Can double‐effect reasoning justify lethal organ donation 2022 Adam Omelianchuk.pdf

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AdamOmelianchuk
ForthcominginBioethics–pleasecitepublishedversion
CanDouble-EffectReasoningJustifyLethalOrganDonation?
Abstract:Thedeaddonorrule(DDR)prohibitsretrieval

compliancewithitcanbemaintainedbysatisfyingthe
requirementsofDouble-EffectReasoning(DER).If
successful,onecouldsupportorgandonationwithout
referencetothedefinitionofdeathwhilebeingfaithfultoan
ethicthatprohibitsintentionallykillinginnocenthumanlife.
Onthecontrary,IarguethatDERcannotmakelethalorgan
donationcompatiblewiththeDDR,becausethereare
plausiblewaysitfailsDER’
thatthetheoriesofintentionandproportionalityassumedin
DERmattersforitsplausibilityasaconstraintonpractical
reasoning.
Thedeaddonorrule(DDR)prohibitsretrievalprotocolsthatwouldbelethalto
thedonor(.,lethalorgandonation,LOD).Donorsaretypicallydeclareddeadbefore
surgerybeginstoavoidkillingthemfortheirorgans;theDDRisaspecificationofthe

,controversyovermixingorgan
,controversyoverthecriteriafor

1Omelianchuk,A.(2018).How(not)tothinkofthe‘dead-donor’
(1),1–:///s11017-018-9432-5
2Miller,.,&Truog,.(2012).Death,dying,andorgantransplantation:Reconstructing
;NewYork:OxfordUniversityPress.
3Ball,.,Sibbald,R.,&Truog,.(2018).VoluntaryEuthanasia—ImplicationsforOrgan
:///NEJMp1804276Ely;.(2019).
Deathbyorgandonation:
(9),1309–:///s00134-019-05702-1;Bollen,J.,Shaw,D.,deWert,
G.,Hoopen,,Ysebaert,D.,vanHeurn,E.,&vanMook,W.(2020).Organdonationeuthanasia
(ODE):(S3),S298.
/
4Lewis,A.,&Greer,D.(2017).
(8),505–:///
1:.
AdamOmelianchuk
ForthcominginBioethics–pleasecitepublishedversion
transplantsurgeryyetremainincompliancewiththenormagainstkillingtheinnocent?
SomearguethisispossiblebysatisfyingtherequirementsofDouble-EffectReasoning
(DER).Ifsuccessful,onecouldsupportorgandonationwithoutreferencetodeath
criteriawhilebeingfaithfultoanintention-sensitiveethicthatprohibitsintentionally
killingtheinnocent;organdonationwouldbeeffectivelydisentangledfromdebatesover
euthanasiaandthedefinitionofdeath.
Onthecontrary,IarguethatDERcannotmakeLODcompatiblewiththemoral
frameworkoftheDDR,becausethereareplausiblewaysitfailsDER’
whatfollows,IoutlinethekeycriteriaofDER,thecaseformakingLODcompatiblewith
theDDRviaDER,
ourunderstandingsofproportionalityandintentionmatterforthemoralrelevanceof
DERinclinicalpractice.
CriteriaforDouble-EffectReasoning5
DERpermitsanactionthathastwoeffects,onegoodandoneevil,ifandonlyifthree
criteriaaremet:

(Unavoidabilitycriterion).
(Pure
Intentioncriterion).
(Proportionalitycriterion).6
5IpreferthisnamecoinedbyCavanaugh,.(2006).Double-effectreasoning:Doinggoodand
;NewYork:OxfordUniversityPress.
6Thenumberofrequirementsvariesdependingonhowtheyarelumpedtogetherorsplitapart.
,DER
requiresthat“theactitself”(theonewithtwoeffects)be“goodorindifferent.”IlumpthisintothePure
Intentioncriteriontoavoid,forreasonsexplainedlater,talkabout“theactitself.”SeeSulmasy,.
(2018).Thelastlowwhispersofourdead:Whenisitethicallyjustifiabletorenderapatientunconscious
untildeath?(3),233–:///s11017-018-
9459-7;Reed,.(2015)..
89(3),441–:///acpq201561557
2:.
AdamOmelianchuk
ForthcominginBioethics–pleasecitepublishedversion
Forexample,intendingthedeathofadyingpatientiswrongbutintendingadequate
symptom-reliefthroughahigh-doseanalgesicsregimenispermissibleevenifweforesee
thattheincreaseddosageswilldepressthepatient’srespiratorydriveandcausedeath.
Thoughempiricalevidenceshowsthisdoesnothappen—properlyadministered
analgesicstendtoextendlife,notshortenit7—thecasuistryofDERpermitsend-of-life
palliationsolongas(1)deathcannotbeavoidedifadequatesymptom-reliefistobe
achieved,(2)deathisnotintendedasanendorameanstosymptom-relief,and(3)the
goodofsymptom-
(1)thedonor’sdeathcannotbeavoidediforgansareremoved,(2)deathisnotintended
asanendorameanstovitalorganremoval,and(3)thegoodofsavingthelivesofthose
inneedoforgansisonparwiththeevilofthedonor’sdeath,
functionoftheDDR,then,istoprohibitusingorgandonationasameanstoeuthanasia;
thefunctionofDER,however,istoallowfortheacceptanceofheroicself-sacrifice
ännsjö,
Bronner,and,writingtogether,
7Chan,.,Treece,.,Engelberg,.,Crowley,L.,Rubenfeld,.,Steinberg,.,&Curtis,
.(2004).Narcoticandbenzodiazepineuseafterwithdrawaloflifesupport:associationwithtimeto
death?(1),286–:///;Mazer,.,Alligood,.,&
Wu,Q.(2011).Theinfusionofopioidsduringterminalwithdrawalofmechanicalventilationinthe
(1),44–51.
/
8Tännsjö,T.(2015).Takinglife:,NY:Oxford
UniversityPress;Bronner,B.(2019).Lethalorgandonation:Wouldthedoctorintendthedonor’sdeath?
TheJournalofMedicineandPhilosophy:(4),
442–:///jmp/jhz008Camosy,.,&Vukov,J.(2021).Doubleeffectdonation.
(2),149–:///,these
authorsrepresentconflictingnormativesystemsofethics:Tännsjöisanact-utilitarian;Bronner,a
deontologist;CamosyandVukov,
concernedwiththePureIntentionpartoftheargument.
3:.
AdamOmelianchuk
ForthcominginBioethics–pleasecitepublishedversion
TheCaseforCompatibility
Tännsjö’sbelievesthosewhoarenotcommittedtoKant’sCategoricalImperative,
yetarecommittedtothesanctityofhumanlifeandDER“mustconcur”withtheclaim
thatitwouldnotbewrongtocutupanddistributetheorgansofanunsuspecting

