By Anthony McCarthy and Helen Watt.
Imagine I am an altruistic person in good health who is struck by how many people my organs (heart, lungs etc) could save if I became a live donor. Perhaps my life is not going well, and I want to make a greater contribution to society than I have done so far. I disagree with suicide but think that my donating vital organs would be not only permissible but meritorious, provided I do not intend my own death but only foresee it as a result.
Is such a choice psychologically possible? Some will deny this, but such a denial seems premature. What we are able to intend, without intending something closely linked, is an empirical question about individual psychology. Perhaps some people would be incapable of donating their vital organs without intending their own death. But there is nothing obviously impossible about this for people generally – any more than it is impossible for doctors to treat cancer patients knowing but not intending the patient will be made infertile by the same act that treats them. The principle of double effect, in daily use in medicine, hinges on the intention-foresight distinction: this is arguably at least an important part of what we should bear in mind when making decisions. Foreseeing an effect of a bodily intervention – whether infertility or death – does not mean that we intend it.
Thus far, we agree with the position of Charles Camosy and Joseph Vukov – who, however, in their 2021 article in the Linacre Quarterly defend not just the psychological possibility but the moral permissibility of what they call ‘double effect donation.’ They are sceptical about brain death diagnoses and whether they reliably establish death. However, they believe that a sick or indeed a healthy person would be justified in donating their vital organs provided that death, however certain a result, is not intended. This is, they think, not suicide, but rather a morally praiseworthy act akin to martyrdom.
Here we disagree. Where we part company with these authors is not on their view of what must or must not be intended with lethal organ donation but on whether such donation is permissible. At issue is, we think, respect for bodily integrity: a key part of bodily self-respect and respect for the bodies of other innocent people. In our own article in response to Camosy and Vukov, we argue that respect for bodily integrity, including self-respect, goes beyond avoiding the intention to kill or be killed. While some side effects (as in the cancer case just mentioned) can and should be tolerated in producing a serious benefit, that does not mean there are no cases where side-effects of bodily interventions are so serious they cannot be outweighed by intended good effects – especially if the person benefited is someone else entirely. For the act to be immoral, it is enough that there is an intention to accept or perform surgery combined with the foresight of lethal harm and no health-related good for the immediate subject.
What might be the societal effects if such a practice were to become institutionalised? Nir Eyal has referred to the “prophylactic membrane” surrounding our bodies as carrying “deep and widespread perceptions about disrespect.” We ignore these intuitions, he says, at our peril. True, he was saying this in the context of non-consensual organ ‘donation’, but the weakening of intuitions surrounding lethal interventions on the body for the benefit of others is a development with severe societal risks. It may be that we would see, as with euthanasia, the consensual give way to the normalisation of the non-consensual once such practices were socially supported. It may also be that lethal donation would encourage euthanasia and assisted or unassisted suicide.
Think how such procedures will look to participants and onlookers, where it will often be unclear what exactly the donor is, or was, intending. This may look to the transplant team and family and friends very like euthanasia accompanied by organ donation, which we already see happening in some parts of the world. Moreover, those with suicidal and/or self-harming tendencies, rather than receiving a social message that discourages such acts and urges the person to seek help, will receive the message that lethal self-harm can be something to celebrate and applaud.
On the consent front, with euthanasia/assisted suicide, a concern often raised is that vulnerable people may consider themselves an undue burden on others where ‘assisted dying’ is legal and socially sanctioned. Now that the option is available and publicly supported through e.g. national health systems, they may feel they have a duty to end their life in order to relieve themselves and others of its burden. Could not similar concerns apply to the proposal that double-effect donation be socially endorsed if mere consent is seen as authorising such self-harming? After all, just as it may be morally obligatory, even if not legally mandatory, to donate bodily parts e.g. to close relatives in certain cases, we can imagine a vulnerable person believing this is morally obligatory even with vital organs, if there is no socially recognised obligation in terms of self-respect to avoid this.
It is a failing of some approaches to medical ethics that fundamental intuitions around respect for the body are cast aside in the name of choice (here, an altruistic choice) which pays scant regard for the body holistically considered. To suggest that autonomy, altruism and/or avoiding the aim to die (or to kill) is all we need to consider is to betray the reality and meaning of the body which serves as the keystone of both medicine and medical ethics.