The Giving and Taking of Organs

In The Patient as Person , published almost forty years ago, when transplantation technology was still in its early stages, Paul Ramsey considered different ways of procuring organs for transplant. One might invite people to “opt in,” to donate organs to be used after their death (or, in the case of a paired organ such as the kidney, even before death). One might require people to “opt out” if they did not wish to have their organs taken after death for transplant, presuming consent unless they (while living) or their next of kin (after their death) specifically declined to ­consent. Or one might establish some kind of system whereby organs needed for transplant could be bought and sold (though he was thinking only of cadaver organs).

The third of these possibilities should, Ramsey believed, be rejected altogether. But his verdict with respect to the first two was more nuanced, a comparison of their relative merits and demerits. “If giving is better than routinely taking organs to prolong the lives of patients needing transplants, then it must also be said that routinely taking them in hospital practice would be better than for us to make medical progress and extend treatment to patients by means of buying and selling cadaver organs. That society is a better and more civilized one, I have said, in which men join together in a consensual community to effect these purposes, than a society in which lives are saved routinely, without the positive consent and will of all concerned to do so. It must also be said, however, that a society would be ­better and more civilized in which men are joined together routinely in making cadaver organs available to prolong the lives of others than one in which this is done ostensibly by consent to the ‘gift’ but actually for the monetary gain of the ‘donor.’”

I recalled this passage when reading of the recent proposal by Gordon Brown, prime minister of Great Britain, to deal with what he called “an avoidable human tragedy” by encouraging more people to “donate” organs. Britain’s National Health Service, Brown suggested on January 14, 2008, should move to a system in which organs of the deceased would be taken for transplant, with their consent presumed, unless before death they had opted out or, after death, their family members objected to such use of their organs.

Ramsey’s comparative analysis might remind us that the prime minister’s proposal is not the worst we can envision. Ours is a world in which an increasing number of voices support some form of payment for organs (or, sometimes, for organs from specific populations, such as prisoners nearing death)”thereby turning potential donors into vendors and the body into a collection of parts that are available and alienable if the price is right. This would, Ramsey seemed to think, and I am inclined to agree, be worse than what Mr. Brown has in mind.

Nor, I think, will it do to object to Mr. Brown’s ­proposal on the ground that my body is my property alone, no part of which should be taken or used ­without my explicit consent. There are, after all, ­occasions”if, for example, an autopsy is deemed ­necessary”when we allow the needs of the larger ­society to override the bodily integrity of a deceased individual. More important, though, is that “property” does not seem to be the right way to think of my body’s relation to me. Thinking in those terms may, in fact, leave us defenseless in the face of arguments supporting a market in organs.

Nor is the body of the deceased best thought of as property of his surviving family. If their wishes about its disposal ought to be honored, that is not because they own the body. It is because the life they shared with this one who has died obligates them to give his body proper burial”and the rest of us should do nothing that makes their duty more onerous than it of necessity is or that forces them, while grieving, to fight for the right to carry out such a fundamental human duty. “There is,” as William F. May once put it, “a tinge of the inhuman in the humanitarianism of those who believe that the perception of social need easily overrides all other considerations.”

Still, there are good reasons to draw back from procuring organs for transplant by means of an opt-out system. We need an Orwell among us to note how strained the language of those, like Mr. Brown, becomes when they describe what they have in mind. His aim, he wrote, is “a different consent system” that would “increase donation levels” significantly. But, of course, it is not really “donation” that he has in mind. It is taking, not giving”and a consent that must be presumed is one that only the articulate and the powerful are likely to avoid giving. Those from whom the organs are taken, whose consent is presumed, might better be thought of as useful resources than as donors. Moreover, it would place a special burden on some groups whose beliefs”often, religious beliefs”lead them (except in special circumstances) to object to the giving or taking of bodily organs after death.

