In this essay I address the question of whether it is permissible to remove organs from the cadavers of people who have not explicitly consented to becoming donors in order to increase the supply of available organs. I will argue that such a practice is ethically permissible on the grounds of what I have termed the Instrumental Value Argument (IVA). I will begin by establishing the normative principles of my argument before outlining the IVA and validating its premises. To do this I will firstly explore the ability of the deceased to suffer moral harms and the basis of protection-rights for cadavers against non-consensual interference, concluding that any moral harms suffered by or rights accrued too the deceased are contingent upon the their former existence. Secondly I will explore some of the costs and benefits of implementing a system of enforced cadaveric organ harvesting and compare competing rights of effected individuals. Finally I will conclude that at least on a consequentialist basis, it is permissible to remove cadaveric organs without explicit consent in instances where structures are emplaced to mitigate associated harms of the practice and propose a model for how this might come about.
Normative Basis
In this essay I assume a consequentialist normative base where a thing is morally good if it promotes the best outcome.[1] I develop this perspective through a loose (but uncommitted) Pluralist Utilitarian approach to value, suggesting that in addition to the classical Utilitarian position of hedonism about the good – where happiness is the only thing with inherent moral worth – other factors such as justice and fulfilment may also contain separate inherent or intrinsic value. I have chosen a less stringent and broader interpretational normative base in an attempt to broaden the relevance of my argument to cover a variety of value theories by assuming that most value theories created by human beings will be supported either directly or in derived terms by maximising overall life expectancy and quality of life and wellbeing.
The Instrumental Value Argument:
From a consequentialist perspective the strongest argument supporting the forcible requisitioning of cadaveric organs from people who have not explicitly consented to be organ donors is the instrumental value argument. It runs as follows:
(P1) The dead have no state of ‘wellbeing’ and cannot suffer moral harm.
(P2) Therefore the moral value of the use of a body is determined on the instrumental basis of how the use of that body affects the living.
(P3) In most instances the instrumental value of utilising cadaveric organs for transplantation is greater than the instrumental value of not using a body for transplantation.
(P4) What is permissible is what brings the best outcome for overall wellbeing of the living.
(C) Therefore transplantation in the absence of explicit consent is permissible in most instances (where the instrumental value of organ transplantation is greater than organ preservation) and the system should change accordingly.
Given that the fourth premise represents my normative base, the discussion that follows is an attempt to validated the first three premises.
(P1) Post-Mortem Moral Harm:
The Experience Requirement:
For a consequentialist moral harms are harms that leave the state of the world materially worse than it otherwise would be. Thus for someone to suffer a moral harm their wellbeing would have to be effected in a way that renders them materially worse off than they were before the harmful act was done. However for wellbeing to be harmed one must be able to have a state of being in the first place so that the harm and reduced wellbeing may be experienced. This metric for the suffering of harms is termed by Stephen Rosenbaum as the ‘Experience Requirement’ (ER) for harm. [2]
The ER states that:
P is only bad for X if X at some experiences P.
Where P = harvesting of organs without consent, then P can only be bad if X experiences P.
(1) X is dead when P occurs.
(2) Therefore P is not something that X can experience.
(3) Therefore P is not harmed by X.
The only exception to this rule is that in some instances non-consensual cadaveric organ harvesting can harm a person during life not as a result of the act itself (as the person to whom the act is done is no longer alive to be harmed) but because of some tangible reduction in a person’s wellbeing prior to the act as a result of the knowledge that it will occur.
The Concealed Betrayal Counter-Example:
- Wilkinson provides a main criticism of this argument. He suggests that wellbeing is itself contingent on the fulfilment of life goals and that it is how an act affects the achievement or fulfilment of those goals that most influences their wellbeing. When a person’s goals are not fulfilled they are harmed.[3] To illustrate this point he cites a counter example to the ER – “Concealed Betrayal”. Here a person’s life goal is to have friends and loved ones. In reality this person (let’s call them Kevin) is actually surrounded by people who hate and despise him but who pretend so convincingly to love and adore Kevin that he will never know otherwise. Wilkinson suggests that because what Kevin values is friendship, not the appearance of friendship he will have suffered harm by not receiving what he values.[4] This would be applicable to the problem of organ harvesting if someone’s life goals were violated without their explicit consent in the process.
