Organ donation after euthanasia: Altruism to mask utilitarianism?

The ethical principles of organ donation jeopardised by the shortage of available organs

The shortage of organs available for transplantation is a global reality. In Europe alone, there will be an estimated 150,000 patients waiting for transplants by 2022, and 19 people will have died every day of that same year for lack of a transplant. Against this backdrop of shortages, euthanasia is increasingly emerging as a way of making up for the shortfall. The testimonies heard at the Sympadot d'Erasme emphasised the idea of a useful death through euthanasia combined with organ donation, which could ‘allow several people to stay alive’ or ‘mourn’. As soon as the line between ‘causing death’ and ‘giving a chance of life’ becomes blurred, the altruism of organ donation could justify euthanasia, which would then no longer be experienced as a failure.                                                                                                                                     

Dr Marc Decroly, a general practitioner who lectured at the Sympadot conference, reiterated that organ donation could never be used as a pretext for euthanasia, and that euthanasia was not a right but an opportunity. Given the steady rise in the number of euthanasia cases in Belgium (more than 3,000 by 2023), how can this utilitarian drift be avoided in practice, given that euthanasia and organ donation are part of the same end-of-life project? Won't the prospect of organ donation lead some people who have already decided to euthanise to do so?

How can the independence of the decision to euthanise and the decision to donate organs be guaranteed? 

In its opinion of 9 January 2023, Belgium's Consultative Bioethics Committee considered the ethical implications of combining organ donation and euthanasia (see: Organ donation after euthanasia: Belgium's Consultative Bioethics Committee sticks to procedural ethics). It recalled the three conditions of ethical acceptability for organ donation after euthanasia:

• Euthanasia and organ donation must remain the subject of two separate decisions and separate operators;
• It is absolutely forbidden to make euthanasia conditional on organ removal, and the possibility of changing one's mind must be guaranteed at all times;
• The patient's informed consent to the medical examinations required for organ removal must be guaranteed.

The Committee remains divided on the role of the doctor in raising the possibility of organ donation with a person who has requested euthanasia. While some members advocate the altruism of donation, which also makes it possible to ‘give meaning to their end-of-life choice’, other members point out the risk of influencing the request for euthanasia, particularly in the case of patients suffering from psychiatric conditions, whose request is often ambivalent, but who are at the same time often eligible for organ donation.

Despite these ethical safeguards, Dr David Fargnoul told the conference that at Charleroi University Hospital, the doctor himself proposes organ donation to the patient during the last consultation before euthanasia. Under these conditions, how can we guarantee that euthanasia is not influenced by organ donation? Moreover, patients may not dare go back on their decision to be euthanised if the possibility of organ donation has been decided in consultation with their doctor. 

In Belgium, between 2005 and 2019, 53 organs were removed following euthanasia, according to the FPS Public Health. This figure could change if organ donation were integrated into the end-of-life project, with the major risk of confusing the utilitarianism of death on demand with the altruism of organ donation.