Introduction

From the time of his seminal 1997 article in the Hastings Center Report ¹ to the present, Robert Truog has argued against the dead donor rule in organ transplantation, and has continued to make his case in a recent article he co-authored with Frank Miller.² Arguing that neither “brain dead” organ donors nor donors after cardiac death are actually dead, Truog and Miller believe that it would be best to admit that these donors are alive. Such donors have severe neurological deficits for which a course of action by some could be to remove life support, which becomes the “proximate cause” of these patients’ deaths.² If, instead, organ donation is the cause of the patient’s death, such killing is justified, given adequate informed consent from “the patient or surrogate,”² due to the great benefit the patient’s organs would yield for recipients.

Is it ever morally right for doctors to kill their patients when the patients would be allowed to die anyway and when such killing would yield great benefit to others? We do not believe so. We will assume, for the sake of argument, that the following statements are true: (1) “brain dead” organ donors are not truly dead, (2) organ donors “by cardiac death” are not truly dead, (3) organ donation is the direct cause of death of these donors, and (4) the benefits for others from organ donation are significant, including extended life and improved lifestyle for organ recipients.

The fundamental problem with killing patients for their organs (or for any other utilitarian end) has to do with the fundamental nature of medical practice. Medicine is a practice in philosopher Alasdair MacIntyre’s sense—it is a “cooperative human activity,” with “goods internal” that can only be achieved gained bythrough the practice of means of the practice itself.³ Central to the practice of medicine, as Edmond Pellegrino and David Thomasma point out, is, at the most fundamental level, a relationship between the patient and the physician, a relationship, a relationship oriented toward healing.⁴ The patient comes to a health care practitioner for help with illness; the physician (or other health care practitioner) has both the knowledge and power to protect and preserve the life of the patient. This end of medicine (“healing”) implies certain moral principles intrinsic to medicine, one of which is the principle of nonmaleficence, “do no harm.” Harming a patient, since it violates the healing relationship between patient and physician, is fundamentally inimical to the practice of medicine.⁴

The vulnerability of the patient also plays an important role in the proper end of medicine. The patient is exposed, and not only in the sense of the uncovering of the patient’s body and invasive medical tests and treatments. The patient is also vulnerable to the greater knowledge and power of the physician. Both beneficence and nonmaleficence play an important role in the responsible use of knowledge and power. On the positive side, knowledge and power should only be used to benefit the individual patient, contributing to the healing and well-being of the patient. On the negative side, nonmaleficence, “do no harm” is essential, since “harming” is the opposite of “healing.” Thus, a physician who willingly gives treatments that do not benefit a patient or that harm a patient is no longer practicing medicine.

Medical treatments must, then, be oriented to the good of the individual patient under the physician’s care. The physician’s ultimate “master” is the individual patient under his or her care.⁵ Such care is not oriented toward the good of other patients, but for that individual patient. Now killing a patient is a subspecies of harming a patient. Killing a patient cannot be morally justified because such an action involves a doctor harming a patient in the most extreme way, ending the patient’s life on earth. Intentionally killing a patient is the supreme violation of the proper goal of the clinical encounter.

It makes no morally relevant difference if the purpose of such killing is to remove organs from a severely neurologically impaired patient for the purpose of helping other patients. The act of killing itself is morally wrong, and no utilitarian calculation can change that. Truog’s claim that since the organ donor candidate would have the ventilator withdrawn anyway also does not make a morally relevant difference. Even if Truog is correct that ventilator removal is the proximate cause of the patient’s death, the patient’s inititalinitial inability to breathe is due to the disease or injury process. Thus, there is a direct causal chain from the disease or injury to the loss of respiration. Removing the ventilator does indeed “let nature take its course.”

Assuming, with Truog, that organ donation surgery kills the patient, it is clear that killing a patient via organ removal is an entirely different kind of action that removing a ventilator from a patient.^6,7 Assuming that Truog is correct in his position that organ donors are not dead, tThe removal of vital organs from the patient’s body is not only the proximate cause of the patient’s death, but the ultimate cause—such organ removal is in no way the result of the natural course of the disease or injury. Instead, it is the surgeon who directly injures and eventually kills the patient by removing the patient’s vital organs. Actively killing a patient, even a patient with severe neurological deficit, violates the fundamental principle of “do no harm.” That the patient or surrogate gave prior permission for donation does not change this fact. Physicians are morally wrong if they kill their patients for any reason, no matter what good may come, and in engaging in such actions they are no longer practicing medicine.