North American Philosophical Publications

When the Dead Do Not Consent: A Defense of Non-Consensual Organ Use

Author(s): J. Jeremy Wisnewski
Source: Public Affairs Quarterly, Vol. 22, No. 3 (Jul., 2008), pp. 289-309
Published by: University of Illinois Press on behalf of North American Philosophical Publications
Stable URL: http://www.jstor.org/stable/40441504 .
Accessed: 14/06/2014 18:49
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .
http://www.jstor.org/page/info/about/policies/terms.jsp

.
JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of
content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms
of scholarship. For more information about JSTOR, please contact support@jstor.org.

University of Illinois Press and North American Philosophical Publications are collaborating with JSTOR to
digitize, preserve and extend access to Public Affairs Quarterly.

http://www.jstor.org

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

Public Affairs Quarterly

Volume22, Number3, July2008

WHENTHE DEAD DO NOT CONSENT:

A DEFENSE OF
NON-CONSENSUALORGANUSE
Wisnewski
J.Jeremy

i. Introduction
theuse
MedicalAssociation
current
regarding
policyof theAmerican
deceasedis toactonlywhen1) thedeceasedis
oforgansfrom
therecently
and2) no member
totheuse ofhisorherorgans,
knowntohavenoobjections
thedeceased'sorthe
use
of
vetoes
oftheimmediate
family,
uponconsultation,
thedeceased'swishes
gans.Thispolicyhasbeencalledthe'doubleveto'i1either
members
orthewishesofthefamily
hisorherremains,
surviving
concerning
thedeceased.
oforgansfrom
tostoptheprocurement
thedeceased,is sufficient
the
Ifeither
vetoesthedecisiontousethedeceased'sorgansfortransplant,
party
will
not
take
of
as
a
matter
place.
policy,
procurement,
I willnot,
I willarguethatthispolicyoughttobeabandoned.
Inwhatfollows,
I
all else.Rather,
shouldtrump
ofthepatient
however,
arguethattheautonomy
on thepartof
consent
reasontotake,without
willarguethatthereis sufficient
is entirely
As I hopetoshow,thisposition
thedeceased,thedeceased'sorgans.
to
we
have
a
facie
view
that
with
the
obligation respectthe
prima
compatible
wishesofthedeceased.
2. Patient Autonomy and the Double Veto
defenseof (at leastpart)of thecurrent
The primary
policy(knownas the
to
relieson theviewthatwe havea moralobligation
Protocol"2)
"Pittsburgh
This
view
can
die.3
these
of
even
after
the
patients
respect autonomy patients,
Whatthe
thanothers.4
in severalways,somemorecontroversial
be defended
in
determinas
one
the
of
is
thus
would
want
deciding-features
regarded
patient
or notsaidpatient's
policyin
organsmightbe used.The current
ingwhether
wouldnot
thata patient
is to presume
medicalpractice
andBritish
American
theorgansof a
consentto organdonation.5
Thus,giventhispolicy,removing
289

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

290

PUBLIC AFFAIRS QUARTERLY

- evenifsucha removalwouldsave multiplelives- cannotbe

deceasedpatient
carriedoutunlessthemedicalstaffhas explicitconsenton thepartof thepatient
(whenhe or she was living),or,thatfailing,on thepartof thepatient-surrogate
(if thepatientdid notspecifyone way or theother),as well as explicitconsent
fromthefamilyof thepatient.
This policy reflectssome ratherintuitiveviews, albeit while ignoringthe
thattheloss ofbodily
them:1) itis thought
philosophicaldifficulties
surrounding
is
the
interests
of
the
the
deceased's
deceased,
integrity against
family,or both,
and 2) consentto theloss of said integrity
is "morallytransformative"
(to use
Alan Werthheimer's
is
It
the
consent
of
all
involved
that
transforms
a
phrase).6
Consent,in thecase oforgandonation,marks
(perceived)harmintoa non-harm.
the difference
betweena violationof one's interestsand a generousact.7By
requiringtheconsentof bothparties(thepatientand thepatient'sfamily),it is
presumedthatwe avoid engagingin morallyquestionableaction.
As I suggestedabove,theseviewsareperfectly
so longas we ignore
intuitive,
someofthephilosophical
difficulties
them
when
we considerthecase
surrounding
ofthedead.I wanttotakea closerlookateachofthesepresuppositions,
andbring
outsomeof thephilosophicaldifficulties
in moredetail.My aim in doingthisis
to beginto considerwhatthedouble vetoleaves wantingas a policyfororgan
In consideringthelimitations
of thedoublevetoby examiningits
procurement.
I
also
problematic
philosophicalunderpinnings, wanttopreparethegroundforan
alternative
view: namely,thatorgansshouldbe harvestedregardlessofwhether
or notconsentis obtainedfromthedeceased or thedeceased's family.
2.1 BodilyIntegrity
is againsttheinterests
of
First,considertheviewthattheloss ofbodilyintegrity
thedeceased,thedeceased'sfamily,
orboth.Ratherthandiveintothevastliterature
on thequestionof whetheror notthedead have interests,8
letus simplyassume
thatthedead do, in fact,have some stakein whathappensaftertheirdeath.If it
can be shownthatthisinterest
in bodilyintegrity
is notsufficient
to avoidorgan
the
case
for
a
of
double
veto
will
be
annihilated.9
donation,
policy
virtually
2.7.7 TheIntrinsically
ValuableView
The mostbasic versionof theview thattheloss of bodilyintegrity
is a harm
consti(whereI willbegin)wouldhaveitthatanyandall loss ofbodilyintegrity
tutesa harmagainstthedeceasedand/or
thedeceased'sfamilysimplyinvirtueof
thefactthatitis a loss. An amputation
wouldconstitute
a loss,on thisview,even
ifitwas requiredforhealth(it is a loss in thesensethat,all thingsconsidered,it
wouldbe betteriftheamputation
hadnotbeennecessary).Likewise,theremoval
of a ruptured
appendixwould countas a loss (on thesame groundsas above).
Let us call thisviewBI1: TheIntrinsically
ValuableView.
Now,as is I hope clear,BI1 has a smelloftheabsurdaboutit.If thedead are
whenanyloss ofbodilyintegrity
harmed,orhavetheirinterests
thwarted,
occurs,

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUAL ORGAN USE

291

itwouldfollowthatanyautopsywouldgo againsttheinterests
ofthedead.10This
would be so even if said autopsywere necessaryin bringingaboutjustice for
evidencethatwouldlead to thecaptureof
thedeceased,perhapsby uncovering
that
it would seem
thedeceased's murderer.
Presuming thedead have interests,
of
thenthatsome loss of bodilyintegrity
(an autopsy)wouldbe in theinterest
of thedeceased,as, ex hypothesi,
all
thedeceased,butalso againsttheinterests
constitutes
a violationoftheinterests
ofthedeceased.
ofbodilyintegrity
disruption
reasontorejectthe(ratherbanal) view
Because thisis absurd,we havesufficient
is itselfof intrinsic
value.11
thatbodilyintegrity
if
is
valuable(ifBI1 is true),itwould
Moreover, bodilyintegrity intrinsically
a harmand/ora thwarting
of
followthatdecompositionitselfwould constitute
theinterests
of thedeceased.12Decomposition,as we now know,is inevitable.13
of what(on thebaIt thusfollowsthatthereis no way to avoid thedestruction
nal view) is positedas havingan intrinsicvalue. The refusalto donateorgans
of thebodyhereseems simply
on thebasis of wantingto preservetheintegrity
ofthebody.Dust willindeedreturn
misguided:one cannotpreservetheintegrity
of a corpsewhenthat
to dust.It seemspointlessto insiston thebodilyintegrity
thesamecorpseonce
the
of
but
to
be
of
some
use,
ignore
integrity
corpsemight
itis in theground.
This consequenceof thebanal view,I think,revealsthatfewpersonsactuthen
ally endorsethisview.If one's aim is to preventloss of bodilyintegrity,
we are notdoingnearlyenoughto preservethecorpse.Even afterembalming,
a corpsewill normallybeginto decomposewithina week.14If we reallycared
of thecorpse,therewouldbe as muchresistance
theintegrity
aboutpreserving
for
as thereis to organdonation.Because themovement
to gravedecomposition
individuals
to
eccentric
is
limited
infinite
(likephilosophy's
veryfew,
preservation
belovedJeremy
Bentham),we havegood reasonto thinkthatthemorecommon
organdonationis a subtlerview thantheone we have
objectionsto mandatory
been considering.
2.1.2 The ClosureView
BI1, we haveseen,is nota particularly
plausibleview.A muchmoreplausible
in
the
idea thatthereare conditionsunder
is captured
view of bodilyintegrity
- butthat
- evendesirable
is permissible
whichtheviolationofbodilyintegrity
inwhichsuchviolationis imperthesearefaroutnumbered
bythecircumstances
forinstance,theviolationof bodily
missible.In thecase of organconscription,
is neitherdesirablenorpermissible.
integrity
advocatedbyphilosoThis formulation
capturesmostoftheviewscurrently
I
thisview
want
to
distinguish
phersand thelaityalike.15For clarity,though,
intofinerstrands.Thereare twotypesofreasonstypicallyofferedagainstorgan
donation:survivor-regarding
reasons,thatplace the benefitof the deceased's
lovedones,or evensocietyas a whole,at thecenterofourdecisionmaking,and
reasons,thatregardthewell-beingof thedead personas of
deceased-regarding

