encouraging others to vote, or even to turn out, runs the risk of distorting electoral outcomes. If there is no clear democratic case for compulsion, then we should not risk even small limits on individual liberty.

The Equality of Lotteries

Lotteries have long been used to resolve competing claims, yet their recent implementation to allocate school places in Brighton and Hove, England led to considerable public outcry. This article argues that, given appropriate selection is impossible when parties have equal claims, a lottery is preferable to an auction because it excludes unjust influences. Three forms of contractualism are discussed and the fairness of lotteries is traced to the fact that they give each person an equal chance, as a surrogate for their equal claim to the good. It is argued that this can be a reason to favour an artificially-constructed lottery to a ‘natural’ lottery where there is suspicion that the latter may be biased.

The Democratic Turnout ‘Problem’

A number of authors, including Lijphart, Hill and Engelen, have recently advocated compulsory voting. While numerous justifications can be given for such measures, it is often said that they are necessary to realise democracy fully, for instance ensuring that everyone casts one vote (no more and no less). This argument rests on the commonly held assumption that low turnout is a problem for democracies – a claim that the present article resists. I argue that democracy as it should be understood requires only that citizens have the opportunity to exercise power. I show that the right to vote can be valuable, even if it is not actually exercised. Leaving people to decide for themselves whether or not to vote is not only more liberal but democratic in so far as it respects their choices and makes it more likely that decisions are made by the relevant constituency. Although voluntary voting makes it likely that different groups will be unequally represented, this is not necessarily a problem; where some are more affected by a given decision there may be good democratic reasons to allow them more influence. Disproportionality can be bad where it exacerbates existing social disadvantage, but here the problem is the social disadvantage, rather than that people do not vote. Moreover, while universal turnout ensures proportionality, the problem of disproportionality is conceptually distinct from low turnout. There may be other reasons to favour higher turnout, including a concern to promote social justice, but it is not necessarily better on democratic grounds.

J. S. Mill's Conception of Utility

Mills most famous departure from Bentham is his distinction between higher and lower pleasures. This article argues that quality and quantity are independent and irreducible properties of pleasures that may be traded off against each other – as in the case of quality and quantity of wine. I argue that Mill is not committed to thinking that there are two distinct kinds of pleasure, or that ‘higher pleasures’ lexically dominate lower ones, and that the distinction is compatible with hedonism. I show how this interpretation not only makes sense of Mill but allows him to respond to famous problems, such as Crisps Haydn and the oyster and Nozicks experience machine.

How to teach moral theories in applied ethics

Recent discussion has focused on whether or not to teach moral theories, and, if yes, to what extent. In this piece the author argues that the criticisms of teaching moral theories raised by Rob Lawlor should lead us to reconsider not whether but how to teach moral theories. It seems that most of the problems Lawlor identifies derive from an uncritical, theory-led approach to teaching. It is suggested that we might instead start by discussing practical cases or the desiderata of a successful moral theory, and then build up to comparing theories such as consequentialism, deontology, and so on. In this way, theories are taught but students do not take them to be the alpha and omega of moral thinking.

Making Voting Pay

Those who regard low turnout as a particular problem for democracy are sometimes led to endorse compulsory voting as a solution. However, even if there is a moral duty to vote, such legal coercion seems illiberal. This article, by appeal to the analogous case of blood donations, suggests that we should consider instead paying people incentives to vote. This would achieve the aim of increasing turnout, particularly among underrepresented groups, without threatening individual liberty in the way that compulsion seems to.