James Stacey Taylor

Routine Recovery of Cadaveric Organs for Transplantation: Consistent, Fair, and Life-Saving

Many families deny organ recovery from recently deceased relatives. As a result, valuable organs and some of the lives they could save are lost. Several plans designed to rectify this tragic situation have been proposed, including organ sales. We suggest another approach that we believe to be superior and that is rarely discussed: routine recovery of all transplantable cadaveric organs without consent. Here we show that this plan is ethically acceptable, more equitable than our current opting-in approach, consistent with other mandatory social programs, and life-saving. Based on these considerations, we believe that it is time to eliminate entirely the consent requirement for recovery of transplantable cadaveric organs.

Death, posthumous harm, and bioethics

If pressed to identify the philosophical foundations of contemporary bioethics, most bioethicists would cite the four-principles approach developed by Tom L Beauchamp and James F Childress,1 or perhaps the ethical theories of JS Mill2 or Immanuel Kant.3 Few would cite Aristotles metaphysical views surrounding death and posthumous harm.4 Nevertheless, many contemporary bioethical discussions are implicitly grounded in the Aristotelian views that death is a harm to the one who dies, and that persons can be harmed, or wronged, by events that occur after their deaths. The view that death is (typically) a harm to the one who dies infuses, for example, the debates over abortion and euthanasia, while the view that persons could be harmed or wronged after their deaths informs much of the debate over, for example, policies for the posthumous procurement of transplant and the ethics of research on the dead. In Death, Posthumous Harm, and Bioethics , I argue that we should reject this cluster of influential Aristotelian thanatological claims, and instead endorse a trio of views that together constitute what I term full-blooded epicureanism: That death is not a harm to the person who dies, and that persons can neither be harmed nor wronged by events that occur after their deaths. …

AUTONOMY, DURESS, AND COERCION

For the past three decades philosophical discussions of both personal autonomy and what it is for a person to “identify” with her desires have been dominated by the “hierarchical” analyses of these concepts developed by Gerald Dworkin and Harry Frankfurt. The longevity of these analyses is owed, in part, to the intuitive appeal of their shared claim that the concepts of autonomy and identification are to be analyzed in terms of hierarchies of desires, such that it is a necessary condition for a person to be autonomous with respect to (to identify with) a desire that moves her to act, that she desires that this desire so move her. (Conversely, on these analyses, a person will not be autonomous with respect to a desire that she is moved by, she will not identify with it, if she does not want to be so moved.) Despite the intuitive appeal of these analyses, however, Irving Thalberg has argued that they should be rejected. This is because, he argues, a person who is forced to perform an action by being subjected to duress of a certain degree of harshness will desire to be moved by her desire to submit. Thus, he continues, the proponents of hierarchical analyses of autonomy and identification will be forced to hold that such a person acted willingly, and did not suffer from any impairment in her autonomy. This, Thalberg concludes, is so counterintuitive as to justify rejecting hierarchical analyses.

Living organ donation: always ethically complex.

In a recent editorial, Reese et al. (1) discussed the “ethics of accepting complex living kidney donors” ( i.e. , donors at added risk). We take exception to three of their main points. (Note that our comments refer to all potential living donors, “complex” or not.) Reese et al. (1) imply that when determining donor acceptability, the risk of donor harm should be balanced against anticipated recipient benefit. We disagree. Such a standard asks physicians to change the primary focus of their loyalty in a major and, we believe, unacceptable way. More than 20 yr ago, Levinsky (2) argued cogently that “in caring for an individual patient, the doctor must act solely as that patient’s advocate.” Physicians cannot accomplish this goal if, when trying to decide whether to recommend a procedure for one patient, they are asked to balance the risks for that person against the benefits for another. Such an approach would pose a clear conflict of interest, the recognition of which has led to the sensible recommendation that potential donors and recipients be evaluated by separate physicians (3), a position that Reese et al. support (1). How then should physicians decide whether a volunteer is acceptable? We propose that, as is true of other medical situations, for a physician to support her patient as an organ donor, she must believe that there will be benefits for her patient ( i.e. , the potential donor) that are …

