Organ and tissue transplantation is a growing area of contemporary medical practice that raises a variety of ethical concerns. This article will consider transplantations from donors after bodily death, including the transplantation of vital organs such as heart, lung, and liver as well as transplantation of tissues such as skin, cornea, and bone, and will examine some of the ethical questions these practices raise.

A Generous Gift of Self

In principle, the donation of organs and tissue after death is a generous and praiseworthy act. Pope Benedict XVI called organ donation a “witness of charity” and was himself a card-carrying donor before his election as pope. However, the goodness of the practice of post-mortem transplantation of vital organs depends upon certain conditions having been met. Among these considerations are: (1) that the transplantation is carried out with the free and informed consent of the donor and (2) that there be practical certainty that the donor is indeed dead at the time when vital organs are transplanted.

Free and Informed Consent

In order for organ and tissue donation to be a praiseworthy gift, it must truly be a gift. It must be a freely chosen donation. If a person’s body parts are taken without consent, there is no praiseworthy gift, but only a blameworthy exploitation. Furthermore, in order for organ and tissue donation to be a gift, it must be a free choice based on a true understanding of what that gift involves. In other words, free and informed consent is necessary in order for organ and tissue donation to be a good thing.

There are serious questions about whether many organ and tissue transplants are being freely consented to. In some countries, consent to being an organ and tissue donor after death is simply presumed. People are free to opt out of being potential donors, but are they given sufficient opportunity to do so? The USA, along with many other countries, allows people to consensually opt-in to becoming donors. However, expressed permission is not the same as informed consent and questions remain as to whether consenting donors are really informed about what organ and tissue donation entails.

One unanticipated consequence of choosing to donate organs and tissue after death may be the way it affects the experience of that death by one’s family and friends. While the donor’s heart still beats, and while she is either still alive or, at least, appears to be alive, the family says their goodbyes and the operating team begins its work. The family’s final moments with their loved one can be shocking, especially when this course of events is not foreknown. The arrangements for the person’s funeral and burial services are also altered and, in many cases, delayed.

Informed Consent and Diagnosing Death

Related to the incongruous experience of “beating heart” transplantation are the criteria by which a person’s death is determined. People whose hearts are beating certainly don’t seem dead. According to many experts and the laws of the USA and many other countries, however, such people may indeed be dead, their deaths having been determined by what is referred to as “the neurological criteria,” namely, the irreversible cessation of all brain function. A person’s heart may continue beating for a time, but if his brain has entirely and irreversibly ceased to function, he can, according to the neurological criteria for determining death, be safely pronounced dead.

The “cardiopulmonary criteria,” according to which a person’s death is determined when respiration and circulation of blood irreversibly cease, is another, older standard according to which death can be declared and transplantation proceedings can commence.

The criteria for determining a person’s death, and the ways in which clinicians determine that those criteria have been met in particular cases, are controversial. Driving those controversies are the practical necessities for successful transplantation of organs and tissues from deceased donors. Very often, successful transplantation depends on the ability to extract organs and tissue from the donor’s body immediately after she is pronounced dead. There is therefore an incentive – and a reasonable one – for wishing to declare the death of a dying organ donor as soon as possible. This incentive creates a tension between two legitimate values: the value of fulfilling the generous intention of organ donors to provide life-saving organs and tissues to people in need, and the value of ensuring that donors have indeed died before their organs are extracted so that their gifts of life are not also causing their own death.

The ethical assessment of how we might safely and responsibly diagnose death in these cases will have to await the next installment of this series. To conclude the present reflection, it will be sufficient to observe that for a person to give free and informed consent to the transplantation of his organs and tissue after death, it is necessary that he understand the criteria and methods by which his death will be determined.