Janet Radcliffe Richards is Professor of Practical Philosophy at the University of Oxford, and Distinguished Research Fellow at the Oxford Uehiro Centre for Practical Ethics. Earlier, she was Lecturer in Philosophy at the Open University, and then Director of the Centre for Bioethics in the medical school at University College London. She is a philosopher who originally specialized in metaphysics and philosophy of science, but has now for many years concentrated on the practical applications of philosophy, and is the author of The Sceptical Feminist (1980) and Human Nature after Darwin (2000). She was drawn into transplant ethics some time ago when a short newspaper article of hers was picked up by transplant surgeons, and she has since been a frequent speaker at transplant conferences around the world. “The Ethics of Transplants: why careless thought costs lives” was published in the UK in March 2012.
The trouble with many significant advances in medicine is that that they take us out of our moral depth. They may raise quite different problems from the ones we are used to and, if we are not careful, we may inadvertently undermine the wonderful potential of new technologies by forcing them into existing legal, ethical and institutional frameworks.
Transplantation is a case in point. Transplants save and transform lives; but the only way to get an organ is to take it from someone else, and this has produced a quite distinctive set of moral and practical problems. Not surprisingly, people have strong feelings about their organs, and ever since they understood that parts of their own bodies could be transferred to others, they have demanded explicit rights to control their use. Thousands of people deteriorate and die every year because the organs that could save them are not available, but transplantation scandals are hardly ever about lives unnecessarily lost: they are about organs said to have been improperly procured. Those are the stories that really stir up the public, and cause donation rates to drop still further.
This is something of which the transplant community is acutely aware. In a democracy, transplantation is entirely dependent on public support, and its practitioners know they must tread carefully, and not appear too rapacious in their search for organs. So they concentrate on working through persuasion (‘education’), constantly reassuring us that nobody has any right to demand the use of our organs. If we allow others to use the ones we can spare while we are alive, or the rest after we are dead, that is entirely through our altruism and generosity.
This policy is fine as far as it goes, but it gives the impression that the only obstacle between patients and the organs they need is the personal decisions of potential donors. That is significantly misleading. Individual decisions are made within the legal and institutional arrangements that control the organization of transplantation, and many of those actually work to obstruct the availability of organs.
For instance, we know that many people are willing to give kidneys in return for payment. They did it openly until it was almost universally prohibited, and of course the effect of prohibition – to the extent that it succeeds – is to reduce the supply of organs. Nobody thinks the would-be vendors would simply become unpaid donors. We also know that some people tried to impose conditions on the use of organs of deceased relatives until that, too, was firmly disallowed, so we may reasonably speculate that many more people might be willing to donate their organs after death if they were allowed some say in who was to get them. We know that even if someone who dies has expressed positive willingness to donate, medics will not override the refusal of the relatives. We know (from the few countries that allow it) that some people would like to die, through suicide or euthanasia, in ways that would allow the use of their organs. And for a long time there was a general resistance to accepting so-called Samaritan donors, who simply offered a kidney to anyone who needed one. All such policies work against both the individual wishes of many potential suppliers of organs, and the saving of lives by transplantation.
Why then do these restrictions – and many others that are less direct – exist? They are certainly not a response to public demand. My impression is that they are all rooted in the problems of dealing with transplantation in a legal and institutional framework that was not designed for it, and from traditions and habits of mind that long predate the transferability of body parts. But of course the people who defend the restrictions argue that it would be morally wrong to allow many kinds of organ procurement – even when the organ providers themselves were willing – and that is the real issue that needs debate.
If ethics is to be taken seriously there is no place for the usual impressionistic blur that passes for public debate about these matters. We know from moral psychologists that most of our moral judgments are direct and immediate, rather than the result of reasoning, and that we are rapid, ingenious and determined rationalizers of those immediate judgments. Philosophers, too, have long known that we are natural experts in justifying our moral intuitions in terms of others that are actually at odds with them. If ethics matters, so does serious moral enquiry, and when we start testing our intuitions, as opposed to trying to defend them, the results can be quite unexpected.
The fundamental problem of transplantation is that organs have radically changed their status. In becoming transferrable from one person to another they have become in many ways like other possessions. This is obviously how people themselves immediately regarded them, as they tried to sell organs during their life, or make conditions about their posthumous use. They saw their organs as theirs. The idea also seemed to be endorsed by the official line, that transplantation involved a generous gift. You cannot give what is not yours. On the other hand, we are not used to thinking of body parts as property. The law has never done so, and to many the idea is repulsive because it (wrongly) seems akin to counting people themselves as commodities. This tension has led to innumerable anomalies in current policies and the status of body parts is still unsettled.
This is the fundamental problem our debates need to address, because all the more familiar, superficial problems about policy depend on the conclusions reached here. When enquiry starts from the idea that organs belong to the people whose organs they are – which the public would probably welcome – its whole course becomes startlingly different.
If we really care about saving life and preventing suffering, and making full use of modern medicine, these matters need intellectually scrupulous investigation. Our fallible moral intuitions are not good enough.