should we allow organ donation euthanasia? - Wiley Online Library

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Should We Allow Organ Donation Euthanasia? 47Organ Donation Euthanasia would conflict with thedead donor rules, and the injunction against physiciankilling. Yet it would not (if appropriate safeguards wereprovided) lead to the death of any patients who wouldotherwise live. The justification for this is not limited toutilitarian considerations. It is a Pareto improvement oncurrent practice for withdrawal of LST and organ donation,and may be Pareto optimal. ODE would apply topatients who are going to die – and soon. It is alreadyaccepted that it is permissible to withdraw life supportfrom these patients. It would prevent those individualsfrom suffering as a consequence of withdrawal of lifesupport. And it would save the lives of up to 9 otherindividuals. Many potential LSW donors, even if theywould have wanted to donate their organs, and theirfamilies consent, are currently unable to donate. Theirorgans die with them.The most acceptable way to introduce Organ-Donation Euthanasia would be to make it available asan option for prospective organ donors. It must benoted, though, that if ODE were made available in thisway, it would have (at least in the short term) only asmall impact upon the organ shortfall since only a fewindividuals would be likely to embrace it. This wouldundermine to some degree the case in terms of organsupply for ODE. But if we can save even one life, that issomething of great moral importance. Many lives couldbe saved even if only a small percentage of people optedfor ODE. And there is also a strong autonomy-basedargument for allowing individuals who wish to donatetheir organs to opt in to ODE (in the circumstance thatthey are severely ill in intensive care and going to havelife support withdrawn.) We should allow people tomake advance directives indicating that they would liketo be eligible for this alternative. We should encourageand support such altruistic desires.To some degree at least, there is a conflict between theneed to supply organs to the largest number of individualsable to benefit from them, and our beliefs about how weought to care for those who are dying or dead. We haveoutlined seven alternatives that may increase the supply oforgans. These alternatives clash with one or more of thetraditionally accepted ethical principles that govern transplantation,though they potentially promote other ethicalvalues including those of autonomy and beneficence.Whichever transplantation policy is adopted, we shouldensure that decisions about withdrawal of life-sustainingtreatment are separated from decisions about organ donation,and that organ donation procedures carry minimalrisks of causing suffering to organ donors. But continuingcurrent transplantation practice comes at a cost, in termsof a significant number of patients who die or continue tosuffer organ failure for want of an available organ. Weshould think seriously about whether it is time to embracean alternative strategy.Box 5: Proposal for allowing Organ DonationEuthanasia (ODE)Definition: Removal of organs from a patient undergeneral anaesthesia.Death follows removal of the heart.Eligibility criteria:1. The patient is dependent on life support in intensivecare2. Withdrawal of life support is planned on the basisof poor prognosis3. Death is predicted to occur within a short periodafter withdrawal of life support4. Prognosis has been independently confirmed5. The patient has consented specifically for OrganDonation EuthanasiaArguments in favour of Organ Donation Euthanasia1. It would promote patient autonomy2. It would provide patients with the greatest chanceof being able to donate their organs after death3. It would be a Pareto improvement over currentpractice for treatment withdrawal and increasethe number and quality of organs available fortransplantation.4. Suffering or discomfort for the patient would beless likely than with withdrawal of life supportArguments against Organ Donation Euthanasia1. It may lead to a fall in organ donation rates due tocommunity non-acceptance2. It could lead to the killing of patients who wouldnot otherwise have diedAPPENDIXEstimating the potential benefit of alternativesin terms of organ supply in the UK per yearIn 2007/2008 in the UK there were 593 heart beating(HB), i.e. brain dead. donors and 131 DCD donors. 96This corresponds to approximately 2312 organs availablefor transplantation. There are 8000 patients on waitinglists for organs (from a deceased donor), and approximately450 patients die on waiting lists per year. 97We have assumed that HB donors yield 3.9 organs perdonor, and DCD donors 2.7 organs per donor. 98 ForOptions 2–7 we have assumed that consent rates aresimilar to current levels in the UK. This assumption maynot be valid. See Section F.96 UK Transplant, op. cit. note 16.97 NHS Blood and Transplant, op. cit. note 7.98UK Potential Donor Audit, op. cit. note 22.© 2010 Blackwell Publishing Ltd.
