In his papers Spital suggests that if accepted and implemented the donor benefit standard would provide a number of clear advantages when compared to currently existing criteria for justified living organ donation. These can be summarised as follows:
‘Incompetent donation’ and the value of consistency
Although donor benefit has not, until relatively recently, been proposed as a necessary requirement for justified living organ donation, it is widely accepted that donor benefit is a necessary requirement of justified organ retrieval in the rare cases where those who lack the capacity to consent—such as the very young and the intellectually disabled—are proposed as organ and tissue ‘donors’.
2
In such cases, although some maintain that such persons should never be used as sources of organs for transplantation given their vulnerability to exploitation and abuse (see, for example: Webb and Fortune
2006; Cheyette
2000), it is more commonly suggested that an outright ban on this practice would serve neither the interests of potential organ recipients nor those of the proposed ‘donors’ themselves (Munson
2002; Wilkinson
2011). For, provided physical, psychological and emotional harms and benefits are taken into account those who lack the capacity to consent may, just like competent donors, suffer greater harms from a decision to forbid organ retrieval than one to permit it.
Thus, it is conventionally held that, in these rare cases, organ retrieval may be justified in the absence of capacity to consent where it can be shown: firstly, that there are no alternative competent sources of donor organs; and secondly, that despite the harms of retrieval, the donor is likely to receive sufficient psychological and emotional benefits that they outweigh the harms inflicted. When, how, and indeed whether such a determination can be made is, of course, questionable given the difficulties associated with donning the mental mantle of another (and especially that of another whose psychology is importantly different from one’s own). However, difficulties aside, in cases where it can be shown that retrieval is in the interests of the ‘donor’—and provided adequately and stringently policed safeguards are implemented to protect against exploitation and abuse—retrieval will be to the advantage of both ‘donor’ and recipient.
This view has not only been advanced in the academic literature but has also been accepted and implemented by the courts in a number of jurisdictions, such that it has played a
key role in legal cases where persons lacking capacity have been proposed as organ and tissue ‘donors’ since the 1950s. In the US, for example, in the case of
Masden v Harrison kidney donation from a 19-year old (who was under the age of majority at the time) to his identical twin brother was permitted by a Massachusetts court as a result of testimony from a psychiatrist that “grave emotional impact may be visited upon [the donor] if the defendants refuse to perform this operation”, and thus that the operation was necessary for the “continued good health and future wellbeing of [the donor]” (Curran
1959, p. 893).
3 Similarly, in the 1972 case of
Hart v Brown, a Connecticut court permitted kidney donation from a 7-year old to her twin sister as a result of psychological testimony which suggested that the procedure would benefit the donor due to her close emotional relationship with her sister and in the form of a happier family life (Hart v Brown
1972)
Donation from incompetent
adults has also been justified in the US on the basis of such considerations, such as in the 1969 case of
Strunk v Strunk where the donation of a kidney from a 27-year old with severe cognitive problems to his brother was permitted by a Kentucky court. In this case, it was held that because the donor was dependent on his brother both “emotionally and psychologically… his wellbeing would be jeopardised more severely by the loss of his brother than by the removal of a kidney” (Strunk v Strunk
1969). In the UK too, although young children and the intellectually disabled have never been used as organ donors (Webb and Fortune
2006), cases have been recorded where individuals lacking capacity have been used as bone marrow donors by reference to testimony that donation was in their best interests. In the 1997 case of
Re Y, for example, the courts permitted bone marrow retrieval from Y, a severely mentally and physically disabled adult to save the life of her sister after expert testimony that whilst Y and her sister did not share close emotional ties, Y was extremely close to her mother whose health—and thus, ability to visit Y—would be negatively impacted by Y’s sister’s death (Re Y
1996).
4
With such cases in mind, Spital suggests that
because a ‘clear benefit standard’ is often used to determine the appropriateness of donation in cases from those who lack capacity it would be inconsistent to claim that the same rules and protections should not apply in the case of competent volunteers. This kind of argument is promising as, should it be the case that to impose different standards on the retrieval of organs from competent and incompetent donors is inconsistent, this would provide some reason to accept and thus implement the donor benefit standard in the case of competent volunteers. After all, despite the derisory opinions of authors such as Huxley who held that consistency is “contrary to nature, contrary to life” (Huxley
1931, p. 125) and Wilde who suggested it to be “the last refuge of the unimaginative” (Wilde
1885), it is generally held, for reasons of both fairness and coherence that like cases should be treated alike and thus that consistency
is something to be sought in the principles and laws that govern our behaviours.
