Cadveric Organ Donors: What is the author’s argument and what is he/she doing with it? Why?

Choose ONE
 of the two articles on “Organ Donation” attached.

 

Book for Comparison: An Introduction to Christian Ethics
 

                                            By: Roger H. Crook

                                                   5th Edition           

                                            ISBN #: 978-0-13-194794-8

 

Please use in-text and “works cited” MLA citatations
, where appropriate. 

More explicit instructions to this assignment are also attached.

Try to answer all 10 guide questions to the best of your ability.

 

The sooner I get a response, the better, but I plead you not to sacrifice quality for punctuality.

However, the reflection is due by 5:00 PM Eastern Daylight Time (EDT) on Sunday, July 22nd, 2012.

Thank you!

PAGE

3

Rel 250 Reflection Paper: Sources and Method

1. The article which you critique must come from a professional journal, not from a news magazine or newspaper. Professional theological and philosophical journals include: Theological Studies, Chicago Studies, Studia Moralia, the various reviews of religion, theology, etc. as well as the journals of the universities which have a major theological or philosophical faculty.
Journals of other professions, such as Hastings Center Report (bioethical issues), may be used if the article cited has a moral question as its central focus.

2. Select an article in which the author takes a stand. The author asserts that something is either moral or immoral. He/she then defends his/her position with evidence and arguments. This is what you are to analyze. Overviews of the issue or summaries of the thought in the current literature are not good subjects for a critique.

3. Select an article which is at least 10 pages (2,500 words) in length. Articles shorter than this will not give you enough material to write a critique of 5-6 pages. You may choose to read a chapter in a book, if that chapter deals with a particular moral issue and the author takes a stand on the issue. .

4. In your critique, state what you intend to do in the first paragraph. Then, summarize briefly the author’s position. Don’t write a caricature. Don’t exaggerate the author’s position. State it clearly and fairly.

5. Analyze the author’s position from the perspective of the content of Rel 250. Some of the following questions should be answered. If you cannot answer the questions, you’d do best to seek another article for critique.

Helpful Questions
in Preparing a Critique for Rel 250

I . What aspect(s) of the human person does your author emphasize: physical, intellectual, emotional, spiritual, social? Find a sentence which reveals this. These reveal the non-moral, or pre-moral values important to your author.

2. What is the author’s attitude towards human freedom? I.e. does he/she perceive people as totally free, or totally conditioned by heredity or environment’? Or, does your author see a balance between freedom and determination?

3. What sources does the author use for moral values: The bible, science, philosophy, authorities (such as Church leaders, or the civil law), human culture generally understood. Cfr. Your notes on Gustafson from the first week of class. Find a sentence which reveals this.

4. What method does your author use? Does he/she cite rules (thus = deontological), goals (thus = teleological), or the virtues/character which people ought to have (thus = aretaic or character-virtue centered).

5. What concept of rights does your author espouse: rights as noninter​ference, or rights as access to goods, or rights as endowments of goods by societal structures? Find a sentence which reveals this in your author.

6. How does your author deal with conflict of values? Does he/she have a hierarchy of values, so that some take priority over others? Or, does your author make use of the double effect? Which characteristics of the double effect does he/she employ: indirectness of the evil, proportionality of the good? Find a sentence which reveal this.

7. What understanding of love does your author reflect? Compare the author to Crook’s understanding of love.

8. Does your author perceive ethics as basically human (presuming that anyone will understand his/her position), or does he/she propose ethics specifically for Christians (heavy use of the Bible would indicate this)?

9. Does your author reveal the kind of participation in a community of value which Crook claims is necessary for making good moral choices?

10. If your author is a Christian, which “Alternative within Christian” ethics does he/she most closely reflect? If your author is not a Christian, which “Alternatives to Christian Ethics” does she/he reflect?

COMPARE YOUR AUTHOR WITH THE CHAPTER IN CROOK THAT ADDRESSES THE SAME ISSUE(S)…

E.g. if your paper is about capital punishment, compare the author’s views with Chapter 12 of Crook. Likewise with other topics…

WHY WE SHOULD NOT PAY FOR HUMAN ORGANS

by Francis L. Delmonico and Nancy Scheper-Hughes

Abstract. The right to buy and sell human organs is challenged
by the authors within the framework of a broad Christian perspec-
tive. Opposition to organ sales is argued in the light of the develop-
ing underclass of poor organ donors throughout the world who sell
their organs to the rich. Very often neither the donors nor the recipi-
ents are fully informed about the medical risks involved in the proce-
dure of organ transplantation.

Keywords: Christian perspective; demand; free market; gift; kid-
ney donation; self-sacrifice; supply.

Organ transplantation is arguably the most intensely social of all medical
practices. Its very existence relies upon a unique trust between society and
its physicians, and it is dependent on the willingness of ordinary people to
share their organs and tissues with a mortally sick loved one or even a
stranger. From the outset, the language of organ sharing and transplanta-
tion has been extremely idealistic, strongly ethical, and (in an unrecog-
nized, subliminal sense) also very Christian. While exhortations to altruism
and heroic acts are found in all the world’s religions, the emphasis of organ
donation on bodily self-sacrifice and charity toward strangers resonates
with the life, death, and teachings of Jesus. Indeed, the Last Supper and
the Crucifixion offer the faithful a divine model of self-sacrifice and bodily
sharing that to this day may motivate acts of organ sharing for transplanta-
tion. These strong symbolic equivalencies between secular transplantation

Francis L. Delmonico is Director of the Renal Transplantation Unit at Massachusetts
General Hospital, the medical director at the New England Organ Bank, and Professor of
Surgery at Harvard Medical School, Department of Surgery, Massachusetts General Hos-
pital, 55 Fruit St., Wnt 505, Boston, MA 02114; e-mail francis_delmonico@neob.com.
Nancy Scheper-Hughes is Director of Organs Watch and Professor of Medical Anthropol-
ogy at the University of California at Berkeley; Medical Anthropology, 305 Kroeber Hall,
Berkeley, CA 94720; e-mail nsh@sscl.berkeley.edu. This essay first appeared in National
Catholic Bioethics Quarterly 2 (Autumn 2002), 381-89, and is reprinted with permission.

[Zygon, vol. 38, no. 3 (September 2003).]
© 2003 by the Joint Publication Board of Zygon. ISSN 0591-2385

689

mailto:francis_delmonico@neob.com

mailto:nsh@sscl.berkeley.edu

690 Zygon

ethics and a sacramental approach to life fostered an early acceptance of
organ transplantation by the Roman Catholic Church, even though it ne-
cessitated the consideration of a new definition of death by brain criteria.1

More recently, the acceptance of brain death was made explicit by Pope
John Paul II in his “Address to the XVIII International Congress of the
Transplantation Society” (2000) while he simultaneously confirmed a prin-
ciple of bodily integrity in stating that the “human body cannot be consid-
ered a mere complex of tissues, organs, and functions” (John Paul II1991).
He reinforced the transplant ethic of altruism and empathy for strangers
that are the prerequisites for cadaveric organ sharing, and condemned an
emerging commerce in human organs from live donors “because to use the
body as an Object’ is to violate the dignity of the human person” (John
Paul II 2000).

Today, the concept of the donated organ as a “gift” is under assault in
many countries where payment for kidneys from living donors has be-
come a lucrative business for clinics catering to wealthy nationals and for-
eign patients (Scheper-Hughes 2000; 2002; Finkel 2001). Consequently,
organ donation from the deceased and genetically related living kidney
donation are being supplanted by transplants using kidneys purchased from
strangers. Though illegal in almost every nation, kidney commerce is not
actively prosecuted because of the prevailing dominance of a market-ori-
ented ethos and a growing sense that the older ideal of donor altruism is
either utterly naive or exploitative of those who would donate freely that
which is now sold by others. A utilitarian ethic of providing the greatest
good for the greatest number has become a singularly important moral
force supporting the right to buy or sell a human organ (Friedlaender 2002;
Schlitt 2002).

Our objective is to bring a broadly Christian perspective to these un-
folding developments, to delineate the problems inherent in a free (or even
a regulated) market-based system of organ transplantation, and to reiterate
an unequivocal opposition to organ sales. We are focusing here, in par-
ticular, on the buying and selling of kidneys from living donors, because
commodified kidneys are today the primary currency—the gold standard,
as it were—in global organ sales.

T H E MOVE TOWARD LIVE ORGAN DONATION

The pioneer surgeon Dr. Francis Moore, chief of the first transplant pro-
gram, predicted many years ago that the pressures of successful transplan-
tation would alter our ethical assumptions about the basic tenet of the
medical profession: primum non nocere—first do no harm (Moore 1988).
The first successful live-donor transplant performed in 1954 by Dr. Joseph
Murray in Boston was between siblings who were identical twins. Since
that historic procedure, the transplantation of a kidney from a living do-

Francis L. Delmonico and Nancy Scheper-Hughes 691

nor has evolved from the early requirements of an identical twin, to the
selection of a human-leukocyte-antigen (HLA)—matched family member,
to the current situation in which virtually any living person willing to do
so, and judged medically and psychosocially suitable, can be a kidney do-
nor (“Consensus Statement” 2000). Because of improvements in immu-
nosuppression, an excellent HLA match between the donor and recipient
is no longer required to achieve a successful outcome (see Terasaki 2000).

The stunning success of kidney transplantation in relieving human suf-
fering has created an unprecedented demand for a very limited supply of
donor organs. As the demand for treatment by organ replacement has
increased each year, the number of donated organs has remained essen-
tially unchanged. Transplant professionals now accept that the cadaveric
source of organs will never be able to resolve the ongoing shortage nor the
problem of expanding waiting lists of frustrated patients. As a result, and
for the first time in 2001, the number of live kidney donor transplants has
exceeded the number of transplants from deceased donors in the United
States.2 Over 20 percent of the donors were genetically unrelated spouses,
friends, and coworkers who donated their kidney for love or friendship.
Nevertheless, a new, extremely troubling, and abundant source of trans-
plantable organs has been found among the world s poor and refugee popu-
lations. The new global economy has produced a large “supply” of displaced
and desperate people willing to trade or sell a kidney in exchange for food,
work, shelter (including shelter for refugees from deportation), and medi-
cal care for themselves or other family members, or to get themselves out
of crippling debt.

