"Dead Donor" versus "Respect for Donor" Rule: Putting the Cart before the Horse

Organ donation presents several ethical concerns but none more central than the concern for what are appropriate means for acquiring organs. Focusing on a specific aspect of this concern, Elysa R. Koppelman (2003) states that the traditional ethical focus on organ donation attempts to achieve "the utilitarian goal of increasing the organ supply" while retaining "the deontologic concern about respect for persons." Within this tradition Koppelman, leaning more heavily toward the deontological side, argues that we have mistakenly put too great an emphasis on determining death when such a focus seems to miss the primary ethical issue—namely, how do we act under these tragic conditions in order to respect persons. Noting the tempering effect the current principle—"it is immoral to kill patients by taking their organs"—has on "the utilitarian goal of increasing the organ supply," Koppelman remarks that the ambiguity of death criteria entails that there are no good ethical reasons to distinguish between permanently "suspended states" such as "whole brain death" and "persistent vegetative states (PVS)." However, the dead donor rule does not go far enough to respect persons. Koppelman maintains that treating persons as ends demands that we take seriously their desires, and some persons not only express desires to donate organs, they also express desires not to be kept alive in PVS-like conditions. She concludes that patients who make it known through advance directives that they wish to donate organs and do not wish to be kept on life support in the advent of PVS should have their organs donated.

While there is much to applaud in Koppelman's account, there is also much that is troubling. First, while Koppelman continues a debate about the function of death criteria that has born a great deal of fruit since the early 1970s, it is not clear her account of deontological respect (as a better tact for ethical inquiry into organ donation) and her hard-line Kantian position is as uncontroversial as she portrays. In fact, she seems to imply a rather weak form of respect that takes a too narrow view of personal context. Furthermore, and more importantly I think, hers (like many others before her) is an analysis of the ethics of organ donation that begins one step too far into the conversation.

Focusing on her deontology, Koppelman's desire to eschew the dead donor rule in favor of a "respect for donor" rule has great affinity with much of the tradition of bioethical principles on the one hand, and current trends on the other. In fact, statements such as "we need to know a person's history to tell whether she is harmed" (Koppelman 2003) arise not only from a deontological ethic but also have the possibility of laying a groundwork for a "narrative ethics" approach to donation. However, while it seems at times that a narrative understanding of patients and situations is what might be called for by her notion of "respect," this is not Koppelman's final position. Even though she notes the importance of understanding the larger context in which individual decision makers find themselves, that context seems to be reduced, on Koppelman's account, to a narrow portrait of individual choice and personal ability. Harm is reduced to denying requests, and respect is reduced to treating requests as ends to be achieved. Also, such an individualist-type account leaves little room for other voices, narrators, actors, or, for that matter, the environment itself. While I agree that there is a type of harm that occurs whenever an interest goes unfulfilled, the context itself might make fulfillment physically or ethically impossible; that is, such basic harms do not rise to the level of moral harms until they are adjudicated in the context of all interests at play in the given situation. The problem, to put this into narrative...