Despite this, the suggestion that the extension of the donor benefit standard from cases of incompetent to competent donors should be seen as a mark of consistency is mistaken. It seems to ignore the fact that, where those who lack the capacity to consent are proposed as ‘donors’, philosophers and the courts are only concerned with the overall balance of donor benefit to burden because they are concerned to act in the donor’s interests were she able to articulate them. In other words, a concern with donor benefit is subordinate to a concern to act in the candidate ‘donor’s’ interests. Benefit is desired, but it is desired as a means to an end, rather than for its own sake. Given this, it seems that if Spital and other proponents of the donor benefit standard are truly concerned with ensuring consistency in the treatment of competent and incompetent living donors, a focus on ensuring donation is in the interests of candidate donors, rather than ensuring a positive balance of harm to benefit, is in order.
Welfare interests and the other regarding concerns of competent donors
Very young children and severely intellectually disabled persons lack a number of interests commonly ascribed to most adults for reasons relating both to their levels of cognitive development (which may preclude their possession of certain, more complex, interests) and communication skills (which makes it difficult to determine what is truly in their interests). As such, it is generally considered safer to attribute to them only egoistic interests in their own wellbeing when it comes to decisions with the potential to significantly affect their welfare. We know, for example that the very young and persons with severe intellectual disabilities will, like all sentient creatures, possess interests in avoiding pain and experiencing pleasure. We do not know, however, if such individuals possess interests in restoring the health of a sick relative except when doing so is likely to serve their welfare interests, such as through maintaining a close and emotionally beneficial relationship or avoiding the pain and confusion that may be caused by their death. A focus, therefore, on the extent to which an incompetent donor will be harmed or benefited seems appropriate in such cases.
Yet, whilst it is prudent to ascribe to young children and persons with severe intellectual disabilities
only self-regarding interests in the context of living organ donation, this will not be the case for most adults. For, their interests do not, except perhaps in cases of those with severe antisocial personality disorders, reduce merely to those of direct and indirect/vicarious interests in their own wellbeing. They also, and importantly, tend to include interests in the interests of others. This is because mature human beings are not, despite the picture painted by many, essentially or ideally independent creatures who are disengaged from others and characterised by self-interest. They are instead socially embedded entities who are “intimately related to other people, groups, institutions and histories” and are thus “motivated by interests and reasons that can only be fully defined with reference to other people and things” (Christman
2004, p. 144).
That such is the case is well-supported in the philosophical literature. Dworkin, for example, suggests that alongside the ‘experiential interests’ persons possess in having desirable ‘felt’ experiences such as comfort and enjoyment and avoiding undesired experiences such as pain, they also possess ‘critical interests’ in having what they value or care about becoming a reality. These may include but are not limited to parental or spousal interests in their children’s or partner’s success and wellbeing, a desire to ameliorate suffering in the world, or to preserve beauty in the world (Dworkin
1993, pp. 201–208). Similarly, Feinberg suggests that persons possess, in addition to interests in their own welfare which may be seen as purely self-regarding, what he terms ‘ulterior interests’. These, he suggests, are a person’s more “ultimate goals and aspirations” (Feinberg
1987, p. 37) and include both “want regarding interests” (Barry
1965, p. 183) in personal fulfilment such as through “producing good novels or works of art… [or] achieving high political office” (Feinberg
1987, p. 37), but also, and importantly, what may be termed “ideal regarding interests” (Barry
1965, p. 183) in such things as “advancing a social cause, ameliorating human suffering, achieving spiritual grace” (Feinberg
1987, p. 37).
With this in mind, we can note that just as a competent person (A) can possess an interest in the wellbeing of another (B) for purely self-regarding reasons (because what promotes B’s welfare interests also promotes A’s welfare interests directly or indirectly) he may also have interests in B’s wellbeing for reasons that fail to regard his own welfare, but regard instead the emotional, social, and moral relationships in which he stands to other human beings. These may include both:
1.