T H E BLACK MARKET FOR ORGANS

The search for living donors is fueled in part by desperate dialysis patients.
Increasingly, medically sophisticated patients are learning from their doc-
tors, from the experiences of others, and from recent reports in the medi-
cal literature that organs transplanted from living donors offer the ” best
quality” and best prognosis for an excellent outcome. They also are keenly
aware that kidney transplantation provides a survival benefit to dialysis at
every age and by every cause of kidney failure (Wolfe et al. 1999; Najarían
et al. 1992). And so, increasing numbers of patients are willing to travel,
sometimes a great distance, to secure the organs they need.

For several years, one of us (Nancy Scheper-Hughes [2003]) has been
actively involved in multi-sited, ethnographic field research in nine coun-
tries on the global traffic in human organs. The pattern of organ distribu-
tion follows established routes of capital: from South to North, from Third
to First World, from poor to rich, from black and brown to white, and
from female to male recipients. Residents of Japan, the Gulf States in the
Middle East (Kuwait, Saudi Arabia, and Oman), Israel, Western Europe,

692 Zygon

and North America now travel in individually tailored or in organized
group packages to medical centers in India, China, the Philippines, South
America, Turkey, and Eastern Europe to purchase kidneys that are not
available locally or legally. They are aided in their quest by a new class of
organ brokers, some of whom operate on the Internet.3

Scarcities drive the new business in transplant tourism. A dearth of
cadaver organs exists in the Middle East, partly because of orthodox and
fundamentalist religious beliefs that permit organ transplantation but ques­
tion the removal of organs from brain-dead donors (Steinberg 1996; Gorgin,
Zand, and Recknagel 2000; Al-Mahdi 1987). Hence, one solution to the
problem of long waiting lists of patients has been the formation of highly
organized transplant tourism packages arranged, in some instances, with
the support of government-sponsored medical insurance programs. These
programs carry affluent patients from Israel, Saudi Arabia, and the Gulf
States to nearby countries, including Turkey, Russia, and Iraq, where kid­
ney sellers are recruited from prisons, unemployment offices, flea markets,
shopping malls, and bars in urban shantytowns and new slums for immi­
grants.

In China, a lucrative form of transplant tourism has been developed
with the participation of Chinese doctors in medicalized executions (“Tes­
timony” 2001). The condemned prisoner is reportedly (Smith 2001a, b)
intubated and surgically prepped for organ harvesting minutes before ex­
ecution, and executions are planned to coincide with prepaid transplant
tours. In India, trading a kidney for a dowry is a strategy for parents to
arrange marriage for an otherwise economically disadvantaged daughter
(Cohen [1999] 2003). Debt peonage also contributes to the formation of
veritable “kidney belts” in the South of India where pauperized agricul­
tural and domestic workers exchange a kidney for job security (Ram 2002).
The United States has not been isolated from this global business. Trans­
plant tourism packages, arranged mostly in the Middle East, have brought
kidney patients to U.S. centers for transplants performed with kidneys
purchased from donors allegedly posing as relatives and friends of the re­
cipient (Friedlaender 2002).

THE CASE THAT IS MADE FOR KIDNEY SALES

A market system of living donor organ sales (of kidneys, but also parts of
livers) has been proposed and defended from many different perspectives
(see Radcliffe-Richards et al. 1998; Mahoney 2000). Some proponents of
legalizing sales note that everyone in the organ transplant process (other
than the live organ donor or next of kin who gives consent for cadaver
donation) is compensated in some tangible way. A salary is provided to
the Organ Procurement Organization (ΟΡΟ) coordinator who obtains
family consent, the ΟΡΟ then charges an acquisition fee for the recovery

Francis L· Delmonico and Nancy Scheper-Hughes 693

of organs, the transplant surgeons and physicians who care for the patient
are paid for their service, and finally the transplant center charges for the
hospitalization. Those who are opposed to monetary compensation for
organ donation respond by pointing out that compensation or services
rendered to the transplant recipient is ethically different from the compen­
sation that would be provided for an organ. Providing compensation to
the transplant center physicians and ΟΡΟ staff is accepted by our society
because these transplant professionals provide a service to patients in the
exercise of their responsibilities; it is this professional service for which
they are compensated.

Others advocate for payment for organs because they hold a libertarian
view in which the autonomy of individuals is paramount, including the
freedom to buy or sell organs. In these transactions, the body is under­
stood as a valuable commodity that belongs to the individual and which
they can dispose of as they see fit. In the rational-choice language of con­
temporary bioethics, the conflict between nonmalfeasance (“do no harm”)
and beneficence (the moral duty to perform good acts) is increasingly re­
solved in favor of a consumer-oriented approach to human freedom, the
“right to choose.” To wit, those able to broker or buy a human organ, it is
said, should not be prevented from doing so. The resulting landslide to­
ward living, unrelated, and paid kidney “donation” is thereby constructed
as a win-win situation that can benefit both parties. Physicians or social
scientists who decry the intrinsic exploitation of the bodies of the most
vulnerable are criticized as inappropriately paternalistic and as excluding
the poor from a valuable new source of income.

Finally, there are those, like Michael Friedlaender (2002), who argue
from a more fatalistic position that, idealistic arguments aside, and as un­
savory as the commerce in human organs may be, Pandoras box has al­
ready been opened, and the only responsible and pragmatic response to
existing “black markets” is to replace them with “white markets”—govern­
ment-controlled and -regulated systems of “compensated gifting” of living
donor organs. Currently, the Ministries of Health in the Philippines and
in Israel are considering various proposals to regulate the sale of organs by
living donors in those countries. But to date only Iran has instituted such
an officially sanctioned system of kidney sales, and it has generated its own
share of controversy within the Iranian medical community (see Zargooshi
2002).

OPPOSITION TO ORGAN SALES IN A SECULAR SOCIETY

Arguments against organ sales from live donors are difficult to defend in a
secular and free-market-dominated society such as ours, because they can­
not be referenced by a traditional Christian morality that holds as first
premises the integrity, value, “goodness”—indeed sacredness—of the body

694 Zygon

and the dignity of all human beings. Nonetheless, there are established
societal norms that restrict the entry of the market into certain protected
spheres of human life. For example, our society does not endorse the sell-
ing of a person into slavery or the buying of children through black-mar-
ket networks in international adoption, even if these are defended in terms
of rescue and life saving, as they often are.

Even the high premium placed in U.S. society on personal autonomy is
not allowed to be the final arbiter of behavior if it can be shown that the
social fabric of society would be threatened or weakened. A civil-rights
law that restricts the rights of property owners to discriminate against races
and classes of individuals seeking to rent or purchase a home is an obvious
case in point. Furthermore, our society still subscribes to a fundamental
principle that all humans are created equal and that each individual life has
an intrinsic value, so that the person cannot be sold or physically dismantled
or bartered away.

Although class distinctions are an almost naturalized part of social life
in all complex societies, in this particular instance the exploitation of or-
gan sellers veers dangerously close to human slavery, as argued by Giovanni
Berlinguer (Berlinguer and Garrafa 1996). The pressures put by organ bro-
kers upon the desperation of the world s dislocated, refugee, and poorest
populations to provide the scarce commodities reveals the limits of argu-
ments based solely on individual autonomy. Yes, even the poorest people
of the world “make choices,” but they do not make these freely or under
social or economic conditions of their own making. Further, the pressure
of organ brokers upon the poor makes their decision to sell an organ any-
thing but a free and autonomous choice. These secular arguments reach a
conclusion similar to one derived from Christian morality—that the sale
of human organs is unethical.

The most disturbing issue of organ sales to both Christian and secular
ethicists is the formation of an economic underclass of organ donors
throughout the world to serve the wealthy. This is not to suggest that
proponents of organ sales are in favor of exploiting the poor but, rather,
that they are indifferent to the social and individual pathologies that mar-
kets in kidneys and other body parts produce, such as the documented
evidence of postsurgery medical complications, chronic pain, psychologi-
cal problems, unemployment, decreased earning power, social ostracism,
and social stigma faced by kidney sellers in many parts of the world (see
Zargooshi 2002; Jimenez and Scheper-Hughes 2002a; Ram 2002).

Proponents of organ sales suggest that a distribution system regulated
with government oversight would prevent these widely known abuses from
occurring, at least in the United States. However, the debate then moves
to another arena for public policy makers to consider. Would a system
regulated by the Department of Health and Human Services (DHHS)
accomplish its objectives and become the only route of organs for pay-

Francis L· Delmonico and Nancy Scheper-Hughes 695

ment? This is doubtful in view of the futility of regulated control of donor
payments suggested by current practice elsewhere. The global market sets
the value based on social, economic, and consumer-oriented prejudices,
such that in todays kidney market an Indian kidney fetches as little as
$ 1,000, a Filipino kidney $ 1,300, a Moldovan or Romanian kidney $2,700,
while a Turkish seller can command up to $10,000 and an urban Peruvian
as much as $30,000 (Scheper-Hughes 2002a, 73; 2002b).

Brokering in the United States would likely be no different. If the cur-
rent policy of prohibition of organ sales was rescinded, there would be
little justification, legally or ethically, to prevent donors from circumvent-
ing the DHHS system and using the Internet to solicit a better price. A
regulated system would either have to outlaw Internet bidding and set a
controlled price or would have to continuously modify the price to outbid
Internet brokers and to keep up with emerging kidney markets elsewhere.

MEDICAL AND SOCIAL CONSIDERATIONS

Living organ donation has medical risk. In a survey of transplant centers
of approximately ten thousand live donor transplants performed between
1999 and summer 2001, the transplant community was made aware of at
least two live kidney donor deaths in the United States and one donor who
developed an operative procedure complication that left the donor in a
persistent vegetative state (Matas, Leichtman, Bartlett, and Delmonico
2002, 138). A national registry of donor events is urgently needed to
inform potential donors of the risks and complications of live organ dona-
tion.

