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Should surgeons be allowed to perform euthanasia by removing patients' hearts and other organs while they're still alive?
The idea, dubbed "Death by Organ Donation," would enable euthanasia patients to donate organs for transplantation in a way that would make their organs more likely to be usable. It would also kill them.
"It would be an ethical thing to do because this is something the patients have chosen for themselves," says Dr. Robert Truog, a physician and bioethicist at Harvard Medical School who co-authored a paper outlining Death by Organ Donation in the New England Journal of Medicine. "They have very generously thought: 'How might my death help other people?' It's a very altruistic, generous thing to do.'"
But the idea is controversial for a variety of reasons, including because it goes against fundamental principles that have guided organ donation for decades. The Dead Donor Rule requires that patients must be dead before any organs are removed. Doctors also can't kill patients in the process of removing organs.
The rule has long generated intense debate, including disputes over how to precisely determine when a person is dead, as well as the development of new ways to extend the lives of dying patients and recover usable organs for transplants.
At the same time, many countries, including Canada, the Netherlands and Spain, have made it legal for doctors to help patients die through euthanasia.
"What if they chose to be organ donors? The problem is that under current standards doctors must not cause death in the process of procuring organs for transplant," Truog says.
So hearts, lungs, livers and kidneys can only be removed from euthanasia patients after they have received a lethal dose of drugs, which makes their organs, especially their hearts, much less useful for transplantation.
"Why would it not be OK for patients to say, 'I've chosen to die by a lethal injection. Isn't there some way I can help others?' They should be able to donate organs as a lasting gift to others. And denying them that option doesn't seem to make any sense," Truog says. "I would say a more appropriate framework is that for patients who are choosing to die from euthanasia they could also choose to have euthanasia linked with organ donation."
A "creepy idea" that might have merit
Euthanasia involves doctors administering lethal drugs to cause the death of a patient. The practice is illegal in the U.S., but a growing number of states have legalized assisted-suicide, in which doctors give patients lethal drugs to take at home.
Instead of a doctor administering lethal medication to a patient, Death by Organ Donation patients would end the patient's life by anesthetizing them and then removing their organs while they are still functioning.
"So the organs would still be in ideal condition," says Truog says.
Some other bioethicists say the argument could have merit.
"The concept of death by donation is an extremely troubling notion at first glance. It's a creepy idea," says Ruth Faden, a bioethicist at Johns Hopkins University. "But in fact if you look at it critically in terms of the foundational ethical considerations, it's not as disturbing as it first appears."
That's because, she says, of the spread and acceptance of euthanasia and the desires of some of those patients to be organ donors.
"If we're committed to respecting the autonomy of individuals at the end of their life. And if they prefer to maximize the good their bodies can do at the end of their life, that's the ethical justification for death by donation," Faden says. She adds it would be important for strong safeguards to be implemented to ensure full informed consent and to protect patients from abuse.
A shift could undermine patient trust
But some other bioethicists are horrified by the mere notion.
"This is asking surgeons to take a living person into the operating room and to come out with a dead person, which I think is murder," says Lainie Friedman Ross, a bioethicist at the University of Rochester. "There are limits to consent. And one of the things we're not allowed to do is consent to saying that somebody else can just murder you."
Others worry this approach would undermine trust in both organ donation and end-of-life care at a time when some potential donors are already wary because of controversies about organ procurement efforts.
"You could be doing real damage to both the physician-assisted suicide system and the organ donation system," says Lori Andrews, a bioethicist and professor emerita at the Chicago-Kent College of Law. "It might give people the image that these are vultures that no longer wait until you die to attack. It does give up visions of body snatchers from prior centuries."
Critics also fear that allowing Death by Donation for euthanasia patients could open the door to someday saying it would be acceptable practice for physician-assisted suicide patients and even potentially hospice patients.
But others argue that for now this approach could be considered for at least some euthanasia patients.
"If there are people who want to donate organs, this would be the way to maximize their wishes and their altruistic goal to help others," says Dr. Carter Winberg, a Canadian critical care physician working on his master's degree in bioethics at Harvard who co-authored the New England Journal of Medicine paper. "These are people who are already consenting to voluntary euthanasia and already consent to organ donation. That warrants a new conversation about whether this is possibly ethical."
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