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Death, Dying, and Organ Transplantation: Reconstructing Medical Ethics at the End of Life
In Death, Dying, and Organ Reconstructing Medical Ethics at the End of Life , Miller and Truog challenge fundamental doctrines of established medical ethics. They argue that the routine practice of stopping life support technology in hospitals causes the death of patients and that donors of vital organs (hearts, lungs, liver, and both kidneys) are not really dead at the time that their organs are removed for life-saving transplantation. These practices are ethically legitimate but are not compatible with traditional rules of medical ethics that doctors must not intentionally cause the death of their patients and that vital organs can be obtained for transplantation only from dead donors.
In this book Miller and Truog undertake an ethical examination that aims to honestly face the reality of medical practices at the end of life. They expose the misconception that stopping life support merely allows patients to die from their medical conditions, and they dispute the accuracy of determining death of hospitalized patients on the basis of a diagnosis of "brain death" prior to vital organ donation. After detailing the factual and conceptual errors surrounding current practices of determining death for the purpose of organ donation, the authors develop a novel ethical account of procuring vital organs. In the context of reasonable plans to withdraw life support, still-living patients are not harmed or wronged by organ donation prior to their death, provided that valid consent has been obtained for stopping treatment and for organ donation.
Recognizing practical difficulties in facing the truth regarding organ donation, the authors also develop a pragmatic alternative account based on the concept of transparent legal fictions. In sum, Miller and Truog argue that in order to preserve the legitimacy of end-of-life practices, we need to reconstruct medical ethics.
In this book Miller and Truog undertake an ethical examination that aims to honestly face the reality of medical practices at the end of life. They expose the misconception that stopping life support merely allows patients to die from their medical conditions, and they dispute the accuracy of determining death of hospitalized patients on the basis of a diagnosis of "brain death" prior to vital organ donation. After detailing the factual and conceptual errors surrounding current practices of determining death for the purpose of organ donation, the authors develop a novel ethical account of procuring vital organs. In the context of reasonable plans to withdraw life support, still-living patients are not harmed or wronged by organ donation prior to their death, provided that valid consent has been obtained for stopping treatment and for organ donation.
Recognizing practical difficulties in facing the truth regarding organ donation, the authors also develop a pragmatic alternative account based on the concept of transparent legal fictions. In sum, Miller and Truog argue that in order to preserve the legitimacy of end-of-life practices, we need to reconstruct medical ethics.
208 pages, Hardcover
First published September 30, 2011
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January 19, 2016
Miller and Truog's volume is a fantastic summary of their views, which, up until the publication of this book, could only be found in medical and bioethics journals. It's up-to-date and easy to read, and best of all, short. I agreed heartily with their critique of the so-called “higher-brain” definition of death, which defines death in terms of the irreversible loss of consciousness. The empirical overview of the uncertain status PVS patients was superb; we simply cannot assume that such people have no conscious experience. Unfortunately, I could not disagree more with many of their findings, particularly their insistence that the dead-donor rule ought to be discarded or at least relegated to some sort of legal “fiction” that is about as relevant as a non-binding resolution passed by Congress. They reach this conclusion through two broadly construed arguments. The first goes like this:
[1] If it is true that doctors should not cause the death of their patients for any reason, then withdrawing life-sustaining treatment at patient request is impermissible.
[2] But it’s not.
[3] Therefore, it is false that doctors should not cause the death of their patients for any reason.
The problem with this assumption is that it “causes death” and its cognates is ambiguous. Surely there is a sense in which withdrawing life-support is causally related to the *timing* of one’s death, but it is dubious to suppose that it is the proximate cause of death, or *the* cause of death. If it were, then a lifeguard who gives up CPR and mouth-to-mouth resuscitation is the primary cause of death for the one whom she rescues but cannot revive no matter how hard she tries. True, her giving up contributes to the time of the victim’s death, yet it is still plausible to say that the primary cause of death is the irreparable damage from nearly drowning, not the cessation of efforts that keep oxygenated blood circulating. But on Miller and Truog’s analysis, it is not plausible to say this, which we should take to be a problem for their view.
The other argument goes like this:
[1] If it is wrong to kill the donor, then it is impermissible to retrieve organs from brain-dead donors or from non-heart-beating-donors.
[2] But it is permissible to do so in both cases.
[3] Therefore, it is not wrong to kill the donor.