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

292

PUBLIC AFFAIRS QUARTERLY

I willcall theabove view,whenbased on survivor-regarding

centralimportance.
reasons,BI2: TheClosureView.Whentheabove viewis based on considerations
View.I will rethedeceased,I will call theview BI3: TheAutonomy
regarding
ofBI3 forsection2.1.3, below.16
reasons
serveconsideration
Survivor-regarding
includethefollowing:
of a loved one wouldpreventtheabilityof a
1) The loss of bodilyintegrity
to
achieve
the
sort
of
closure
normally
providedbya funeralservice.
family
benefit
Ifthebodyis tamperedwith,withorgansremoved,thetherapeutic
of a viewingof thebodywill be nullified.Indeed,a viewingof thebody
in sucha statemightverywell be traumatic
to theliving.
2)

survivors
Relatedto (1), and as F. M. Kammhas pointedout,17
mayhavea
to
for
the
of
one's
desire
a
loved
"use-history"
bodyparts end with
strong
thehistoryof thatloved one. Much as we wouldnotwanta spouse's ring
to be re-usedafterthedeathof a spouse,we mightfeela strongdesireto
putall of a lovedone to rest.

3)

It mightbe thoughtthat,by givingconsentto taketheorgansof a loved

This,
one,we arecomplicitin theloss ofthatlovedone's bodilyintegrity.
towardorgan
betweenourattitudes
ofcourse,wouldexplainthedifference
on theother.
removal,on theone hand,and decomposition,

Finally,a generalpolicyoforganremovalmighthaveseriousconsequences
forthewaywe regardourselvesas agents.As Kammputsit,"oursenseofourforgoodorill" (221).
selvesas different
embodiedpeoplemaydiminish,
it seems to me, failsto adequatelyjustifyBI2. ArguEach of thesearguments,
in thiscontext,as theybothinvolve
ments(1) and (2) can be dealtwithtogether
theimmediatewell-beingof thoseclose to a lovedone.
First,itis notatall obviousthata viewingofthedeadprovidesthetherapeutic
effect
thatitis oftenclaimedtohave.Itis perhapsrevealingtonoticethattheviewbuta universalculturalpractice.This suggests,at
ingofthedeceasedis anything
a minimum,
thattherearemanywaysto achievehealthyclosureaftertheloss of
a lovedone,as itis unreasonableto suggestthatonlyculturesthathaveviewing
are adequatelydealingwiththefactof death.18
So, evenifitis truethatviewing
an intactcorpsecan aid in themourning
to achieve
process,allowingsurvivors
the
closure,it is nottheonlyway to findsuchclosure norevendemonstrably
best.Indeed,itmightevenbe thecase thatourattitudes
aboutviewingthebody
are in factan instanceof our inabilityto deal withthefactof death.Consider
Kamm'sremarkson thispoint:
4)

thatthelastcontactofthelivingwiththedeadshouldbe
[I]tseemsimportant
withwhatseemstobe anintact
elsemaytakeawaya continuing
body;anything
illusion
oflife.Peoplemayprefer
thattheundeniable
ofdeathandradievidence
cal changethata dismembered
surface
ordecaying
cometoexist
bodypresents
(222)
beyondsight.

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUAL ORGAN USE

293

As Kamm goes on to (correctly)pointout,even if such viewingis crucially

ithas almostno relevanceto theissue
forthebenefitof thesurvivors,
important
can be disguisedforthe
of internalorganremoval.Anyloss of bodilyintegrity
benefitof thefamily.Even ifit is truethatgrievershave therightto experience
an intactbody,it does notfollowthatthebodymustactuallyremainintact.All
- andthis
thatfollowsis thatwe havea dutytomakethebodyappear tobe intact
Of course,if
can be accomplishedin conjunctionwiththeremovalof organs.19
thiswerea generalpolicy,familiesmightwell demandknowingwhetheror not
organswereused.As a workablepolicy,then,thisone wouldbe highlyunsatisfacin theintegrity
ofthe
tory.To counterthedemandsofthosewitha stronginterest
of thosesurvivingthedeceased
corpse,we thusneed to showthattheinterests
(or even of thedeceased himself)can be trumped.This,I think,can be shown
to thisbelow).
quiteeasily(I will return
Let us now turnto the"dirtyhands"objection:theview thatconsentingto
organremovalmakesthegrievingpartof theviolationof thedeceased,implidifference
between
Thereis indeedan important
catingthemin a wrong-doing.
to theimmediate
in thegrave,andconsenting
allowingthebodyto lose integrity
betweenremovingorgansandletting
The difference
loss ofthatbody'sintegrity.
betweenkillingandlettingdie. Evenifwe
themrotis analogoustothedifference
we neednothavea handin it.Thus,whiletherotof
cannotstopdecomposition,
thegravemightwell be lamentable,it is nottheresultof a directactionon the
partof thefamilyof thedeceased (in normalcases). Allowingorgantransplant,
andhencewouldimplicatethem
wouldinvolvetheactionofthefamily,
however,
of thebody.
in thedestruction
butclear.
But noticethatwhatwe are to concludefromthispointis anything
One mightconclude,as it seems thedouble veto does, thatthefamilyshould
have vetopowerwhenit comes to organdonation.This enables thefamilyto
eventhough
fromhavinga handintheloss ofbodilyintegrity,
themselves
prevent
thatloss is inevitable.But anotherperfectly
plausibleresponseis to simplytake
thechoice out of thehandsof thefamily.Givingthefamilyno say whatsoever
wouldservetwofunctions.
First,itwouldactuallyserveas a meansofrespecting
in
a
policydoes not(because thefamily
patientautonomy way thatthecurrent
whenthedeceased wished
the
deceased
wishes
of
the
override
could no longer
to donateorgans).Second,itwouldpreventforcinga familyto dirtytheirhands
witha decision theyare perhapsill-equippedto make (emotionally,morally,
On thisview,then,theobjectionto organdonationactually
or intellectually).
worksagainstBI2: by removingthepowerof thefamilyto veto,we effectively
of the
eliminatethedouble threatof dirtyhands(thattheyviolatetheintegrity
but
of
the
the
body, thereby
body,andso save a life;orthattheypreserve sanctity
let someonedie).
abovewarrants
The finalobjectionmentioned
onlya wordortwo.Itmaywell
woulddrastically
be thecase thata generalpolicyof organconscription
change

