CCBI News: Organ Donation after Euthanasia (MAID) Ethical Questions

October 23, 2023

Dear Friends of CCBI,

Organ Donation Part Three: Ethical Questions Associated with Organ Donation After Euthanasia (MAID)

This third part of our ‘Organ Donation’ series considers the ethical questions associated with organ donation after euthanasia, which in Canada is called Medical Assistance in Dying (MAID). First, it’s important to know that such donation is increasing as the number of people who request euthanasia increases. Some ethical questions about what is known as ‘directed donation’ have arisen, where the donor wants to choose the person(s) who will receive specific organs, post-MAID. Second, it’s important to restate that although CCBI is discussing these ethical questions, it is in light of Catholic teaching that euthanasia and physician-assisted death are completely wrong and that life is to be protected as a gift from God from conception until natural death.

Directed Donation and the ‘Dead Donor’ Principle

Until now, the ‘dead donor’ principle has been in effect, meaning that organs will be given to patients first in line on the waiting lists maintained by the provincial organizations responsible for organ donation. There is a generosity about organ donation that marks it as an altruistic and noble action planned in advance by those approaching death, for someone else’s benefit. Those awaiting transplants are the first to express their gratitude for such acts of charity. On the other hand, in ‘live donation,’ the donor is often related to or friends with the person in need of a specific organ. We frequently hear that family members or friends have donated a kidney or part of their liver to someone they hold dear, while at the same time many donors remain anonymous strangers who respond to the need of others.

As MAID took hold, questions started to be asked about directing organs to a specific person after death has occurred. Potential donors asked why they could not make a direct gift of their organs to someone they already knew, instead of their organs being allocated to those first in line on the transplant waiting list.

New Guidelines for Organ Donation After Euthanasia

Guidelines published in the Canadian Medical Association Journal on June 26, 2023, “Deceased Organ and Tissue Donation after Medical Assistance in Dying: 2023 Updated Guidance for Policy,” provide recommendations about the handling of this matter by transplant organizations and programs. As guidelines, however, their legal enforceability is unclear, meaning that a person on the waiting list could challenge the transplant organizers, presumably on the question of more urgent need. The guidelines recommend that organ donation organizations develop their own policy; that directed donations be on a case-by-case basis: that the designated recipient be already on the transplant waiting list; and, even if the donor designates a recipient, the organ should go to the person highest on the list in need of a specific organ.

The last recommendation, however, reiterates the existing ‘dead donor’ rule and could result in challenges by MAID donors. Not only that, but such donors might even decide not to donate their organs if they cannot name a recipient. The literature on this topic seems to imply that transplant organizations would prefer to maintain the ‘dead donor’ rule, i.e., allocating organs to those in greatest need, yet are reluctant to overstate this for fear of losing organs from donors after MAID. Should ‘greatest need’ continue to be the operating principle in these situations or should designated donations be accepted? The latter decision would mean that some would receive organs on a preferential, designated basis, which is unfair to the person in most urgent need. On the other hand, accepting designated donations allows other potential recipients to move up higher on the waiting list. Needless to say, organ donation societies and the medical world are divided on this issue.

Intertwining of MAID and Organ Donation

A letter to the CMAJ in 2019 pointed out some dangers in allowing designated recipients after MAID. The author was concerned about whether those asking for MAID should also be asked at the time of requesting the procedure about their willingness to be organ donors. She believes this sort of question adds a note of seeming altruism to the decision to be euthanized and could be a significant factor in encouraging the person to choose euthanasia, resulting in an increase in numbers of those using the procedure. Her main concern is that many people considering euthanasia as an ‘answer’ to their current life or health problems are often in an extremely vulnerable state and ‘susceptible to influence.’ The likelihood of genuinely full consent is thereby jeopardized and diminished.

The author’s point is that while people have the right to change their minds about receiving MAID right up until the last minute, they may be dissuaded from doing so for fear of disappointing those to whom an organ has been ‘promised.’ She writes, “The inevitable intertwining of the choice for MAID and the decision to donate means that any participation in the subsequent transplant process has the potential both to validate and promote MAID.” As an anesthesiologist, she is refusing to participate in the transplantation of organs from those who have had MAID because she fears these ethical questions are not being given due consideration.

Catholic Teaching on Using Donated Organs After MAID

So far, there is no specific teaching on accepting organs retrieved after euthanasia procedures. The practice of euthanasia is slowly spreading but has been rejected in many parts of the world and is far from being a universal procedure. It has gained ground in more developed countries and partly can be seen as a manifestation of the ethics of choice – “my body, my choice” – itself a product of the more western, individualistic and relativistic approach to ethics, where “I” and ‘my choice’ feature more prominently than the objective rightness or wrongness of the action in question.

Catholic Teaching

Is receiving an organ donated after euthanasia allowed for Catholics? Looking at the Church’s response to using vaccinations obtained from sources using fetal cells, I believe it would be acceptable. The death and serious illness rates from COVID-19 before vaccinations became available led the Church to say that in such life-threatening circumstances even such vaccinations should be accepted. Non-fetal tissue-based vaccines were developed and the Church said they should be preferred, but where unavailable, people should receive those that were available. The Church taught that the level of moral cooperation in evil in doing so was sufficiently ‘remote’ and definitively not ‘formal,’ therefore the grave reason of protecting life was to be followed.

By extension, I suggest that organ donation is a means of saving life. Those awaiting organs do so because their lives are in danger, and they have every reason to accept the first donated organs that become available. The ‘optics’ of receiving an organ from someone who has chosen MAID would, to anyone who rejects euthanasia, appear problematic, yet the recipient had no part in the way the person died and in no way cooperated in the person’s death. I believe receiving organs in such situations is morally acceptable, and it’s important to remember that most organ donations are anonymous.

‘Directed donation,’ however, raises a major ethical question: if a person who needs an organ is named a designated recipient in anticipation of the death of the donor by MAID, then the recipient would be acquiescing to that person’s death and would not only be ‘intertwined’ with a morally wrong decision but would be cooperating formally in the donor’s decision. Catholic teaching finds this completely wrong, and I would add that this is another reason why the ‘dead donor’ rule should be maintained.

Canadian Medical Association Journal
Letter, “Organ donation after MAiD: it’s not that simple.” CMAJ 2019 September 23;191: E1062. doi: 10.1503/cmaj.7298

Pope Francis’ Intentions for October

For the Synod
We pray for the Church, that she may adopt listening and dialogue as a lifestyle at every level, and allow herself to be guided by the Holy Spirit towards the peripheries of the world.

Moira and Bambi