Transplantation Ethics (review)

Transplantation Ethics. By Robert M. Veatch. Washington DC: Georgetown Univ. Press, 2000. Pp. xvii + 427. $65.

In Transplantation Ethics, Robert M. Veatch offers a systematic account of many of the ethical and policy issues raised by organ transplantation. It is a masterpiece of bioethics. Veatch logically argues for some complex positions in easy-to-read prose. His ethical analysis is made more accessible because he shares anecdotes from his experience on numerous transplantation policy boards, including the national UNOS Ethics Committee, the North American Transplant Coordinators Organization, the Washington Regional Transplant Consortium, as well as committees at Georgetown.

Transplantation Ethics is organized into three major topics--the definition of death; the procurement of organs; and the allocation of organs--with two introductory overviews on (1) a wide range of religious and cultural perspectives on organ transplantation; and (2) secular ethical frameworks for approaching the questions raised by organ transplantation.These overviews are comprehensive yet brief.The first chapter is important for a global appreciation of how a multicultural consensus might be reached for many policy questions, but it is not critical for the rest of the book. The second chapter is particularly important to understand the framework for Veatch's positions in the rest of his book. Veatch maintains that "Our public policies depend on how we compare the moral force of the principles of utility-maximizing and justice" (p. 36). He is convinced that justice (equity) should prevail over efficiency (utility), although justice will need to be balanced against other principles grouped under the rubric of respect for persons (including the principles of autonomy, fidelity, veracity, and promise-keeping). Nevertheless, he provides "a moral framework for thinking about transplantation as a matter of public policy--that is when both consequences (efficiency) and just allocation (equity) are taken into account" (pp. 37-38).

Veatch's section on the definition of death is exhaustive, appropriate given that the policy debates about the definition, meaning, and standards of death began in the late 1960s at least partly in response to the need for organ procurement for the emerging field of transplantation. As Veatch notes, the debates continue, given that there is wide disagreement about the use of the whole brain-death concept from both those who believe it is too expansive and those who believe it is not expansive enough.

In these chapters, Veatch argues that death is more of a philosophical and moral question rather than a medical or scientific one. Several times Veatch explains that the Harvard Ad Hoc Committee to examine the Definition of Brain Death only established operational criteria of what is called irreversible coma, but did not and could not declare whether patients in irreversible coma are dead. Although many consider the criteria in this paper to serve as the criteria for brain death, Veatch argues that it is only one of several possible sets of criteria. Veatch continues with a thorough discussion of which functions should be identified as critical for deciding that the individual as a whole should be treated as dead. He examines the three most popular candidates: (1) cessation of heart and lung function; (2) cessation of all brain function ("whole brain"); or (3) cessation of higher brain centers. Veatch favors a policy that allows patients or patients' agents to choose among these plausible death concepts. For an even richer and more complete discussion of this topic, I would urge the reader to read an earlier book by Veatch, Death, Dying and the Biological Revolution (New Haven: Yale Univ. Press, 1989).

Having clarified the definition and criteria of death, Veatch's section on the procurement of organs focuses mainly on cadaveric organs. Veatch begins with a chapter distinguishing between two modes of organ procurement: giving and taking.The giving mode is characterized by the gift model and relies on donations, preferably by competent patients making requests on organ donor cards. In fact, Veatch worries a bit about surrogate consent, because data shows that families are more...