The soundness of this argument depends on the claim, defended in two separate and very interesting chapters, that brain-dead bodies are not dead bodies, and that the cardiac function in the accepted donation-after-cardiac-death protocols is not irreversible, something that is assumed to be necessary for death (resurrection is assumed to be impossible). Let’s suppose this is right. Why think premise [2] is true? Answer: neither the consenting “brain-dead” donor nor the consenting non-heart-beating donor are harmed by transplant surgery, which of course causes their death (though they advise that they should be given general anesthesia to make sure). What makes killing wrong, then, is explained in terms of the harm done to the one killed, or the disrespect to one autonomy if there is no valid consent (or both). The the life of an innocent person must be protected unless (1) the innocent will die imminently in any case, and (2) the innocent is willing to die; that killing someone who meets these two conditions might benefit others, as it probably would in organ donation, only serves to bolster the reason for the killing via transplant surgery. But this view is no good; it would still be wrong to hang today an innocent though willing person (unfortunately) on death row scheduled to die tomorrow so as to appease a murderous mob who would kill a hundred more today if the hanging were not to occur today. The innocence of the victim seems to make a difference in this case despite the fact it satisfies Miller and Truog’s criteria. Perhaps intuitions will vary one this, but more needs to be said for why innocence doesn’t matter in the context of vital organ donation, especially from those like Miller and Truog who reject utilitarianism as a sound moral theory.
Miller and Truog’s positive case for causing death in the context of vital organ donation is conditioned on a prior decision by the would-be donor to withdraw life-sustaining treatment. As they see it, no one would be made dead by the process of procuring vital organs who would not otherwise be made dead by withdrawing life-sustaining treatment, provided that withdrawing life-sustaining treatment causes death (p. 116). But as we’ve seen, that is a controversial proviso. They readily acknowledge that some patients will die by transplant surgery who might otherwise continue to live because of our imperfect ability to prognosticate death after the withdrawal of life-sustaining treatment. The example of Karen Ann Quinlan is a good example. They are willing to accept this risk, however, in light of the benefits that would come to the organ recipient as well as the respect for the wishes of the donor to end her life. What they are not willing to risk is possibly damaging the organs from warm ischemia in a protocol that would begin surgery *after* withdrawing life-sustaining treatment and at the time of asystole (p. 121). On their view, the risk of harming the organs outweighs the risk of harming of the donor, something that is incompatible with the intuition that protecting the donor from harm should take precedence over protecting the organs from harm. This wretched asymmetry of value in favor of the organs over the the life of the donor is common to all proposals that reject the DDR, and Miller and Truog’s is no exception.
What about healthy people? Can they consent to their own deaths in some act of “organ donation euthanasia”? No says Miller and Truog. To be sure, they concede that no wrong would be done to a healthy donor if she were to give valid consent to her death by organ donation (p. 129). But in their view, the surgery team would still act wrongly if they followed through, because doing so would violate a widely accepted standard of professional integrity, that killing a healthy person conflicts with the goals of medicine. But the goals of medicine turn out to be relative to their culture context. Says Miller and Truog:
“Suppose further that the request to donate was made by a patient living in a country, such as the Netherlands and Belgium, that legally permits euthanasia by lethal injection. In this particular context, the logic of our ethical framework for vital organ donation would permit organ procurement in this case, and no valid considerations of professional integrity would preclude it (p. 131).”
Thus “professional integrity” appears to be a wax nose that can be shaped by the mores of the culture and not anything objectively moral. Medical ethics, however, should reach for something more firm than the shifting sands of moral relativism: safeguarding the health of the patient and not destroying it no matter how little of it may be left should be a universal goal.
The short of it: this is a good book to read if you want to get the skinny on how revisionists would reshape ethics at the end of life. The authors are forthright, honest, and provide a nice bibliography of the relevant literature. But, as I see it, the main arguments in favor of their policy recommendations need work.
[1] If it is true that doctors should not cause the death of their patients for any reason, then withdrawing life-sustaining treatment at patient request is impermissible.
[2] But it’s not.
[3] Therefore, it is false that doctors should not cause the death of their patients for any reason.
The problem with this assumption is that it “causes death” and its cognates is ambiguous. Surely there is a sense in which withdrawing life-support is causally related to the *timing* of one’s death, but it is dubious to suppose that it is the proximate cause of death, or *the* cause of death. If it were, then a lifeguard who gives up CPR and mouth-to-mouth resuscitation is the primary cause of death for the one whom she rescues but cannot revive no matter how hard she tries. True, her giving up contributes to the time of the victim’s death, yet it is still plausible to say that the primary cause of death is the irreparable damage from nearly drowning, not the cessation of efforts that keep oxygenated blood circulating. But on Miller and Truog’s analysis, it is not plausible to say this, which we should take to be a problem for their view.
