DIFFICULT MORAL QUESTIONS

Question 50: May a person with kidney failure accept a transplant?

I am thirty-five, married, with four children, aged twelve, nine, seven, and three. I have a serious kidney disease, and, after suffering from chronic renal inadequacy for many years, I am now experiencing end-stage renal failure. I depend on hemodialysis, which has considerably improved my health, and I can expect to remain about the same.

I am able to function reasonably well on dialysis, which I manage at home, connecting myself to the machine three times a week for four hours each time. The treatment is not painful once I have cannulated a large vein in my arm with the two needles that allow the blood to flow through the machine and back. The major problem is the time commitment, not only for me but for my wife, who must assist during the treatment. The setting up of the machine, the time spent connected to it, and cleaning up afterwards involves both of us for about eighteen hours every week, during which I can do little work and she cannot leave the house. In addition, the machine sometimes requires repair, which delays things until a technician comes; this uncertainty also limits employment possibilities.

Given these drawbacks, my physician is urging me to accept a kidney transplant. I would, except that I am worried about whether it is the right thing to do. If I receive a kidney, it must come from either a supposed cadaver or a live donor willing to sacrifice a kidney for my sake. There are serious reasons for reservations about both of these possibilities.

I never have been entirely convinced by the idea that people really are dead when they suffer so-called brain death—that is, the complete and irreversible cessation of all brain function. Moreover, I know how to use a medical library and have looked into the ways doctors go about determining that people are “brain dead.” As a result of this research, I now have serious questions about both the adequacy of the criteria used in determining “brain death” and how carefully they are applied in practice. My conclusion is that even if “brain death” really is death, many people may actually be killed by the removal of their organs. So, I am not willing to accept a kidney that may well have been taken from someone falsely pronounced dead.

Several of my brothers and sisters have offered to give me one of their kidneys. In particular, one of my brothers took the initiative in getting tissue typed, and we match well. He regularly restates his offer and tells me to let him know whenever I decide to accept it. I know most theologians think such donations can be morally good and the Church has not said they are wrong. But there are risks, both of trouble connected with the operation itself and of future difficulty, in case at some point the donor suffers impaired kidney functioning. I appreciate my brother’s offer, but since he has a family, I am not sure I ought to accept it.

In itself, the disease I have is no blessing, yet in some ways it has been good for me, not least by making me acutely aware of the fragility of life. While many people today seem to have forgotten about heaven and hell, I never forget. I am more concerned to do the right thing than to stay alive or have an easier time of it, and shall be grateful for straightforward advice.

Analysis:

The question is whether to accept a transplant, and a sound reply can only articulate considerations that the questioner should take into account. His unwillingness to accept a kidney that may well have been taken from someone falsely pronounced dead seems reasonable. In my judgment, however, he probably could uprightly accept a kidney from his brother. If a living person who is well informed offers with full freedom to donate a kidney, the offer may be accepted, assuming the potential donor is morally free to make it. The questioner’s brother is morally free to donate a kidney, provided his wife wholeheartedly supports his doing so and appropriate medical examination reveals no special risk. If these conditions are met, the donating brother and his wife would benefit morally by doing that work of mercy, and that benefit provides some reason to accept their offer.

The reply could be along the following lines:

I wish everyone who proposed difficult moral questions shared your clearheadedness and eagerness to get at the truth. May the Lord help you persevere in your sound attitude.

You do not say whether you have talked this problem over with your wife. If not, it seems to me you should. Even your children, especially the eldest, deserve to have their thoughts and feelings considered, since you have taken responsibility for them, and your well-being is vital to theirs. Therefore, I hope you will share my reply with your wife and, insofar as feasible, with your children.

Given that you function reasonably well on dialysis and given your grounds for hesitation about accepting a kidney transplant, I do not think you have any obligation to accept it—certainly not at the present time, perhaps not ever.

Unlike you, I have regarded the concept of brain death—meaning the irreversible cessation of all brain functions—as acceptable in principle.¹⁷⁵ Still, some reasonable objections to it have been advanced.¹⁷⁶ Moreover, though one cannot know for certain how often the criteria for determining death on this basis are either inadequate or misapplied, it is clear that some, and perhaps even most, determinations of brain death would not meet adequate criteria properly applied.¹⁷⁷ That being so, your unwillingness to accept a kidney that may have been taken from someone falsely pronounced dead seems to me reasonable.¹⁷⁸

You might consider publicizing your position on this matter and your reasons for it, not only by communicating personally with relatives, friends, and acquaintances but also in other feasible ways. That would bear witness to the sanctity of human life and provide an example for people tempted to violate it. Moreover, you could call many people’s attention to the arguability of the concept of brain death, the inadequacy of some methods of trying to determine it, and possible abuses in applying the methods that have been adopted. That in turn might lead to wider discussion of these problems, clarification of what is going on, and needed corrections. Of course, such publicity could make severe demands on you and your loved ones, and information about questionable practices might distress people who have received organs taken from donors perhaps not yet dead as well as such donors’ families and friends. So, you might conclude that most of the possible ways of making your stand known would not promise sufficient benefits to warrant accepting the foreseeable burdens.

