Wednesday, December 14, 2011

On organ transplants.

It's Wednesday. Let's talk ethics. Specifically, let's talk organ transplants. Not so much on ethical issues involving bodily integrity (a concept which, frankly, has never made sense to me) nor on whether there is an obligation to donate organs (which is weird, but not incoherent). No, my question is systemic: is the system of organ donation as such ethical?

Right now, as all should be aware, organ transplants are performed on a donation basis. Patients who need organs enter the hospital system and are placed on various registries; and people who donate organs are on similar registries. When there's a match betwen the latter -- the available organs -- and the former, the former are served on the basis (approximately) of need. (I say approximately as issues such as likelihood of organ rejection, recovery, etc. also count.)

It's important to note that this system functions basically on luck. It's sheer luck whether or not someone donates an organ that is needed. It's sheer luck whether or not someone who needs an organ gets one before the lack of one kills them. There's something a little weird about making life or death decisions -- which is what's involved in organ donation and transplant, after all -- on the basis of chance.

There's only an ethical problem, though, if there's an ethically preferable alternative. After all, if organ transplants on the basis of luck are the best we can do, it's nonsense to insist there's anything wrong with it. It'd be like saying there's something wrong with oxygenating our blood.

Well, in 1975, philosopher John Harris published an article called "The Survival Lottery" (if you're interested, it's in The Journal of the Royal Institute of Philosophy, vol. 50, pp. 87-95.) which purports to do just that. I'm not going to rehearse all of the technical details of the argument, as they speak to ongoing philosophical disputes in ethical theory. But the proposal is intriguing. Harris suggests that everyone, at birth, should be provided with the equivalent of a lottery ticket. When physicians/hospitals run out of organs made available by happenstance, they can trigger the selection of someone through this lottery. Presume that the tickets are numbered in such a way as to account for blood type, age, medical history and other factors relevant to the success of the transplant. Whoever is thus selected is killed, and their organs harvested.

When I've told this little story to students, it's the turn at the end that gets their attention, and reprobation. But what, exactly, is wrong with it?

Ordinarily, it's certainly wrong to kill people at random, and that seems to be what's going on here. But transplant situations are not ordinary circumstances: someone will die no matter what. The issue is whether we kill someone and harvest the organ, or sit back and wait while the person in need of a transplant dies.

Perhaps the problem is that the person selected has no choice in the matter. People may make great sacrifices for the well-being of others, even sacrificing their lives, but only if they choose to do so freely. Of course, this again ignores the patient in the scenario: no one, except maybe the most well-informed and willing alcoholic, chooses to need an organ transplant. Why is the interference in the freedom of the sacrificed person worse than the interference in the freedom of the person in need of a transplant?

Perhaps the problem is that the person selected is being actively interfered with by another person, while the person who needs the transplant is being actively interfered with by an accident of nature, i.e., whatever disease or injury or medical condition has caused the relevant organ to need replacement. But this is just false, as if the patient is left to die without an organ, then that is the choice of another person, namely the potential sacrifice who refuses to be sacrificed.

One might sharpen the point in a different way by introducing some kind of concern about bodily integrity, that no one may interfere with or compel us to do things with our bodies that we do not want to, because the bodies in question are ours. But this fails, on one of two grounds. Either one can point out that the right to bodily integrity is surely secondary to the right to stay alive, or one can argue that, on the assumption that the sacrifice'sbodily integrity is as important to him/her as the patient's is to him/her, it follows that the sacrifice doesn't have the right to place the preservation of his/her bodily integrity over the repair of the patient's.

One might worry about the consequences of the survival lottery. Would it lead to more deaths, as the system was abused? Perhaps it would lead particularly to the deaths of the poor, as the rich and powerful manipulate the results to ensure that they are never selected? These sorts of worries aren't about the ethics of the lottery scheme, though; they are worries about whether it could be implemented in a (fairly corrupt) society such as ours.

One might worry that people would disdain their own lives, given that they might be selected for the survival lottery at any time. But, on the other hand, any of us might need an organ transplant at any time. One false step into the street, and, suddenly, we need a new liver or lung or heart. That possibility doesn't seem to lead us to avoid leading meaningful lives; why would another random possibility do any worse?

So, the survival lottery seems like it can avoid most challenges to it. It's certainly not going to result in more deaths than under our current, luck-based regime. Yet -- and this is the odd thing about Harris' survival lottery -- it seems ethically abhorrent. But it's important to see that most of the features of the lottery that we find abhorrent are already present in our current system of organ allocation and transplant.

Which means that, as ethically wrong as the survival lottery seems, the system of organ donation is just as wrong. And isn't that a bit of a problem?


Catelli said...
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Catelli said...

Where I can't follow the logic is the equating of random outcomes. Currently for my organs to be donatable I have to have chosen to let that happen, and whatever fate that occurs to me leaves my organs in a usable state+I have to die unexpectedly (from something other than old age). This also assumes that my lifestyle leaves my organs in a usable state.

A lottery removes some of the those factors, in essence increasing the certainty that my organs are harvestable. In the long run more people are certain to be killed to make their organs available that will not certainly save the patient receiving the organs (besides rejection issues, major surgery is always risky, the patient receiving the organ may die on the operating table). By trying to control chance (through a mandatory lottery), we are increasing harm to the healthy population at a greater ratio than we are decreasing it on the unhealthy population.

ADHR said...

I see the concern about harm, but I'm not sure the two sides -- harm to the donating population, benefit to the receiving population -- don't balance out after all. Right now, there's a lack of organs available. Under the lottery, that lack is (more or less) solved, which looks like a benefit at least as significant as the harm done. (Assuming you can just add up lives like this, which not everyone will agree to.)

Keep in mind, the issue is not that the lottery is clearly better, only that it's not clearly worse, which suggests that our current system is just as bad (ethically) as the lottery.

Actual numbers here would be helpful, of course. I'm not sure who tracks this kind of thing, honestly. You'd think Ministry of Health, but I wonder if they make it available.

It's also worth noting that your objection here isn't to the lottery as such. It's mostly to the risks associated with transplant surgery. If we could reduce those to near-zero, then I think you'd have to allow that the lottery would be at least as (ethically) desirable as our current system.

Catelli said...

Assuming that we can make it a zero risk/100% guaranteed successful surgery (the life is indeed saved/prolonged) then yes, it is a straight value proposition. (For the record I don't agree that accepting chance and risk, or rather, not eliminating chance is an ethical proposition. But I don't want to get into an argument I won't win. ;) )

Fortunately (or unfortunately) life isn't like that. Surgical recovery of organs is more akin to recycling cars. Energy (or "lifeforce" or some other term for that value) is lost in the transfer. You wouldn't recycle a brand-new car to build another brand-new car because energy/time/money is lost in the process. Same with harvesting organs from a healthy individual and putting them in an unhealthy individual. "lifeforce" (life expectancy, overall health, etc.) is lost. It is unlikely that the recipient will live as long as the original donor would, assuming equivalent healthily lived lives. Adding in the risk of failure decreases the overall resultant entropy of the "lifeforce" equation.

ADHR said...

I don't think you really want to make that argument. ;) It implies that it's ethical to sacrifice people for the sake of other people who would live longer. So, if Jim would live to 52, and Bob would live to 70, it seems that, should he need them, Bob deserves Jim's organs.

So, really, we should modify the lottery with actuarial tables. Someone will only be sacrificed for you if you're likely to live longer than they will.

Basically, while it might be true in general that people who receive transplants don't live as long as people who don't, it may not be true in specific cases that this transplant recipient will not live longer than this donor.