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

294

PUBLIC AFFAIRS QUARTERLY

Butthis
thebody,andso forth.
thewaywe thinkabouthumanbeings,personhood,
die
from
failure
is incredibly
When
several
day
organ
every
speculative.
people
thespeculativepossibilitythattheway we thinkabout
due to lack of transplant,
humanagencymightalterseemslikea distantworry.Indeed,ourcurrent
policy
morethanhelpingtreat
suggeststhatwe value ownershipof organspostmortem
thosepersonswho desperately
wanta normallifespan.I welcomesomechange
in theway we thinkof organs.
2.1.3 TheAutonomy
View
ofbodilyintegrity
The otherclass ofarguments
in supportofthepreservation
I called "deceased-regarding"
above. In essence,thesearguments
areconcerned
to respectthe wishes of the deceased. At thispoint,however,I wantto limit
myconcernsto whetheror notthecurrentpolicyof double vetoactuallydoes
exploring
respecttheautonomyof thedeceased. I do thisas a meansof further
In defending
an organ
ourcurrent
(and criticizing)
policyfororganprocurement.
1
will
I
will
do
in
3
return
to the
which
sections
through5,
conscription
policy,
of thequestion.
providinga moresustainedtreatment
questionof autonomy,
As mentionedabove, the double veto requiresthedeceased as well as the
deceased's immediatefamilygive consentto the removalof organsfromthe
deceased. On theface of it,thispolicyseems to conflictwiththeautonomyof
thepatient:ifmywishesto be an organdonorcan be overridden
by thewishes
of myfamilyto preservemybodilyintegrity,
it seemsthat,primafacie,myautonomouswishescan be trumpedby thewishesof myfamily.Thus,it appears
thatthedouble vetopolicyis notin factcompatiblewitha truerespectforthe
autonomyof thepatient.
But thisincompatibility,
it mightbe argued,is onlya primafacieone. T. M.
Wilkinsonprovidesthefollowinganalogy:20
If myparentsrefuseto allow me to
be married,theyhave indeedviolatedmyautonomy.If,however,thewomanI
intendtomarry
refusestomarry
me unlessmyparentsapprove,myautonomy
has
notbeen violated.Likewise,if a doctorwill onlyremoveorgansfroma patient
on theconditionthatboththepatientand thepatient'sfamilygiveconsent,the
doctorhas notviolatedanyone'sautonomy.
to theclaimthatthedoubleveto
This,I think,is a powerfulcounterexample
doesnotrespecttheautonomy
ofthedeceased.Butitis important
nottoexaggerate
theforceofthisargument.
Itdoes notshowthatautonomy
is neverviolatedinthe
doubleveto.It merelyshowsthatitis logicallypossibletorefrain
fromactingon
someone'srationalwisheswithouttherebyfailingto respectthosewishes.
thatthisdoes notaddresstheissueofwhether
thedoubleveto
Notice,however,
itself
is
based
on
for
if
Wilkinson's
policy
respect autonomy.Indeed,
marriage
analogyis a good one,thedoublevetowouldseemto be based moreon respect
fora surgeon'sdesirenotto cause offense.Whilethisis notobjectionableperse,
itdoes pointto a limitation
in theviewthatthedoublevetois designedtoprotect
theautonomyof a patient.Whileitmightnotnecessarilyviolatesaid autonomy,

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUAL ORGAN USE

295

neitherdoes it do muchby way of insuringthattheautonomouswishesof the

deceased are carriedout. Thus, any defenseof thedouble veto cannotrelyon
foreven
theclaimthatthepolicyis justifiedas a meansofprotecting
autonomy,
neither
does
it hold
the
not
violate
autonomy,
though policymight necessarily
highregard.
autonomyin particularly
This pointcan perhapsbe made moreclearlywhenwe noticetwo sensesin
one strong,theotherweak. Rewhichone mightrespectanother'sautonomy,
in
the
weak
sense
can be accomplishedthrough
someone's
autonomy
specting
I respectyourautonomy
a policyof non-interference.
just insofaras I do notdo
out
wishes.
The strongersense of
to
from
carrying your
anything preventyou
chosen
oftheautonomously
autonomyinvolvestheactualpromotion
respecting
someone'sautonomyin thissense,one is required,
endsof others.In respecting
To trulyrespectyourendsinvolves
as Kantclaims,tomakeone's endsmyown.21
wherepossible,to theatbutactuallycontributing,
notmerelynon-interference,
chosen
tainment
of yourmorallypermissible,
autonomously
goals.
thatthedouble
Wilkinson's
forcefully
marriage
analogy,itseems,demonstrates
vetois compatiblewithrespectforautonomyin itsweakersense.A doctoris not
chosenend of donatingmyorgansby allowwithmyautonomously
interfering
is thusa formofrespect.Butthisis a far
veto.
Her
non-interference
a
ing family
whichwouldrequirethe
form
for
of
from
the
respect myautonomy,
cry
stronger
to carryoutmywishesonce I have died.
doctorto activelyattempt
senseofrespect
can be madethatthestronger
Now,I thinkthatan argument
forautonomyis theonlyone thatcan be meantwhenwe talkaboutposthumous
Afterall, it is onlythroughothersmakingourends theirown thatour
interests.
Leftto theirown devices,thedead can acposthumouswishescan be fulfilled.
versionofrespectforautonomy
the
non-interference
complishnothing.Indeed,
wouldresultin nothingbutallowingthedead to decay.On thisview,failureto
a formof
burythedead,ortoconductanytypeoffuneralservice,wouldconstitute
withwhatis naturally
happeningto yourcorpse).
respect(as I am notinterfering
versionof respectfor
As I thinkis obvious,thisis ludicrous.Thus,thestronger
theautonomy
are
about
whenever
we
seems
respecting
talking
required
autonomy
of thosewho have died. If thisis correct,though,we can see thatWilkinson's
thatthedoublevetois compatiblewith
marriageanalogydoes notdemonstrate
herorgans.
respect(in thestrongsense) forthepatient'swishesregarding
does notrespectthewishesof thedeceased
The current
policy,to reiterate,
any morethananotherpolicy not allowingsuch veto decisionswould. Thus,
defenders
ofthecurrent
policycannotappeal to theautonomyofthedeceasedif
the
also
acknowledge poweroffamilymembersto overridethedecisionof
they
thedeceased whenthefamilyobjectsto organtransplant.22
theremightstillbe a case tobe madeon
But,ifwe objectto familyoverrides,
in otherwords,might
thebasis of autonomy.Respectingan agent'sautonomy,
wellbe a reasontorejectthedoubleveto- butitmightalso be a reasontorefrain

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

296

PUBLIC AFFAIRS QUARTERLY

is requiredto save a life,

fromorganconscription,
evenwhensuchconscription
or evenseveral.
This is an important
argument.Indeed, it is the most powerfulargument
I advocate.Dealing withthis
availableagainstthepolicyof organconscription
requires,I think,comingto termswiththelimitsof autonomygenerargument
ally.These limitsare marked,in myview,by thevitalneedsof others.Thus,on
will
myview,insofaras an organshortageexists,a policyof organconscription
claimto theirorgans,as well as a
be justified,evenifthedead havea legitimate
In ordertomorefully
claimagainstthelivingtorespecttheirautonomy.
legitimate
defendthisview,I turn(in section3) away fromthedoubleveto,and towarda
formandatory
organremoval.Beforedoingthis,however,the
positiveargument
some (minimal)attention.
secondassumptionof thedoublevetowarrants

2.2 Consentas MorallyTransformative

of thedouble
I now wantto turnmyattention
to thesecondpresupposition
Thereare a largeclass of
veto:namely,thatconsentis morallytransformative.
cases (all involvingtheliving)wherethetransformative
powerofconsentis obvious.I do notwishto disputethesecases. The issue,though,is whetheror not
thisprincipletransfers
cleanlyto thecase of thedeceased.
betweenthelivingand thedead. The
Thereare some obvious asymmetries
in thecase of thelivingis
veryreasonthatconsentis morallytransformative
thatthe livingdo not object to whatis being done to them.They are willing
in theeventsin whichtheyareinvolved.Exactlywhat"willingness"
participants
- butitseemsclear
examination
consistsin is a questionwellbeyondmycurrent
that"beingwillingto x" is some typeof psychologicalstate.It is mostlikelya
verycomplicatedone (such thatone mightthinkone was willingto x, butupon
realizethatone was onlywillingto y). Ifthisis so, thenoccupyingthe
reflection
stateof "beingwillingto x" psychologicalstate.
If thisis so, it is notclearthattheconsentof thedead has thesame morally
transformative
powerthattheconsentof thelivingdoes. Afterall, partof the
forceof consentis thatitcan be withdrawn
at anymoment:theinstanta person
to
no longerwants have sexual relations(and expressesthis),thesexual act in
whichsaid personis engagedbecomesrape.Consentis significant
onlyif it is
possibleto withholdit.
Ofcourse,thelivingpatientwhoconsentstodonatingorganscouldchangehis
mindat anymoment.In thisrespect,his consentis perfectly
But,as
meaningful.
I mustinsist,thelivingpatienthas different
than
the
he
properties
corpse leaves
A
behind.23 corpseis unableto withholdconsent,and hencecannotconsentto
thosethingsit undergoes.Once again,we findthatconsentis onlydefensible
hereifwe presumeitis possibleto haveobligationsto thedead.
I do notmeanto suggestthatconsentis irrelevant
I thinkconsent
postmortem.
of
is morallytransformative.
in
this
brief
examination
the
secondunMy point

