On the Ethics of Organ Transplantation: A Catholic Perspective is a document authored by a working party under the auspices of the Anscombe Bioethics Centre. The members or the working party are as follows:
Rev. Dr. Michael Jarmulowicz (chair), MB BS (London), BSc (London), FRCPath, KSG,
Pathologist, London UK
Prof. David Albert Jones (secretary), MA (Cantab), MA, MSt, DPhil (Oxon),
Director, Anscombe Bioethics Centre, Oxford UK
Rev. Dr. Nicanor Austriaco, OP, BSE, STB, MDiv, STL, PhD, STD (cand),
Molecular Biologist and Bioethicist, Providence USA
Dr. Rupert Beale, MB BChir, PhD, MRCP,
Clinical Lecturer in Nephrology, Cambridge UK
Dr. John Curran, MB, PhD, FRCA,
Anaesthetist, Nottingham UK
Prof Pedro Errasti MD, PhD,
Professor of Nephrology and of Organ Transplantation, Navarre Spain
Mr. Oswald N Fernando FRCS(Eng), FRCS(Edin),
Emeritus Consultant Transplant Surgeon, London UK
Rev. Nigel Griffin, BSc, DipTh, MA,
Parish Priest and Former Hospital Chaplain, London UK
Dr. Dermot Kearney, MB BCh, BAO (NUI), MD (NUI), MRCPI,
Cardiologist, Gateshead UK
Prof. Patrick Lee, BA, MA, PhD, John N and Jamie D McAleer
Professor of Bioethics, Steubenville USA
Prof. Neil Scolding, PhD, FRCP,
Burden Professor of Clinical Neurosciences, Bristol UK
Prof. Nicholas Tonti-Filippini, BA (Hons), MA (Monash), PhD (Melb), FHERDSA, KCSG,
Bioethicist, Melbourne Australia
The purpose of the report is to clarify and analyze the “ethical requirements which must be met if transplant medicine is to achieve its true end, and merit the support of Catholics and, more generally, of men and women of good will” (3). The document is also particularly concerned with addressing “the criteria for diagnosing death and the issue of presumed consent” (3).
The document is divided into two parts. The first part treats live donation in the context of the legal structure and professional guidance practices of the United Kingdom and Ireland and select ethical issues that arise as a result. The second part treats post mortem donation (again contextualized by the legal structure and professional guidance practices of the United Kingdom and Ireland and select ethical issues that arise as a result). The purpose of this post is to provide a brief overview of Part I. Jana Bennett shall provide an overview of Part II in the coming days.
The Catholic Church is a strong supporter of organ donation. Archbishop Peter Smith demonstrates this point in the foreword through a reference to St. John Paul II’s affirmation that “We should rejoice that medicine, in its service of life, has found in organ transplantation a new way of serving the human family” (1). Indeed, advocacy for organ donation has been articulated recurrently by popes. This strong support is at least part of the explanation for the fact that the “highest rates of organ donation in the world occur in European countries with a strong Catholic heritage” (3). At the same time, the Church does set forward certain criteria that must be met in order for organ donation to be morally praiseworthy:
Organ transplants are in conformity with the moral law if the physical and psychological
dangers and risks to the donor are proportionate to the good that is sought for the recipient. Organ donation after death is a noble and meritorious act and is to be encouraged as an expression of generous solidarity. (CCC 2296)
This being stated, the ethical issues treated in Part 1 of the document are as follows:
The goods of transplant medicine
Is it in principle acceptable?
Limits to acceptability
Payment, remuneration, and exploitation
Is live donation ever a duty?
Taking organs and tissues from children
Paired and pooled donation and donation with restricted use
Less than ideal donors
Consent for research on tissue in biobanks and possible commercialisation
Let us now take these headings in turn. The first heading, “the goods of transplant medicine” is concerned with elucidating, well, the goods of transplant medicine: using and gaining “knowledge and skill to save life, to restore health and to alleviate suffering.” These goods are entirely consistent with the “Hippocratic tradition of ethical medicine.” However, from the standpoint of the Catholic moral tradition, particularly as articulated by St. John Paul II, we would add the goods of “a visible expression of human solidarity” and furtherance of the “culture of life” (5).
Because of goods such as these, organ transplantation is “in principle acceptable.” Nevertheless, there are “limits to acceptability.” First and foremost, “organ donation is justified only as an act of charity and not through a subordination of the individual to the greater good of society.” It is on the basis of this distinction that Pius XI can condemn “eugenic sterilisation as an illegitimate attempt of the State to exercise power over the bodily integrity of its citizens” (Casti Connubii (1930), 22-23). Natural law and virtue, as opposed to utilitarianism, are the proper context for assessing the ethics of organ transplantation.
Second, organ donation is only morally acceptable so long as the donor takes “reasonable risks” with his or her health. The donor may not implore the doctor to perform an operation that will “harm the functional integrity of the body.” Thus, different donor scenarios need to be prudentially evaluated and discerned on a case by case basis. Obviously, vital organs can only be donated post mortem. Donating a kidney is acceptable assuming the presence of another functioning kidney in the donor. However, more tricky are cases such as “partial liver and lung lobe transplants” both of which “involve significant risk to the life of the donor” and in some cases “loss of function” (6). This raises a difficult question: what degree of diminishment of functional integrity must be present in order to move the act from the “morally acceptable” category to the “morally unacceptable” category? Where is the line?
