Medical Assistance in Dying and Organ Donation Should Be Separate Decisions

By Will Boggs MD

June 07, 2019

NEW YORK (Reuters Health) - The decisions to seek medical assistance in dying (MAiD) and to offer organs and tissues for transplant should be separate, according to guidelines proposed by Canadian organizations.

"The main ethical concern around this practice is the potential for the decision to donate organs to drive the decision about end-of-life care," said Dr. James Downar of the University of Ottawa and The Ottawa Hospital, in Canada.

"Specifically, that someone might initially choose palliative care and a natural death, but then learn that they could potentially donate organs if they receive MAiD, and therefore they request MAiD," he told Reuters Health by email.

The guideline appeared online June 3 in CMAJ.

Dr. Downar and colleagues, in collaboration with the Canadian Blood Services, Canadian Critical Care Society, Canadian Society of Transplantation and Canadian Association of Critical Care Nurses, aimed to develop ethical, legal and clinical guidance for policies about organ donation decisions in conscious, competent donors, including those seeking medical assistance in dying (MAiD).

The guidelines begin with the recognition that individuals like these, who are conscious and competent to provide first-person consent, should be given the opportunity to donate organs and tissues.

Any discussion about organ donation, however, should take place only after the decision for MAiD or withdrawal of life-sustaining measures (WLSM) has been made.

To avoid potential conflicts of interest (or the appearance thereof), teams assessing eligibility for MAiD should be completely separate from those involved in donation discussions.

Even with consent to donate organs or tissues, the dead-donor rule must always be respected, the authors note. Vital organs can be procured only from a donor who is already deceased, and the act of procurement cannot be the immediate cause of death. The organ procurement process cannot be implicated in the death of the patient in any way.

Patients should be informed and understand that they may withdraw consent for MAiD or donation at any time and that withdrawal of consent for donation does not affect their consent for or access to MAiD or WLSM.

The guideline also addresses conscientious objection. Participation of healthcare professionals in MAiD and in organ donation by patients who received MAiD should be voluntary, and those who object to MAiD or WLSM should nevertheless ensure that their objection does not impede the ability of the patient to donate.

"These guidelines were not developed to increase organ donation," Dr. Downar said. "Organ-donation organizations (ODOs) had no interest in looking at this initially. The guidelines were developed in response to multiple patient requests across the country, which led ODOs to ask for guidance."

"Although many of these recommendations were informed by experience and data, areas of research remain, to ensure that a person's final wishes are honored without placing their family, health care providers or potential recipients at risk of harm," the authors conclude.

"Experience in the Netherlands has shown that the wish for organ donation after MAiD originates from patients themselves," writes Dr. Johannes Mulder from the Guideline Organ Donation after Euthanasia working group, in Leiden, the Netherlands in a related editorial. "The idea of donating their organs after death gives them a sense of purpose and fits with the autonomous determination of the final phase of their life."

The Dutch guidelines also maintain a policy of keeping the MAiD and organ-donation procedures as separate as possible by having all contact regarding donation, at the initiative of the patient, take place via a trusted person, such as the family physician.

As far as concerns raised regarding the direct influence of MAiD itself on organ quality, Dr. Mulder notes that, "in 50 cases of organ donation after MAiD in the Netherlands to date, no issue has arisen regarding damage to organs as a consequence of the process of MAiD, but research is still needed."

"When preparing policies for a sensitive subject such as organ donation, the explicit focus must be on the patient undergoing MAiD," he concludes. "To preserve the confidence of the public, policies must clearly center on protecting the patient who has chosen MAiD. With procedural decisions, the interests of the living patient who has chosen MAiD always take priority over whatever organs they might pass on after death."


CMAJ 2019.