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUAL ORGAN USE

297

of thedoublevetois to showthatendorsingthisview(let's call itthe

derpinning
of
Consent)does notapplyunproblematically
Principle MorallyTransformative
to thecase of thedeceased,and hencecannotbe appealedto as supportforour
current
philosophicaldifficulties
organprocurement
policyunlessthesubstantial
thisview (whenappliedto thedead) are addressed.
surrounding
2.3 VetoingtheDouble Veto
My aim thusfarhas been to showthatthedoublevetopolicyin place in the
oftenpresentedin its
The sortsof arguments
US and UK is deeplyproblematic.
favordo notcarrytheweighttheyare sometimesthoughtto have.This is obviin establishingthata policyof mandatory
organdonationis
ouslyinsufficient
andpractical
even
this
involve
as
greater)
philosophical
equal (or
might
preferable,
are
to whatconsiderations
It is thusnecessaryto turnmyattention
difficulties.
in
of
available favor organconscription.
3. An Argument Against Consent: Reconsidering Autonomy
fortheviewthatthereareobligationstothedead.24
Therearegood arguments
the
dead is somethingwe routinelydo. Does this
of
the
Respecting autonomy
thatthewishofthedeceasedto be buriedwithall ofhis organsis a
demonstrate
reasonto so burythedead?
sufficient

3.1 A Thought
Experiment
Considerthefollowingcase.
Imaginethatyou own vast amountsof farmingland in remoteportionsof
thatitpleases you to thinkof thisland as beingunAfrica.Imagine,moreover,
inhabitedby humanbeings.Finally,imaginethatitis totallyimpossibleforyou
new aboutthisland,and
everagainto use thisland,see thisland,hearanything
so on. In fact,youhaveneverseenthisland- thoughyoucouldhave,atan earlier
time,ifyouhad been willingto engagein some ratherdangerousor uncomfortthefactthatyouownthislandgivesyoucertainprima
able procedures.
Certainly,
to determine
the
facierights.But thequestionis this:are theserightssufficient
basis for
use of theland in question?Is yourownershipof theland a sufficient
itis
limits
to
what
or
there
are
to
the
will
what
land,
happen
ultimately
deciding
withinyourrights(morally)to do?
Suppose a tribebeginsto use yourland forforagingand thelike.Whileyou
wouldpreferforthetribenotto be there(so you could imagineyourland with
itis byno meansclearthatthemerepresenceofthispreferease as uninhabited),
fortheremovalof thetribe.To complicatethings,
ence is sufficient
justification
clean waterin thatarea is to be foundon your
source
of
the
that
only
imagine
land- land,thereaderwill recall,whichyou will neverbe able to visit,to use,
or to hearanynewsabout.Supposethat,ifthetribeis forcedoffyourland,their

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

298

PUBLIC AFFAIRS QUARTERLY

chancesof findinganothersourceof freshwaterare quiteremote.Indeed,it is

likelythattheywill die iftheyare removedfromyourland.
Again,I am perfectly
happyto admitthattheownerofthisimaginedlandhas
certainrightsin regardto thisland. I am evenwillingto admitthatothershave
certainobligationsto thelandowner.Thus,ifthislandwerehijackedby a large
oil company,andthelandwereusedforprofit,
therightsofthelandownerwould
be violated.But thisis notequivalentto sayingthattherightsof theland-owner
In theimaginedcase, theland
cannotby overriddenin certaincircumstances.
ownerhas nothingto gain in refusingto allow thetribeto use thewateron his
ifnotimmoral.Ifthelandland.Indeed,sucha refusalseemsoutright
irrational,
ownersimplyrefusesuse ofthelandon thebasisthathe willbe unabletoimagine
his landas he wouldliketo,and this,moreover,
leads to actualhumandeath,the
- namely,the
landownermightjustlybe accusedoftheworstkindofnarcissism
kindthatkills.It is myviewthatthepreference
of theland-ownerin a case like
thisshouldsimplybe overridden.
This analogyis meantto trackour situationwhenit comes to theorgansof
thedeceased. Even if a personhas certainrightsregardingherorgansaftershe
has died,itdoes notfollowthatthispersoncan do withherorganswhatevershe
wants- nordoes it followeventhatthewishesof thedeceased shouldhave de
factopriority
overotherconsiderations.
Indeed,whilewe oughtto give weight
to thewishesof thedead- respectingtheautonomyof theformerly
living,and
their
our
have
limitations.
wisheswherepossible, respectmust
honoring
Ofcourse,onemightobjectthattheanalogyI havedrawnhereis inappropriate,
as we beara fundamentally
different
to ourbodies thanwe do to a
relationship
distantland.I thinkthispointis correct:ourlivingbodiesarenothing
whatsoever
likeunseenland in Africa,ifonlybecause ourbodyas a wholeis us- or,minimally,itis moreplausiblyus thanan unseenpiece of landevercould be.
But I thinktheanalogyis closer thanthissuggests.Afterall, I am specifically talkingaboutour organsafterwe die. While we have all experiencedour
- veryfewof us eversee our organs.Veryfewof us
bodies- have livedthem
feela particular
attachment
to ourpancreas,forinstance.So, itis misleadingto
talkof thebodyas thoughit is coextensivewithour internalorgans.While the
more
bodyis unlikeunseenland,our internalorgansare actuallysubstantially
analogoustosuchland.Whenwe add tothisthatwe (as dead) cannotexperience,
theanalogyis evencloser.The corpse,again,does nothavethesameproperties
as thelivingbody.
Thisis an important
point,as itderailsone important
objectiontothethought
I
have
been
The
runs
as follows:in orderto
experiment
considering.25 objection
obtainorgans,one mustcompromisetheownerofthoseorgans.Thereis simply
no otherway to getthem.The same is nottrueof distantland.Thus,actionson
someone'sbodyareimportantly
fromactionsinvolving
different
distantproperty.
If thelivingbody(whichis theownerof theorgans)has thesame properties
as

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUAL ORGAN USE

299

thecorpse(thebodythatis no longerliving),thenthisobjectionis devastating

thattheownerof the
Afterall, it woulddemonstrate
to thethought
experiment.
in
to
utilize
the
violated
order
must
be
organshe possesses.
physically
organs
- responsetothisobjectionis topointoutthat
Thesimple- andI thinkintuitive
thecorpseis notidenticalto thepersonwhohad possessionoftheorgansnowin
thecorpse.The livingbodyhas died,and theentitythatremainsis nottheentity
thatwas therebeforedeath.Rather,we havemereremains,nota subjectthatcan
ofitsorgans.Hence,eventhoughthebodymust
be violatedbyourprocurement
inordertoretrieve
be compromised
organs,thiswouldonlycountas an objection
if
to ourthought
experiment thebodypriorto deathwas thesame (had thesame
as thebodyafterdeath.Because thecorpseis themereremainsofthe
properties)
does notwork.
theobjectionto thethought
earlierentity,
experiment

and ExpansionoftheThought
3.2 Implication
Experiment

- a shortagethatis life-threatenThereis a well-publicizedorganshortage26

has serveditspurpose,we arein a positionto see
experiment
ing.If mythought
thatour obligationsto respectthewishesof thedeceased (regardingtheirown
bodies) are sometimestrumpedby thevitalconcernsof others.To reiterate:I
of thedead and dyingare irrelevant.
am notclaimingherethatthepreferences
I thinkthatwe have an obligationto respectthewishesof thedeceased- butI
also thinkthatthisobligationcan be overridden.
Consideranothercase, theexampleoftheUruguayanrugbyteamthatcrashed
As I haveargued
to cannibalismas a meansof survival.27
in theAndes,resorting
consider
thewishesofthe
to
we
like
a
case
in
this, ought
elsewhere,28 considering
to
not
be eaten.Insofar
well
have
the
deceased
that
dead: itmatters
preferred
may
as we do notrespecttheirwishes,thisis lamentable butit is nowherenearas
lamentableas allowingmorepeopletodie fromstarvation.
Thus,despitethefact
- thatwe shouldrespecttheirwishes- the
thatthedead are owed ourattention
wishesof thedeceased mustbe constrained
by theneedsof theliving.
to
are
less
reluctant
we
acknowledgethisin othercases. In a vast
Interestingly,
that
thewishesof thedead can be trumped
we simplyaccept
arrayof situations,
bytheneedsoftheliving:someone'sdesiretobe displayedatoptheEiffelTower
withtheneedsof
afterdeathwill notbe honored,ifonlybecause thisinterferes
theliving(if onlytheneed notto see dead bodies on theEiffelTower).When
ofthedeceased arenotrationally
thepreferences
founded,or demandtoo much
can be trumped
these
the
of
on
the
ofa sacrifice
byother
preferences
living,
part
if it
even
when
dead
to
be
eaten
considerations.
So, even if one prefersnot
can be overridden
morewilldie ofstarvation thispreference
meansthatfifteen
is
donation
of
The
case
of
the
the
needs
exactly
parallel with
organ
living.
by
thiskindof cannibalismcase. Even ifthefamilyof thedeceased objectsto the
cannibalizingof theirfamilymember(because theycannotstomachtheidea of
a lovedone beingtreatedas merefood),thisreluctanceon theirpart(or evenon

