The Ethics of Transplants: Why Careless Thought Costs Lives

Organs for transplantation come from other human beings, who may be alive or dead at the time of donation. Each option entails emotive and ethical issues, compounded by the fact that the number of people who might benefit from organ transplantation exceeds the number of organs available. How to fill that gap is a question that exercises practitioners and politicians alike.

As Janet Radcliffe Richards notes, there are few who disagree with her starting proposition that if a person's "life or health can be saved by means of a transplant, that is in itself a good thing". However, she characterises current debates as largely a "Confused Noise", thus motivating her "pre-political enquiry" to clarify just what is worth disagreeing about in relation to organ procurement. In this quest, Radcliffe Richards presents herself as an honest broker, clearing away woolly thinking to allow the voice of reason to prevail. This is an admirable aim, but she falls short of achieving it, not least because of the way in which she sets up the parameters of the debate. For while organ transplantation may generally be a good thing, it by no means follows that it is always, invariably (ie, intrinsically) good, and even if it were, it does not follow that there should be a presumption against any obstruction to organ procurement. But Radcliffe Richards presents these as obvious truths, thereby taking for granted matters that should be investigated.

Views about organ markets are polarised between those who take a laissez-faire approach and those who think, for various reasons, that organs should not be bought and sold. Radcliffe Richards aims to show that opposition to organ markets is based on intuition rather than reason. She examines and dismisses many of the familiar arguments, including harm to sellers, coercion of various sorts, exploitation and commodification. Her dismissals do not do justice to serious questions about the relationship between our bodies and our identities, or about the nature of autonomy, which cannot be simply equated with unfettered choice.

The background assumption that procuring organs saves lives remains unchallenged, even though the organs in question are kidneys, and while it is true that people are generally better off with a kidney transplant than they are remaining on dialysis, kidney transplants are not commonly life-saving.

Post-mortem organ donations raise a different set of issues, and here Radcliffe Richards presents a number of provocative suggestions. First, we should formally and legally accept that organs are property. This would allow organs to be willed like other property, thereby defusing questions of family consent. Second, directed donation should be permitted; and third, reciprocity should be mandated - so that only those who are willing to be donors are eligible to receive transplants.

The most interesting questions are raised in the final chapter on recognising death. Our technological prowess has dissociated previously contemporaneous events occurring at the time of death, such that permanent loss of brain function can now occur in the presence of continuing cardiorespiratory function. We no longer have a settled and objective sign of death. Radcliffe Richards argues that the declaration of death cannot be determined by medical investigation; rather it is a moral question concerning what it is about life that matters.

Radcliffe Richards succeeds in being confrontational and will no doubt stimulate debate. But overall, this book is disappointing and misleading; this is not a "pre-political" dissection of fundamental issues to do with organ donation. Rather, it seems to be an unacknowledged attempt to steer the debate in a particular direction.