Abstract
We are grateful for the opportunity to respond to two letters1,2 on our paper on conscientious objection to organ donation. We knew this would be a contentious issue.3 Indeed, the Deceased Donation Working Group of ELPAT had robust discussion on the extent to which healthcare professions should be allowed conscientious objection (CO) to organ donation. That is why we chose the format of a pro/con paper to explore these issues.
Dr Pruski and Dr Saad argue that we neglect the important role played by CO in terms of the integrity of the medical system; “CO is a mechanism which highlights flaws in a system (e.g. when a clinical situation is unsafe or unjust), while also protecting individual integrity and autonomy … When such conflicts arise, CO can force a reasoned debate.” However, this is a misrepresentation of CO. While CO can be used to highlight flaws in a system, within a healthcare context, it is first and foremost a means for individual clinicians to opt out of particular services. All medical institutions and organisations have systems for raising concerns and whistleblowing, which can be used to highlight any flaws noticed by medical professionals.
In their letter, Dr Verheidje and Dr Rady take issue with several aspects of our article. First, they dispute the statement on CO made by an international workshop on the topic that declared CO incompatible to some extent with modern medicine. They claim that “the workshop lacked balanced representation of the diverse legal, philosophical, and ethical opinions on CO and that the recommendations of the workshop were biased and should not drive a change in national policy on CO.” We and our colleagues were not present at the workshop, but the participants were some of the most respected bioethicists in the world, representing a variety of different perspectives. Their job is to consider issues from an objective stance. While it is certainly possible to disagree with the workshop’s conclusion, this does not mean that bias was involved. The arguments should stand or fall on their own merits.
Second, they criticize our argument that permitting CO to donation sends a mixed message to the public, arguing that: This is similar to transplantation advocates recommending the publication of only those articles that are supportive of deceased organ donation. This recommendation is authoritarian, counter intuitive to academic freedom and an implicit attack on the dominant principle of autonomy in Western bioethics.
Third, Verheidje and Rady claim that, “The authors ignored that the real concerns of those expressing CO is most likely because of the possibility of harm to donors and their families if indeed organs are being procured from donors who are not truly dead.” This is simply not the case. We specifically state that: a stronger moral reason for CO to donation concerns the definition of death and different types of donation. It is quite understandable that someone who does not accept one or both of these standards would not wish to take part in a process that involves the removal of organs from a living patient, as that removal would kill the patient and that would be murder, even if societally sanctioned.
Given that Dr Rady is both a critical care physician and has published against the concept brain death, it is disappointing he did not choose to express in his correspondence whether he conscientiously objects to organ donation in his institution, or brain death diagnoses, or if he therefore favors donation after circulatory death over donation after brain death. It would be fascinating to know, what allowances are made in his institution, the Mayo clinic, for his obviously strong beliefs. This would also help to foster the discourse we hoped our paper would generate.