When the living donors are sellers, poor and trapped in life-threatening
environments, they may face complicated recoveries without access to
medical care. In the village of Mingir and in the city of Chisinau, Moldova
kidney sellers reported that they were unable to sustain the demands of
heavy agricultural or construction work, the only labor available to men of
their skills and backgrounds. They experienced deep shame and resent-
ment, they were stigmatized as male “prostitutes,” excommunicated from
their local Eastern Orthodox churches, alienated from their families and
coworkers, and, if single, excluded from marriage. Even their families were
affected; their children were ridiculed as “one-kidneys” (Jimenez and
Scheper-Hughes 2002a).

Transplant patients relying on paid donors are also at risk. Paid donors
who have an economic need for compensation may conceal aspects of their
medical history that would disqualify them. Systemic infection transmit-
ted by a donor organ can result not only in a loss of the transplant but also
in the death of the immunosuppressed recipient. Even as new technology
is being used to detect viral antigen in the blood of a donor within days of
exposure, the issue of accurate and honest medical history remains critical

696 Zygon

to assuring the safety of the organ transplant. In Manila, minors (those
under the age of eighteen) inflate their age so that they are not excluded
from the sale of their kidneys. In the covert kidney market of Istanbul,
sellers may angrily insist on the transaction with a kidney broker who ques-
tions their heath (Jimenez and Scheper-Hughes 2002b). Physicians, whose
primary responsibility is to provide care, should not enable a practice that
degrades a poor person, that compels anyone to sell his or her body parts,
or that encourages anyone to take a medical risk of death for the sole pur-
pose of securing a monetary payment.

A RETURN TO THE GIFT

“The material needs of my neighbor are my spiritual needs.”
—Immanuel Lévinas, Nine Talmudic Readings

(cited by Donoghue 1996, 39)

We end this essay with a reminder of the original ethical challenge implied
in organ sharing. What is essential here is to retain the ultimate value of
the body as a gift to the donor, meaning also that it is a gift to the self. The
body and its parts remain inalienable without free and informed consent.
It is through the body that humans experience and live in the world as
conscious subjects.

In his 1970 classic, The Gift Rehtionship, Richard Titmuss anticipates
many of the dilemmas now raised by the global human organs market.
His assessment of the negative social effects of commercialized blood mar-
kets in the U.S. could also be applied to the global markets in human
organs and tissues.

The commercialism of blood and donor relationships represses the expression of
altruism, erodes the sense of community, lowers scientific standards, limits both
personal and professional freedoms, sanctions the making of profits in hospitals
and clinical laboratories, legalizes hostility between doctor and patient, subjects
critical areas of medicine to the laws of the marketplace, places immense social
costs on those least able to bear them—the poor, the sick, and the inept—increases
the danger of unethical behavior in various sectors of medical science and practice,
and results in situations in which proportionately more and more blood is sup-
plied by the poor, the unskilled and the unemployed, blacks, and other low in-
come groups. (Titmuss 1997, 314)

A broader conception of medical ethics, including attention to social
justice, underscores the violation of trust in the buying and selling of hu-
man organs. Transplant physicians should be attentive to the motivations
of organ donors and receive assurances that an organ donation is voluntary
and uncoerced. Finally, the risks and benefits of organ transplantation
need to be more equally distributed among and within nations, ethnic
groups, genders, and social classes. The division of the world into organ

Francis L. Delmonico and Nancy Scheper-Hughes 697

buyers and organ sellers is a medical, social, and moral tragedy of immense
and not yet fully recognized proportions.

NOTES

1. Within a year following Christiaan Barnard’s first heart transplant, the Dean of Harvard
Medical School appointed a committee to examine the definition of brain death. This Harvard
Ad Hoc Committee, composed of ten medical specialists, one lawyer, one historian, and one
theologian, produced “A Definition of Irreversible Coma” (1968), a report published in ûit Jour-
nal of the American Medical Association. Following a discussion of the diagnostic procedures to be
used in establishing a diagnosis of brain death and a legal commentary suggesting that the judg-
ment of the criteria for establishing brain death is a medical, not a legal, issue, the report cites an
address by Pope Pius XII to an International Congress of Anesthesiologists in which the Pope
declared that it was not within the competence of the church to determine the moment of death,
that this was a task appropriate to the attending physician, and that, moreover, it was not obliga-
tory for the physician to continue to use extraordinary measures in obviously hopeless cases (Pius
XII [1957] 1958:398). Thus, from the outset, the establishment of a radically new definition of
death escaped the kind of acrimonious debates that have followed the abortion question and
euthanasia.

2. Information from The United Network for Organ Sharing, Richmond, Virginia {www.
network 17. orglpservicesl unos, htm).

3. A Web site called “Liver4You” {www.liver4You.org, last visited 25 June 2003) promises
speedy liver transplants from living donors to transplant patients willing to travel to Thailand or
the Philippines. “Want a Living Organ Next Week or a Morgue Organ in 5 Years?” the site asks
provocatively.

REFERENCES

Al-Mahdi, Mokhtar. 1987. “Donation, Sale and Unbequeathed Possession of Human Or-
gans.” Paper given at the Medical Jurisprudence Third Symposium on “The Islamic
Vision of Some Medical Practices,” 18-21 April, www.islamset.com/bioethics/vision/
drmmahduhtml (last visited 25 July 2002).

Berlinguer, Giovanni, and Vilnei Garrafa. 1996. 0 Mercardo Humano: Estudo Bioetico da
Compra e Venda de partes do Corpo [The Human Market: A Bioethical Study of the
Buying and Selling of Body Parts]. Brazilia, Brazil: Editora UnB. Portuguese transla-
tion of La Merce Finale.

Cohen, Lawrence. [1999] 2003. “Where It Hurts: Indian Material for an Ethics of Organ
Transplantation.” Daedalus 128(4): 135-65. Reprinted in this issue oí Zygon; see pp.
663-88.

“Consensus Statement of the Live Organ Donor.” 2000. Journal of the American Medical
Association 284.22 (December 13): 2919-26.

“A Definition of Irreversible Coma.” 1968. Journal of the American Medical Association 205.6.
Donoghue, Denis. 1996. “The Philosopher of Selfless Love.” New York Review of Books

(March 21).
Finkel, Michael. 2001. “Complications: This Little Kidney Went to Market.” The New

York Times (May 27), Sunday Magazine section, cover story.
Friedlaender, Michael. 2002. “The Right to Sell or Buy a Kidney: Are We Failing Our

Patients?” The Lancet359 (March 16): 971-73.
Gorgin, Azain, Jamshid Zand, and Charles Recknagel. 2000. “Iran: Guardian Council Moves

to Make Donor Organs More Available.” Radio Free Europe, December, www.rferl.org/
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Jimenez, Marina, and Nancy Scheper-Hughes. 2002a. “Doctor Vulture: The Unholy Trade
in Human Organs.” National Post (Toronto), March 30 , Bl, B4, B5
. 2002b. “Europe’s Poorest Sell Their Kidneys.” The National Post, 29 March.

John Paul II. 1991. “To the Participants of the First International Congress on the Trans-
plant of Organs,” June 20. Insegnamenti, XIV/1.

http://%7bwww.liver4You.org

http://www.islamset.com/bioethics/vision/

http://www.rferl.org/

698 Zygon

. 2000. “Address to the XVIII International Congress of the Transplantation Soci­
ety,” August 29.

Mahoney, J. D. 2000. “The Market for Human Tissue.” Virginia Law Review 86.2:103-
223.

Matas, Α., A. Leichtman, S. Bartlett, and F. Delmonico. 2002. “A Survey of Kidney Donor
Morbidity and Mortality.” Proceedings of the American TranspUnt Congress, April, Ameri­
can Journal of Transplantation 2 Suppl 3 (2002): 138.

Moore, Francis D. 1988. “Three Ethical Revolutions: Ancient Assumptions Remodeled
under Pressure of Transplantation.” Transpkntation Proceedings 20:1061-67.

Najarían, J. S., B. M. Chavers, L. E. McHugh, and A. J. Matas. 1992. “Twenty Years or
More of Follow Up of Living Kidney Donors.” The Lancet 340:807-10.

Pius XII. [1957] 1958. “The Prolongation of Life,” 24 November 1957. The Pope Speaks
[1958]: 398.

Radcliffe-Richards, J., A. S. Daar, R. D. Guttmann, et al. 1998. “The Case for Allowing
Kidney Sales.” The Lancet 351:1950-52.

Ram, Vidya. 2002. “Karnatakas Unabating Kidney Trade.” Frontline (India), 12 April,
61-76.

Scheper-Hughes, Nancy. 2000. “The Global Traffic in Human Organs.” Current Anthro-
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. 2002a. “The Ends of the Body: Commodity Fetishism in the Traffic in Organs.”

SAIS Review XXII. I (Winter-Spring): 61-80.
. 2002b. “A Cancer in the Social Body.” Times Higher Education Supplement, Lon-

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. 2003. “Keeping an Eye on the Global Traffic in Human Organs.” The Lancet

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(October 18), Al.
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Steinberg, A. 1996. “Ethical Issues in Nephrology—Jewish Perspectives.” Nephrology Di-

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http://www.house.gov/international

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Delimiting the Donor

by J O H N A . R O B E R T S O N

The scarcity of vital organs has prompted several calls to

either modify the dead donor rule or interpret it more

broadly. Given its symbolic importance, however, the

rule should be changed only cautiously.

A lthough living persons donate
/t–j\ kidneys, cadaveric donors are

JL IV. the main source of solid or-
gans for transplantation. Yet cadaver-
ic donations have never been suffi-
cient to meet the needs of persons
with end-stage organ disease. One
factor among many that limits the
availability of cadaveric organs is the
dead donor rule—the ethical and
legal rule that requires that donors
not be killed in order to obtain their
organs.

Laws and norms against homicide
forbid killings done for any purpose,
including killings done to obtain or-
gans to save the life of others. These
laws and norms apply even if the per-
son is unconscious, extremely debili-
tated, or very near death. The effect
is to create the dead donor rtile—the
rule that states that organ retrieval it-
self cannot cause death. Removal of
organs necessary for life prior to
demise would violate the dead donor
rule regardless of the condition or
consent of the donor because re-
moval of those organs would kill the
donor. Removal of nonvital organs
prior to death would not violate the
rule, though it would implicate other
laws and ethical norms.

John A. Robertson, “The Dead Donor Rule,’
Hasting Center Report 1^, no. 6 (1999): 6-14.