The weaknesses of this argument are twofold.
Firstly Wilkinson implicitly attempts to reappropriate a consequentialist viewpoint by appealing to metaphysical principles of the true state of things in opposition to the consequential state of things. That is, he assumes that moral harms can occur by the mere fact of our experience being false. This is not countenanced by consequentialism on basic principles. The consequentially right thing to do in a given situation is that which will maximise the best outcome. If continuing to let someone live under the false apprehension that they are loved does not adversely affect material wellbeing of all parties then consequentially it is the right thing to do. Moreover it assumes that all people are entitled to fulfil their goals. If Kevin is quite simply not a very nice person, is it a morally untenable situation for him to feel loved and to have a better life because of it than he normally would if people’s true opinions of him were demonstrated?
Secondly, even if we agree with his proposition and include truth in our normative metric of things that have an inherent worth, Wilkinson’s friendship example is dis-analogous to the case of a person’s goals being violated after death in one key respect. The person no longer exists and all the goals and values they once had have ceased to exist with them. To suggest goals are extemporal and that we should respect them beyond the grave is not only nonsensical but practically stupid. On a very basic level if someone’s goal was to be venerated or even just loved is it our responsibility to learn as much about their lives to try to allow that goal to be facilitated? Could we even begin to ascertain the goals or wishes of the dead once they are in fact dead if they were not explicitly stated? The answer seems to be no, except in the case of a legal last will and testament where a person extends their legal person over their estate to order its final distribution. In this instance it is possible to uphold a person’s goals and we could argue that this creates better consequences because it simplified the division of estates and has the added benefit of comforting us with an element of control over how we leave this world and a knowledge that our explicit goals would be upheld when we too perish – likely increasing wellbeing. However even if Wilkinson’s argument is correct the value of upholding these rights is still contingent on the wellbeing of the living, and suggesting that we should follow the explicit wishes of a dead person does not render impermissible the practice of removing cadaveric organs in the absence of explicit consent, rather it would only be impermissible where someone explicitly refused to undergo the procedure while alive, something which would likely occur if the practice violated their goals and which could be effectively accommodated an opt-out system of donation where individuals are required to choose not to donate.
(P2) Instrumental Value:
If the dead cannot suffer a reduced wellbeing then the moral permissibility of the use of a body must be determined by its instrumental value in how its use influences overall consequential wellbeing. The justification for this depends on what identity we view human remains as bearing. In general, the two strongest positions are:
(1) We are our bodies – our identity is literally defined by our bodies and any tampering with our bodies in the absence of our explicit consent is an assault against us, or
(2) We own our bodies – bodies are property and we should be able to determine how they are treated after life.
If (1) is true, then assuming that death is the end of our interest in and control over our bodies (which must be the case because like it or not the body will degrade and return to the environment) we cannot have a negative-right against interference because there are no longer any interests to protect and no harms can be suffered. Depending on where we draw the line on the end of personal rights over our bodies we could accept that an individual does have rights over their body while alive, and could therefore explicitly specify a manner in which they wished their body to be treated after death, rendering support for an opt-out system. Alternately, and more validly, we could suggest that if personhood has ceased then there is no reason to follow any instructions one way or another and we should use the morally inert organs in a manner that maximises beneficial outcomes.
If (2) is true then there is no reason that our bodies should not be treated like any other form of property we own.
