Question

Argument essay about organ retrieval should be performed on all deceased persons despite objections from loved ones.

Answer 1

Introduction

Conscientious objection (CO) in medicine allows healthcare professionals to excuse themselves from participation in provision of a treatment or service that they find problematic for moral or religious reasons. It is most well-known with regard to religious objection to abortion and contraception, but CO is also used by healthcare professionals who do not wish to be involved in provision of assisted suicide or euthanasia in jurisdictions where those practices are permitted. Generally, CO involves healthcare professionals excusing themselves from activities which they regard as harmful: abortion destroys a foetus and euthanasia kills a patient, even if at his or her request.1 Less dramatically, some jurisdictions require healthcare professionals who do not wish to perform non-therapeutic circumcision of male infants to invoke CO.2

A recent consensus statement on the topic of healthcare professional CO argued against the status quo in many countries where healthcare professionals can object, on grounds of conscience, to granting access to ‘legally available, societally accepted, medically indicated and safe services requested by patients in practice for any reason’.3 CO to participation in organ donation might seem stranger still; if a patient wants to save lives by donating organs, what objections could healthcare professionals have? Yet our various experiences in clinical practice indicate that some nurses and doctors do object, sometimes strongly so, to organ donation. This paper, therefore, explores the case for and against permitting CO to organ donation by healthcare professionals. We hope that in doing so, we can stimulate debate in an area of organ donation that is seldom discussed.

The case for permitting CO to participation in organ donation: It is already occurring in secret

There is a long history of CO to certain procedures and practices in medicine that is explicitly recognised and accepted by professional bodies. For example, the UK General Medical Council guidance on CO at the end of life states the following:

You can withdraw from providing care if your religious, moral or other personal beliefs about providing life-prolonging treatment lead you to object to complying with:

(a) a patient’s decision to refuse such treatment or

(b) a decision that providing such treatment is not of overall benefit to a patient who lacks capacity to decide.

However, you must not do so without first ensuring that arrangements have been made for another doctor to take over your role. It is not acceptable to withdraw from a patient’s care if this would leave the patient or colleagues with nowhere to turn.4 (p. 41)

Public support for organ donation is said to be around 90%.5 Yet when families are actually asked to make a decision regarding organ donation, the consent rate proves to be much lower (60% in the UK). Indeed, families are often permitted to invoke a type of CO in terms of allowing family overrule of a known wish to donate. It should therefore be no surprise that some healthcare professionals, just like the general public, will not support organ donation wholeheartedly and even wish to use CO to avoid involvement. Some healthcare professionals may have specific moral or religious objections to how death will be declared or to deceased donation itself. Others might regard organ donation and the procedures required to facilitate it, both before and after death, as against the interests of the patient, whatever the apparent wish of the patient or family to donate. Alternatively, organ donation might be regarded as a distraction from caring for living patients or an unfair distribution of resources, while others still may resent the burden that organ donation processes place on staff, intensive care units and surgery theatres.6 Genuine negativity to organ donation will exist in some individuals, even in the intensive care unit (ICU) community, and this can act as an ongoing barrier to donation either by individual outright obstruction to donation or by more subtle, perhaps even unconscious, obstructions. Un-COs and secret conscientious objecting are very hard to address in a hospital.

Permitting CO would be one potential way to allow people who are strongly uncomfortable with organ donation to step back, rather than remain part of the process in a half-hearted way that may become detrimental. The GMC guidance above can be fulfilled more easily in a system that has ensured arrangements can be made for another healthcare professional to take over patient care where CO exists. Such arrangements can help staff deal with new developments in donation. For example, the single biggest change in deceased donation over the last decade has been the rise of Donation after Circulatory Death (DCD) also known as non-heart-beating donation. DCD now accounts for 42% of all UK deceased organ donors. It has not been without controversy among clinicians.7,8 In the East Midlands of the UK, three years after DCD was first commenced, high negative attitudes to DCD remained strongly evident among ICU healthcare professionals.9 When Children’s Hospital Boston first sought to introduce DCD into their hospital, divided healthcare professional opinion was accommodated by providing for staff CO. The hospital policy anticipated that if DCD were to become widely accepted, newly hired staff might be expected to participate without a right to CO.10 (We do not consider in this paper entire hospitals objecting to DCD for faith reasons, which is more problematic.11)