Laws and norms against killing
are most clearly applicable when the
person killed has not consented to
the killing. But they also apply when
a person requests death, whether to
avoid suffering or to provide organs
for transplant. The dead donor rule
would thus prevent a person from
committing suicide in order to pro-
vide organs to his family or others. In
the short run the rule is deontologic
rather than utilitarian, for it prevents
the killing of one person for organs
that would save the three or more
lives that can be saved by a single ca-
daveric donor.

The dead donor rule is a center-
piece of the social order’s commit-
ment to respect for persons and
human life. It is also the ethical
linchpin of a voluntary system of
organ donation, and helps maintain
public trust in the organ procure-
ment system. Although it is possible
that some changes in the dead donor
rule could be adopted without a
major reduction in protection of per-
sons and public trust, changes in the
rule should be measured by their ef-
fect on both those fiinctions.

Several recent proposals to in-
crease the supply of cadaveric organs
would create exceptions to the dead
donor rule to allow donation when
the donor lacks an upper brain and
will imminently die (anencephalic

infants) or will be executed (death
row prisoners).’ These proposals do
not challenge the rule’s core function
of protecting persons against un-
wanted demise. They do not, for ex-
ample, propose a “survival lottery” in
which persons are picked by chance
to be killed to provide organs to sev-
eral others.-̂ Nor would they permit
competent persons to choose suicide
by organ retrieval in order to save
others. Instead, they would modify
the rule at the margins of human life.

Proposals to permit donation
from anencephalic infants or con-
demned prisoners aim to maintain
respect for the core values underlying
the dead donor rtile while conclud-
ing that the benefits of relaxing the
rule in these marginal cases outweigh
the loss in respect for life and trust in
the transplant system that might re-
stilt. In contrast, proposals to retrieve
organs from non-heart-beating do-
nors claim to respect the dead donor
rule as such by permitting organ re-
trieval only after the donor has been
pronounced dead on cardiopulmon-
ary grounds. Ethical controversy aris-
es there, however, because uncertain-
ties in determining cardioptilmonary
death create a risk that the donor will
not be dead when organ retrieval oc-
curs, but will die as a result of the re-
trieval itself

A closely related question con-
cerns whether it is ethically accept-
able for physicians to implement pro-
posals that violate the dead donor
rule in these marginal cases. From the
time of Hippocrates, codes of med-
ical ethics have condemned killing by
physicians. This tradition continues
strongly today in medical, ethical,
and legal opposition to active eu-
thanasia, physician-assisted suicide,
and the participation of physicians in
capital punishment and torture.’ If
the dead donor rule is relaxed to fa-
cilitate organ procurement in these
marginal cases, it will require a con-
comitant relaxation in prohibitions
against physicians killing. Many per-
sons would count such a change as
an additional reason for opposing ex-
ceptions to the dead donor rule.

®

HASTINGS CENTER REPORT November-December 1999

Pnnr to ©eatlh

The dead donor rule limits onlyorgan retrieval that causes death.
It says nothing about situations in
which organ retrieval itself would not
cause death. Removing nonessential
organs or tissue from incompetent
persons on the basis of substituted
consent—for example, retrieving kid-
neys from retarded individuals or
from those in persistent vegetative
states—would not violate the dead
donor rule because organ or tissue
retrieval in those cases would not
cause death. Retrieval of nonessential
organs would, however, implicate
concerns about showing proper re-
spect for the dignity and well-being
of incompetent persons, for example,
not treating them as mere means to
the ends of others. Although it would
not violate the dead donor rule, re-
trieval in such cases still could not
occur unless applicable ethical and
legal requirements for consent by the
donor or family had been met.

Some persons have mistakenly
viewed the dead donor rule as also
prohibiting retrieval of nonessential
organs from comatose or incompe-
tent persons prior to their death be-
cause ordinarily such organs are re-
moved only after death has occurred.
The fact that organ and tissue re-
trieval usually occurs after death,
however, does not mean that retrieval
cannot occur before death if ethical
and legal norms for what may be
done to persons prior to their death
are observed.

An example that nicely illustrates
the distinction between the dead
donor rule and rules for respecting
incompetent persons would arise in a
situation in which a family member,
say the father, would like to donate a
kidney to his daughter who suffers
from end-stage kidney disease and
who is not tolerating dialysis well.
Medical examination shows that he
has a serious heart condition that
rules him out as a live donor. Soon
after, he suffers a massive cardiac ar-

rest that leaves him in a permanent
coma in which he can be maintained
indefinitely.”* At this point, removal of
a kidney from him for transplanta-
tion to his daughter would not vio-
late the dead donor rule because it
would not cause his death. Whether
it is ethically and legally acceptable,
however, would depend on whether
removal is consistent with laws and
norms for respecting the interests of
incompetent persons. In this case,
based on his prior expressed wishes to
donate to his daughter and the ab-
sence of harm to him from the dona-
tion, a plausible claim can be made
that removal of the kidney is ethically
and legally acceptable. If this option
were not acceptable to the family,
they could request that he be treated
as a non-heart-beating donor, that is,
have life support stopped, and then
retrieve his kidney after he has been
pronounced dead.

Akey factor in observing the dead. donor rule is the determination
of death. The United States and most
European countries now accept that
death can be determined by tests that
show irreversible cessation of circula-
tory and respiratory function or irre-
versible cessation of all functions of
the entire brain.’ The latter tests—
tests for whole-brain death—are nec-
essary when the irreversible cessation
of cardiopulmonary functions in a
mechanically assisted patient cannot
be independendy established.

Determining death by tests for
total brain death does not contradict
or violate the dead donor rule be-
cause whole-brain death (“permanent
cessation of the clinical functions of
the entire brain,” including the brain
stem) is the criterion that indicates
that death (“the permanent cessation
of critical functions of the organism
as a whole”) has occurred.”

Critics argue that brain death tests
for death lead to violations of the
dead donor rule because studies have
shown the presence of residual spon-

taneous electroencephalographic ac-
tivity in some brain dead patients.”
But as James Bernat argues, the rudi-
mentary and random elecroencephal-
ographic activity found in these stud-
ies “represents merely the isolated
physiologic activity of a few surviving
neurons and does not represent the
systematic integrating function of the
kind necessary to achieve classifica-
tion as a clinical fiinction.”* Thus the
continued functioning of some neu-
rons after declaration of whole-brain
death does not mean that the person
is still alive because such electric ac-
tivity does not show that the critical
integrative functions of life produced
by the brain still exist. If they have
otherwise suffered the permanent loss
of all clinical functions of the brain
(whole-brain death), such persons are
dead and organs can be removed
without violating the dead donor rule.

Although the needs of organ
transplantation have driven the devel-
opment of brain death, whole-brain
criteria for death should not be
viewed as a subterfuge for the judg-
ment that brain-dead persons are in
fact alive but because of severe mental
impairment may be killed for their
organs. Persons who argue that whole-
brain death is not an indication that
death of the individual has occurred
must either disagree about what criti-
cal loss counts as death or what tests
count as adequate evidence that such
critical loss has occurred. Although
some misunderstanding and confu-
sion about brain death continues to
exist, even among physicians and op-
erating room nurses, it is now well
settled that brain death determina-
tions of death do not violate the dead
donor rule, but rather provide an ad-
ditional set of tests for determining
whether death has occurred.’

One proposal to change the deaddonor rule would allow the re-
trieval of vital organs from anenceph-
alic infants before they have suffered
whole-brain death. Because few chil-
dren die in circumstances where

November-December 1999 HASTINGS CENTER REPORT

brain death is pronounced, organs for
pediatric transplant, where organ size
is a crucial factor, are in very short
supply. Faced with the shortage of
pediatric hearts, one center tried un-
successfully to transplant a heart from
a baboon to an infant with hypoplas-
tic heart disease.'” Because of medical
and ethical opposition to further use
of xenografts, the center then pro-
posed with parental consent to use
organs from anencephalic newborns
who had expired after treatment was
withdrawn.” When it was found that
viable organs could not be obtained
from anencephalic infants after death,
consideration turned to removing or-
gans before brain stem activity had
ceased.

Such an alternative, however, is
blocked by the dead donor rule. Al-
though anencephalics lack an upper
brain, they do have brain stem func-
tion, and thus are legally alive under
existing criteria and tests for whole-
brain death. Removing hearts and liv-
ers from anencephalic infants prior to
total brain death would thus violate
the dead donor rule and could be
punishable as homicide. If anen-
cephalics were to be a viable source of
organs for pediatric transplant, an ex-
ception to the dead donor rule would
have to be enacted into law and in-
corporated into ethical norms.

An ethical argument in favor of re-
laxing the rule in the case of anen-
cephaly can be made on the ground
of beneficence to the potential recipi-
ents and the families who wish to do-
nate and the absence of harm to the
anencephalic donors. Because anen-
cephalic infants have only a brain
stem, they clearly lack consciousness
or interests.’^ They will not survive
for long, even with aggressive treat-
ment, and there is no ethical or legal
obligation to treat them aggressive-
ly—even to treat them at all.” Par-
ents faced with this personal tragedy
welcome the opportunity to donate
organs, and may even initiate the re-
quest to take vital organs before brain
stem activity has ceased. Many chil-
dren desperately await transplanta-
tion. They and their families would

greatly benefit by the organs that
became available from anencephalic
donors under the proposed excep-
tion. Because anencephalics are born
without any upper brain, a narrow
exception to the dead donor rule
could be written without also extend-
ing the exception to persons in per-
sistent vegetative states or other con-
ditions of consciousness who were
born with an upper brain and were
once competent.'”*

Strong arguments also exist against
recognizing an exception. A primary
one is the need to keep a bright line
against killing individuals who are
alive. Opponents also cite the diffi-
culties in diagnosing anencephaly
and the corresponding risk of mis-
taken diagnoses, the small number of
children who would benefit, and the
risk that this exception would make
it much more likely that additional
exceptions to the dead donor rule
would be enacted for those in persis-
tent vegetative states or with severe,
irreversible mental illnesses.” An ex-
ception might also reinforce public
fears that the interests of organ
donors would be sacrificed to obtain
organs, and violate symbolic concerns
for showing respect for human life
by not killing. Finally, physicians
would, in the very act of retrieving
vital organs, be killing the anence-
phalic patient.

