The End of Humanity: Does Circumventing "Death" Help the Cause?

Elysa R. Koppelman (2003) reminds us that "brain death" has not gained universal, routine acceptance as just one mode of death. She argues that we cannot expect to resolve the question of whether patients without cerebral function are dead and, furthermore, that this is not the truly important question—at least as far as allowing organ donation. Instead, taking the term "donation" seriously, we should focus on what people have chosen and mandate transplantation of vital organs from live donors in PVS or similar states.

This is an intriguing and, at times, well-argued position. Yet it depends upon an extremely problematic contention. As Koppelman well realizes, the logic of her proposal would seem to extend far beyond its intended reach. According to Koppelman, if a person chooses to donate a vital organ—sacrificing his or her life to save another—she is not harmed if, being (for example) in a persistent vegetative state (PVS), her organs are in fact removed and transplanted. Indeed, failing to comply with this choice constitutes harm to the frustrated donor. But it is hard to see why this logic should be limited to PVS donors. After all, an incompetent patient does not, strictly speaking, have any present wishes; his or her choices must be read from an advance directive (or perhaps other evidence of past wishes) and applied to the present. And while I tend to agree with Koppelman about the validity of applying past desires to current states of existence, how can real-time choice be less compelling? If the determining factor is autonomous choice, then a competent patient who wishes here and now to give his heart and lungs to save three other people must surely be obeyed.

Harris (1975) long ago famously put forward the argument for compulsory taking of needed organs so long as the victim is selected fairly. Realizing the disturbing nature of his position, Harris also argued for an alternative, more modest proposal: that people would do well to sign on to a "survival lottery" scheme, in which whenever several lives could be saved by sacrificing one (healthy) individual for transplants, this would be done. It would, he pointed out, be irrational not to sign on, insofar as the scheme would increase each participant's life expectancy. ¹ In any case, Harris took it for granted that a choice to join—made long before its implementation—would be binding. Certainly, if an individual volunteers here and now for such a sacrifice, free of undo pressure, it is not easy to explain why the donation should be disallowed.

Were it actually the case that living persons could donate vital organs for lifesaving transplantations, there would be a solid starting point for Koppelman's position. She would simply have to show that vital-organ donation should be no exception to our widespread policy of extending personal autonomy through advance directives; that the (previously documented) wishes of a person in PVS should carry no less weight than the stated wishes of a competent individual.

In fact, however, vital organ donation by a living, competent person—whether healthy or ill—is a complete taboo. Indeed, in most locations even a nonvital organ such as a kidney may not be accepted from a nonrelated live donor, whether by sale or as a gift. ² I do not know what Koppelman thinks of this latter prohibition, but regarding vital-organ donation she is quite clear. A central part of her paper consists in strongly affirming the prohibition of such donation and in explaining why it does not apply to patients in PVS. I will thus proceed to critically examine this distinction upon which her position crucially depends.

Why may a person not give up his or her life to save, say, five others? Koppelman tells us that the answer "lies with Kant . . . [d]oing so . . . violates the categorical imperative as it fails to celebrate...