Procedural safeguards cannot disentangle MAiD from organ donation decisions

Abstract

In the past, a vast majority of medical assistance in dying (MAiD) patients were elderly patients with cancer who are not suitable for organ donation, making organ donation from such patients a rare event. However, more expansive criteria for MAiD combined with an increased participation of MAiD patients in organ donation is likely to drastically increase the pool of MAiD patients who can serve as organ donors. Previous discussions of ethical issues arising from these trends have not fully addressed difficulties involved in separating decision to end one’s life from the one to donate one’s organs. However, realities of organ donation logistics and human decision making suggest that this separation can be extraordinary difficult. The need to maximise quality of donated organs complicates dying experience of the donor and is likely in tension with the dying experience the patient envisioned when first considering MAiD. Furthermore, the idea that patients will think about MAiD first, and only when firmly decided to end their life, consider organ donation, runs contrary to organ donation policies in some countries as well as end of life and everyday decision making. This opens the door for organ donation to serve as an incentive in MAiD decisions. Dispensing with the simplistic assumption that organ donation can never be a factor in MAiD decisions is, therefore, essential first step to properly addressing ethical issues at hand.

Practice and challenges for organ donation after medical assistance in dying: A scoping review including the results of the first international roundtable in 2021

“…There are several reasons why it is inherently impossible to adhere to the strict principle of separation of care pathways, as advocated in the withdrawal of life-sustaining therapy/DCDD practice to minimize the risk of influence. 91,96,110,[146][147][148][149] First-person consent with ODE respects the interests of autonomy better than deemed or surrogate consent. Some ODEH modes enhance this, as patient care pathways do not intertwine on the final day while the patient is still conscious.…”

“…There is an inevitable intertwining of care pathways and ongoing interactions with the OPO representatives/donor coordinator might influence the donor to maintain consent for MAiD and donation. The MAiD provider needs to understand the dynamics of human decision‐making and the inherent psychological processes of altruism and social desirability that could uniquely influence the MAiD consent process in the context of ODE (but not when MAiD is the only consideration) 146,150–154 …”

“…Resolving the consent issues in ODE starts with the recognition that the death pathway and donor pathway in DCDD involve the same potentially influenceable MAiD patient. There are several reasons why it is inherently impossible to adhere to the strict principle of separation of care pathways, as advocated in the withdrawal of life‐sustaining therapy/DCDD practice to minimize the risk of influence 91,96,110,146–149 . With the withdrawal of life‐sustaining therapy/DCDD, an unconscious patient's decision to donate is not subject to influence if deemed/advance consent is present.…”

“…There are several reasons why it is inherently impossible to adhere to the strict principle of separation of care pathways, as advocated in the withdrawal of life‐sustaining therapy/DCDD practice to minimize the risk of influence. 91 , 96 , 110 , 146 , 147 , 148 , 149 With the withdrawal of life‐sustaining therapy/DCDD, an unconscious patient's decision to donate is not subject to influence if deemed/advance consent is present. In its absence, approaching the family to obtain surrogate consent is explored.…”

“…The MAiD provider needs to understand the dynamics of human decision‐making and the inherent psychological processes of altruism and social desirability that could uniquely influence the MAiD consent process in the context of ODE (but not when MAiD is the only consideration). 146 , 150 , 151 , 152 , 153 , 154…”