Bioethics in Faith and Practice, Volume 3, Number 1

Bioethics in Faith and Practice ⦁ 2017 ⦁ Volume 3 ⦁ Number 1 15 the potential donor is either opposed to donation or her desires are unknown, a conflict arises between beneficence to the donor and to the recipient, and no decision can be made based solely on beneficence. One other possible application of beneficence remains. In theory, if a presumed consent system were enacted, a subtle shift in the attitudes of medical personnel could take place. Since the working assumption would shift to the notion that every patient is a donor unless evidence says otherwise, doctors could be tempted more frequently to refrain from using every effort to save a patient who they do not expect to return to a high quality of life. Although the principle of ‘decoupling’ must be followed by hospital staff, meaning the decision to harvest organs must be separated from the determination of death, subtle shifts in thinking may still occur . 32 When saving several lives is possible at the expense of one that could only maintain minimal quality of life, utilitarian calculations become enticing. Yet, beneficence requires doing everything in one’s power to help the patient at hand, and a presumed consent system could subtly erode that way of thinking. All in all, there are too many unknowns and competing interests involving beneficence to use it alone for a judgment of presumed consent. Thus, one must default to the input of another moral principle. Non-maleficence Primum non nocere, or “first, do no harm,” is perhaps the first principle most people would think of when broaching the topic of medical ethics. Though this exact phrase is not found in the Hippocratic Oath, the assumption is there, and common sense cements it as an important medical principle. Some of the same difficulties seen in applying beneficence show up again with this principle; it is not obvious that an individual can be harmed as a donor, assuming a correct declaration of death has been made. Once again, however, it could be argued that transgressing the declared wishes of the decedent would be doing harm. A more practical application of non-maleficence to presumed consent stems from the importance of a trusting relationship between doctors and patients. Even if the failure of beneficence does not occur as described above, and doctors always do everything they can to save every patient, a presumed consent system could lead patients to think they will be treated as a resource instead of a person in need. Even if no physical harm takes place, the erosion of trust in the patient-medical professional relationship is a real harm. While there is no guarantee this type of suspicion would occur, it is certainly possible and worth consideration. In sum, while non-maleficence cannot be construed to endorse presumed consent, it also cannot be used on its own to condemn it, and we must again defer to another principle. Justice In biomedical ethics, justice mainly applies to the concept of fairness and equal opportunity. Any policy that discriminates against a particular class or group of people would be unjust. One author argues for a presumed consent system on justice grounds by pointing out that any increase in the supply of available organs reduces the need to decide who receives them and who must wait, and thus reduces the potential for wrongful discrimination. This argument, of course, assumes that an opt out policy would increase the organ supply, which we have established is not a given. On the other side of the question, one must consider the possible negative impact of presumed consent on the equal application and administration of healthcare. If the default were to consider everyone a potential donor, one possible outcome could be that doctors with prejudices against certain groups of people might be even more apt to simply view them as a resource to save others. Some evidence already suggests that racial discrimination impacts referral for transplant receipt, as African-Americans are about 23% less likely than whites to be referred to a transplant center . 33 Thus, it is not much of a leap in logic to assume discrimination also occurs on the donor end. While there is no direct evidence that presumed consent would exacerbate this type of discrimination, it is a plausible scenario.