The arguments against recogniz-
ing an exception to the dead donor
rule for anencephalic infants have
carried the day. For example, the fa-
vorable 1992 opinion of the Council
on Ethical and Judicial Affairs of the
American Medical Association was
withdrawn in the face of wide oppo-
sition and never reissued.”^ Nor have
legislative proposals to permit such
retrievals been enacted. In a 1991
case the Supreme Court of Florida re-
flised to add “brain absent” as an ex-
ception to the brain dead or homi-
cide laws despite the request of par-
ents who wished to donate their in-
fant’s organs, noting that such a
major change would have to come
from the legislature not the courts.”’

An additional factor conserving

the dead donor rule in the case of
anencephalic infants is the necessity
for the government openly to autho-
rize a change in the definition of
death or in the law of homicide to
allow killing by organ retrieval of
anencephalic infants. Even if legal
immunity from prosecution were
provided, medical opposition to phy-
sicians removing organs that cause an
anencephalic child’s death might still
continue. Indeed, transplant physi-
cians might refuse to retrieve or use
organs from anencephalics to prevent
erosion of public trust in the organ
donation and transplant system.

Although hearts and livers could
not be taken from anencephalic chil-
dren without a relaxation of the dead
donor rule, parents could consent to
have their anencephalic child serve as
a living kidney or tissue donor with-
out violating the dead donor rule.

Interestingly, however, few such
uses have occurred, just as persons in
persistent vegetative states have rarely
been used as the source of nonessen-
tial organs and tissues, even though
they would not be directly harmed by
such use. Persons who oppose such
use would likely argue that taking
nonvital organs prior to death de-
grades or disrespects the anencephalic
newborn or vegetative person because
it so deliberately treats them as a
means for the good of others.

Proponents would contest the ac-
curacy of the claim that anencephalic
or vegetative donors in such cases are
degraded by being used as a source of
organs or tissue for others on the
ground that ethical concerns about
using people as mere means do not
apply to persons who due to absence
of cortical function lack interests al-
together. They might also argue that
the situation offers them the oppor-
tunity, through proxy consent, to
participate in the very human act of
helping other humans to survive.
Still, there has been little movement
to use anencephalic newborns or veg-
etative patients as donors even in sit-
uations that would not violate the
dead donor rule or otherwise direcdy
harm the donors.

HASTINGS GENTER REPORT November-December 1999

SIS a
F o r m ©if

With over 3,200 persons nowawaiting execution in the
United States and some forty to sev-
enty-five prisoners executed each
year, proposals to retrieve organs for
transplant from capital punishment
have surfaced in recent years.’* The
idea gained slight momentum in the
early 1990s when a condemned pris-
oner in Ceorgia offered to donate or-
gans as part of his execution and sued
unsuccessfully for the opportunity.”
Bills to permit organ retrievals from
executions have been introduced in a
few state legislatures (pp. 432-33).

In considering proposals to use the
organs of condemned prisoners, we
must distinguish procuring organs
from executed prisoners after their
death or during their lives from
procuring organs from them as a
form of execution. There is no ethical
or legal objection to removing organs
or tissue from executed bodies after
death, if consent of the deceased or
next of kin has been obtained. Al-
though most methods of execution
would render organs unacceptable for
transplant, the unclaimed bodies of
executed inmates are routinely given
to medical schools for anatomical
study.̂ ^ Nor is there any ethical bar
to a condemned prisoner serving as a
living donor of a kidney or tissue, as
long as the prisoner freely consents.
Indeed, Texas and other capital pun-
ishment states permit live donations
from condemned prisoners.^’

The question of execution by
organ retrieval is quite diflFerent. To
avoid the damaging effects on organs
from execution by lethal injection,
electrocution, hanging, gas, or firing
squad, organ retrieval itself would
become the method of execution. The
condemned prisoner would request
this method five to seven days before
the execution date.̂ ^ At the time se-
lected for execution, the prisoner
would be taken from death row to the
prison hospital and strapped on a
gurney as in preparation for execu-
tion by lethal injection. Witnesses to

the execution, including the victim’s
family, could view the insertion of in-
travenous lines and administration of
anesthetic outside of the operating
room. When the prisoner became
unconscious, he would be moved to
an operating room where the trans-
plant team would then remove all his

rule. The state in any case will be ex-
ecuting the prisoner, and the excep-
tion would permit the state to kill an-
other in a way that salvages his or-
gans. In addition, an exception for
execution by organ retrieval has the
salutary effect of respecting and pre-
serving the lives of recipients at the

A mode of execution that protects organs would not

harm the prisoner or deprive him of continued life.

and thus would not infringe or deny the core values

underlying the dead donor rule.

organs. When organ removal was
completed, ventilatory or other me-
chanical assistance would be termi-
nated, as occurs in retrieval from
brain-dead, heart-beating cadavers.
Death would be pronounced as hav-
ing occurred either at the time that
the heart and lungs were removed, or
when mechanical assistance was ter-
minated. The retrieved organs would
then be distributed to consenting re-
cipients in accordance with existing
rules for distributing organs.

Such a procedure would clearly
violate the dead donor rule. Retrieval
of vital organs itself would be the
cause of death because once heart,
lungs, and liver are removed one
would soon have to turn off the
heart-lung bypass machines that are
sustaining function during removal
of vital organs. Physicians retrieving
organs would thus also be executing
the prisoner. For such a procedure to
be acceptable, an exception to the
dead donor rule in the case of execu-
tions would have to be recognized.

The main argument for an excep-
tion in this case is that the prisoner
will in any case be executed. An ex-
ception to the rule to permit a mode
of execution that protects organs
would not harm the prisoner or de-
prive him of continued life, and thus
would not infringe or deny the core
values underlying the dead donor

very moment that the condemned
person’s life is taken as punishment
for his having previously taken the
life of others.

Supporters of such an exception
might require that several other con-
ditions be met for execution by organ
retrieval to be acceptable: Organ re-
trieval executions might be permitted
only at the request of the condemned
prisoner made at a specified time in
advance of the execution. The per-
mission of the victim’s family might
also be required. Potential recipients
would be free to reject organs from
this source. Most important, the in-
mate’s request for execution by organ
retrieval should not influence prior
decisions about guilt and punish-
ment, or later decisions for clemency.

For persons opposed to capital
punishment, execution by organ re-
trieval is as objectionable as execution
by other means. They may also doubt
that the prospect of organ donation
by execution would not influence the
willingness to impose capital punish-
ment at earlier stages of the process,
or that condemned prisoners would
voluntarily choose such an option.
Persons who believe that capital pun-
ishment is morally and legally justi-
fied might also oppose such execu-
tions. They might fear that such a
practice could weaken public accep-
tance of capital punishment by mak-

November-Decemberl999 HASTINGS CENTER REPORT

ing executed criminals who donate
look altruistic and thus deserving of a
reprieve, or tainting all executions by
associating them with allegations of
Chinese practices of executing pris-
oners to obtain organs to sell on the
international market. Finally, many
persons would oppose execution by
organ retrieval in order to maintain
strict adherence to the dead donor
rule and strict separation of doctors
and killing.̂ 3

The opponents of execution by
organ retrieval have prevailed, and are
likely to prevail for some time to
come. The great aversion to an excep-
tion to the dead donor rule in the
case of lawful executions is not ade-
quately explained by the values un-
derlying the dead donor rule. If state
employees may legally kill a con-
demned criminal by drug, gas, or
more violent means, it should not
matter that execution occurs by re-
moval of vital organs. This would not
constitute an unconstitutional “cruel
or unusual” punishment because
there is nothing crueler about this
method of execution, chosen by the
prisoner, than other methods.

A stronger ground for opposition
is the role that transplant physicians
and nurses would necessarily play in a
system of execution by organ re-
trieval. Execution by organ retrieval
could not be carried out by non-
physician executioners as now occurs
with execution by lethal injection and
other methods. Even if some trans-
plant doctors and nurses who accept
the moral validity of capital punish-
ment might be willing to participate
in organ retrieval executions, their
participation would violate medical
ethical pronouncements against the
participation of physicians in execu-
tions. The execution would also have
to occur in the operating room of a
hospital. If the prison hospital lacked
adequate facilities, a hospital willing
to allow organ retrieval executions on
its premises would have to be
found—and it is likely that few trans-
plant teams or hospitals would be
willing to participate.

Opposition to such an exception
also arises from the need to keep the
death penalty separate from other so-
cial institutions. The death penalty is
highly problematic morally, legally,
and socially in those states that allow
it; it would become even more so if it
also served as a method of organ pro-
curement. Interjecting transplanta-
tion into the controversy over capital
punishment could also taint public
perceptions of the beneficence of
transplantation. Members of the
public might come to view organ
procurement teams as “killers” who
harvest organs before or after death.
Such a perception could reduce the
willingness of families to donate, and
thus impair the prospects of persons
awaiting transplants. The purpose
and effect of capital punishment is to
end the life of a person who has him-
self taken life. Trying at the same time
to preserve other lives through execu-
tion by organ retrieval only confuses
the situation. It is best for organ
transplantation and capital punish-
ment to go their separate ways.

A nother proposal to increase the
2y^ supply of cadaveric organs for
transplant focusing attention on the
dead donor rule is the use of non-
heart-beating cadavers as organ do-
nors. The first cadaveric organ donors
were persons declared dead on car-
diopulmonary criteria, who either
suffered cardiac arrest in the hospital
or who arrived there dead.-̂ ‘* With
the acceptance of whole-brain criteria
of death, organ procurement shifted
to heart-beating cadaveric donors—
those persons who were found to be
brain-dead while cardiopulmonary
functions were mechanically sus-
tained. The shortage of brain-dead
heart-beating donors has now refo-
cused attention on the use of non-
heart-beating donors (NHBDs).

The use of NHBDs that impli-
cates the dead donor rule involves
those cases that are planned or con-
trolled, as opposed to those persons
who are brought to the hospital dead.

