Presumed consent? Let's not be presumptuous!
CMAJ 1998;159:135
In his winning 1997 Logie Medical Ethics Essay "Organ procurement: Let's presume consent" (CMAJ 1998;158[2]:231-4 [full text]), Dr. Fady Moustarah proposes that Canada adopt a presumed-consent model for the procurement of organs. He writes that many people who support organ donation find it hard to contemplate donation because it is difficult for them to envision their own deaths. He then argues that society errs by assuming that the absence of expressed consent implies a refusal to donate. "Alternatively," he writes, "presuming consent allows us to meet better the wishes of most people. Hence, presuming that the majority favour organ donation is the morally correct way to proceed because it finds its roots in the recognition of the unexpressed but autonomous will of most members of society. . . . In other words, it would be safe to assume that people who have not registered an objection want to donate their organs" [emphasis in original].
What to think of this proposal? Many of us do indeed have difficulty envisioning our own deaths. I suspect this is central to our humanness: it reflects our capacity to feel, think, reason and "project futures." I'm not sure, though, that the difficulty I may have envisioning my own death leads me to struggle with the question of organ donation.
Further, Moustarah may well be right in suggesting that those who have not signed their organ donor cards in fact think organ donation is good. But to move from this claim to a presumption that their organs are there for the taking is, quite simply, wrong. Even more troubling is his suggestion that this practice can be justified on ethical grounds as a reflection of "the unexpressed but autonomous will of most members of society." What might this mean? Why should my silence — the fact that I haven't signed my organ donation card — be interpreted as consent to take my organs? My silence says more about my ambivalence than anything else. To suggest that my silence is really my "unexpressed but autonomous will" and to conclude that I really want to donate my organs because I have not "registered an objection" is presumptuous and disrespectful — a classic non sequitur.
George C. Webster, PhD
Clinical Ethicist
Health Care Ethics Service
St. Boniface General Hospital
Winnipeg, Man.
gwebster@sbrc.umanitoba.ca
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