By Steven J. Squires
It is impossible to cover all the ethical dimensions of a complex issue such as organ donation in a short space, but we will look at some key considerations using the structure Jack Glaser’s three realms of ethics.
Societal (including the Universal Church)
Global ethics issues include consent or lack thereof by donors, transplantation from one species to another, and scarcity and commodification (buying, selling) of organs. In the U.S., commodification is illegal. Donation follows one of two paths – living or deceased.
Ethics discussions around deceased donation cover a wide range of concerns. Family objections cannot trump first-person consent in some states, despite dubious, prior “informed” first-person processes such as driver’s license branches. Hospital protocols all maintain the difficult perceptual balance between providers and others not harming in life while performing acts of charity after death. The “dead donor rule,” definitions of death by neurological criteria vs. circulatory criteria, and organ procurement organizations all play a role in the ethical balance.
Death is a process, not an event. Ethics discussions can also include the attending physicians preparing a dying patient for transplant with interventions of little to no benefit to the patient, as well as issues surrounding the proper amount of time needed to harvest vital organs after circulation irreversibly ceases.
However, the breadth of ideology within the Catholic Church about organ donation has perceptually narrowed over time. Pope John Paul II framed all donations as “acts of self-giving love” and “praiseworthy” in Evangelium Vitae in 1995 and his address to the International Congress of the Transplantation Society in 2000. Around 40 years earlier, Pope Pius XII said in a 1956 address that a person can use his or her body (after death) for morally useful purposes, including the aid of others. Parish church bulletins often reinforce the selfless love of organ donation as modeling Jesus’ agapeic love and healing. Chaplains can assuage patients and families with Gospel interpretation, or Church teaching. These are exemplars of selfless, morally praiseworthy acts.
Organizational (including the U.S. bishops)
The scope of control in organ donation is almost entirely regional, not national. States differ in how they define death, with subtle differences in what they adopt from the Uniform Determination of Death Act — which, despite the title, is a non-binding text that serves as a guide for state legislators.
Organizational participation rates in organ retrieval and distribution are uneven. In Making Health Care Decisions, Sr. Pat Talone cites a Joint Commission statistic that 80 percent of donations are from 20 percent of all U.S. hospitals. Healthcare and organ procurement organizations must partner and engineer specific contracts and protocols for organ donation. Ideally, these support chaplains providing guidance, for instance, by ensuring that living donors aren’t coerced.
“Honor walks” are a contemporary ritual in which hospital staff members line corridors as the patient or body is wheeled from the hospital room to the OR, often with family members accompanying to show support. While the practice is almost universally lauded, a presentation at the American Society for Bioethics and Humanities raised concerns about real-life blunders. Failures to emotionally prepare family members, to have informed consent discussions, and to discuss video recording and online posting have all caused harm. Chaplains are uniquely situated and skilled to address these challenges within healthcare organizations.
The direction provided by the U.S. bishops in the Ethical and Religious Directives for Catholic Health Care Services exemplifies the mutual complementarity of faith and science. Organ donation directives support the role for medical expertise (e.g., determining death) and “commonly accepted scientific criteria” as well as informed consent, preventing conflicts of interest, and “encouraging and providing means” for donation. Emphasizing this reciprocity can quickly ameliorate misunderstandings, such as the myth that organ donation is somehow anti-Catholic.
Chaplains may encounter patients and family members who need help framing the decision to donate organs. For living donors, Benedict Ashley, Jean deBlois, and Kevin O’Rourke recommend using the following conditions in Health Care Ethics: A Catholic Theological Analysis, 5th Ed.:
2) The donor’s functional integrity “will not be impaired, even though anatomical integrity can suffer.”
3) The risk of the donor’s act of charity “is proportionate” to the recipient’s good result.
4) Both the donor and recipient have “free and informed” consent.
A useful lens for these terms is a benefits/burdens analysis using Directives 27, 56, and 57. Family members of deceased donors may have misperceptions, sometimes before their loved one’s death. The “Organ donation: Don’t let these myths confuse you” webpage by the Mayo Clinic attends to common myths, including misconceptions that families will be charged for donation and that organ donors cannot have open-casket funeral. Having correct information may mitigate emotional and spiritual distress.
Patients and family members may have concerns about organ donation, religion, and for some, salvation. The Mayo Clinic says, “organ donation is consistent with the beliefs of most major religions” and specific questions can go to the patient’s clergy. Accurate information may not eliminate all distress, especially in the midst of grief. It is then that chaplains can model Pope Francis’ accompaniment during an encounter so that patients and family members can, in the words of Directive 55, receive “spiritual support … in order to prepare well for death.”
Steven J. Squires, PhD, MA, Med, is vice president of ethics at Bon Secours Mercy Health in Cincinnati.