These protocols developed out of
family requests to donate organs in
situations in which it was unlikely
that death would be pronounced on
brain death grounds, thus preventing
solid organ donation from occurring.
Organ donation is a significant posi-
tive experience for those facing the
death of a loved one; if these families
are to have that positive experience,
organ donation would have to occur
immediately after death has been de-
clared subsequent to withdrawal of
life support—the non-heart-beating
donor situation.

In controlled NHBD cases a fam-
ily requests that treatment be with-
drawn from a loved one who is termi-
nally ill but not brain dead and that
his or her organs then be donated for
transplant. To minimize warm is-
chemic time damaging to organs,
ventilatory assistance to the patient
may be withdrawn in the operating
room, where the family may choose
to be present. After withdrawal of
life support, the patient’s attending
physician, who is not part of the or-
gan recovery team, determines wheth-
er the heart and respiration have
stopped. The physician will then pro-
nounce the patient dead or, to pro-
vide an additional margin of safety,
in some cases will wait an additional
two to five minutes after cardiac
function has stopped before pro-
nouncing death. At this point the
physician and any family that is pre-
sent would withdraw, and the trans-
plant team, which has been prepped
and waiting in an adjoining room,
will enter and retrieve organs from
the recently dead cadaver. Studies
have shown that organs retrieved in
this way sufFer little damage and are
viable for transplant.

Current interest in the use of con-
trolled NHBDs arose from a 1992
protocol at the University of Pitts-
burgh Medical Center.^’ The proto-
col developed out of family requests,
and intensivists, transplant physi-
cians, nurses, and others developed a
protocol responsive to identified con-
cerns and presented it to the hospi-
tal’s ethics committee. Aft:er approval

“fl® HASTINGS CENTER REPORT November-December 1999

by the ethics committee, the issues
were examined at a bioethics confer-
ence in Pittsburgh and in scholarly
publications.^”^ Many in the trans-
plant field see NHBDs as a key source
to meet the growing demand for
organs, and many other NHBD pro-
tocols have been proposed. Twenty-
eight organ procurement organiza-
tions now have active NHBD pro-
grams, though many others do not.^”

The ethical and legal questions
raised by controlled NHBDs received
national attention in April 1997
when a bioethicist charged that a pro-
posal at the Cleveland Clinic to re-
trieve organs from NHBDs amount-
ed to killing patients for their organs,
and brought the protocol to the at-
tention of the district attorney’s of-
fice.̂ ^ A 60 Minutes story on the
Cleveland situation gave the impres-
sion that there were serious violations
of the dead donor rule occurring at
institutions that used NHBDs.

As a result of the growing contro-
versy. Secretary of Health and
Human Services Donna Shalala in
1997 requested that the Institute of
Medicine (IOM) examine the med-
ical, ethical, and legal aspects of
NHBDs. In its final report, the IOM
recommended much greater use of
NHBDs, in accordance with publicly
adopted protocols that followed
guidelines it identified.^’ Its provision
of a uniform protocol for the practice
has now encouraged other programs
to begin using NHBDs.

Ethical and legal controversy sur-
rounds the use of controlled NHBDs
because of the fear that retrieval of or-
gans in the controlled setting could
violate the dead donor rule, ‘̂’ in ei-
ther of two ways. One was that the
drugs administered prior to death in
N H B D protocols—anticoagulants
(heparin) and vasodilators (regitine)
to minimize the efiFects of warm is-
chemia on organ viability—could
hasten or even cause death.3′ This
was a key issue in the Cleveland con-
troversy.̂ -̂ Whether the drugs used
in NHBD protocols cause or only
hasten death, in either case the dead
donor rule would have been violated.

The doctrine of double effect would
not shield an unintended death from
these drugs from moral and legal dis-
approval because the intended benefit
is for persons other than the patient.^^

Transplant physicians with experi-
ence with these drugs deny that they
are administered to hasten death or
that they are given in such doses that
they could have that
effect, and the IOM
found that administer-
ing heparin and regit-
ine prior to death to
preserve organs gener-
ally does not harm the
donor and are justifi-
able as part of routine preparation for
organ retrieval.̂ ‘̂ However, it noted
that “in the occasional NHBD with
ongoing intracranial bleeding or de-
ficiencies in blood volume” the ad-
ministration of such agents “is not
indicated because it could actively
cause death” (p. 52). Accordingly, it
recommended “case-by-case deci-
sions on the use of anticoagulants
and vasodilators, and consideration
of additional safeguards such as in-
volvement of the patient’s attending
physician in prescribing decisions”
(p. 52). Carefiil attention to whether
such drugs need to be administered
to the near-death patient to preserve
organs and whether the dosages used
are contraindicated because of the
patient’s condition should minimize
the risk that efforts to preserve or-
gans prior to death will inadvertent-
ly violate the dead donor rule.

A second way in which NHBD
protocols are said to violate the dead
donor rule is that they allow retrieval
of organs before cessation of pul-
monary function is irreversible. The
risk is that death will be pronounced
so quickly after the removal of life
support and induction of cardiac ar-
rest that the person will not have irre-
versibly lost cardiac fijnction and thus
will still be alive when organs are re-
moved. That is, the person will ap-
pear to be dead, but might actually, if
given longer time to breathe on his
own or if̂ immediately resuscitated,
regain spontaneous respiration and

circulation. If organ retrieval has al-
ready begun in such patients, retrieval
will then be the cause of death, thus
violating the dead donor rule.

To guard against such mistakes,
NHBD programs have traditionally
waited a few minutes after determin-
ing that cardiopulmonary function
has ceased before pronouncing death

Do new proposals amount to

killing patients for their organs?

and beginning organ retrieval. The
IOM, for example, recommended a
wait of at least five minutes together
with electrocardiographic monitor-
ing. NHBD programs in Pittsburgh
and the University of Wisconsin wait
two minutes. Yet some have argued
that no additional wait after cardiac
arrest should be required before pro-
nouncing death because no addition-
al wait is required for pronouncing
death in the case of cardiac arrest in
ICUs or other situations in which
donation is not planned.^’

Although very few studies have
been done, no data suggest that au-
toresuscitation five minutes after car-
diac arrest is a serious risk, and there
is no reason to think that further
studies would reveal a different re-
sult.^” A more difficult problem
concerns whether non-heart-beating
donors pronounced dead after car-
diac arrest and a two-to-five minute
wait have irreversibly lost all car-
diopulmonary fijnction. The loss of
function must be “irreversible” to sat-
isfy the criteria for death under the
laws of every state.

But who determines “irreversibil-
ity,” and under what circumstances?
Two understandings of irreversibility
are relevant here. A strong under-
standing of the term would hold that
patients who have suffered cardiac
arrest have not irreversibly lost car-
diac function and thus are not dead if
they could have been resuscitated.
Under this view of irreversibility

November-December 1999 HASTINGS CENTER REPORT “B “D

NHBDs who are pronounced dead
five minutes after cardiac arrest are
not dead because persons have been
resuscitated—restored to respiratory
and cardiac function—for up to ten
minutes after cardiac arrest.

A second view of irreversibility
would hold that “a function is irre-
versibly lost if a morally defensible
decision has been made not to reverse
the loss” (p. 6). Because the patient
had issued a prior directive against
resuscitation or his family had law-
fully requested a do not resuscitate
order, no resuscitation after cardiac
arrest would be morally and legally
acceptable in situations of potential
non-heart-beating donation. There-
fore, the patient may legitimately be
viewed as having irreversibly lost all
cardiopulmonary function when
death is pronounced on cardiopul-
monary grounds.

Whether N H B D protocols ob-
serve or respect the dead donor rule
thus will depend upon which mean-
ing of the inherently ambiguous term
“irreversible” one adopts. Civen the
strong protection now given to the
right of patients and their families to
reject resuscitation after cardiac arrest
in situations very close to death, there
is a very strong argument that the
second construal of irreversible—
whether a morally defensible decision
against resuscitation has occurred—is
the appropriate one in these cases. If
so, NHBD protocols would involve
no violation of the dead donor rule.

Because patients and their families
have strong legal and moral rights to
reject life support and resuscitation
after cardiac arrest, it is difficult to see
why one should adopt a construal of
irreversibility that ignores whether
the patient could in fact legally or
morally be resuscitated. And because
a severely debilitated patient with a
do not resuscitate order who has suf-
fered cardiac arrest after withdrawal
of life support will not be resuscitated
even if it were technically feasible to
do so, there is no good reason why
the stricter construal of irreversibility
should be adopted over a construal of
reversibility that focuses on whether

resuscitation after cardiac arrest has
ethically and legally been rejected.

A decisional view of irreversibility
reflects commonsense views of death,
for the person is not now breathing
and never will again. Not to regard
her then as dead because she might
have been resuscitated in a situation
in which she never will be resuscitat-
ed is counterintuitive to common un-
derstandings of death held by the
general public, families, health care
providers, and most ethicists, philoso-
phers, and lawyers who study these
issues.

Ethical and legal issues beyond the
question of irreversibility also arise
with NHBD protocols, but they do
not implicate the dead donor rule.
The practice of administering he-
parin or regitine prior to withdrawal
of life support in order to minimize
warm ischemic time in carefully se-
lected cases does, however, raise the
question whether administration of
drugs not for the patient’s benefit is
respectful of the incompetent patient.
This question should be resolved on
the basis of whether the drugs harm
the patient and whether the patient
or the proxy have lawfiiUy consented
to them. If no harm is shown and
there is lawfiil consent, the mere fact
that something is being done to the
patient not for his benefit would not
in itself make administration of the
drugs unlawful or unethical. A simi-
lar analysis would apply to cannuliza-
tion of the patient prior to death so
that cold perfusion to preserve organs
after death has been pronounced can
be administered rapidly. If the patient
will not be harmed by the cannuliza-
tion and there is proper consent, it is
ethically acceptable prior to death.

