Fondazione Zoé

Is it immoral to request an organ when you are not willing to donate your own?

Since 1967, when Christiaan Barnard conducted the first heart transplant, and particularly since the beginning of the 1980s when use of cyclosporin to overcome the majority of organ rejection became widespread, transplants have become a recommended treatment for many pathologies. But, along with surgical and pharmacological technology successes, there is a constant increase in the number of patients waiting to receive an organ. According to the “Centro Nazionale Trapianti” (Italian National Transplant Centre), in Italy in 2010, 9,489 patients were on a list with an average waiting time from 1.86 year for a lung to 3.25 for a pancreas. This generates a strong fear in patients  that it will not happen in time to be useful, and indeed a significant percentage die before an organ is made available (for hearts 8.8%).

Various factors determine the number of transplants. Of these, the most important is certainly organisation, the ability to manage the complex process from the organ’s availability to its next job. For this, Italy has just established the “Società Italiana di Medicina Gestionale dei Trapianti” (SIMGeT – Italian Society for Medicine of Transplant Management) under president Paolo Geraci. But, in transplants from corpses, legislation also plays an important role: judicial systems based on the necessity for a specific expression in favour of being a donor (“opt in”) are more or less favourable in comparison to systems which presume consent unless lack of consent is specifically expressed (“opt out”). In Italy, the matter is regulated by 1991 law L.n.91 which foresees an “opt out” system, but today a transitory discipline is still in place waiting for it: it would definitely be opportune to put the law fully in place.

The fact remains that, even with improvements to organisation and legislation, as use of artificial organs is not imminent, long waiting lists are likely to get even worse. From this point it seems an important moral principle must be emphasised: reciprocity. I am referring to the fact that today people can be added to lists and receive an organ even when there is no donor. That is to say, a person might die following a transplant operation (or while waiting) and there is no way to use their organs because there is no explicit declaration of willingness to donate (or they have specifically shown themselves to be against it).

Beyond a concrete increase in organs (which could even be only small), I think we should say that, in cultural terms, the immorality of requesting an organ when you are not willing to donate your own is evident. Immanuel Kant demonstrated once and for all that immorality can be distinguished as expecting something for yourself which you would not concede to others. This leads, so noted Kant, the pragmatic self-contradictory behaviour of immoral actions: if immoral behaviour was universalised, it would be impossible. Kant’s two examples are: if everyone lied, it would be impossible to lie (because no one would believe the lie); if everyone kept promises, it would be impossible to promise without the intention of fulfilling it (such that the promise was not longer this). Immoral action, therefore, has as a characteristic an impossibility of it being extended to everyone: there is always parasitical nature in altruistic morality. So, if no one donated organs after death, no one could receive one; therefore those who receive and do not donate behave immorally profiting from altruistic generosity. If everyone acted in this way, even this person could not have received a transplant.

I have spoken of immoral actions, but this by no means should signify belittling access to treatment or the possession of determined values and beliefs. Kant’s moral are notoriously formal and not material. So, the unavailability of organ donors is immoral not because it goes against values or beliefs, but because its universal nature makes it impossible to the point at which a subject who is opposed to donating incoherently still wants to receive an organ.
Sometimes we object to this reasoning, saying that the Italian Constitution guarantees the right to health, but does not subordinate it to choices like the future of our own corpse. This objection seems to miss an important point: the exercising of right, even when they are inviolable rights, is never detached from the 2nd article of the Constitution: “unalterable duty to solidarity”. Therefore, the right to receive an organ (a fundamental right in health) cannot be separated from the duty of solidarity, particularly when the fulfilment of this duty means the possibility of exercising the same right for others.

With thanks to Paolo Geraci (Centro di Coordinamento Donazioni e Trapianti dell’Ospedale San Matteo di Pavia – Centre for Donation and Transplant Coordination a San Matteo Hospital, Pavia).

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