Conscription of Cadaveric Organs for Transplantation - Cambridge ...

Perspectivescadaver which has no autonomy andcannot be harmed.” 2Not everyone agrees with Jonsen.Those who disagree claim that peoplemay have interests that survive theirdeaths. Glannon suggests that oneexample of a surviving interest is adesire for “bodily integrity afterdeath.” 3 He and others argue thatthwarting this interest, by conscriptingorgans from the bodies of peoplewho had, while alive, expressed oppositionto posthumous organ donation,would harm these people after theirdeaths. To my mind the concepts ofsurviving interests and especially posthumousharm are difficult ones and Ihave yet to be convinced of their existence.But even if they are real, theycannot possibly be as important as theinterests of the living. As Harris pointsout: “[T]here is almost universal agreementthat death is usually the worstharm that can befall a human personwho wants to live. ...[R]ights or interestswould have to be extremely powerfulto warrant upholding such rightsor interests at the cost of the lives ofothers....[T]heinterests involved afterdeath are simply nowhere near strongenough [to justify doing this].” 4 Furthermore,it should be remembered,but often is not, that although somepeople wish to remain intact afterdeath, this is impossible —the bodyalways decays and returns to the“biomass.” 5The possibility that surviving familymembers could be harmed is moretangible and concerning. But just asin the case of surviving interests, howevermuch harm conscripting organswould impose on the family, the magnitudeof such harm could never belarge enough to justify allowing peoplewith end-stage organ disease todie for lack of a transplant —a transplantthat could have been performedhad organs not been discardedin the name of respecting familywishes. In this regard, Harris argues:“If we can save or prolong the livesof living people and can only do soat the expense of the sensibilities ofothers, it seems clear to me that weshould. For the alternative involvesthe equivalent of sacrificing people’slives so that others will simply feelbetter or not feel so bad, and thisseems nothing short of outrageous.” 6Similarly, Emson claims that it is “morallyunacceptable for the relatives ofthe deceased to deny utilisation ofthe cadaver as a source of transplantableorgans. Their only claim upon itis as a temporary memorial of a lovedone, inevitably destined to decay orbe burned in a very short time. Tome, any such claim cannot morallybe sustained in the face of what Iregard as the overwhelming and preemptiveneed of the potential recipient.”7 And note that society acceptsthat a military draft may sometimesbe necessary even though the deathof young soldiers would be muchmore traumatic to surviving familymembers than would be mandatoryremoval of organs for transplantationfrom relatives who are alreadydead.Another concern is that allowingpeople to opt out on religious groundscould greatly reduce the efficacy ofthe program if many objectors wouldclaim this exemption regardless of theirreligious beliefs. But this is unlikelyif a strong burden of proof of religiousobjection is required of thosewho attempt to invoke this exclusion,as was true for conscientious objectorsto military service. Furthermore,because conscription of cadavericorgans would cause little if any harm,it is likely that for many objectors thebenefit of getting out of the programwould not be worth the effort requiredto do so.A final concern about conscriptionof cadaveric organs is that it would109