becommittedtoaruleagainstthewrongfuluseofanotherifwearetoexplainwhysuch
,howcouldthePureIntentioncriterionbesatisfied?“When
thedoctorcutsupthepatient,”hewrites,“

thepatient,thenhewoulddoso.”10Similarly,Bronnersays,“ifthedoctorwereto
believethatadonormightsurvivetheoperation(perhapsondialysis,perhapsbya
miracle),hewouldnotalterhisproceduretoensuredeath—byremovingadditional,
non-transplantableorgans,forinstance.”11CamosyandVukov,inspiredbythefilmJohn
Q,12imagineahypotheticalinwhichasurgeontransplantsaheartfromafathertohis
,heartless,andonextracorporeal
membraneoxygenation(ECMO),anotherheartbecomesavailableandthesurgeon
,theactofremovingavitalorganfortransplant“doesnotofits
verynatureaimatdeath.”13Counterfactualtestslikethesesupposedlyshowthatone
doesnotintendtheevileffectasameansifone’schoiceofactionwouldachieveone’s
goalswithoutcausingtheevileffect.
9Tännsjö():205
10Ibid.
11Bronner():447
12Cassavetes,N.,Washington,D.,Duvall,R.,&Oltean,G.(2002).,
Burg/KoulesProductions,EvolutionEntertainment.
13Camosy,Vukov():157
4:.
AdamOmelianchuk
ForthcominginBioethics–pleasecitepublishedversion
Furthermore,thesurgeonneednotintendthedeathofthedonorifone’s
intentionisspecifiedonlybythedescriptionsunderwhichaproposalforactionis

fromtheblast.“Thecaseoflethalorgandonationisrelevantlysimilar,”saysBronner:
[I]ntending(1)thatone’sorgansbeextractednomoreinvolvesintendingdeath
thanintending(2)thatone’(1)and(2)may
beforeseeablylethal,butinbothcases,deathisnotwhatoneaimstobring
,thenthedoctor
performingthesurgeryneednotintendthedonor’,likethe
donor,intendstobenefitthetransplantrecipientsbyextractingorgansfromthe
’
Whatisintendedasameansisjustone’sdescriptionofwhatisnecessarytoachieve
one’’sreasonforactingis“tosavethelivesofthosewhoneedahealthy
organ,”andtodothat,onechooses“toextracttheseorgansfortransplant,”andtodo
that,onechooses“tocutintothedonorandsurgicallyremovethem,”thenitdoesnot
followthatonechoosestokillthedonor,becausethedonor’sdeathappearsnowherein

therecipient(s),itneednotbechosenbythedonororthesurgeontoaccomplishtheir
goals.
Theseaccountsofintentionarenarrowbecausetheyrelyexclusivelyonthefirst-

contrast,wideraccountsofintentioncombineinformationfromboththefirst-and
third-personstandpoint—thestandpointofanobserver—
14Bronner():445–46,emphasisoriginal.
15AnarrowviewthatreliesalmostexclusivelyonthestandpointofanobservercomesfromSidgwick,
H.(1893).Themethodsofethics(5thed.).London;NewYork:Macmillan.:,“Ithink,
however,thatforpurposesofexactmoralorjuraldiscussion,itisbesttoincludeundertheterm
‘intention'alltheconsequencesofanactthatareforeseenascertainorprobable.”
5:.
AdamOmelianchuk
ForthcominginBioethics–pleasecitepublishedversion
AwideraccountofintentionispresupposedinFoot’sclassicdiscussion16ofhowDER
adjudicatesremovingababystuckinthebirthcanalbywayofacraniotomy,which
involvescuttingintothebaby’sskull,removingthebrain,andcollapsingtheskullto
achievealife-
becausetheprocedureandthebaby’sdeathare“muchtooclose,”meaningonecannot
-centeredviewof
intention,however,,Grisez,andBoyle18believethedoctorneednot
intendthebaby’sdeathbecausedeathplaysnocausalroleinachievingsafedeliveryand
,thechoicesmade
fromthefirst-personstandpointoftheactingagentexclusivelydeterminesthe
-person
standpointofanobserverwhetheritbenaturalfactsabouttheworld,socialcontextsin
whichsharedpracticesemerge,theproximityofcausestooneanotherortheir
impressiveeffects,specifiesouractionsorintentions.
Anarrowagent-centeredviewofintentionisassumedbyTännsjöforthesakeof
augment,assertedmorecarefullybyBronner,butcuriouslydeniedbyCamosyand
Vukovwhothink,“thecraniotomyofalivinghumanbeinghasdea