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

300

PUBLIC AFFAIRS QUARTERLY

thepartof thedeceased) is notsufficient

to determine
themoralpermissibility
of theaction.
As theseexamplesshow,I think,mandatory
is a policy
organprocurement
in
to
the
current
one.
We
a
situation
where
the
ofperare
preferable
preferences
sons are allowedto overridethepotentiallife-savingcapacityof donororgans.
As I havebeenclaiming,thispolicyis compatiblewiththeclaimthatwe should
respectthewishesof thedeceased (as well as thedeceased's family),provided
thatwe recognizethatthereareconditionsunderwhichthesepreferences
should
be overridden.
It is mycontention
thatthecurrent
stateoforgan-availability
constitutes
sucha condition.Thus,pausingoverthewishesofthedeceased(or their
families)is,inmyview,an immoralpracticeakintotalkingabouta land-owner's
rightto havefantasiesabouthis land as he sees fit,evenwhenthiswill resultin
theunnecessarydeathsof persons.Untilwe have rectified
theorganshortage,
we shouldnotworryourselveswiththewishesofthedeceased,as whatever
their
for
these
will
not
the
interests
those
are,
preferences bodilyintegrity
outweigh
of
whoselivesare in dangerdue to lack ofavailable organs.
Thereis a powerfulobjectionto thisview,involvingreligiousbelief,thatreAs discussedabove,respecting
theautonomyofan agent
quiresmoreattention.29
(in thestrongsense) involvesmakingtheends of an agentour own. Thereare
personswhohavemorethana merelypassingobjectionto organdonation:their
theintegrity
of
verysenseofthemselvesas moralagentsdependson maintaining
thebody.Respectingthesepersonsthusseemsto requireallowingthemto keep
theirorgansafterdeath,as to failto do so wouldamountto forcingthesepeople
to live a liferepletewithhorror.30
Thoughmanyrejectreligiousbeliefstoutcourt,thisproblemcannotsimply
be dismissed.No mattermy level of epistemicconfidenceregardingreligious
matters,
myrespectfortheautonomyof agentsseems to requirethatI respect
those(morallypermissible)
thisis
thingsthatmakeagentswhotheyare. Certainly
partoftheminimum
conceptionofrespectforpersons:torespectwhattheyhave
chosento be. Even on theweakersense of respect,to forcesuch
autonomously
with
personsto donateorganswould seem to amountto a formof interference
theirpractical,moralidentities:31
a policyof mandatory
donation
would,
organ
in effect,forcethesepersons(forexample)to believethattheywould notsee
thekingdomof God, or wouldbe condemnedto an unworthy
life,or something
else of thesame sort.Here,it seems,we have a case whererespectmightwell
requirean exceptionto organconscription.
Beforeconcedingthispoint,though,a fewthingsneed to be noted.First,a
does notentailthateveryone'sorganswillbe used.
policyof organconscription
Afterall,olderpersonsdo nottypically
havereadilyusableorgansfortransplant.
even
if
someonebelievedtheyneededto be buriedwiththeirentirebody,
Thus,
it wouldn'tfollowthatthepolicywouldprecludethisbeingso. The removalof
one's organswouldbe feared,to be sure(muchlikeotherthingsthatwouldlead

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUAL ORGAN USE

301

to scattered
burialwouldbe feared),butsuchfearwouldlikelybe insufficient
to
an
moral
identity.
actuallydestroy agent's
Second,therearecases whereevenourmostcherichedbeliefsareover-ridden
bypolicy(as in epidemics,wherepublichealthconcernstrumptherightto reliSo itisn'tclearthatthemerepresenceofthesestrongbeliefsis
giouspractice).32
forexemption,
whenlifeis at risk.More argument
would
sufficient
particularly
thatis notimmediately
be requiredto establishthis- argument
apparent.
Even if we acknowledgetheimportanceof strongreligiousbelief,though,
thisneed notentailthatthepersonwithsaid beliefswill be exemptfromconto a solutionof theorganshortage.It simplyis notclearthata person
tributing
maintainthattheymusthaveall oftheirownorgansafterdeath.
can consistently
Considerthefactthatmanysuchpersonswouldwillinglytakeinfusionsofblood
or accepttransplanted
organs.If thisis so, thenthereshouldbe no inprinciple
removal
of at leastsomeorgans.
to
the
objection
thathe be buriedwithall organs,
If one insisted,on pain of irrationality,
will
to thecause. Irnotcontribute
thisneed notentailthatourimaginedagent
as usual, comes at a price.Allowingcertainexceptionsmightwell
rationality,
to theorgancause in otherways. Someone who
be conditionalon contributing
insistedon beingburiedwithall ofherorgansmightbe grantedsucha right,for
instance,onlyon conditionthatshe contribute
organswhilelivingthatwould
for
bone marrow,as well as liver
There
is
need
lifetime.
her
rejuvenateduring
to
portions,thatcould be metin thisway,thusallowinga personto contribute
at death.While I am
theorganshortagewhilealso protecting
bodilyintegrity
ofthissortofpolicy,itdoes demonstrate
unsureaboutthefeasibility
(alongwith
theotherreasonsgiven)thatevenrespectfortheautonomyof an agentneednot
organdonation.
produceexceptionsto a generalpolicyof mandatory
4. Two More Objections
Thereare (at least) twoadditionalobjectionsto myviewthatare worthconsidering.These objectionsare as follows:
theuse of mandatory
forjustifying
organ
1) theview advocatedis sufficient
donationsfromlivingpersonsas well as fromthedeceased,thustheview
is unacceptable.
whatwe
This view ignoresourcustomary
abilityto do withourproperty
after
to
be
able
to
is
wantafterdeath.It customary
bequeathproperty death
The bodyis simply
and
of
a will,thegiving inheritance, so forth.
through
is
view
this
To
one morepiece of property. reject
equivalentto rejecting
is
view
thus
wills.
The
therightsof personsto have
unacceptable.
in turn.
I will deal witheach of thesearguments
2)

