Is organ donation helping us to make better decisions?

Abstract

Shaw and Gardner are to be congratulated on their editorial highlighting some of the ongoing ethical concerns about rapid expansion of the UK organ donation programme 1. Whether intended, however, their reasoning comes across as too utilitarian and simplified when describing the moral issues that clinicians face. Sometimes I consider that the organ donation lobby employs retroactive justification when developing its arguments, however worthy. Simply stating (without context) that three patients a day in the UK die while on the transplant waiting list does not support any case for why organ donation should ‘trump’ emergency surgery, for example. By such utilitarian reasoning, there would seem to be a greater moral argument for reducing road traffic accident deaths, which kill 4.69 people a day in the UK 2. Although I acknowledge the concept of ‘moral distance’ in redistributing help according to need rather than by moral or geographical proximity to the donor, it would seem as important to acknowledge that the donor (in this case a clinician) is not an immoral being, but acts in a similar way to the vast majority of people, by acting to treat the immediate need of the patient in front of him/her, over and above that of an equally needy but more physically distant one. Appealing to clinicians’ ‘moral imagination’ is also unlikely to produce fair and consistent outcomes, simply because these are individuals with conflicting interests and demands. To ask for a change in moral thinking while demanding year on year ‘competitive’ improvements in organ donation rates will only inflict a moral toll on the decision-makers. Furthermore, such a change in clinicians’ moral outlook is unlikely to take place if clinical independence is superseded by protocolised decision-making imposed by regulatory bodies. As a thought experiment in understanding utilitarianism and human nature in relation to abortion, the ‘trolley problem’ is an excellent exercise, but was not considered either correctly or completely in relation to organ donation 3. The editorial only mentions one limb of the problem, namely pulling a lever to save five lives rather than one. Shaw and Gardiner failed to mention the important alternative of pushing a large man in front of the trolley to stop its transit, saving one person but killing the large man. Organ donation is better represented by this second limb, in which the large man might be represented, for example, by a patient with a ruptured aortic aneurysm who is denied surgery so that his organs might be harvested for donation shortly after his inevitable death. The complete trolley problem describes how most people will pull a lever that ‘unintentionally’ kills one person but saves five, but will balk at ‘intentionally’ pushing someone to their death to save others. As such, the question of intent is of greater importance, and Shaw and Gardiner should have included further deontological debate about the moral acceptability of actions rather than merely outcomes. I think that most anaesthetists have already embraced some of the changes to ‘moral’ decision-making suggested by the authors. A bigger problem may lie in overcoming the ingrained attitudes of surgeons.