Cecile Fabre argues as much through her analogy between organ harvesting and estate taxes. Fabre approaches the question of cadaveric organ harvesting from the complementary normative position of a rights-based theory of distributive justice to advocate for a system of distributive justice that attempts to increase the ability of the less fortunate to ‘flourish’ without substantially detracting from the ability of the more fortunate to flourish. The key difference between this point of view and my Pluralist Utilitarianism is that for Fabre, it is not merely morally correct for us to pursue actions that realised the greatest potential level of ‘flourishing’ and wellbeing but that the less fortunate have a positive right to excess resources that would enable them to flourish, adding further onus to the proposition that cadaveric organ harvesting is permissible if this normative base is accepted.[5]
Importantly Fabre provides two conditions to what can be redistributed for ‘minimal flourishing’ by the less fortunate, which also influence the consequential effects of redistribution.[6] If transferred or ‘redistributed’ neither the goods nature, nor the personhood of the transferring party can be altered. In both instances neither the nature of an organ nor an individual’s personhood can be violated by harvesting – an organ is still an organ whether harvested or not, and a cadaver is no longer a person. Thus from both a rights-based and pure consequential standpoint, there is nothing inherently impermissible about the transfer of organs. For Fabre this conclusion carries the implication that organs belong in the same category as any resource that is redistributed to increase the ability of individuals to “flourish” in society, which means that there “are good grounds to confer on the ‘medically poor a right to the organs of the ‘medically rich’”[7] much as there are ground to redistribute wealth in a similar fashion.
Thus whichever view of the relationship between identity and body is taken, there seems to be ample grounds for forced cadaveric transplantation in the absence of (or potentially even with) explicit refusal.
(P3) Value, Transplantation and Exceptions:
Having established that it can be permissible to conduct cadaveric organ harvesting in the absence of explicit consent I will now attempt to argue that it is permissible in more cases than not to conduct this practice by firstly assessing the impacts on different groups and proposing a model which will maximise the benefits and minimise the harms of such a system.
It is undeniable that recipients of cadaveric organs have their wellbeing significantly benefited as a result of transplantation. Their life expectancy increases dramatically while other ‘wellbeing costs’ associated with deteriorating health, regular medical treatment such as the administration of dialysis are removed. In addition to the large benefits to recipients increased levels of donation also benefit society more broadly by reducing demand for medical institutions and resources for continuous and extensive treatment for organ failure and through the various benefits to the loved ones of recipients accrued by the increased longevity and wellbeing of the recipient themselves.
How organ harvesting affects potential donors entirely depends on who potential donors are, something that can only be determined by establishing when if ever it is legitimate for an individual to be exempt from donation. To answer this question I will compare the costs and benefits of donation in instances where a person is entirely unwilling to donate their organs and where a person has merely failed to consent to donation.
The Unwilling:
Unwilling donors experience detrimental effects as a result of organ harvesting either as a result of having their wishes violated (the experience requirement for harms from my earlier discussion rules this out) or from the way the knowledge that their organs will be harvested influences their wellbeing.
Fabre identifies two types of potentially unwilling donors. Conscientious and non-conscientious objectors.
Non-Conscientious:
Non-Conscientious objectors reject donation as a result of unsubstantiated sentiments or emotions including discomfort or disgust at the idea of cadaveric transplantation. [8] This latter position potentially invokes John Stuart Mill’s initial conception that the only way to determine a things utility under a Utilitarian ethic is if people actually desire it.[9] This would suggest that knee jerk reactions of disgust to cadaveric organ harvesting are a legitimate ethical reason to avoid the practice.
I fundamentally disagree with the legitimacy of these objections on two grounds.
Firstly I cite the counter-example of autopsies. No matter how abhorrent the practice is to a person or their family, in our society it is taken for granted that in circumstances of suspicious death autopsies must be performed. This is because the need for justice to be served, or to catch killers and protect citizens universally outweighs any disgust or concern for disrespect to personhood. It is my contention that we should view cadaveric organ harvesting on the same terms.
Secondly I also suggest that even if we take Mill’s view of determining what is morally right to be true it does not discount the ethical permissibility of harvesting organs without explicit consent, it merely suggests that there needs to be a change in attitudes for this to occur, something that could be achieved through education and policies which attempt to alter the beliefs and emotional responses of individuals in relation to harvesting.
Conscientious:
Fabre defines conscientious objectors as individuals who can show that their life would be “rendered less minimally flourishing if one’s body or that of one’s relatives were not left intact”.[10] This would seem to suggest that if a deeply held religious/moral belief is contravened by organ harvesting then the reduction in wellbeing this creates is enough to warrant an exemption. On normative grounds I reject this low burden for exemption. From a consequentialist perspective, if Fabre’s metric is used and a needless innocent death occurs because of a ‘strong’ religious conviction then other needless deaths of innocents could also be permitted where they satisfy a deep religious or moral conviction, thereby potentially justifying the ‘religious’ practice of human sacrifice.