As for transplantation from a live donor, no potential kidney recipient should assume that every relative’s or friend’s offer to donate can be taken seriously. Even if all conditions are ideal, the donor’s self-sacrifice goes beyond duty and is called for only as an act of generous love, that is, as a work of mercy. Family members and friends may feel constrained to offer a kidney or may even be manipulated into doing so; such offers also sometimes are made impulsively, without due deliberation about risks and burdens.¹⁷⁹ But so great a work of mercy ought to flow from sufficient reflection and full freedom of choice. Before accepting any offer, the potential recipient should make certain it has been made after careful deliberation and with full freedom. This condition is not met until the potential donor has been informed of the burdens and risks involved in the operation.¹⁸⁰

Still, since your brother has regularly repeated his offer, I think it likely that you could rightly accept a transplant from him.¹⁸¹ I say “I think it likely” because at least two conditions must be fulfilled. First, in view of the responsibilities your brother assumed in marrying and having children, it surely would be wrong for him to proceed with the donation if his wife were opposed or even ambivalent. But since he has made and regularly repeated his offer, I assume he has his wife’s wholehearted approval and support. Second, your brother almost certainly would not be accepted as a donor by the physicians concerned and certainly should not proceed without a thorough physical examination, including a careful medical history, ruling out possible reasons for thinking his giving you a kidney would involve a risk other than the risks always accepted by healthy kidney donors.

Assuming these conditions are met, I think your reasons for hesitating to accept your brother’s offer are sound, but not so morally compelling that accepting would be wrong. There is a certain risk for your brother, and he and his wife should place a very high priority on their responsibility to work together in raising their children. Still, the risk to your brother and his family probably would not be great, while the benefit to you and your family probably would be great.

Moreover, if the conditions have been met, an additional consideration in favor of accepting your brother’s offer can come into play, namely, that he and his wife also stand to benefit. Since they love you, the improvement in your functioning would be a benefit for them. Besides, assuming their full and free agreement to donating the kidney, they already have become better as individuals and as a couple by making so generous an offer. In transforming their benevolence into beneficence—their good will into a good deed—they would make an additional sacrifice and deepen their love for you and for each other. Indeed, the potential moral benefits to them, perhaps even more than the health benefit to you, provide you with good reason to accept their offer with grateful love.

175. On the concept of brain death, see Germain Grisez and Joseph M. Boyle, Jr., Life and Death with Liberty and Justice: A Contribution to the Euthanasia Debate (Notre Dame, Ind.: University of Notre Dame Press, 1979), 59–78; Working Group of the Pontifical Academy of Sciences, The Determination of Brain Death and Its Relationship to Human Death (10–14 Dec. 1989), ed. R. J. White, H. Angstwurm, and I. Carrasco de Paula (Vatican City: Pontifical Academy of Sciences, 1992), 81–82.

176. See Paul A. Byrne et al., “Brain Death: The Patient, the Physician, and Society,” Gonzaga Law Review, 18:3 (1982–83): 429–516; Josef Seifert, “Is ‘Brain Death’ Actually Death? A Critique of Redefining Man’s Death in Terms of ‘Brain Death’,” in Working Group of the Pontifical Academy of Sciences, op. cit., 95–143; D. Alan Shewmon, “Recovery from ‘Brain Death’: A Neurologist’s Apologia,” Linacre Quarterly, 64:1 (Feb. 1997): 30-96.

177.  On the application of inadequate criteria, see Peter J. McCullagh, Brain Dead, Brain Absent, Brain Donors: Human Subjects or Human Objects? (New York: John Wiley and Sons, 1993), 7–103, 225–47.

178. In stating this conclusion and assuming it to be decisive for the questioner, I do not mean to settle the issue of whether other patients could rightly accept the transplant of an organ that might have been taken from someone wrongly pronounced dead. In view of present (Jan. 1997) uncertainties about relevant facts, I believe that upright people can reach and act on different reasonable judgments on this matter.

179. Helpful works on diverse aspects of donation by a living person: Renée C. Fox and Judith P. Swazey, Spare Parts: Organ Replacement in American Society (New York: Oxford University Press, 1992), 31–48; Marc D. Smith et al., “Living–Related Kidney Donors: A Multicenter Study of Donor Education, Socioeconomic Adjustment, and Rehabilitation,” American Journal of Kidney Diseases, 8:4 (1986): 223–33.

180. Once donors have recovered from the operation, their risk in living with only one kidney does not appear to be great; see Barry M. Brenner, ed., The Kidney, 5th ed., vol. 2 (Philadelphia: W. B. Saunders, 1996), 2036, and the studies cited.

181. On the moral acceptability of such transplants, see National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (Washington, D.C.: United States Catholic Conference, 1995), directives 29 (with n. 16) and 30; LCL, 544, including n. 147; Donald G. McCarthy and Edward J. Bayer, eds., Handbook on Critical Life Issues, rev. ed. (Braintree, Mass.: Pope John Center, 1988), 122–34; William E. May, “The Ethics of Organ Transplants,” Ethics and Medics, 21:7 (July 1996): 1–2.