Choosing to Be Harmed: Autonomy and its Limits in Living Organ Donor Transplantation

Abstract

The field organ transplantation has experienced rapid and dramatic advances and increases in the use of living organ donors during the past twenty years. During this time, important questions have emerged about the acceptability of their use, including the extent to which these donors can and should be understood as acting autonomously with regard to the decision to donate. I argue that the standard model of ethical decision-making currently being applied in the context of living organ donor transplantation distorts the philosophical requirements of the bioethical principles of beneficence/nonmaleficence, respect for persons, and justice. I argue that this model relies on a simplistic accounting of the concept of beneficence that reduces the goal of medicine to the promotion of the narrowly-defined health-based self-interests of individual patients and so cannot accommodate the various goods and harms that are legitimately given weight in risk/benefit calculations made by donors. I suggest a broader understanding of the requirements of beneficence that can be adopted to accommodate individual donor's conceptions of the good. Related to this, I argue that the picture of agency being applied in living organ donor decision-making relies on a superficial view of choice that equates freedom with independence from moral and emotional connections to other people and so cannot accommodate the complex choices embedded within many of the donor-recipient relationships that are often brought to bear in the context of living organ donor transplantation. I suggest that a different understanding of the role of emotion in donor decision-making - one that includes recognition that emotions have a positive role to play in decision-making - is needed in the context of living organ donor transplantation. I further argue that proponents of paying for organs rely on a conceptual mistake related to the picture of agency being applied in this area that conflates the philosophical requirements of the bioethical principle of respect for persons with those of justice. I suggest that a different conception of the requirements of these bioethical principles is needed in the context of living organ donor transplantation in order to adequately account for how potential living organ donors' values, goals, and moral connections to other people might complexly and legitimately influence their decisions, particularly the decision to donate. Though consideration of various paradigmatic cases, I demonstrate the essential practical importance of gaining a clear understanding of the requirements of these bioethical principles for informing practices and policies that effectively address some of the ethical complexities and challenges in this area.