How should society respond to the increasingly long list of people waiting for organs [2] on a transplant list? You’ve no doubt heard of “black market” [3] organs in foreign countries, but are there other options that should be off the table? If you were on a transplant list, would it matter to you if the organ was obtained from a living person who died because of the donation procedure itself? What if she had volunteered?

Your thoughts on this topic have implications beyond the issue of transplantation. As the former co-director of Vanderbilt University’s lung transplant program and a practicing intensive care unit physician, I see organ donation a selfless gift to those approaching death on transplant wait lists. However, I’m wrestling with the emerging collision between the worlds of transplantation and euthanasia.

Cause of death: organ donation?

We understand that Benelux countries and Canada have approved physician-assisted suicide and euthanasia (PAS-E), while others are adamantly opposed to this practice. The American Medical Association just voted to uphold its long tradition of opposition to PAS-E [4], while at the same time its journal (JAMA) published a report of retrieval of organs for 409 liver transplants from a single Belgian center, of which 11 (2.7%) were from cadavers of patients following death by euthanasia [5]. The topic covered below is about something qualitatively different: death by donation.

At international medical conferences in 2018 and 2019, I listened as transplant and critical care physicians discussed “donation after death”. This refers to the rapidly expanding scenario in Canada [6] and some Western European countries [7] whereby a person dies by euthanasia, with a legalized lethal injection that she or he requested, and the body is then operated on to retrieve organs for donation [5]. At each meeting, the conversation unexpectedly shifted to an emerging question of “death by donation”—in other words [8], ending people’s lives with their informed consent by taking them to the operating room and, under general anesthesia, opening their chest and abdomen surgically while they are still alive to remove vital organs for transplantation into other people. The closest thing to this previously discussed is Imminent Death Donation (IDD), but in IDD the patients agreeing to end their lives are ill and on life support [8] whereas “death by donation” would include volunteers who are without illness.

The big deal here is that death by donation would bypass the long-honored dead donor rule [9], which forbids removal of vital organs until the donor is declared dead. Death by donation would, at present, be considered homicide to end a life by taking organs. The mechanics of obtaining organs after death from either euthanasia or natural cardiac death (both already legalized in Canada, Belgium and Netherlands) can be suboptimal for the person receiving the transplant, because damage occurs to organs by absence of blood flow during the minutes and sometimes even hours long dying process. This interval is called ischemia time [10]. Note that organ retrieval from brain-dead, heart-beating donors accrues no ischemia time. Death by donation purports [11] to offer a novel solution to ischemia time accrued after euthanasia. Instead of retrieving organs after death, organ removal would be done while organs are still being receiving blood. There would be no ischemia time and organ removal would be the direct and proximate cause of death.

Whereas the lawful practice of PAS-E involves ultimately one physician taking the action of prescribing or injecting lethal medications, “death by donation” would involve an entire team of medical professionals. Would all of the members of such a team likely consent to be involved in such a procedure? And then the recipients of the organs: can they object to receiving an organ from a person whose life was ended by taking out vital organs?

Unintended, unavoidable consequences

Recently, the New England Journal of Medicine (NEJM) published an article [12] by two Canadian physicians and an ethicist from Harvard Medical School, who contended it might be ethically preferable [13] to ignore the dead donor rule if patients declare they want to die in order to donate their organs. While literally “giving yourself” to others might seem commendable at first glance, let’s discuss three downstream considerations to abandoning the dead donor rule.

  • People with physical and mental disabilities have expressed that they feel stigmatized and that society devalues their lives. Would this send them a not-so-subtle message to get out of the way and do something noble with their healthy organs?

  • How quickly would we see expansion whereby those who can’t speak for themselves are included as donors?

  • What does it mean for all of us when our healers—physicians—are in a position that directly overrides nearly 2500-year-long [14] prohibitions against taking life?

Consider the case of Ben Mattlin, who suffers from spinal muscular atrophy. In a 2012 column for the New York Times [15], he wrote of the “thin and porous border between coercion and free choice” for those who feel devalued. On the subtle erosion of his autonomy, he wrote: “You also can’t truly conceive of the many subtle forces (to die)—invariably well meaning, kind-hearted, even gentle, yet as persuasive as a tsunami—that emerge when your physical autonomy is hopelessly compromised”. Civil society is measured by how we treat our most vulnerable members. Euthanasia laws are structured to protect vulnerable populations, but what are the facts?

Murder by any other name

According to a 2015 article in the NEJM [16], of the 3882 deaths due to physician-assisted suicide or euthanasia in Flanders, Belgium, in the year 2013 alone, 1047 (27%) involved physicians deciding to administer medication dosages to hasten death without patients’ consent. Such patients are generally unconscious and may or may not have family members around.

In 2014, a statement on end-of-life decisions by the Belgian Society of Intensive Care Medicine asserts that “shortening the dying process” should be permissible “with use of medication… even in absence of discomfort” [17]. When discussing these facts, two prominent physicians, one from the Netherlands and another from Harvard, told me that where they come from, they call that murder.

These two doctor's both used the word ‘murder,’ which might at first glance seem strong. Yet, I realized this accurate statement pivots entirely on physician intent and patient awareness.

When physicians are participating in a procedure designed to take a person’s life, will patients feel 100% certain that their physician is firmly on the side of healing? What message does it send about the value of every human life when physicians endorse the exchange of one life for another? What effect has it already had on physicians complicit in such death-causing procedures?

In the 1973 science fiction classic “Soylent Green”, detective Frank Thorn searches for answers to dying oceans and a deteriorating human race on overcrowded Earth. He discovers the high-protein green food produced by the Soylent Corporation is recycled, euthanized humans. “Soylent Green is people!” he screams.

“Soylent Green” was set in 2022. We are 3 years away.