The New England Journal of Medicine continually publishes advocacy articles that promote radical changes in medical ethics and public policies. For example, it uncritically published the Groningen Protocol, the infanticide bureaucratic checklist used by doctors in deciding which disabled or dying babies to euthanize in the Netherlands.

Now it has published an advocacy article expressing the wish that imminently dying patients be able to donate a kidney before death. Joshua Mezrich tells the story of W. B., dying of ALS (amyotrophic lateral sclerosis, or Lou Gehrig’s disease), who wanted this harvest and then die procedure. From “Altruisim in Extremis:”

Mezrich could not fulfill W.B.’s wish. As W.B. grew sicker, wheelchair-bound and unable to swallow, he and Mezrich devised a plan for “imminent death donation” (IDD). W.B. would go to the hospital, receive general anesthesia, have one kidney removed, then return to the intensive care unit, where he’d be extubated and die, presumably, from ALS. But despite “overwhelming” ethics-committee support, the attorneys the hospital consulted informed Mezrich that he and any staff involved would risk being charged with murder or acceleration of the patient’s death. So W.B., whose mind remained sharp and alert despite being unable to move, swallow, or speak, spent his final days in the hospice where he died. None of his organs were donated.

This is why I don’t trust hospital-ethics committees. Members are often trained to respond positively to nakedly relativistic utilitarian analyses that ignore venerable moral values and the intrinsic dignity of human life.

But Wesley, that’s what the patient wanted. And if someone wanted to sell herself into slavery, should we permit it? No. Establishing a precedent in a hard case sets us down a bad road. There are larger societal issues at stake than the case at hand.

When organ-transplant medicine was launched, a wary society was solemnly promised that organs would be taken only from the dead, a concept known as the “dead-donor rule.” Also, that prospective donors would never be objectified. Hence, no actions are supposed to be taken in preparation for donation that could harm the still-living patient and/or accelerate his or her death.

Resistance to crossing this once inviolable red line seems to be weakening. Indeed, an ethics committee convened by United Network for Organ Sharing to opine on this issue seems to have been more concerned about public relations than maintaining inviolable ethical boundaries:

Though the committee found no ethical problem with IDD [imminent death donation] under circumstances like W.B.’s, in which first-person consent is possible and the donor is well-informed, they focused on the more ethically fraught scenario of a patient with devastating neurologic injury for whom a surrogate would be deciding about organ donation before withdrawal of treatment. They noted the lack of data for determining whether permitting “live donation prior to planned withdrawal” (LD-PPW) would lead to an increase or decrease in available organs. This unpredictability speaks to the Catch-22 of a utilitarian approach to these scenarios. A practice such as LD-PPW could theoretically yield more donor organs. But if LD-PPW is perceived as unethical (surgeons as “vultures” stealing organs from those not quite dead), then, regardless of safeguards, potential donors may be lost. That’s why, as Peter Reese, a University of Pennsylvania nephrologist who led the ethics committee, explained to me, “We did not find an ethical problem. We found a political problem.” [My emphasis]

Yes, we allow altruistic kidney donation. But this bending of the dead-donor rule has been accepted by society because — even though there is a remote risk of death, often overlooked in glowing media stories — great care is taken to ensure that the donors recover and go on with their lives.


This is different. Taking a kidney from a dying patient would harm the still living human being. It would materially impact the timing of death, or perhaps cause death. Moreover, it would lead quickly to the next logical step: allowing euthanasia by organ harvest, already proposed in some journals. In short, imminent-death donation would elevate the importance of organ retrieval over the equal moral worth and lives of patients.

Organ-transplant medicine has saved countless lives. But the people from whom organs are retrieved matter too — as does their humanity until death. We must reject attempts to further undermine the dead-donor rule because if we ever go over that cliff, there is no turning back.