Instead I propose that a true conscientious objector could only be justified if the harms done to a person or family by the contravention of their beliefs amounted to death or worse (the likely consequence of their refusal), something that would be incredibly difficult to demonstrate.
That is not to say that I propose we enforce a near universal system of cadaveric organ harvesting, such a system would be Orwellian in nature and no democratic government would receive support for such a proposition at this time. However it is a system of cadaveric organ harvesting which is more rationally cohesive with consequentialism and which could be moved towards in the future as organ harvesting becomes a more regular practice.
Proposal:
For now, despite the above arguments I suggest that an opt-out system is both the most practically feasible and beneficial currently available. It would allow both conscientious and non-conscientious objectors to exempt themselves from donation and would avoid any radical changes that might cause elements of mass fear or mistrust of government such as might be caused by a universal harvesting system. It also allows for individuals who really would be effected to such an extent that their wellbeing would be reduced in a manner equivalent to death to avoid transplantation without having to address the problem of determining when such an extent is reached – presuming that individuals would use free will to opt-out of the system to protect their own interests. It also increases likely donation rates than in an opt-in system by using the remains of individuals who do not feel strongly enough to explicitly consent to or reject donation for the best consequential ends. Finally this policy if complimented by education and other policy initiative could contribute to a society that is more accepting of cadaveric transplantations, decreasing opt-out rates and making an even more consequentially beneficial policy approach more viable in the long term based.
Conclusion:
In this essay I have sought to prove that from a Pluralist Utilitarian perspective that it is morally permissible to harvest cadaveric organs from those who have not explicitly consented to the procedure. I attempted to do this by presenting the Instrumental Value Argument and by examining its premises. Finally I proposed an opt-out system that in practical terms provides both the most feasible and the most morally permissible outcome alongside pro-donation public awareness and education programs that would help to create a more prevalent desire within society to increase donation rates.
Bibliography
Fabre, Cecil ‘Justice and the Coercive Taking of Cadaveric Organs’ (2004) British Journal of Political Science 34, Cambridge University Press, UK pps. 69 – 86.
Mill, John Stuart ‘Utilitarianism’(1863) Project Gutenberg eBook (2004). Accessed via <http://www.gutenberg.org/files/11224/11224-h/11224-h.htm#CHAPTER_I> 04/10/13.
Rosenbaum, Stephen ‘How to Be Dead and Not Care: A Defense of Epicurus’ (April 1986) American Philosophical Quarterly 23, no. 2, North American Philosophical Publications, USA pps. 119 – 134.
Sinnott-Armstrong, Walter ‘Consequentialism’ (Winter 2012) Stanford Encyclopaedia of Philosophy. Accessed via <http://plato.stanford.edu/entries/consequentialism/#WhaGooHedVsPluCon> 01/10/13.
Wilkinson, T ‘Ethics and the Acquisition of Organs’ (2011) Oxford University Press Inc. NY.
[1]Sinnott-Armstrong, Walter ‘Consequentialism’ (Stanford Encyclopedia of Philosophy). Winter 2012.
[2] Rosenbaum, S ‘How to Be Dead and Not Care: A Defense of Epicurus’ (April 1986) American Philosophical Quarterly 23, no. 2.
[3] Wilkinson, T ‘Ethics and the Acquisition of Organs’ (2011), Oxford University Press, pp. 31.
[4] Ibid pp. 33.
[5] Fabre, C ‘Justice and the Coercive Taking of Cadaveric Organs’ (2004), British Journal of Political Science, 34 p. 71.
[6] Ibid p. 72.
[7] Ibid p. 76.
[8] Fabre, C ‘Justice and the Coercive Taking of Cadaveric Organs’ (2004), British Journal of Political Science, 34 p. 82.
[9] Mill, J S, Utilitarianism (1863).
[10] Fabre, C ‘Justice and the Coercive Taking of Cadaveric Organs’ (2004), British Journal of Political Science 34 p.83.
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