Loving interests A has an interest in promoting/securing the wellbeing of B
because, as a result of the emotional and social relationship in which he stands to B, “he desires B’s good
not simply as a means to the promotion of the other ulterior aims that are components of his own good, but quite sincerely as an end in itself” (Feinberg
1987, p. 71).
2.
Ideal-regarding interests A has an interest in B’s interests because as a result of his personal values and moral commitments (i.e. a desire to increase levels of happiness in the world or a desire to decrease inequality) B’s interests are in his personal interest.
Extended to the case of organ donation, A may have an interest in donating an organ to B both because A will be either directly or vicariously harmed should he be barred from donating but also, and importantly, because as a result of the relation in which he stands to B (mother, brother, wife, friend, fellow human being etc.) A has purely other regarding interests in B’s wellbeing. That is, an individual may possess an interest in donating an organ to another not simply as a means to securing his own future wellbeing but also because as a result of both the moral and emotional relationships that obtain between individuals, he possesses an interest in donating an organ for the recipient’s own sake.
Of course, whilst the distinction between self-regarding and other/ideal-regarding interests might be clear in theory this will not always be the case in practice. Loving or purely other-regarding interests are “commonly intertwined with and reinforced by… self-regarding interests” as “most of the things we desire for their own sakes we also desire as a means to other things” (Feinberg
1987, p. 72). A husband or father, after all, may be motivated to donate an organ to his daughter or wife primarily because her declining health violates the other-regarding interests in her welfare he possesses as a result of his love for her, but also because it is instrumentally damaging to various of his self-regarding interests: constituting a drain on economic resources, a burden on his time and energy, a strain on his emotional stability etc. Similarly, a woman who donates an organ, such as a kidney, or, indeed, a uterus, to a stranger may well be motivated by a commitment to alleviate the suffering of another and at the same time, by numerous self-regarding reasons: because seeing suffering in the world causes
her emotional distress and/or because she desires to be viewed by others as ‘good’ or ‘virtuous’ etc.
Given this, it seems that the extension of the donor benefit standard from cases of ‘donation’ involving minors and those with intellectual disabilities to cases of donation from autonomous adults is inconsistent with the motivation which underlies its acceptance in the former case. For, whilst when applied to cases of ‘donation’ involving minors and the intellectually disabled, the standard will, more often than not, result in outcomes that can be said to be in the interests of the ‘donor’, this will not be so when it is applied to competent volunteers. As shown above, the donor benefit standard’s sole focus on welfare interests discounts a vast swathe of human interests which may arise from the emotional bonds characterising normal and loving human relationships as well as a number of less common interests and values, such as that of selfless concern for the interests of others motivated by altruism and other strongly held moral commitments and ideals which may be frustrated should the candidate donor’s offer be refused.
Similarly, that the donor benefit standard discounts purely other-regarding interests and values such as altruism and solidarity casts serious doubt on Spital’s claim that the donor benefit standard “accommodates and considers individual values” (Spital
2004a, p. 106). For, while the donor benefit standard directs welcome attention to the
interests of living donors, many of whom do seek benefits from donation, it seems odd and more than a little paternalistic to suggest that in cases where candidate donors are primarily motivated by prosocial and other-regarding values, donation may be justified
only where a physician is convinced that a donor will attain
undesired (albeit not necessarily unwelcome) benefits.
Importantly then, in order to prove truly consistent with existing moral standards for the treatment of incompetent donors and in order truly to accommodate and consider the individual values of mature human beings, proponents of the donor benefit standard (as laid out by Spital) should adjust their focus from benefits to that of ‘interests’ more broadly construed. This, however, would require that transplant physicians be permitted to retrieve organs from living donors in cases both where they are convinced that donation serves the welfare interests of donors (providing them with emotional, psychological and social benefits that outweigh the harms they suffer) and/or where donation results in net donor harm but forwards the other-regarding interests of donors.
On the primary role-responsibility of the physician
As seen in the preceding subsection, the donor benefit standard is neither consistent with existing standards for the retrieval of organs from persons lacking capacity to consent to their donation nor able to truly accommodate and consider the individual values of competent organ donors. Provided, however, its proponents are willing to expand their account such that donation is justified where it can be shown to serve the interests of candidate donors - where interests are more broadly construed and include both self-regarding and other regarding interests—such criticisms can be avoided. Despite this, however, it is suggested in this section that an additional criticism of the donor benefit standard may not be so easily solved by emendation.