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

302

PUBLIC AFFAIRS QUARTERLY

4.1 The Organs of theLiving

The first
utilitarobjectionstemsfromtheviewthatmyanalysisis ultimately
ian in nature.Thus,theobjectionruns,ifviolatingtheinterests
of thedead can
be justifiedbecause it will save lives,thenso too can violatingtheinterests
of
theliving.The resultof this,theobjectioncontinues,is a positionin whichwe
wouldacceptmurdering
healthyyoungadultsiftheirmurderwouldpromiseto
benefitseveralneedytransplant
patients.
The first
of
thingto say in responseis thatI accepttheviewthattheinterests
some shouldbe violatedwhenlives are at stake.Thus,theinterest
of warlords
in Africato eliminatecertaingroupsoughtto thwarted,
and theseoughtto be
thwarted
theseinterests
would amountto negpreciselybecause notthwarting
ligenthomicide.
But itdoes notfollowfromthisthatI endorsetheviewthatinnocentpersons
inthenameofmaximizing
shouldbe sacrificed
between
happiness.The difference
thetwocases is plain:Harvesting
from
thelivingwoulddeprivesaid perorgans
sonofsomething
thedead (bydefinition)
cannotbe deprivedof(namely,life).In
takingtheorgansof thedeceased,I am nottakinghis life,or,indeed,anything
he is using.Because thereis no deprivation
takingplace in thecase of thedead,
and to failto transplant
theorgansof thedeceased is simplyto wastethem,the
case of thedead is quitedifferent
fromthecase of theliving.
But thereis a moredifficult
case to consider.Are thelivingobligatedto give
up organswhensuch a sacrificewill nottherebykill them?Thatis, even if we
rejecttheview thatit is permissibleto kill someoneto harvesthis organs,we
muststillface thequestionof whetherit is acceptableto forcea personto give
up organswhenthiswillnotresultin death.
I thinkthattherearepowerfularguments
againsttakingtheorgansofthelivthese
are
not,on myview,absolutelydecisive.The mostimportant
ing,though
on thistopicremainsJudith
Thomson'simportant
violinist
thoughtexperiment
case. To remindthereaderof thedetailsof thiscase:
You wake up one morningand findyourselfback to back in bed withan unconsciousviolinist.A famousunconsciousviolinist.He has beenfoundtohavea fatal
kidneyailment,and theSocietyof Music Lovershas canvassedall theavailable
medicalrecordsand foundthatyou alone have therightblood typeto help.They
havetherefore
kidnappedyou,andlastnighttheviolinist'scirculatory
systemwas
pluggedintoyours,so thatyourkidneyscan be used to extractpoisonsfromhis
blood as well as yourown.33

someoftheimportant
differences
betweenusing
Now,I thinkthiscase highlights
theorgansof theliving,on theone hand,and usingtheorgansof thedead, on
theother.Most intuitions,
in thiscase, go againsttheviolinist(and noticethat
theviolinistis a personin needof a donatedorgan).Despitethepredicament
of
theviolinist(organ-recipient-to-be),
an agenthas no directdutyto give up her

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUAL ORGAN USE

303

- something
organs.To do so, we all recognize,wouldbe an actofmoralheroism
butcertainly
nothingrequiredof theaveragemoralagent.
saintly,
But our intuitionsshift,I think,whenwe imaginetheviolinistattachedto
dead. The burdencreatedbytheviolinistforthedonor
someonewho is recently
is simplynotthesame in thetwocases. Thus,evenif thedead are obligatedto
donatetheirorgans,it simplydoes notfollowthatthelivingare. Now, importhelivingmightbe so obligated,butI do notthinkthispositionfollows
tantly,
on these
thusfarconsidered,nordo I thinkthatourintuitions
fromthearguments
whether
ornotthe
cases areidentical.My taskhere,however,is notto determine
livingmustgiveup theirorgansto thosein need. It is merelyto ask whetheror
or
notthispositionis entailedbythepositiondefendedhere,and hencewhether
notit mightbe seen as an untenableconsequenceof myview.ThoughI am not
surethepositionis, in fact,untenable,thereis good reasonto thinkthatitis not
a directconsequenceof theview defendedhere.
- one thatis substanThereis an additionalcase thatmustherebe considered
the
from
thanthecase of takingorgans
alreadyliving.The case in
tiallytrickier
questioninvolvesthecomatose:is it acceptableto removeorgansfrompersons
who arecomatosein orderto save others?If so, one mightcontend,theposition
thanitinitiallyseemed.Takingorgansfrom
advocatedhereis evenless intuitive
thecomatoseis veryclose to outright
killingthem.
the
note
that
First,let me
questionof whetheror nottakingorgansfromthe
theterm"comatose."Obvicomatoseis permissible
hingeson howwe understand
ously,someonewho is comatose,butwho has a reasonablychanceof emerging
fromthisstate,shouldnotbe subjectedto mandatory
organdonation.This is so,
I think,
forthesamereasonthatthenon-comatose
livingshouldnotbe subjected
to thispolicy.Whateverthepreferred
explanationforthewrongnessof killing,
to
seems
thisexplanation
applyequallywell to livingpersonsand to thosewho
comatose.
arerecentlyand retrievably
Whenthecase shiftstocovertheirretrievably
comatose,myabovearguments
toremoveorgansafterlifesupport
seemto supporttheviewthatitis permissible
has beenremoved
(whendeathoccurs).Ofcourse,thisdoes nottouchthequestion
not
whether
or
of
My owntemptaneedingorgansis a reasontoendlife-support.
a
euthanize
tionis to arguethatit is permissibleto
livingbodyforitsorgans,if
in a comatosestate.This hunch,
we knowinfact thatthepersonis irretrievably
Whatwill decidethisissue,itseemsto me,
ofcourse,cannotpass forargument.
availablein theeuthanasiadebate.If one accepts,as
will be thebestarguments
I do, thatsomeonewho will notrecoverfroma vegetativeor comatosestatecan
be allowedto die (say,in orderto save resources,to respecttheperson,or anyof
to denythatsavingotherlives is nota
severalotherreasons),it seems difficult
reasonforeuthanizing.
Thus,theorgandraftwouldapplytothosewho
legitimate
be euthanized.Again,though,whatis crucialin thiscase seemsto
canjustifiably
Ifeuthanasiaisjustifiedinthesecases, so too
be thateuthanasiaitselfis justified.

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

304

PUBLIC AFFAIRS QUARTERLY

I do notpretendthatthis
will organprocurement
(giventheabove arguments).
settlestheissueofacquiringorgansfromthecomatose,butitdoes (I hope) point
outwhatwillsettlethisquestion:namely,thequestionofthemoralpermissibility
of euthanasia(activeor passive) in thecase of theirretrievably
comatose.

42 TheBodyas Property
The secondobjectionpositstherightto property
as a rightwhichcoversour
will.
of thisright,theobjection
to
do
with
our
bodies
what
we
Because
ability
we
bodies
muchas we handleother
should
be
to
handle
our
runs,
permitted
pieces of property.
I havetworesponsestothisobjection.First,evenifwe acceptthatthebodyis
a piece ofproperty,
whatever
itdoesn'tfollowthatwe can do withthisproperty
we want.Indeed,even ifparts of thebody are property,
thisdoes notfollow.
Much of theargument
forthisclaim has been givenin theprecedingpages. To
reiterate:
we cannotleave ourproperty
in places wheresaid property
endangers
thelivesof others,forexample.Likewise,ifmyabove arguments
work,thereis
in thinking
thatmyrightto do specific
somethingquitemorallyreprehensible
with
another's
more
basic
things
myproperty
trumps
rightto life.
But thereis an even strangerresponseto be made here.As Cecile Fabre
has recentlyargued,iforgansare felicitously
consideredas amongthe scarce
resourcesof the world,principlesof distributive
justice would demandtheir
availabilityto thosein need.34WhileI am skepticalthatbodies,or partsof boditturnsoutthatthisneednotbe demonstrated
ies, can be construedas property,
in orderto showthatproperty
arenotadequateto rejectan organ
considerations
A
has
conscription
policy. powerfulargument been advanced(by Cecile Fabre)
to theeffectthat,/bodypartsare construedas thingsthatcan be property
(as
at the
resources),thenjusticewill commitus to a policyof organre-distribution
timeof death.Thus,evenifmyuncommonintuition
aboutbodies and property
is misguided,an argument
fromproperty
rightscannotstand:evenifbodies and
we havegood reasonto advocatea policyofmandatory
bodypartsare property,
donation.
organ
This leaves open thequestionof whetheror nottheinterests
of thedead in
regardto the dispersalof theirgoods oughtto be respected.It mightwell be
thecase thattherightto inheritone's family'swealthcan be overridden
by the
needsothershave forbasic medicaltreatment,
food
and
adequate
clothing,and
so on. This is an important
it
but
is
fromthe
different
question,
importantly
of
or
not
whether
we
have
the
to
determine
with
what
to
do
(each
question
right
partof) our bodies once we are deceased. Thus, the second objectionagainst
myview fails.