The debate over the use of
NHBDs shows that their use in ac-
cordance with guidelines such as
those recommended by the IOM
does comply with the dead donor
rule. Unlike the case of anencephaly,
where the donor is clearly alive under
whole-brain criteria of death when
vital organs are taken, the use of
NHBDs involves no violation of the
dead donor rule and requires no

public alteration or exception to it.
Nevertheless, it is important that
NHBDs are used only according to
publicly announced protocols that
contain clear procedures for minimiz-
ing the risk of any such violations.
Such protocols should require that
death is pronounced according to the
attending physician’s judgment with-
out pressure from transplant person-
nel, that tests and waiting periods are
used that are reasonably certain to
correctly ascertain cardiopulmonary
death, and that administration of an-
ticoagulants or vasodilators does not
occur in circumstances that might
hasten death or harm patients.

amidl

*” II ”he dead donor rule plays an im-
-IL portant role in protecting per-

sons and engendering trust in a vol-
untary system of organ donation.
Any change in the rule to increase
organ supply requires convincing evi-
dence that more benefit than harm to
persons and the transplant system
would result from such a change.
Even then, strong resistance to modi-
fying the rule would exist based on
the prudential and symbolic advan-
tages of strict maintenance of a rule
against death by organ retrieval.

It is thus no surprise that none of
the proposals for explicit exceptions
to the dead donor rule have been
adopted. Removing vital organs from
anencephalic infants requires public
recognition that such lives are so di-
minished or lacking in value that they
may be killed for their organs. Al-
though these newborns will immi-
nendy die and will suffer no harm
from retrieval of vital organs, the
symbolic costs of relaxing the dead
donor rule appear to be too great to
be tolerated. Similarly, organ retrieval
executions have little support, despite
their attempt to wring some good
from society’s deliberate taking of life.

The use of NHBDs, on the other
hand, is morally and legally accept-
able because of their careful attempt
to respect the dead donor rule. The

112 HASTINGS GENTER REPORT November-December 1999

debate over the use of NHBDs, how-
ever, illustrates the strong opposition
that probably would exist if vital or-
gans were taken from non-heart-beat-
ing donors who were not dead or if
drugs administered to preserve organs
also caused death. Despite the brief-
ness and poor quality of the life re-
maining to such donors, violation of
the dead donor rule would most like-
ly be as strongly opposed here as it is
with anencephalic infants.

The conservative posture that now
exists toward maintaining the dead
donor rule is likely to continue for
some time, but not because of logical
necessity. One could imagine that the
question of how strictly the dead
donor rule should be adhered to in
order to maintain respect for persons
and trust in the organ procurement
system might be answered differently
as medical, ethical, and social condi-
tions and perceptions change. We
might, for example, come to accept
that persons who have only brain
stem function or who are permanent-
ly unconsciousness are so close to
being dead that we are willing to take
their vital organs when clear benefits
to others could be shown.̂ ^ Oppo-
nents or proponents of capital pun-
ishment might come to accept the
need to save lives even as executions
occur, and support execution by
organ retrieval. Only a slight shift in
attitude would then be needed to
view the transplant team’s role in ex-
ecutions as life-affirming, just as it is
in organ retrievals from brain-dead,
heart-beating cadavers whose cardio-
pulmonary functions are ended by
organ retrieval. Such shifts in the
strictness of the dead donor rule could
occur without impairing respect for
human life generally or diluting per-
ceptions of physicians as healers, be-
cause the life at stake in these cases is
so marginal in quality or expectancy
and the resulting preservation of life
in recipients is so significant.

Yet it is highly unlikely that such
changes in perception or practice will
soon occur. The symbolic importance
of the dead donor rule is so great that
even the slightest explicit deviation

from it confronts a very high pre-
sumption of unacceptability. An im-
portant factor in strictly maintaining
the rule is the small number of lives
that would be saved as a result. With
roughly fifty executions and fifty
anencephalic births occurring each
year, and only a portion of these pris-
oners or families likely to opt for
organ donation, relatively few lives
would be saved at the price of cross-
ing an important symbolic threshold.
Of course, any additional contribu-
tion to the pool of donor organs is
welcome. Each cadaveric donor made
possible by changes in the dead
donor rule could save or extend the
lives of three or more existing indi-
viduals. But saving the lives of others,
as the dead donor rule itself shows,
has never been a uniformly privileged
activity. Efforts to increase organ sup-
ply would be more fruitfully directed
to increasing acceptance of NHBDs
and the desirability of donating or-
gans generally than to changing the
dead donor rule.

The author is grateful to Mitchell
Berman for helpful comments on an
earlier draft.

IRe1?eireinices

1. American Medical Association, Coun-
cil on Ethical and Judicial Affairs, “The Use
of Anencephalic Infants as Organ Donors:
A Critique,” JAMA 273 (1995): 1614-18;
Laura-Hill M. Patton, “A Call for Common
Sense: Organ Donation and the Executed
Prisoner,” Virginia Journal of Social Policy dr
Law 3 (1996): 387-434; Stuart J. Youngner
and Robert M. Arnold, “Ethical, Psycho-
logical, and Public Policy Implications of
Procuring Organs from Non-Heart-Beating
Donors,”/XAM 269 (1993): 2769-74.

2. John Harris, “Survival Lottery,” Phi-
feo/-^^ 50 (1995): 81-87.

3. William J. Curran and Ward Casscells,
“The Ethics of Medical Participation in
Capital Punishment by Intravenous Drug
Injection,” NEJM 302 (1980): 226-30;
American Medical Association, Council on
Ethical and Judicial Affairs, “Physician Par-
ticipation in Capital Punishment,” JAMA
270 (1993): 365-68; Robert D. Truog and
Troyen A. Brennan, “Participation of Physi-
cians in Capital Punishment,” NEJM 329
(1993): 1346-50; American College of
Physicians, Breach of Trust: Physician Par-

ticipation in Executions in the United States
(Philadelphia: American College of Physi-
cians, 1994).

4. Stuart J. Youngner, personal commu-
nication.

5. President’s Commission for the Study
of Ethical Problems in Medicine and Bio-
medical and Behavioral Research, Defining
Death (Washington, D . C : U.S. Govern-
ment Printing Office, 1981); James L.
Bernat, “A Defense of the Whole-Brain
Concept of Death,” Hastings Center Report
28, no. 2 (1998): 14-23.

6. Bernat, “A Defense,” p. 17.
7. Amir Halevy and Baruch Brody,

“Brain Death: Reconciling Defintions, Cri-
teria, and Tests,” Annals of Internal Medicine
119 (1993): 519-25.

8. Bernat, “A Defense,” p. 18.
9. Stuart J. Youngner, Martha Allen,

Edward T. Bardett et al., “Psychological and
Ethical Implications of Organ Retrieval,”
Af£/A/313 (1985): 321-23.

10. Arthur L. Caplan, “Is Xenografting
Morally Wrong?” Transplant Proceedings 24
(1992): 722-27.

11. “Anencephalic Infants: A Source of
Controversy” [Symposium], Hasting Center
Report 18, no. 4 (1988): 5-34.

12. Medical Task Force on Anencephaly,
“The Infant with Anencephaly,” NEJM’522
(1990): 669-74.

13. Child Abuse Amendments of 1984,
codified at 42 U.S.CA. 5102, 5106, 5111-
5113, 5115 (West Supp. 1998).

14. John A. Fletcher, Michael R. Harri-
son, and John A. Robertson, “Primates and
Anencephalic Infents as Sources for Pedi-
atric Organ Transplants,’ Fetal Therapy 1
(1996): 150-64.

15- D. Alan Shewmon, Alexander M.
Capron, Warwick J. Peacock, Barbara L.
Schulman, “The Use of Anencephalic In-
fants: A Critique,” JAMA 261 (1989):
1773-81.

16. Diane M. Giannelli, “Ethics Coun-
cil Reverses Stand on Anencephalic Organ
Donors,” American Medical News, 25 De-
cember 1995, p. 3.

17. In reT.k.C.V., 609 So.2d 588 (Fla.
1992).

18. George Lardner, “74 Executions
This Year: The Most Since 1995,” Seattle
Times, 15 December 1997. Jack Kevorkian,
the former pathologist who has challenged
laws against assisted suicide, first proposed
the idea in 1985. See Jack Kevorkian,
“Medicine, Ethics, and Execution by Lethal
Injection,” Medicine dr Law 4 {\9850: 307-
312.

19. Patton, “A Call for Common Sense.”
20. Vernon’s Ann. Texas Code Criminal

Procedure Art. 43.25 (West, 1998).

November-December 1999 HASTINGS GENTER REPORT “0 3

21. “Condemned Man Is Hoping to
Save the Lives of Others; He Seeks to Do-
nate His Organs for Transplant after Execu-
tion,” Dallas Morning News 25 October
1993.

22. Patton, “A Call for Common Sense.”
23. Curran and Cascells, “The Ethics of

Medical Participation in Capital Punish-
ment”; American Medical Association,
“Physician Participation in Capital Punish-
ment”; Truog and Brenan, “Participation of
Physicians in Capital Punishment”; Ameri-
can College of Physicians, Breach ofTrtist.

24. Institute of Medicine, Non-Heart-
Beating Organ Transplantation: Medical and
Ethical Issues in Procurement (Washington,
D.C.: National Academy of Sciences,
1997), p. 20.

25. Institute of Medicine, Non-Heart-
Beating Organ Transplantation; University of
Pittsburgh Medical Center, “Policy for the
Management of Terminally 111 Patients Who
May Become Organ Donors after Death.”

2 April 1992, Pittsburgh, Pennsylvania.
26. Conference on Ethical, Psychosocial,

and Public Policy Implications of Recover-
ing Organs from NHBCDs, 10 October
1992, University of Pittsburgh Medical
Center, Pittsburgh, Pennsylvania; “Non-
Heart-Beating Donor Protocols to Increase
Organ Donation” [Special Issue], Kennedy
Institute of Ethics foumal 25 (1993): 1-262.

27. Institute of Medicine, Non-Heart-
Beating Organ Transplantation.

28. Gina Kolata, “Controversy Erupts
over Organ Removals,” New York Times, 13
April 1997.

29. Institute of Medicine, Non-Heart-
Beating Organ Transplantation.

30. Youngner and Arnold, “Ethical, Psy-
chological, and Public Policy Implications”;
Institute of Medicine, Non-Heart-Beating
Organ Transplantation.

31. Institute of Medicine, Non-Heart-
Beating Organ Transplantation; James E
Childress, “Non-Heart-Beating Donors of

Organs: Are the Distinctions between Di-
rect and Indirect Effects and between
Killing and Letting Die Relevant and Help-
ful?” Kennedy Institute of Ethics foumal 3
(1993): 203-216.

