Skip to main content
I read with interest the guidance for policy on donation after MAiD etc by Downar et al1and Mulder’s commentary2. Broad discussion and consultation are essential for an issue of this complexity and I would like to contribute to what I hope is an ongoing debate with the following comments.
Firstly, I think that it should be recognised that MAiD and WLSM are not equivalent ethical entities and should be addressed separately in the context of organ donation. Although both involve conscious and competent potential donors, the withdrawal of perhaps increasingly invasive active interventions that are prolonging an inevitable death (WLSM) is very different from the deliberate and active termination of life in MAiD. While cases of donation after WLSM bring some different practical issues to those after circulatory determination of death (DCD), for me WLSM and DCD are similar (and far less problematic) ethical issues, so the rest of my remarks will apply only to the issue of donation after MAiD.
I have serious concerns that organ donation after MAiD has the potential to significantly influence the decision of individual patients to proceed with MAiD and also to increase the number of requests for MAiD. Patients contemplating MAiD are “vulnerable and susceptible to influence”2 and exposure to, for example, the national broadcasting in the Netherlands of the first domestic case of organ donation after MAiD3, might be the proverbial thumb on the scale that tips the balance towards a decision for MAiD. The authors do acknowledge that, “it would be difficult to exclude the possibility that the decision regarding organ donation had driven the request for MAiD, either to facilitate the donation process or to enhance the function of the transplanted organ.”1 This statement refers to directed deceased donation, but I respectfully suggest that it is equally applicable to all cases of donation in association with MAiD. They suggest that this “should be managed by ensuring that any discussion about organ donation takes place only after the decision for MAiD…is made.” However, the widespread availability of relevant information (about organ donation and the shortage of suitable organs) makes it unlikely that the request for MAiD and the decision to donate can be such a linear process. I also agree with Mulder that this “ignores the dynamic nature of the patient’s decision-making process……sometimes people change their minds about MAiD right up until the end,”2 and I am concerned that once a initial decision to donate has been made, subsequent discussions and the whole process of donor testing may unduly influence patients to follow through with MAiD to avoid disappointing expectations raised by their earlier decision to donate.
The inevitable intertwining of the choice for MAiD and the decision to donate mean that any participation in the subsequent transplant process has the potential to both validate and promote MAiD. The authors suggest that it is not logical to object to organs from MAiD patients but then be willing to use those from victims of suicide and homicide. However, there are crucial differences between these scenarios: no one is motivated to proceed with suicide or homicide because of the subsequent opportunity to donate organs, and we as physicians actively strive to prevent both suicide and homicide whenever possible, rather than facilitate death as with MAiD.
As an anesthesiologist working at a major transplant centre, I have recently informed my department that I am not willing to be involved in the transplantation of organs from MAiD donors, and collegial discussions are underway about the implications for myself and the rest of the department. The numbers of such cases are currently low, and for the reasons outlined above, if numbers were to rise significantly, this should be viewed with deep concern. The already inconsistent application of criteria for MAiD in this country,4 the vastly more liberal euthanasia guidelines in some other countries, and the discussion about ante-mortem harvesting happening not only in the public domain5 but also in a high impact medical journal,6 must surely give everyone in the transplant community (including organ recipients) pause for thought.
Claire Middleton MBChB, MRCP(UK), FRCPC
Staff Anesthesiologist,
University Health Network, Toronto.
1. CMAJ 2019 June;191:E604-13.doi:10.1503/cmaj.181648
2. CMAJ 2019 June;191:E595-6.doi:10.1503/cmaj.190352
3. ALS patient donates his organs after euthanasia, EenVandaag [documentary] Amsterdam:AVROTROS Productions; 2017. Available: wwwnpostart.nl/als-patient-donates-his-organs-after-euthanasia/11-05-2017/POMS_AT_8838678 (accessed 2019 June 8)
4. Medically assisted death allows couple married almost 73 years to die together, Kelly Grant, Globe and Mail, April 1, 2018
5. Taking organs from the living, Sharon Kelly, National Post, May 23, 2019
6. NEJM 2018 September 6: 379(10):909-911.doi:10.1056/NEJMp1804276