Since its inception, bioethics has paid special attention to organ and tissue donation for transplantation purposes, given its close relationship with human health and the multiplicity of conflicts of interest that can affect the various actors involved. These conflicts include abuse, discrimination, research involving human beings, communication with the donor’s family, informed consent and autonomy of the living donor, organ procurement, the concept of brain death, criteria for selection of recipients, fairness in organ distribution, cost-effectiveness, equitable allocation of public resources, and the problems of organ buying and selling and the organ market[1]. Given the inherent complexity of organ donation for transplantation, a wide range of controversies, questions and ethical tensions can be expected.
However, reducing the controversies and risks associated with organ donation requires a deeper understanding and application of bioethical principles. These principles can contribute significantly to fostering greater awareness of organ donation as a means of saving lives and promoting the advancement of medical science by building a renewed vision that respects human dignity. The purpose of this reflection is to analyse the contribution of the four classical principles of bioethics in the field of organ donation: justice, non-maleficence, autonomy and beneficence[2]. Although these principles may conflict in some situations, they are indispensable to any study related to human health and fundamental to overcoming the various challenges inherent to organ and tissue donation for transplantation purposes.
Organ donation for transplantation, as already mentioned, is a very complex activity. This complexity requires the application not only of existing legal rules, but also of universal ethical principles in order to prevent abuse and any form of injustice that may occur during the process. In this context, the principle of justice, understood as the act of “giving to each according to his or her right or equity in the distribution of risks and benefits”, can play a fundamental role. Its proper application in organ donation manifests our moral and legal responsibility towards others. Indeed, respect for this principle prevents any manifestation of discrimination and guarantees equal opportunities between individuals, ensuring that everyone has the same chance of being an organ donor or recipient. Therefore, the principle of justice, by its very nature, requires the existence of unambiguous protocols, i.e. clear rules defining the circumstances under which a person can or cannot be a donor. The principle of justice aims to safeguard the quality of donation and the health of the donor and the recipient, as well as to protect all the elements involved in the donation activity. It is undeniable that there are legitimate concerns about the criteria used for organ access and distribution. For this reason, these criteria must be medical and objective in nature, constantly oriented towards the recipient’s welfare, but also subject to review. The whole process is part of the dynamics of the administration of justice.
The principle of justice seeks to minimise conflicts of interest that may arise between the various actors involved in organ donation. At the same time, it demands the highest technical and human quality at every stage of the process. From this point of view, the principle of justice is based on the inviolability of the individual. Indeed, if the population perceives the application of justice and transparency in organ donation, they are likely to support this practice significantly. Therefore, the challenge for increasing the number of donors lies in strictly applying the principle of justice and ensuring transparency throughout the donation process.
Another fundamental bioethical principle in organ and tissue donation for transplantation is non-maleficence. This principle, intrinsically linked to the principle of justice and others, is fundamentally aimed at avoiding harm. In any donation process, non-maleficence must be guaranteed, seeking at all times the absence of suffering and the comfort of the patient. While in some circumstances the omission of a good may be permissible, causing harm is never acceptable. As already mentioned, the activity of organ donation involves several actors and thus entails several risks. It is therefore of utmost importance to ensure the well-being and respect for the fundamental rights of all persons involved. The principle of non-maleficence requires, like the principle of justice, clearly defined protocols. For example, when diagnosing brain death, it is crucial to clearly and precisely explain the necessary diagnostic process. Unfortunately, in cadaver organ donation, the donor’s wishes are not always respected. In such cases, the principle of non-maleficence would apply to ensure that the donation is carried out in accordance with the expressed wishes of the donor. Certainly, an early, sincere and respectful dialogue with the donor’s relatives is necessary; however, the application of this principle aims to ensure maximum respect for the patient and his or her relatives throughout the process, as well as for the patient’s body after his or her death. In the case of a living donor, the aim is to ensure that the donation is the result of a free and informed decision, informed of the risks inherent in the act of donation and free from any economic or social pressure.
The voluntary nature of organ donation by a living donor underlines the principle of autonomy. In the act of donation, the living donor’s capacity to act knowingly and without restriction must invariably be privileged. In this context, the principle of autonomy guarantees respect for the individual’s right to be or not to be a donor, as well as to accept or refuse a donation after being fully informed about its risks and benefits. The individual, as an autonomous moral subject, possesses the capacity to deliberate on his or her personal ends and to act in accordance with that deliberation[3]. However, it is crucial to note that the principle of autonomy does not authorise anyone to cause harm to others. Therefore, when every effort is made to ensure the procurement of organs under the best possible conditions, the principle of autonomy is reinforced. In this context, allowing organ donation always becomes an action that benefits both the patient and society. The greater the benefit to patients and society resulting from the act of donation, the greater the public’s trust in the donation process. The principle of autonomy also plays a significant role in ensuring the dignity and respect of the body, preserving the personal, cultural and religious values that the person had during his or her lifetime.
The principle of autonomy also requires the existence of a prior will of the patient in a brain-dead state for the donation to be accepted; however, it has been proposed that the body of the deceased (corpse) can legally be considered as a res comunitatis, i.e. as an asset belonging to the community, available for the common good, provided that there is a social need and that no contrary will was expressed by the donor during his or her lifetime[4]. However, a question arises: is it ethically justifiable to consider the body of a deceased person as an asset available for the common good? And if so, what role should relatives play? Indeed, to admit that the body of a deceased person automatically becomes a common good is not to deny the inherent respect for the body. The situation is complex and it is considered essential to always include the family in the decision-making process.
Another fundamental bioethical principle to be considered in organ donation activity is the principle of beneficence. This activity must always benefit not only the recipient patients, but also society as a whole. Donation must always pursue the welfare of the patient without causing any harm to the donor. From this perspective, donation is understood as an act of profound generosity, as it implies the gift of an intrinsic part of the person, which ennobles both donor and recipient. Considering that the primary duty of medicine is primum non nocere (first do no harm), organ donation is only justified to the extent that the risks to the donor are minimal and the benefits to the recipient are reasonable. Therefore, the physician’s minimum ethical obligations include a proper evaluation of the risk/benefit ratio and ensuring that the donor acts with complete freedom.
Finally, it can be argued that fundamental bioethical principles, if properly understood and implemented in donation activity, can significantly contribute to strengthening public confidence in organ donation and improving donation rates, especially after death, with the aim of saving lives. If the gap between supply and demand for organs is to be reduced, it is essential to build ‘an organised and professionalised system that patients can trust. Donors must feel comfortable knowing that their expressed wishes will be respected after death[5] “. The way forward is to build trust.
P. Jean Rolex, CM
[1] Cooley, D.A., Fung, J.J., Young, J.B., Starzl, TE., Siegler, M. & Chen, PW. (2008). Transplantation innovation and ethical challenges: what have we learned? Cleaveland Clinic J Med, 75 (6), 524-532.
[2] Gracia Guillen, D. M. (2004). Come arqueros al blanco. Studies in bioethics. Madrid: Triacastela.
[3] Ibid,
[4] Pérez Hernández, I. (2016). Ethical aspects in organ donation, beyond mere generosity. Gastroenterol. Latinoam, 27 (1), 76-78.
[5] The Lancet. (2016). Organ donation depends on trust. 387 (10038), 2575.