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUALORGAN USE

305

5. Conclusion
In thispaper,I havearguedthattheconsentofthedeceasedshouldnotbe
in orderto use theorgansof thedeceasedin life-saving
operations.
required
toconsider
theinterests
ofthedead,I
WhileI agreethatwe havean obligation
ofthedeadshouldcontrol
thelivesofthe
do notaccepttheviewthattherights
will
is
in
matters
that
determine
who
who
amongtheliving
living particularly
andthedead.35
Hartwick
College

NOTES
1. See T. M. Wilkinson,"IndividualandFamilyConsentto OrganandTissueDonation:Is theCurrentPositionCoherent?"JournalofMedical Ethics,vol. 31 (2005), pp.
587-590.
ofOrgansFollowing
CardiacDeath:
2. H-370.975EthicalIssuesintheProcurement
havebeenadopted:ThePittsProtocol:Thefollowing
ThePittsburgh
guidelines
who
fortransplantation
from
inwhichorgansareremoved
patients
burgh
protocol,
be
treatment
havehadlife-sustaining
withdrawn,
may ethicallyacceptableand
the
shouldbe pursuedas a pilotproject.The pilotprojectshould(1) determine
thenumber
andusability
to thepublic,and(2) identify
protocol'sacceptability
thisapproach.The protocolcurrently
of organsthatmaybe procuredthrough
consent.
ofinterest
andensuring
conflicts
forlimiting
has provisions
voluntary
in caringforpotential
ofinterest
It is criticalthatthehealthcareteam'sconflict
as theprotocol
donorsattheendoflifebe minimized,
currently
provides,
through
ofproviders
theseparation
caringforthepatientat theendof life
maintaining
In addition
totheprovisions
fororgantransplantation.
andproviders
responsible
arerecadditional
intheprotocol,
thefollowing
contained
safeguards
currently
ofinterest,
theprotocolshould
ommended:
(a) To protect
againstundueconflicts
tothepossibility
ofthehealthcareteamtobe sensitive
warnmembers
explicitly
treatment
decisions
thatorgandonationdecisionsmayinfluence
life-sustaining
ifthereis somereasonto
whenthedecisionsaremadeby surrogates.
Further,
shouldbe required,
thenthehealthcareteammembers
suspectundueinfluence,
of
toobtaina fullethicsconsultation,
notmerelyencouraged,
(b) Therecipients
ofthesource
underthePittsburgh
protocolshouldbe informed
organsprocured
defectsinthequalityoftheorgans,so that
oftheorgansas wellas anypotential
whether
to accepttheorgansor waitfor
theymaydecidewiththeirphysicians
shouldbe developedtoensurethat
moresuitableones,(c) Clearclinicalcriteria
whoseorgansare reasonably
candidates,
likelyto be suitable
onlyappropriate
areconsidered
fortransplantation,
eligibletodonateorgansunderthePittsburgh
CSA Rep.4, 1-02).http://www.amaprotocol.(CEJARep.4 - 1-94;Reaffirmed:
assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-370.975.
2, 2007.
HTM, lastaccessedon January
This has been amendedas follows:

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

306

PUBLIC AFFAIRSQUARTERLY
E-2.157OrganDonationAfter
CardiacDeath:Giventheincreasing
needfordonor
organs,protocolsfordonationaftercardiacdeath(DCD) havebeendeveloped.
Controlled
whohaveagreedtobe takenoffoflifesupport
DCD allowspatients
ortheirsurrogate
decisionmakerstheopportunity
todonatethepatients'organs
in or
once deathhas beendeclared.In thesecases,lifesupport
is discontinued
neartheoperating
roomso thatorganscan be removedpromptly
afterdeathis
DCD also maybe considered
frompatients
whosuffer
pronounced.
unexpected
cardiacdeath(uncontrolled
thattheybecannulated
andperfused
DCD). Itrequires
withcold preservation
fluid(in situpreservation)
withinminutes
afterdeathto
maintain
theviability
oforgans.Bothofthesemethods
be
may ethically
permistocertainsafeguards.
sible,withattention
detailsoftheDCD process,such
(1) Hospitalpoliciesshouldspecifyimportant
as therequired
timedelaybeforedeathcan be pronounced
aftercardiacarrest.
itis criticalto avoidperceivedoractualconflicts
ofinterest
(2) In all instances,
in thehealthcareteamwithrespectto caringforthepatientversusfacilitating
careat theendof life
organdonation.The healthcareprofessionals
providing
shouldbe distinct
fromthoseparticipating
on thetransplant
team.No member
ofthetransplant
lifesupport
teammayhaveanyroleinthedecisiontowithdraw
orintheprocessleadingtopronouncement
ofdeath.
canshouldbe inplacetoensurethatonlyappropriate
(3) Clearclinicalcriteria
are
didates,whoseorgansarereasonably
likelytobe suitablefortransplantation,
considered
eligibletodonateorgansundertheseprotocols.
afterremovaloflifesupshouldcontinue
(4) PalliativecareforDCD candidates
portuntildeathis declared.
lifesupport
shouldbe madeby
DCD, thedecisiontowithdraw
(5) In controlled
thepatient
orthepatient's
decisionmakerbeforeanymention
oforgan
surrogate
donation(unlessthepatientor surrogate
broachesthesubject).
spontaneously
Thisis meantto ensurethatwithdrawal
oflifesupport
is notinfluenced
bythe
oforgandonation.
prospect

Theinformed
consentforcontrolled
DCD shouldincludespecificdiscussionof
interventions
aimedatorganpreservation,
theopportunity
toimprove
pre-mortem
forsuccessful
thantobenefit
rather
thepatient.
Interventions
that
transplantation,
arelikelytohastendeathmustnotbe used.
DCD, priorconsentof thedecedentor consentof
(6) In cases of uncontrolled
thedecedent'ssurrogate
decisionmakeris ethically
Perfusion
without
required.
consentto organdonationviolatesrequirements
ofinformed
consentformedical procedures
andis notpermissible.
(I, III, V) IssuedJune1996basedon the
"EthicalIssuesin theProcurement
ofOrgansFollowingCardiacDeath:
reports
The Pittsburgh
Protocol"and"EthicalIssuesin OrganProcurement
Following
CardiacDeath:In SituPreservation
of CadavericOrgans,"adoptedDecember
1994.UpdatedNovember2005 based on thereport"OrganProcurement
FollowingCardiacDeath,Amendment"
adoptedJune2005. http://www.ama-assn.
org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-2.157.HTM,
lastaccessedJanuary
2, 2007.
3. Thereare important
whendeathshouldbe said to occur.As
questionsurrounding
thecontroversy
is notimmediately
relevantto mycurrent
I will
sortingthrough
inquiry,
nothereaddresstheissue. For an arrayof positions,see The DefinitionofDeath: Con-

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUALORGAN USE

307

ed. StuartJ.Youngner,RobertM. Arnold,and Renie Schapiro

Controversies,
temporary
Press,1999).
(Baltimore:JohnsHopkinsUniversity
4. An obviouswaytodefendtheviewis to claimthatwe haveobligationstorespect
thewishesof all humanbeings,and allowinghumanbeingsto dispose of theircorpses
as theywishis partof whatis involvedin respectinghumanbeings.
tounderstand
Thisview,ofcourse,facessomeobviousproblems:itis difficult
whyan
it
the
Other
as
would
to
human
extend, were,beyond grave.
obligations
persons
obligation
clearlydo notso extend(like,forexample,an obligationto help someonemove).When
one dies, one ceases to be a humanagent,and hence loses themoralstatusof human
agents(or so one objectionmightrun).Whilewe shouldrespecttheautonomyof all huto thinkthata corpseis a humanbeingin thesamemoralsense
manbeings,itis a stretch
as a livingpersonis. A corpseis notresponsible,cannotrespondto claimsmadeuponit,
and,afterall, is notautonomousin any sense of theterm.Thus,evenifitis truethatwe
oughtto respectthewishesof humanbeings,it simplydoes notfollow(directly)from
thisthatwe have a moralobligationto respectthewishesof a personwhenthatperson
no longerexists(I assume,forthesake of convenience,thatdeathis final).
To defendtheview thatwe shouldrespectthewishesof thedeceased thusrequires
are
fortheviewthatwe haveobligationsto thedead. Whilesucharguments
an argument
available- and quiteconvincingones,in myview- I am willingto simplyconcedethat
Let us grantthatthereare obligationsto thedead,
we can escape theabove difficulties.
and thattheseinvolverespectingthewishesof thedeceased.
5. This, of course,is notthecase in manycountriesin Europe,wherea policyof
presumedconsenthas becomethelaw of theland in manynations.
ConsenttoSexualRelations(Cambridge:CambridgeUniversity
6. AlanWertheimer,
in BuffaloCriminalLaw
Is Consent?And Is itImportant?"
"What
also
See
Press,2003).
Review,vol. 3, pp. 557-583.
andbat7. The sameanalysisappliestonumerousothercases: rapeandsex,surgery
onlyin thatone ofeach pairinvolves
pleasurediffer
tery,violenceand sado-masochistic
consent,whereastheotherlacks it. Indeed,thepresenceof consentin all of thesecases
changesthemoralstatusof theactionin question.
8. A nicecollectionofsomeoftheseminalarticlesis TheMetaphysicsofDeath,ed.
Calif.: StanfordUniversity
Press,1993).
JohnMartinFischer(Stanford,
9. The secondassumptiontobe explored,as mentionedabove,is thattheconsentof
of
If itturnsoutthatviolationofbodilyintegrity
thedeceasedis morallytransformative.
thedeceased is notproblematic,
though,therewill be no needforanymoraltransformation.Thus,ifthefirstassumptionbehindthedoublevetois to be abandoned,thesecond
assumptionsfallsas well. I will have moreto say aboutthisbelow.
thestatereservestherightto conductan autopsyregardlessof the
10. Interestingly,
wishesof thefamilyor deceased.
and
11. Of course,one mighthereobjectthatthedead can havecompetinginterests,
in endingbodilyintegrity.
Rather,
servedin an autopsyis notan interest
thattheinterest
servedthroughautopsy.This
injustice,whichis (contingently)
thedead has an interest
as
be
cannot
however,
interest,
regarded trulycompetingwiththe(necessary)
contingent
ofbodilyintegrity
in themaintenance
interest
(whenpositedas an intrinsic
good). I find
warrants
butitnevertheless
ifnotoutright
thisresponseunconvincing,
question-begging,
further
argument.