Black markets, transplant kidneys and interpersonal coercion

One of the most common arguments against legalising markets in human kidneys is that this would result in the widespread misuse that is present in the black market becoming more prevalent. In particular, it is argued that if such markets were to be legalised, this would lead to an increase in the number of people being coerced into selling their kidneys. Moreover, such coercion would occur even if markets in kidneys were regulated, for those subject to such coercion would not be able to avail themselves of the legal protections that regulation would afford them. Despite the initial plausibility of this argument, there are three reasons to reject it. Firstly, the advantages of legalising markets in human kidneys would probably outweigh its possible disadvantages. Secondly, if it is believed that no such coercion can ever be tolerated, markets in only those human kidneys that fail to do away with coercion should be condemned. Finally, if coercion is genuinely opposed, then legalising kidney markets should be supported rather than opposed, for more people would be coerced (ie, into not selling) were such markets to be prohibited.

Routine recovery: an ethical plan for greatly increasing the supply of transplantable organs

Purpose of reviewAll current organ procurement policies require some form of consent. Many families refuse to permit organ recovery from a recently deceased relative; therefore, the major cost of requiring consent is the loss of some lives that could have been saved through transplantation. Here, we argue for a much more efficient approach to organ procurement from brain dead individuals – routine recovery of all transplantable organs without consent. Recent findingsCareful analysis of the relevant literature shows that, compared with its competitors, routine recovery has the greatest potential to increase cadaveric organ procurement and save lives while causing very little harm. Furthermore, a recent survey suggests that 30% of the US public would already accept routine recovery even though the respondents were not educated regarding the value of this approach. SummaryPatients on the transplant waiting list are dying while organs that could have saved them are being buried or burned because of family refusal to allow posthumous organ procurement. Routine recovery would eliminate this tragic loss of life-saving organs without violating ethical principles. Indeed, we argue that of all the proposals designed to increase the supply of transplantable cadaveric organs, routine recovery is the best.

Autonomy and Organ Sales, Revisited

In this paper I develop and defend my arguments in favor of the moral permissibility of a legal market for human body parts in response to the criticisms that have been leveled at them by Paul M. Hughes and Samuel J. Kerstein.

A “Queen of Hearts” trial of organ markets: why Scheper-Hughes’s objections to markets in human organs fail

Nancy Scheper-Hughes is one of the most prominent critics of markets in human organs. Unfortunately, Scheper-Hughes rejects the view that markets should be used to solve the current (and chronic) shortage of transplant organs without engaging with the arguments in favour of them. Scheper-Hughes’s rejection of such markets is of especial concern, given her influence over their future, for she holds, among other positions, the status of an adviser to the World Health Organization (Geneva) on issues related to global transplantation. Given her influence, it is important that Scheper-Hughes’s moral condemnation of markets in human organs be subject to critical assessment. Such critical assessment, however, has not generally been forthcoming. A careful examination of Scheper-Hughes’s anti-market stance shows that it is based on serious mischaracterisations of both the pro-market position and the medical and economic realities that underlie it. In this paper, the author will expose and correct these mischaracterisations and, in so doing, show that her objections to markets in human organs are unfounded.

In Defense of Routine Recovery of Cadaveric Organs: A Response to Walter Glannon

Walter Glannon argues that our proposal for routine recovery (also known as conscription) of transplantable cadaveric organs is unacceptable “even if the consequence of [continuing to require consent] would be fewer organs for transplantation and fewer lives saved.” After carefully reviewing his counterarguments, we conclude that, although some of them have merit, none are sufficiently strong to warrant abandoning this plan. Below we respond to each of Glannons concerns.

Market Incentives and Health Care Reform

It is generally agreed that the current methods of providing health care in the West need to be reformed. Such reforms must operate within the practical limitations to which any future system of health care will be subject. These limitations include an increase in the demand for costly end-of-life health care coupled with a reduction in the proportion of the population who are working taxpayers (and hence a reduction in the proportionate amount of health care funding that can be secured through taxation) and the fact that the imposition of bureaucratic regulations on health care systems is costly. Recognizing these limitations should naturally lead one to consider market-based reforms. Yet despite the practical impetus for such reforms, there is still widespread concern that market-based health care is unethical. The purpose of this paper is to address this concern and, in so doing, to pave the way for the market-based reform of health care to proceed.