48 Dominic Wilkinson and Julian SavulescuSome alternatives could yield more organs thanwould be needed to prevent the death of patients onwaiting lists. Additional organs would reduce thewaiting period for transplantation, and may also makeit possible for patients previously excluded from transplantationto be offered organs. It is not clear howmany patients fall into this latter category, but thenumber may be considerable. 991. Not all patients who currently consent (or whosefamilies consent) to organ donation end up donatingtheir organs. This might be because their organs areunsuitable for donation (for example if they do notdie quickly after withdrawal of LST, or if an unsuspectedmalignancy is found at the time of organdonation). So the total number of donors with conscription= Total No. Potential donors * conversionrate (for consenting patients)2. In the UK potential donor audit, 2% of potential HBdonors (where the organ donor register was checked)were listed on the register, but their family declinedconsent for organ donation. 3% of potential DCDdonors were registered donors, but their familydeclined consent. This would potentially translateinto a 2.3% increase in HB donors and a 4.5%increase in DCD donors 1003. The maximum benefit for organ donation euthanasiadepends upon the number of eligible patients.Current patients who are DCD donors would be ableto donate more organs (they would become HBdonors – this is the reason for the negative netnumber of DCD donors). There would be additionalpatients who currently are not eligible to donate byDCD because they do not die soon enough afterwithdrawal of LST. In the UK Potential DonorAudit 93 potential DCD patients from whomconsent was obtained for organ donation did not endup donating. Assuming that these patients fall intothis category of slower death, euthanasia prior toorgan donation would lead to an additional 93 (HB99 Smith & Murphy, op. cit. note 2.100 UK Potential Donor Audit 1 April 2008-31 March 2009 (personalcommunication 27 Nov 2009).equivalent) donors. However, this is likely to be anunderestimate. 101 Based upon Swiss data, 80% ofpotentially eligible patients having withdrawal ofLST took more than 1 hour to die. 102 So an alternativeestimate for the number of patients who could beable to donate (following organ donation euthanasia)would be 5 times the current number of donors.4. This would potentially lead to a similar number ofdonors as organ donation euthanasia, though thenumber/viability of organs would be similar tocurrent DCD donors (so the overall number oforgans would be less).5. It is hard to quantify the number of organs thatmight be available. The maximum number would beclose to the number available following organ donationeuthanasia, however, the viability of organs maybe compromised.6. This option may improve the viability of some organscurrently donated (e.g. kidneys), but would likelyyield less organs than Option 3. Here we haveassumed 1.7 organs per additional donor.7. This is based upon an assumption that shorterperiods of asystole would allow donation of heartand lungs (at a ratio similar to HB donors) fromDCD donors.AcknowledgementsDominic Wilkinson is supported by an Oxford Nuffield Medical Fellowship,Eric Burnard Fellowship, and Royal Australasian College ofPhysicians Astra-Zeneca Medical Fellowship. The funders had noinvolvement in this work.Dr Dominic Wilkinson is a paediatrician and Oxford Nuffield medicalresearch fellow. He has trained and worked in adult and paediatricintensive care. He has a particular interest in ethical issues in end-of-lifecare, has previously completed a Masters degree in Human Bioethicsand is currently undertaking a doctorate at the University of Oxford.Professor Julian Savulescu is Uehiro Professor of Practical Ethics at theUniversity of Oxford, Fellow of St Cross College, Oxford, and Directorof the Oxford Uehiro Centre for Practical Ethics. He also has a backgroundin medicine and completed his MBBS (Hons) at Monash University,Melbourne.101 See note 23.102 Revelly, op. cit. note 23.© 2010 Blackwell Publishing Ltd.
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