Informed consent is not a moral disinfectant either. The real issue is prudence and more precisely the relationship between prudence and courage. As the document notes, if two parents wish to “donate a lung lobe to a child with cystic fibrosis, the procedure has a chance of being a triple mortality” (6). Parents, Husbands, and Wives may be willing to take major risks for the sake of loved ones, but these risks cease to be courageous and become instead foolhardy if divorced from prudential discretion. Running in to a burning building to save your mother is virtuous when there is a real possibility that you can save her. The same action is rash if there is no possibility of that. The morality of the subsequent act is determined by the accuracy of the preceding prudential judgment. Donors must act on the basis of a truthful vision of reality. The true precedes the good.
With respect to “payment, remuneration, and exploitation,” John Paul II is willing to go much further than is Pius XII in declaring all forms of this immoral. However, both are agreed about these dangers in principle. It does not require an extraordinary leap of the imagination in order to envision the kinds of abuses that would, and in some cases already follow from the commercialization of transplantation. Yet, a legitimate question does arise with respect to “the issue of reimbursement of expenses and recompense for time, risk, or inconvenience, and from time away from paid employment” (7). Here the document argues that remuneration for expenses directly related to the procedure are not a problem but that anything beyond this will exacerbate the already present commodification of the body mentality that pervades much of modern consumer culture as well as lead to perverse incentives and a host of dangerous and illicit practices.
Perhaps the most interesting discussion in Part I occurs under the heading of “is live donation ever a duty?” According to Catholic teaching, the answer is both yes and no. Donating is not a duty in the “general or objective sense” (8). In fact, a danger concurrent with the normalization of organ donation is what the document refers to as a kind of “familial conscription” whereby a given family member may feel obliged to donate in certain circumstances, such as but not limited to when a child is involved (8). The document makes clear that hospitals need to assure that donors are not being coerced, and here “to coerce” is taken in a broad sense. Objectively speaking, no one could ever have a greater right to a part of my body than I do and so I am never obliged to donate. However, if the Holy Spirit is calling me to donate to someone, then I do have such an obligation derived from the virtue of charity.
Next, the document considers when, if ever, it is permissible to take “organs and tissues from children.” There are a very strict set of conditions that must be met for such an act to be permissible. I will not review them all here, but the most essential factor is “the nature of the relationship between donor and recipient” (10). Taking an organ from a person who is not competent to make that choice should be “a last resort,” but may be justifiable under certain circumstances. Imagine, for example, an instance where a parent needed an organ from the child to survive. Imagine further that the procedure involved “minimal risk to the child” and offered “proven efficacy.” In such a case, the child, too, benefits from the procedure since by it he or she is prevented from having to endure the tragic and unnecessary loss of a parent.
The discussion of “altruistic donation” concerns a kind of paradox. On the one hand, medical institutions tend to be most suspicious of non-relative “altruistic” donors, since in such cases there may exist undisclosed financial incentives. On the other hand, according to the Catholic view, while such suspicions are not entirely unwarranted, altruistic donation “represents the purist form of donation, understood as an act of generosity” (10). The altruistic donor donates purely as a response to the calling of the other.
“Paired and pooled donation” is normally when a relative wants to donate but is not a match. In such cases, two people wishing to donate but who are not matches may donate to each other’s respective relatives. To do so does not violate the norms of justice. However, in cases of “anonymous altruistic live donation” the key issue concerns whether “the further extension of the practice of directed donation to paired and pooled donation undermines the ethos of donation” (11). Such determinations must be prudentially discerned on a case by case basis in view of “the medical and social goods at stake.” (11)
“Domino donation” refers to the “donation of an organ which has been removed incidentally as part of a prior transplant procedure” (11). For instance, since doctors prefer to transplant the lungs and the heart concomitantly, someone who receives a new lung may also receive a new heart even if their own heart was perfectly healthy. In such cases, the individual’s heart may then be given to a different person who needs a new heart. There must be consent, of course, but it would seem a perfectly reasonable thing to do.
The discussion of “less than ideal donors” is quite edifying. There are a host of reasons why a candidate may be excluded from donating. Say, for example, that a husband wanted to donate a kidney to his wife who is experiencing renal failure and has a GFR of under 20. Suppose that the husband is in good health but at increased risk of diabetes and also has bilateral kidney stones. In such an instance, the husband may donate his kidney without violating the functional integrity of his body. However, by doing so he is placing himself at increased risk since both the diabetes and the kidney stones could very well damage his remaining kidney later in life. According to Catholic teaching, in such cases the husband is certainly not obligated to donate. However, he may elect to do so as an act of “heroic virtue” out of love for his spouse (13). Hospital oversight committees violate the moral law if they disallow such a husband from making the aforesaid choice on the basis of mere probabilistic judgments cloaked in the language of scientific objectivity.
“Consent for research on tissue in biobanks and possible commercialization” is the final section of Part I, and it involves the large number of tissue samples “maintained in culture so as to provide a service to researchers” (13). While there is not anything intrinsically illicit about such a practice, “providing relevant information and obtaining consent should be fundamental to the exchange of custody of tissues and any future commercial use” (13). Before consenting to provide tissues the tissue donor must be “informed of downstream uses and commercialisation possibilities.” (13)
In sum, the purpose of On the Ethics of Organ Transplantation: A Catholic Perspective is to examine the “ethical requirements which must be met if transplant medicine is to achieve its true end, and merit the support of Catholics and, more generally, of men and women of good will.” Part I of the document, reviewed above, considers live donation in the context of the legal structure and professional guidance practices of the United Kingdom and Ireland and select ethical issues that arise as a result. The document provides a helpful overview of Catholic perspectives on the issue of organ transplantation and draws attention to the importance of charity and prudence operating as guides to help one navigate through the maze of situations that Catholic moral theologians and ethicists alike must confront.