32. Kolata, “Controversy Erupts.”
33. Childress, “Non-Hean-Beating Donors

of Organs,” p. 211.
34. Institute of Medicine, Non-Heart-

Beating Organ Transplantation, p. 52.
35. Stuart J. Youngner, Robert M.

Arnold, Michael DeVita, “Issues in Deter-
mination of Death in Non-Heart-Beating
Donor Protocols.” Unpublished manuscript
prepared for the Institute of Medicine
Committee on Non-Heart-Beating Organ
Donation.

36. Youngner, Arnold, DeVita, “Issues in
Determination of Death.”

37. Robert M. Veatch, “The Impending
Collapse of the Whole-Brain Definition of
Death,” Hastings Center Report 23, no. 4
(1993): 18-24.

When Is “Dead”?
by S T U A R T J. Y O U N G N E R ,

ROBERT M. A R N O L D , and

M I C H A E L A. D e V I T A

One way of increasing the supply of vital organs without

violating the dead donor rule is to declare death on

cardiopulmonary criteria after withdrawing life support.

The question then is how quickly death may be declared.

TTn 1996, 60 Minutes ran a story
about the ethical issues associated

J_Lwith procuring organs from indi-
viduals who have been declared dead
using cardiopulmonary criteria—so-
called “non-heart-beating donors”

Stuart J. Youngner, Robert M. Arnold, and
Michaei A. Devita, “When Is Dead?” Hastings
Center Report 2^, no. 6 (1999): 14-21.

(NHBDs). They raised questions
about the ethical appropriateness of
the procedure, intimating that pa-
tients were being given drugs that
would shorten their life in order to
improve organ quality. The story was
quickly picked up by newspapers
around the country that ran head-
lines such as “Murder She Wrote.”‘
In response, in 1997 the U.S. De-

partment of Health and Human Ser-
vices asked the Institute of Medicine
to “explore the medical and ethical
balance between steps to ensure the
availability of as many organs in the
best condition for the transplant and
the rights of patients who may be-
come donors to the highest quality of
care separate from extraneous condi-
tions such as donor organ supply.”^
The IOM’s report found a great deal
of variability in how different trans-
plant centers procured NHBDs. In
an effort to set standards, the report
also presented recommendations for
NHBD protocols.

One of the more controversial
topics the IOM faced was the timing
of death in controlled NHBD proto-
cols. Because of the need to reduce
warm ischemia, organs must be taken
as quickly as possible after death is
pronounced. There are no clear clini-
cal guidelines upon which to make
such a declaration. The question is,
when, in the course of ascertaining
death, is the patient dead, so that the
organs can be taken?^ There is a ten-
sion between making certain that the

HASTINGS CENTER REPORT November-December 1999

Insert Surname Here 7

Name:

Tutor:

College:

Course:

Date:

Cadaveric Organ Donors:

Over the past 20 years or so, arguments of human donations have been debated repeatedly since the act was made a law in most states globally. (What act? By the way this requires a citation). However, Christians have a negative attitude towards donations because it has been turned into a business in most states. In spite of the continual progression in medicine and technology, today the stipulation for organs has become a common issue globally. More than a few authors from different nations have written about advantages and disadvantages of giving human donations. In United States of America, most people have been executed in order for their organs to be retrieved for transplant. The argument from Christian perspective is broad because people have turned the whole issue into a mere business. However, Robertson has diverse answers based on Cadaveric organ donors.

1. What aspect(s) of the human person does your author emphasize: physical, intellectual, emotional, spiritual, and social? Find a sentence which reveals this statement. These reveal the non-moral or moral values important to your author.

“The Dead Donor Rule” is a professional journal written by John Robertson highlighting issues based on vital organs such as kidneys. Based on the author’s arguments, he emphasizes social and physical aspects of a human being regarding Cadaveric Organ especially the kidneys. Despite the scarcity of vital organs, legal rules have been broken concerning cadaveric donations. Robertson’s statement “ethical and legal rule requires donors not to be killed in order to obtain their organs” reveals non-moral values which have been broken reputedly and the legislation has not taken action on the matter.

2. What is the author’s attitude towards human freedom? Does he/she perceive people as totally free, or totally conditioned by heredity? Does your author see a balance between freedom and determination?

Robertson attitude towards human freedom is significant. However, he describes how people like prisoners have been manipulated by the government because they are seen as nonproductive to the society. According to Robertson, proclaims that people are not achieved the maximum liberty required. The author is against the “dead donor rule” which limits organ limits only organ retrieval that causes death. (What are you trying to say here; it’s unclear). The author argues that the dead donor rule should focus on morals and respect before they retrieve the organs because some organs can cause death to an innocent person. (Here too and are you talking about the donor, receiver, or both? What causes this potentially detrimental aspect)? In addition, sometime prisoners are forced to give their organs through execution because they are seen as nonproductive to the society.

3. What sources does the author use for moral values: The bible, science, philosophy, authorities (such as Church leaders, or the civil law), human culture generally understood. Your notes on Gustafson from the first week of class. Find a sentence which reveals this statement.

In this case, Robertson uses authorities for moral values such as a civil law. For instance, the author describes the exclusion of the “dead donor rule” as a burden to some people, for example the prisoners. The author argues that it is wrong for the authorities to under rate prisoners and the needy because they are a humiliation to the society. Over 3,000 people wait for execution yearly in United States in order their organs to be retrieved for transplant. (Citation please)! According to “Gustafson notes”, authorities sometime do not make the right decision to the public. Proposals to retrieve organs for transplant from capital punishment are not a wise decision from the United States Administration.
(Is this according to Gustafson, Robertson, Both, Crook, or you? Whoever it is, this requires a citation).

4. What method does your author use? Does he/she cite rules (thus = deontological), goals (thus = teleological), or the virtues/character which people ought to have?

According to Robertson, he uses different methods to describe the virtues that people should have. The author supports the “dead donor rule” that states that individual should not be killed in order to obtain their organs. In addition, Robertson supports the “dead donor rule” because it prevents people from committing suicide. He also supports Christian virtues that state “it is wrong to sell organs”. According to Christian argument, medical department does wrong to inquire sold organs from unknown people. In addition, Robertson argues that people should be treated like a human being despite their character. (Can you cite this)?

5. What concept of rights does your author espouse: rights as inter​ference, or rights as access to goods, or rights as endowments of goods by societal structures? Find a sentence which reveals your author perceptions.

The rights that Robertson espouse based on “the dead donor rule”, is the rights as endowment of goods by societal structures. For instant, in his statement, “laws and norms against homicide forbid killing s done for the purpose of retrieving vital organs”. The authors support this statement from the law because some people kill in order to benefit from the cost of the organs which are very expensive. Rights of endowment of goods by societal structures are an aspect that most people disrespect. For instance, killing prisoners to have their organs is unethical and against the “dead donor rule”.

6. How does your author deal with conflict of values? Does he/she have a hierarchy of values, so that some take priority over others? Or, does your author makes use of the double effect? Which characteristics of the double effect does he/she employ: indirectness of the evil, proportionality of the good? Find a sentence which reveals this.

Robertson deals with conflict values in different ways in order to benefit the society in general. (What do you mean here)? The author has a chain of command that takes priority over others such as the issue of killing in order to retrieve organs. Conversely, the author admits that it is ethical to offer organs to the needy, for instance people with a special need. This kind of double effect contributes significantly to people relations towards one another. “The dead donor rule is a center-piece of social commitment to respect and human life”. (Citation Please)!

7. What understanding of love does your author reflect? Compare the author to Crook understands of love.

Crook is against the execution of people by the government and the rich who demand for the vital organs. It is unethical and disrespect people and God according to the Christian arguments. (Citation Please)! An additional statement from the crook states that “Removing nonessential organs or tissue from incomplete persons is unethical”. Robertson argues that it is not right to retrieve prisoners’ organs because they are not useful to the society. (This contradicts what you’ve said about Robertson and his position on cadaveric organ donations from prisoners thus far. It requires a citation nevertheless). For instance, the author argues that doctors should be human while handling patients. (Do you mean humane and if so, how? Is this author you refer to Crook or Robertson)? Therefore, Crook and Robertson emphasize people to have love for people equally.

8. Does your author perceive ethics as basically human (presuming that anyone will understand his/her position), or does he/she propose ethics specifically for Christians (heavy use of the Bible would indicate this)?

According to Christian perception it is against the will of God to purchase human organs. (Citation Please)! Robertson in this case does not perceive ethics as basically human; neither proposes ethics specifically for Christians. According to Robertson, Christian objective based on unfolding development of retrieving human organs by force is not ethical. (What do you mean here and by the Christian objective?)
In addition, it is not good to sale organ for transplantation to another individual because it is they belong to God creation. (Citation)?

9. Does your author reveal the kind of participation in a community of value which Crook claims is necessary for making good moral choices?

Robertson reveals the kind of participation in a community value described by Crook in many ways. The author argues that the “dead donor rule” should focus on morals and respect before they retrieve the organs because some organs can cause death to an innocent person. Robertson’s statement “ethical and legal rule requires donors not to be killed in order to obtain their organs”, this sentence reveals good moral values which have been broken reputedly and the legislation has not taken action on the matter. (This is too repetitive! You said pretty much all of this, in an earlier question or more; please change is up a bit. Thank you.)

10. If your author is a Christian, which “Alternative within Christian” ethics does he/she most closely reflect? If your author is not a Christian, which “Alternatives to Christian Ethics” does she/he reflect?

Robertson in this case is not a Christian; however his alternative reflects Christian ethics in different insights. The author states that it is illegal to execute patents in order get their organs. Conversely, Christians are against human killing because based on their teaching, human being should not kill others. Christian supports that individual like prisoners should be done to prisoners willing to offer their organs. (Citation please)! The author supports the “dead donor rule” that states that individual should not be killed in order to obtain their organs. , Christians have a negative attitude towards negative donations because it has been turned into a business in most states.

Work Cited

Crook, Roger H. An Introduction to Christian Ethics. Englewood Cliffs: Prentice-Hall, 1990. Print.

Robertson, J., J. “The Dead Donor Rule” Hasting Center Report 29, no. 6. 1999: 6-4. Prit.