Unimpeachable Logic?

The logic is, of course, unimpeachable: If doctors are permitted to kill, why should they not kill and harvest at the same time?

There is nothing especially new here. Death by organ donation is a common theme in literature and film. It is the foundation of Kazuo Ishiguro’s very popular book Never Let Me Go. In that work of fiction, the donors give up their organs gradually, eventually resulting in their deaths. The donors consent to this. In the film The Island, the organs are removed without the consent of the human clones, who are completely unaware of what their purpose in life is.

The authors of the New England Journal of Medicine article, however, envisage harvesting organs from those who already want to die. The donors have consented to voluntary euthanasia or assisted suicide. These people are therefore already vulnerable.

The overall argument is that, due to the growing acceptance of voluntary euthanasia, patients who have consented to their own deaths should also be permitted to donate their organs. Unfortunately for the authors, the limitations on this are currently ethical as well as practical.

The Ethical Quandary – When Is Death?

First, there is a difference between doctor-assisted suicide and doctor-administered euthanasia. In the case of assisted suicide, the doctor prescribes a lethal dose of poison and the patient administers it. If the patient is physically unable to do this, in some jurisdictions a mechanism is set up whereby the patient can still administer the lethal dose. In this case, it is the patient who is committing suicide, although a medical professional assists them.

In doctor-administered euthanasia, the doctor directly kills the patient by administering the lethal dose.

The problem, according to the authors, is that because the patient must die first, after taking a certain lethal cocktail of drugs, this compromises the suitability of some organs that can be harvested, especially the heart.

The ethics of organ donation also complicate matters for the utilitarian organ harvester, because a patient must be medically dead before organs can be harvested.

The three authors of the piece argue, first, that if a patient consents to both voluntary euthanasia and organ harvesting, it should not matter what order those things happen in: the outcome is death either way.

Second, they argue that the medical definition of “death” is already a gray area; some patients can be kept alive, in the sense that their blood is still circulating, before they are truly dead.

Organ Donor or Crop Awaiting Harvest?

But the fact that death is already a gray area is an argument for clarifying the definition, not widening it. The uncertainty is one of the reasons many people do not consent to be organ donors after death.

When Ireland moved to an automatic opt-out system of organ donation, thousands of people opted out of the system. Many people already do not trust the medical profession when it comes to organ donation and what actually constitutes death. Liberalizing the scheme so that patients who have consented to die can have their organs harvested first and then be killed as a result of that harvesting would undermine trust even further.

The authors also rely upon the argument from consent. In the West, because society is more atomized and individual liberty is prized above almost all else, any system that stops a person doing something, even harming themselves, is usually met with the argument from consent. But consent is not enough in a whole host of areas.

In the UK, it is still the law that a person cannot consent to sadomasochistic sex that amounts to actual or grievous bodily harm. In R v Brown [1993], it was established that a victim’s consent is not a valid defense to actual bodily harm or grievous bodily harm. The House of Lords ruled that individuals cannot legally consent to the infliction of serious harm or wounding for the purpose of sexual gratification. Society, it held, must protect itself from the cult of violence.

In most jurisdictions, a surgeon cannot amputate a perfectly healthy limb, even if the patient consents. And there are hundreds of regulations imposed on civilians in European countries to protect their health and safety. Refusal to abide by them, on the grounds that one does not consent, is not a defense.

The Obvious Risks of Exploitation

The other objection should be the clear and obvious risk of exploitation. If the only limitation is consent, then it should be open to some people to consent to their deaths so that their organs can be harvested for commercial gain for their families. But no jurisdiction permits people to sell one of their kidneys, despite the fact that a person can survive with one.

An increasing number of jurisdictions are also making the commercial use of wombs, in surrogacy, illegal. It would make perfect sense on a utilitarian basis for a family member in the Global South to sacrifice themselves for the huge financial gain to be made from selling perhaps five organs, with the payment benefiting their family. The gross exploitation involved is the reason why we do not have an international organ market.

The international surrogacy market is proof enough of how it is always the poor who are exploited when consent is deemed to be the only limiting factor in medical ethics. And of course there is the matter of pressure, societal and familial: Why should a sick person linger when one of their healthy organs could potentially save another?

Those, for a start, are reasons why this dangerous proposal should be rejected. We are human beings, not a collection of spare parts.