It's Wednesday. Let's talk ethics. Specifically, let's talk organ transplants. Not so much on ethical issues involving bodily integrity (a concept which, frankly, has never made sense to me) nor on whether there is an obligation to donate organs (which is weird, but not incoherent). No, my question is systemic: is the system of organ donation as such ethical?
Right now, as all should be aware, organ transplants are performed on a donation basis. Patients who need organs enter the hospital system and are placed on various registries; and people who donate organs are on similar registries. When there's a match betwen the latter -- the available organs -- and the former, the former are served on the basis (approximately) of need. (I say approximately as issues such as likelihood of organ rejection, recovery, etc. also count.)
It's important to note that this system functions basically on luck. It's sheer luck whether or not someone donates an organ that is needed. It's sheer luck whether or not someone who needs an organ gets one before the lack of one kills them. There's something a little weird about making life or death decisions -- which is what's involved in organ donation and transplant, after all -- on the basis of chance.
There's only an ethical problem, though, if there's an ethically preferable alternative. After all, if organ transplants on the basis of luck are the best we can do, it's nonsense to insist there's anything wrong with it. It'd be like saying there's something wrong with oxygenating our blood.
Well, in 1975, philosopher John Harris published an article called "The Survival Lottery" (if you're interested, it's in The Journal of the Royal Institute of Philosophy, vol. 50, pp. 87-95.) which purports to do just that. I'm not going to rehearse all of the technical details of the argument, as they speak to ongoing philosophical disputes in ethical theory. But the proposal is intriguing. Harris suggests that everyone, at birth, should be provided with the equivalent of a lottery ticket. When physicians/hospitals run out of organs made available by happenstance, they can trigger the selection of someone through this lottery. Presume that the tickets are numbered in such a way as to account for blood type, age, medical history and other factors relevant to the success of the transplant. Whoever is thus selected is killed, and their organs harvested.
When I've told this little story to students, it's the turn at the end that gets their attention, and reprobation. But what, exactly, is wrong with it?
Ordinarily, it's certainly wrong to kill people at random, and that seems to be what's going on here. But transplant situations are not ordinary circumstances: someone will die no matter what. The issue is whether we kill someone and harvest the organ, or sit back and wait while the person in need of a transplant dies.
Perhaps the problem is that the person selected has no choice in the matter. People may make great sacrifices for the well-being of others, even sacrificing their lives, but only if they choose to do so freely. Of course, this again ignores the patient in the scenario: no one, except maybe the most well-informed and willing alcoholic, chooses to need an organ transplant. Why is the interference in the freedom of the sacrificed person worse than the interference in the freedom of the person in need of a transplant?
Perhaps the problem is that the person selected is being actively interfered with by another person, while the person who needs the transplant is being actively interfered with by an accident of nature, i.e., whatever disease or injury or medical condition has caused the relevant organ to need replacement. But this is just false, as if the patient is left to die without an organ, then that is the choice of another person, namely the potential sacrifice who refuses to be sacrificed.
One might sharpen the point in a different way by introducing some kind of concern about bodily integrity, that no one may interfere with or compel us to do things with our bodies that we do not want to, because the bodies in question are ours. But this fails, on one of two grounds. Either one can point out that the right to bodily integrity is surely secondary to the right to stay alive, or one can argue that, on the assumption that the sacrifice'sbodily integrity is as important to him/her as the patient's is to him/her, it follows that the sacrifice doesn't have the right to place the preservation of his/her bodily integrity over the repair of the patient's.
One might worry about the consequences of the survival lottery. Would it lead to more deaths, as the system was abused? Perhaps it would lead particularly to the deaths of the poor, as the rich and powerful manipulate the results to ensure that they are never selected? These sorts of worries aren't about the ethics of the lottery scheme, though; they are worries about whether it could be implemented in a (fairly corrupt) society such as ours.
One might worry that people would disdain their own lives, given that they might be selected for the survival lottery at any time. But, on the other hand, any of us might need an organ transplant at any time. One false step into the street, and, suddenly, we need a new liver or lung or heart. That possibility doesn't seem to lead us to avoid leading meaningful lives; why would another random possibility do any worse?
So, the survival lottery seems like it can avoid most challenges to it. It's certainly not going to result in more deaths than under our current, luck-based regime. Yet -- and this is the odd thing about Harris' survival lottery -- it seems ethically abhorrent. But it's important to see that most of the features of the lottery that we find abhorrent are already present in our current system of organ allocation and transplant.
Which means that, as ethically wrong as the survival lottery seems, the system of organ donation is just as wrong. And isn't that a bit of a problem?