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

308

PUBLIC AFFAIRSQUARTERLY

12. Thereis of coursea distinction

to be made betweentheharmsand theinterests
of thedead, butI will leave thisaside, as it is notimmediately
germaneto thecurrent
discussion.
13. Most people probablythinkwe always knew this.Surprisingly,
though,early
ofembalming
claimedthattheirprocedurewouldpreservethecorpseforever.
practitioners
We now knowthisto be woefullyinaccurate.Indeed,thebestway to preservea corpse
- a processthatappearsto be able to maintaintheintegrity
now seemsto be plastination
of thecorpseforan estimated10,000years.
14. See KennethV. Iserson,Death toDust: WhatHappens to Dead Bodies? 2nd ed.
(Tucson: Galen Press,2001).
15. But notall. See, forexample,Cecile Fabre,WhoseBodyIs ItAnyway?(Oxford:
OxfordUniversity
Press,2006); and Aaron Spital,"Conscriptionof CadavericOrgans
forTransplantation:
NeglectedAgain,"KennedyInstitute
ofEthicsJournal,vol. 13, no.
2 (2003), pp. 169-174.
16. Of course,it is possible forsurvivor-regarding
and deceased-regarding
reasons
to overlap.The distinction
shouldbe understoodas heuristic.The deceased mightwell
have an interest
in thefamilyviewingthebodyof thedeceased,forexample.
17. See, Morality,
vol. 1: Death and WhomtoSave FromIt (Oxford:Oxford
Mortality,
Press,1993), pp. 221-222.
University
18. Indeed,thelargestcountry
toengageinsuchpractices(theUS) is routinely
referred
toas "death-denying"
inthesociologicalandanthropological
literature
ondeath.See Robert
to theStudyof theCollectiveRepresentation
Hertz,A Contribution
ofDeath, in Death,
and Burial:A Cross-Cultural
Reader,ed. AntoniusC. G. M. Robben(Maiden,
Mourning,
Mass.: Blackwell Publishing,2004), pp. 197-212; ElisabethKubler-Ross,Death: The
Final Stage ofGrowth(New York:Touchstone,1986); GaryLaderman,Restin Peace: A
CulturalHistoryofDeath and theFuneralHome in Twentieth
America(Oxford:
Century
OxfordUniversity
Press,2003); GaryLaderman,TheSacredRemains:AmericanAttitudes
TowardDeath,1799-1883 (New Haven,Conn.:Yale University
Press,1996); andJessica
TheAmericanWayofDeath Revisited(New York:AlfredA. Knopf,1998).
Mitford,
19. These same considerations
of an orapplyto thedesireto have theuse-history
withthehistoryof theperson.The mostthatfollowsfromthisis that
gan co-terminate
thefamilyshouldnotbe informed
thatthedeceased's organshave been harvested.This
wouldallow 1) thefamilyto have thecomfort
of an endeduse-history,
and 2) thebenefit
of harvesting
usable organsto save thelivesof thosein need.
20. See T. M. Wilkinson,"Individualand FamilyDecisionsAboutOrganDonation,"
JournalofAppliedPhilosophy,vol. 24, no. 1 (2007), pp. 26-40.
21. In The Metaphysicsof Morals, Kant claims thatthe categoricalimperative,
in
theformulaof humanity,
captures,amongotherthings,the"dutyto makeothers'ends
myown (providedonlythattheseare notimmoral)"(Cambridge:CambridgeUniversity
Press,1996), 6:450.
22. This is notto say thatthepolicyis inconsistent.
See T. M. Wilkinson,"Individual
and FamilyConsent."
23. Even thosewho thinkwe are ourbodies,likeFredFeldman,wouldagreeto this
point.(On Feldman'sview,we continueto existafterwe die, butwe existas a corpse.

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions

A DEFENSE OF NON-CONSENSUALORGAN USE

309

Althoughthepersonis identicalto thebody,thedead body[whichcarrieson afterdeath]

withthe
has different
propertiesfromthe livingbody. See Feldman's Confrontations
Oxford
Press,1994]).
University
Reaper [Oxford:
24. See, forexample,Bob Brecher,"Our Obligationto the Dead," JournalofApplied Philosophy,vol. 19, no. 2 (2002), pp. 109-119; GeoffreyScarre,"Archaeology
and Respectforthe Dead," JournalofAppliedPhilosophy,vol. 20, no. 3 (2003), pp.
237-249; T. M. Wilkinson,"Last Rights:The Ethicsof Researchon theDead," Journal
Wisnewski,"A Defense
ofAppliedPhilosophy,vol. 19,no. 1 (2002), pp. 31^1; J.Jeremy
vol. 18, no. 3 (July2004), pp. 265-272; and
of Cannibalism,"PublicAffairsQuarterly,
Wisnewski,"WhatWe Owe theDead," JournalofAppliedPhilosophy(forthcoming).
A possibleresponse
raisedbyan anonymousreferee.
25. Thisobjectionwas forcefully
- was also suggestedby this
to thisobjection- theone thatI use, it shouldbe admitted
referee.
26. Accordingto the 2005 OPTN/SRTRAnnualReport,therewere nearly87,000
patientson thewaitinglistforvariousorgans.
27. This was popularizedin thefilmAlive!
28. Wisnewski,"A DefenseofCannibalism";and"Murder,Cannibalism,andIndirect
World,
Suicide:A PhilosophicalStudyofa RecentCase,"PhilosophyintheContemporary
vol. 14,no. 1 (Spring2007), pp. 11-21.
29. I am deeplyindebtedto Cecile Fabre'sdiscussionofthisissue,as well as ofsome
to
solutions,in WhoseBodyIs ItAnyway?The idea of livingdonationsas an alternative
book.
from
this
is
I
use
which
below,
donations,
important
postmortem
30. I haveinmind,forexample,personsoftheJewishfaith,whobelievethatthebody
mustbe buriedwholeifit is to pass intothecompanyof God.
Wisnewski,
3 1. For a moredetaileddiscussionofthiskindofproblem,see J.Jeremy
"StrongEvaluations,Criticism,and Agency,"Journalof Value Inquiry,vol. 40, no. 1
(March2006), pp. 45-57.
to Leah McClimansforbringingthispointto myattention.
32. I am grateful
in Ethics:History,Theory,and
JarvisThomson,"A DefenseofAbortion,"
33. Judith
Issues, ed. StevenCahn and PeterMarkie (Oxford:OxfordUniversity
Contemporary
Press,2002), pp 739-750, p. 740.
?
34. Fabre,WhoseBodyIs ItAnyway
version
35. I wouldliketothankLeah McClimansforhercommentson an embryonic
of thispaper.I wouldalso like to thankan anonymousrefereewho providedcomments
thathave shapedthispaperin tremendous
and criticisms
ways.If onlyall refereeswere
so helpful!

This content downloaded from 188.72.126.41 on Sat, 14 Jun 2014 18:49:55 PM

All use subject to JSTOR Terms and Conditions