This criticism attaches to the claim at the heart of the donor benefit standard: the suggestion that for a physician adequately to
fulfil her role she must believe that donation provides benefits for her patient that offset the harms of donation and thus that living organ donation absent this requirement poses a
clear and problematic conflict of interest for the physician.
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Now, Spital
seems in good company when he makes this claim. The suggestion that a doctor’s role should primarily be that of his patient’s advocate and thus that he should always endeavour to act in their best interests has historically played, and continues to play, a central role in medical ethics. It is, through “images of the physician at the bedside, dedicated to his present patient… consecrated in art and literature” (Wendler
2010, p. 66) and is enshrined still in virtually all national and international guidelines and legislation governing the practice of medicine. In the UK, for example, the General Medical Council’s guidelines for ‘Good Medical Practice’ instruct the physician to “make the care of their patient their first concern.” (General Medical Council
2013, p. 6) The Canadian Medical Association requires too that the physician must “consider first the wellbeing of the patient” and “take all reasonable steps to prevent harm to patients” (Canadian Medical Association
2004, pp. 1–2). Similarly, the American Medical Association requires that “A physician shall, while caring for a patient regard responsibility to the patient as paramount” (American Medical Association
2016, p. 1), the American College of Physicians stipulates that the “physician’s primary commitment must always be to the patient’s welfare and best interests” (Snyder
2012, p. 75) and the World Medical Association holds that “A physician shall owe his/her patients complete loyalty” and “act in the patient’s best interests when providing medical care” (World Medical Association
2006).
Yet, although there is widespread endorsement of this view, close examination of both medical practice and medical guidelines shows that there is also widespread endorsement of the view that the physician’s obligation to act in the best interests of her patients admits of numerous exceptions and must be balanced against other considerations.
Indeed, Wendler notes that there are, in fact, 27 exceptions to this rule which are generally considered appropriate (Wendler
2010, p. 66). Many of these, he suggests, can be traced to the simple fact that physicians are often patient-rich but time-poor and thus “cannot always promote the present patient’s interests without undermining the medical care of their other patients.” (Wendler
2010, p. 66) The physician, after all, is not generally criticised when he leaves one patient’s bedside to respond to code, postpones the care of one patient to administer care to another who is in more immediate need, or is forced to divide his time between the care of his own patients and those of a sick colleague. Some exceptions to this rule, however, are based in other considerations. These include, but are not limited to: respect for patient autonomy, such as in cases where less effective alternatives to blood transfusions are used in surgery in order to respect the religious beliefs of Jehovah’s Witnesses; respect for physician autonomy such as where physicians are permitted, on the basis of religious and other beliefs, to refuse to perform certain medical interventions such as abortions and instead refer those who seek them to other physicians willing to perform such procedures; public health and other societal interests such as where a physician may refuse antibiotics to patients in order to avoid resistance or quarantine and report infectious diseases to public health officials to protect the wider public, and provide less effective and less expensive medication in order to preserve medical resources for others; for the purposes of physician training;
and the wellbeing of physicians such as by ensuring their working hours are manageable, and allowing them such luxuries as holidays and retirement even though to do so may sometimes compromise the care of individual patients (Wendler
2010, p. 67).
The physician’s role is far more complex than Spital assumes, and the obligation of the physician to act as patient advocate should, in fact, be seen to constitute a pro tanto obligation rather than an absolute one. It is important but must also be balanced alongside competing considerations. In the context of living organ donation many of these considerations may not apply. Yet some, such as respect for the autonomy and religious beliefs of candidate donors, as well as a wider concern with the health and welfare of other members of society do seem relevant and thus cast doubt on the suggestion that in the context of living organ donation a physician may never be justified in retrieving organs unless he is convinced that to do so will be to the benefit of his individual patient. Given this, it seems inconsistent to suggest that a physician may not appeal to similar considerations to justify retrieval in cases where a competent donor is unlikely to benefit on balance from her donation but is also unlikely to suffer such significant and enduring harms from retrieval that his capacity to consent may be questioned.