One of the authors (see below) has even had personal experience that suggests that permitting CO to organ donation in the short term may win people over to supporting organ donation in the long term. This case centred around the development of a DCD programme within an acute hospital. Healthcare professionals in the operating theatres voiced considerable objections to being asked to participate in the retrieval of organs from donors who had, only minutes before, had their death confirmed on the ICU using circulatory criteria (DCD category 2). The staff were objecting on what they saw as moral grounds, as they felt that the speed and approach required to ensure rapid cooling and flushing of organs with cold perfusate was undignified for the deceased. The staff did not feel that this was in keeping with their duty of care (which they saw as persisting after death) and therefore objected to being involved. A total of 20 people initially signed a register of staff who did not wish to be involved in DCD organ retrieval. This was not officially or informally referred to as a CO process, but rather as a register of staff who did not wish to be involved in DCD donation. Nonetheless, it was a type of CO procedure. Despite their initial reservations and refusals to be involved, after being supported over time, the staff were given the option to witness the retrieval and to understand the clear benefits to others, and the donor families, from the process. They began to understand that patients’ dignity was maintained and that the process was something they could support. Ultimately all the staff removed their names from the register of objections. This example shows that allowing CO may reduce unspoken objections to donation and accommodate individuals by finding alternative personnel willing to care for the donor. Box 1 summarises this case.

Box 1.

An example hospital DCD programme which allowed for CO.

The Canadian ‘Ethics Guide for Donation Physicians’ specifically recognises the role donation physicians have in providing respectful and sensitive education to allay healthcare professionals’ concerns.12 Where CO persists, the Guide states that donation physicians must ensure alternative access to donation services such that family and patient wishes are not compromised. The Guide even recognises that whole hospitals may conscientiously object to new donation procedures which may necessitate not only transfer of care to another physician but potential transfer of the patient to another facility that will offer this donation service.

These approaches suggest that organ donation guidelines should provide explicit recognition that there are differing views on aspects of transplant medicine, and that the views of those with COs should, in principle, be respected, and recognise that those who express genuine COs do not usually wish to obstruct the proper working of the transplant system. Within the guidelines, mechanisms to both accommodate CO without jeopardising organ donation should be agreed in advance and outlined in practical detail.

Allowing for CO is a well-established facet of delivering health care in a modern pluralistic society, recognised by many medical regulators worldwide. Not allowing a system for healthcare professionals to object to donation might mean that obstructionist or half-hearted support for organ donation, often unrecognised and occurring in secret, will continue, to the detriment of patients and the success of organ donation. Box 2 summarises potential reasons for permitting CO to organ donation.

Box 2.

Reasons for permitting healthcare professionals CO to donation.

The case against permitting CO to participation in organ donation: Can healthcare professionals step back from saving lives?

Despite some strong arguments in favour of permitting CO, there are also strong arguments against doing so. Are the reasons healthcare professionals might give as objections to participating in organ donation genuinely conscientious? And even if they are, should they be permitted in life-saving areas of medicine?

CO normally involves religious or moral objections. Of these two reasons, religion is perhaps the simpler type; some people believe that organ donation is contrary to the tenets of their religion, and therefore do not want to be involved. This seems like the most traditional type of CO, and if organ donation is really contrary to the beliefs to which the healthcare professional adheres, CO should probably be permitted as it would be elsewhere in medicine (in the context of the army, religious objectors found it much easier to avoid military service than those who merely invoked moral grounds). However, organ donation is supported by most major world religions, so in most cases the supposedly conscientious objector will actually be mistaken about what his religion says on the matter.13 In such cases, suggesting a conversation with a faith leader or chaplain is likely to be more appropriate than permitting CO. If the healthcare professional still objects to organ donation despite theological clarification, it seems more likely that the objection is not truly of a religious nature.

Does it make sense to talk about a moral objection to organ donation? As stated above, it is at least plausible to have a moral objection to abortion because it destroys a foetus and stops a person being born; similarly, many healthcare professionals regard it wrong to be involved in directly ending a patient’s life. However, in the case of organ donation, there is no clear substantial harm to the patient which could form the grounds for CO. (Some premortem measures can be considered as harmful, but would not normally be described as causing substantial harm.) Furthermore, unlike assisted dying and most cases of abortion, organ donation actually saves (other) people’s lives. Healthcare professionals who step back from respecting a patient’s wish to donate also step back from saving other patients’ lives. Therefore, one might expect that the moral reason for CO to organ donation would have to be even stronger than in other healthcare contexts.