Perspectivesgenerate outrage among the public.Although there likely would be publicresistance at the outset, people mightbecome more accepting of the ideaonce they understood the very favorablerisk/benefit ratio of the plan.Supporting this prediction is the observationthat there already exist widelyaccepted coercive practices that aredesigned to benefit the public and thatrequire participation of all citizensregardless of their wishes. Examplesinclude mandatory autopsy when foulplay or contagious disease may be thecause of death, a military draft duringwartime, forced taxation, and therequirement to serve on juries. Just asis true of these examples, I suspectthat had we been born into a societyin which conscription of organs afterdeath were an established practice, seenas serving the public interest at anacceptably low cost, very few of uswould ever question it.Further Justification forConscription of Cadaveric OrgansThere is a general consensus that thereexists a moral obligation to rescue whenthere is little or no risk or cost for therescuer —for example, throwing a lifepreserver to a person in danger ofdrowning. It has been argued cogentlythat posthumous organ donation isanother example of an easy rescue ofan endangered person because organrecovery and transplantation are oftenlifesaving for recipients and entail littleif any risk for cadavers. Based onthis reasoning, Peters claims that consentingto posthumous organ recovery“is not an act of charity. It is, rather, amoral duty of substantial stringency.” 8Unfortunately, under our current voluntarysystem, refusal rates for organdonation are high, which indicates thatmany people do not meet this obligation.Therefore, conscription of cadavericorgans can also be justified asnecessary to ensure that people dowhat they should have done on theirown but did not.I recognize that there is a differencebetween a moral duty and a legal dutyand that the law does not alwaysrequire us to do the right thing. However,in the special case of easy rescueof an endangered person, where thepotential benefit is enormous and thecosts and risk of harm are negligible, Ibelieve that our moral duty to helpshould be written into law. GoodSamaritan laws that have been enactedin several states and many Europeancountries provide precedent for thisapproach.SynthesisCareful consideration of the pros andcons of conscription of organs afterdeath leads me to conclude that it isnot only ethically acceptable but actuallyethically preferable to our currentvoluntary approach to cadaveric organprocurement. In discussing this issue,Emson goes even further: “It is immoralto require consent for cadaver organdonation.” 9 Of course, not everyoneagrees, and this issue remains highlycontroversial. In general, controversiesabout policy proposals can onlybe resolved through actual experience.I believe that the arguments in favorof conscripting cadaveric organs fortransplantation are strong enough torecommend a pilot study to see howwell the system would work. At thesame time, I recognize that any plan,no matter how seemingly sound intheory, is doomed to fail if it is widelyopposed by the public. Furthermore,attempting to implement policies withoutpublic support risks damaging thesystem we have in place. Therefore,before undertaking a trial of conscription,it is essential to explore publicattitudes.110

PerspectivesAttitudes Toward Conscriptionof Cadaveric Organs forTransplantation amongthe U.S. PublicTo investigate public attitudes towardconscription of cadaveric organs fortransplantation, I contracted HarrisInteractive, a national polling organizationwith many years of experience,to conduct a telephone survey aboutthis issue. One thousand fourteenadults living in the continental UnitedStates, all at least 18 years of age, wereinterviewed in September 2003. Thesubjects were chosen by a random digitdialing technique that reaches peoplewith listed and unlisted phone numbers.The responses were weighted toknown proportions for age, geographicregion, sex, and race among the U.S.adult population. This method is designedto produce a sample of respondentsthat is representative of thegeneral public. The maximum marginof error for the response rates wasplus or minus 3%. The introductionand questions were written by theauthor, reviewed by Harris to minimizethe likelihood of bias, and pretestedfor understanding on 10members of the lay public. The relevantsections of the introduction andthe question are reproduced below.(Another question that asked aboutthe acceptability of a nonfinancialincentive to donate was included inthe survey; because the arguments forand against that proposal differ sogreatly from those of conscription, theresults for that question will be reportedin a separate publication.)Introduction: “Transplantation is ahighly successful life-saving treatmentfor people with failing organs.Most transplanted organs come frompeople who have just died. Unfortunatelythere are not enough of theseorgans for all who need them, in partbecause many families say no whenasked for permission to take organsfrom a loved one who has just died.Several plans have been suggested inthe hope of making more organs available.One of these . . . is to allow hospitalsto remove organs from peoplewho have died without asking for permission.Like a military draft, thiswould be a draft of organs after deathexcept for people who objected on religiousgrounds. What do you thinkabout these ideas? As you answer,please keep in mind that the doctorswho determine that someone has diedare not the same doctors that removeorgans for transplantation.”Question: “In view of the tremendousshortage of life-saving organs,would you be willing to accept a policythat allows trustworthy medicalteams to remove organs from peoplewho have died without asking for permission,unless they had objected onreligious grounds?”Participants could choose from the followingpossible responses: yes, probablyyes, probably no, no, don’t know,or refuse to answer.Thirty-one percent of the respondentssaid they would likely accept apolicy of cadaveric organ conscription;19% definitely would and 12%probably would. Sixty-six percent saidthey would oppose conscription; 53%definitely would and 13% probablywould. Three percent said they didn’tknow or refused to answer. Responseswere similar among males and femalesand among blacks and whites, althoughthe percentage of blacks thatsupported conscription was slightlyhigher than the percentage of supportivewhites. College-educated participantswere less supportive ofconscription than were less educatedgroups, and younger respondents weremore supportive of the plan than wereolder respondents. Among those aged25–44, nearly 40% would likely acceptconscription.111