The prime minister’s language”of “an avoidable human tragedy” that could be averted were more organs available for transplant”is the sort of talk that has come to characterize most discussions of transplantation, and it begs for careful examination. It is the sort of language that can be used to justify almost anything that promises to help avoid the tragedy of death. And this is exactly the sort of language that, we have come to see, has often distorted the practice of medicine, teaching us to suppose that anything that can be done to ward off death must be done. But the deeper moral truth is that how we live, not how long, is what matters most. And among the possible “tragedies” with which we must reckon would be to live longer by means that debase or undermine our humanity.

Why is giving of organs better than taking, even if taking may provide a greater supply for transplant? To look on potential “donors” chiefly as handy collections of spare parts to be used by others is to lose the sense of the embodied human person as one who, because made finally for God, transcends every location in space and time. A person does not belong, to the whole extent of his being, to any earthly community.

Even the deceased person does not. Why, for example, did an al-Qaeda-led group in Iraq release footage of two corpses that it said were those of U.S. soldiers killed in June 2006? The video showed a decapitated body and several dead bodies being stepped on. This dishonoring of the corpses could have no point were not even the dead body still a reminder of the presence of the person, who can be the “property” of none of us, not merely a “resource” to be used for our purposes, however important they may be.

To see this, however, is to begin to see the deepest truth of all: Even the giving of organs for transplant is not unproblematic. If we first see how troubling even the giving is, we can understand why, if organs are used, they should be given rather than taken.

Human beings are animals, but not just animals. They are almost godlike in some of their powers, but are not gods. To honor and uphold the dignity of our humanity requires that we respect the peculiar nature of this in-between condition. A person is present to us and among us only as one who is embodied”even if also somehow more than body. And we, in turn, know ourselves not simply as a collection of organs but as a unified living being: not reason or will alone, not physical strength or spirit alone, but an integrated union of body, mind, will, and spirit.

Thus, as neurologist-psychologist Erwin Straus once wrote, the truth that “only with eyes can we see” does not mean that we see with the eyes. On the contrary, it is the person, that unified living being, who sees. “Seeing is,” as Straus put it, “located neither in the eye nor in the retina, nor in the optic nerve . . . the brain does not see.” It is the person who sees. For certain ­limited purposes, we may think of or reduce the embodied person to a collection of parts, thinking of the person (from below, as it were) simply as the sum total of those parts. But we do not know either ­ourselves or others that way.

All organ transplantation, therefore, even when organs are given, not taken or purchased, invites us to think of ourselves and others in ways that risk the loss of the full meaning of our embodied humanity. All organ transplantation”even when undertaken for the best of reasons and even when justified”remains troubling. It tempts us to think of the body, in terms Paul Ramsey used, as just an “ensemble of parts,” just a resource.

But a gift cannot so easily be severed from its giver. When an organ is freely given, that gift”like all gifts”carries with it the presence of the giver and directs our attention back to one who is not just a collection of alienable parts but a unified living being. Indeed, what the donor gives is not simply an organ but himself or herself. The gift can never be entirely severed or alienated from the giver. (Which is why, for example, we would think it wrong for a living donor to give an unpaired vital organ, such as the heart. The gift would undermine the very integrity of bodily life that it aimed to express.)

Taking organs, however, even under the somewhat euphemistic rubric of presumed consent, is a quite different matter. Although it does not alienate the organ from the person as decisively as would a system of buying and selling organs, it does go a long way toward treating persons as handy repositories of interchangeable parts. Learning to think of ourselves and others that way would be the true human tragedy and may still, just barely, be “an avoidable human tragedy””to adapt Prime Minister Brown’s words to my own quite different purpose.

We will avoid it, though, only to the degree that we cease to be simply cheerleaders in the cause of transplantation and regain, instead, an older wisdom of and about the meaning of the body. Fortified in that way, and aware of what is troubling about all organ transplantation, we will be better able to think about how it may be done rightly and how it should not be done even in the name of avoiding tragedy.
Gilbert Meilaender holds the Duesenberg Chair in Christian Ethics at Valparaiso University.