It is possible that most ‘moral objections’ to organ donation are in fact based on vague moral qualms about donation, which perhaps are based on intuition or ‘gut feelings’ rather than considered and reasoned judgement – only if some justification is offered for CO can the status of such claims be considered. Just as healthcare professionals should not be able to invoke religious CO if they are mistaken about what religious authorities say, they should not be able to invoke CO without providing reasons that would convince an impartial observer that their objection is genuine – in other words, they should not be able to invoke CO for vague reasons. We concur with Robert Card’s14 argument that ‘medical professionals seeking a conscientious exemption must state reasons in support of their objection and allow those reasons to be subject to evaluation’. The example given in Box 1 might make it sound as if permitting CO is a useful and pragmatic compromise, but in fact it merely illustrates that the initial objections from staff were not genuine CO. If someone really has a genuine, well thought-out moral objection to CO, he or she is not going to change it within a few months, as did everyone in the example, simply because he or she is allowed to invoke CO. Rather, this example suggests that the way to deal with declared objections to donation is not to simply permit CO for all staff but to discuss the issues with them, educate them to dispel any misconceptions and explore reasons for objection – and perhaps then permit any remaining genuine conscientious objectors to step back. (In the example given, there appear to have been no genuine objectors.)

However, there are two stronger moral objections to donation, one of which is also partially legal. What if the motivation for CO is the belief that donation and transplantation processes use up too many resources in terms of staff time, ICU beds and operating theatre time, when those resources could be used on other patients whose lives could perhaps be saved? This reason is not a vague moral qualm, but a specific moral claim. However, it is nonetheless based on a potentially mistaken assumption that organ donation will benefit potential recipients less than using the resources in question to benefit patients who are not potential recipients.15 On greatest benefit (utility) arguments, organ donation should generally be given higher priority in terms of resources.16 Therefore, CO does not seem justified on resource grounds. Furthermore, by invoking CO, those who object on resource grounds themselves make the staff resource issue more pressing, trapping themselves in a paradox.

The other stronger moral reason for CO to donation concerns the definition of death and different types of donation. First, some healthcare professionals may not accept one or both of the current standards that are used to determine when a patient is dead – when death is diagnosed and confirmed using neurological or circulatory criteria (commonly referred to as brain death or circulatory death). It is quite understandable that someone who does not accept one or both of these standards would not wish to take part in a process that involves the removal of organs from a living patient, as that removal would kill the patient and that would be murder, even if societally sanctioned.

In relation to objection to the diagnosis of death using neurological criteria, brain death is accepted in law as the point at which a person is dead, and CO in this context makes less sense. Furthermore, neurological criteria for diagnosing and confirming death are not only used in the context of organ donation. As such, the CO is to the criteria used to diagnose and confirm death, not to organ donation. Anyone who objected to their use in donation would also have to invoke CO in all other cases too.

Similar arguments apply, though less strongly, to the use of circulatory criteria in the context of DCD. As mentioned above, DCD raises some ethical issues. Some healthcare professionals see DCD as violating the dead donor rule as they claim that, were cardiopulmonary resuscitation (CPR) or other resuscitation efforts be made, the patient could be resuscitated even after they have been declared deceased.7 Given that in DCD all patients already have a Do Not Resuscitate Order or CPR has been demonstrated to be futile, this is a theoretical possibility rather than practical. However, if healthcare professionals really believe that their colleagues are involved in removing organs from patients who are not yet dead, why are they not contacting the police? Anyone who does not do so is either complicit in this supposedly unethical practice or tacitly admitting that their CO has no foundation.

Finally, another more general reason for not permitting CO to organ donation is that it sends a mixed message to the public. If healthcare professionals can opt out of taking part in the donation and transplantation process, some members of the public might wonder why they are objecting – is organ donation not a good thing? This indicates the potential downside of letting people invoke CO easily when there are really very few legitimate reasons for it in this context.

Conclusion

CO is a long-standing concept in medicine. In limited circumstances, it allows healthcare professionals to step back from practices to which they hold a genuine moral or religious objection. But CO in general has recently faced a great deal of criticism from ethicists for being unprofessional3 and this seems particularly true in the context of organ donation. Finding good reasons for CO to organ donation is particularly challenging because it involves objecting to participating in a process that aims at saving other patients’ lives. In fact, it may be contrary to professional obligations to refuse to take part, as healthcare professionals have a duty not just to a patient who wishes to donate but also to those who need organs.

There is some merit in the argument that temporarily permitting CO enables dialogue with healthcare professionals that will ultimately result in greater support for organ donation, but there are and should be limits to refusing to participate to a legally available, societally accepted, medically indicated and safe services requested by patients. Healthcare professionals who wish to object for reasons of conscience should be required to at least explain the rationale for their decision. Dialogue is indeed a more plausible alternative in most cases, and we support this stance in the context of organ donation as it will ensure that healthcare professionals have given due consideration to their CO. In other words, it will ensure that any objections are really conscientious. With a few rare exceptions relating to genuinely held reasons for objection, those seeking to exercise CO to organ donation risk moral complicity in letting patients die.