The other argument goes like this:
[1] If it is wrong to kill the donor, then it is impermissible to retrieve organs from brain-dead donors or from non-heart-beating-donors.
[2] But it is permissible to do so in both cases.
[3] Therefore, it is not wrong to kill the donor.
The soundness of this argument depends on the claim, defended in two separate and very interesting chapters, that brain-dead bodies are not dead bodies, and that the cardiac function in the accepted donation-after-cardiac-death protocols is not irreversible, something that is assumed to be necessary for death (resurrection is assumed to be impossible). Let’s suppose this is right. Why think premise [2] is true? Answer: neither the consenting “brain-dead” donor nor the consenting non-heart-beating donor are harmed by transplant surgery, which of course causes their death (though they advise that they should be given general anesthesia to make sure). What makes killing wrong, then, is explained in terms of the harm done to the one killed, or the disrespect to one autonomy if there is no valid consent (or both). The the life of an innocent person must be protected unless (1) the innocent will die imminently in any case, and (2) the innocent is willing to die; that killing someone who meets these two conditions might benefit others, as it probably would in organ donation, only serves to bolster the reason for the killing via transplant surgery. But this view is no good; it would still be wrong to hang today an innocent though willing person (unfortunately) on death row scheduled to die tomorrow so as to appease a murderous mob who would kill a hundred more today if the hanging were not to occur today. The innocence of the victim seems to make a difference in this case despite the fact it satisfies Miller and Truog’s criteria. Perhaps intuitions will vary one this, but more needs to be said for why innocence doesn’t matter in the context of vital organ donation, especially from those like Miller and Truog who reject utilitarianism as a sound moral theory.
Miller and Truog’s positive case for causing death in the context of vital organ donation is conditioned on a prior decision by the would-be donor to withdraw life-sustaining treatment. As they see it, no one would be made dead by the process of procuring vital organs who would not otherwise be made dead by withdrawing life-sustaining treatment, provided that withdrawing life-sustaining treatment causes death (p. 116). But as we’ve seen, that is a controversial proviso. They readily acknowledge that some patients will die by transplant surgery who might otherwise continue to live because of our imperfect ability to prognosticate death after the withdrawal of life-sustaining treatment. The example of Karen Ann Quinlan is a good example. They are willing to accept this risk, however, in light of the benefits that would come to the organ recipient as well as the respect for the wishes of the donor to end her life. What they are not willing to risk is possibly damaging the organs from warm ischemia in a protocol that would begin surgery *after* withdrawing life-sustaining treatment and at the time of asystole (p. 121). On their view, the risk of harming the organs outweighs the risk of harming of the donor, something that is incompatible with the intuition that protecting the donor from harm should take precedence over protecting the organs from harm. This wretched asymmetry of value in favor of the organs over the the life of the donor is common to all proposals that reject the DDR, and Miller and Truog’s is no exception.
What about healthy people? Can they consent to their own deaths in some act of “organ donation euthanasia”? No says Miller and Truog. To be sure, they concede that no wrong would be done to a healthy donor if she were to give valid consent to her death by organ donation (p. 129). But in their view, the surgery team would still act wrongly if they followed through, because doing so would violate a widely accepted standard of professional integrity, that killing a healthy person conflicts with the goals of medicine. But the goals of medicine turn out to be relative to their culture context. Says Miller and Truog:
“Suppose further that the request to donate was made by a patient living in a country, such as the Netherlands and Belgium, that legally permits euthanasia by lethal injection. In this particular context, the logic of our ethical framework for vital organ donation would permit organ procurement in this case, and no valid considerations of professional integrity would preclude it (p. 131).”
Thus “professional integrity” appears to be a wax nose that can be shaped by the mores of the culture and not anything objectively moral. Medical ethics, however, should reach for something more firm than the shifting sands of moral relativism: safeguarding the health of the patient and not destroying it no matter how little of it may be left should be a universal goal.
The short of it: this is a good book to read if you want to get the skinny on how revisionists would reshape ethics at the end of life. The authors are forthright, honest, and provide a nice bibliography of the relevant literature. But, as I see it, the main arguments in favor of their policy recommendations need work.
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