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Editorials and Perspectives: Forum

Organ Donation After Assisted Suicide

A Potential Solution to the Organ Scarcity Problem

Shaw, David M.

Author Information
doi: 10.1097/TP.0000000000000099
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Abstract

Switzerland has a surprisingly low rate of deceased organ donation, at 12 donors per million people compared to over 23 per million in neighboring countries. This rate may be partially a result of sociocultural factors such as religion and conservatism, although the lack of a central donor registry may also be implicated (1). Only around 100 people donate their organs after death each year in Switzerland, with 96 doing so in 2012 (2). Together with 37 organs provided by donors elsewhere in Europe, the organs from these donors benefited 453 recipients (3), meaning that each donor helped four people on average. However, a record 1,165 people were waiting for an organ at the end of 2012; the waiting list is growing substantially each year because of the country’s low donation rates. Furthermore, 53 patients died while waiting for an organ. Despite the efforts of Swisstransplant, 2012 was a worse year for donation than 2011, and no significant improvement is currently envisaged.

Swiss law permits citizens and foreigners to obtain assistance in committing suicide (4). Hundreds of Swiss citizens and people from abroad (and particularly from Germany, France, and the United Kingdom) have ended their lives in Switzerland with assistance from Dignitas, the assisted dying organization (5). There are also several other organizations that limit assistance to Swiss citizens. Together, Dignitas and Exit (6) helped 560 people end their lives in 2011 (7). Although non-physicians are permitted to assist in suicide if they do not stand to benefit from the death (8), euthanasia is not permitted, and those seeking assistance in suicide must go through a rigorous procedure of safeguards designed to check that they meet all the necessary criteria. Although assisted suicide appears to be widely accepted in Switzerland, many doctors remain opposed, and the Swiss Academy of Medical Sciences has stated that the practice is problematic (9).

Organ Donation After Assisted Suicide

People who use assisted suicide services in Switzerland are not currently able to donate their organs for transplantation, for a number of practical reasons (see below). This amounts to massive waste of an extremely precious resource: over 500 people die in Switzerland every year in entirely controlled circumstances, with their time of death established days or weeks in advance. It is likely that many of them wish to donate their organs, yet none of them can currently do so. A simple calculation reveals that enabling people in this group to donate would have a significant effect on the organ scarcity problem. Currently around 100 people donors help around 400 recipients each year in Switzerland (a ratio of 1:4), with over 1000 more people currently needing organs. If 250 more people donated their organs each year, that would be enough to meet demand, provided sufficient infrastructure was in place to prevent organ loss through inefficient systems. In other words, if 50% of those who commit suicide with assistance each year agreed and were able to donate, Switzerland could achieve a surplus of organs once the current large waiting list is reduced.

Organ donation after assisted suicide also offers several advantages over donation after unwanted death (see Box 1). These include more accurate estimation of time of death, the ability to arrange the time of transplant and carry out HLA typing weeks in advance, and a virtual guarantee that the deceased’s organs will be used if they meet the medical criteria for donation. Furthermore, the ability to discuss consent to donation in depth with donors and relatives means that families are very unlikely to veto donation.

T1-4
BOX 1:
Key advantages of donation after assisted suicide

The preparation for assisted suicide is quite extensive, and requires signatures and various paperwork. As such, it would be relatively easy to ensure that the person wishing to die also indicated whether he would like to donate his organs. Although asking this question and recording the answer is easy, ensuring that the deceased’s wishes regarding donation are fulfilled in cases of assisted suicide raises several practical, ethical, and legal issues.

Practical Issues

Transport to Hospital

Most assisted suicides in Switzerland involve the provision of a lethal dose of sodium pentobarbital to the patient at home or at accommodation provided by the right-to-die organization. The most obvious practical problem with the proposal to allow organ donation after assisted suicide is ensuring that the organs reach a hospital in time to be transplanted. The most realistic option to solve this problem would be for the suicide to take place within hospital grounds in a non-medical environment suitable for the circumstances. Cooperation between the assisted suicide organizations and Swisstransplant could enable suicides to be conducted in or very near to hospitals. This would allow organs to be transplanted in time. However, some patients might not want to die anywhere near a hospital; one of the attractions of the Swiss assisted suicide system is the option of dying at home. Therefore, a better option could be to have an ambulance booked to arrive at the time of death; there is as long as 30 min between the person falling asleep and dying, which would be sufficient for transport to the hospital. However, this option raises objections about moving and potentially operating on the patient before death (see Ethical Issues section).

It might seem unlikely that these organizations would be willing to collaborate, but Eurotransplant was willing to cooperate with Belgian doctors in facilitating the transplantation of organs after death by euthanasia (10). Both Swisstransplant and groups like Dignitas could benefit from such an arrangement; the former from improved supply of organs, and the latter from facilitating the dying wishes of many of their patients, who currently cannot perform this important last “act”. Furthermore, facilitating lifesaving organ donation could help assisted suicide organizations combat their negative image as “merchants of death”. However, cooperating to facilitate donation after assisted suicide (DAS) could also lead to some negative publicity that such organizations might prefer to avoid.

Donation After Cardiac Death

The issue of rapid transport to hospital is complicated by the fact that assisted suicide would involve donation after cardiac death (DCD), which requires very rapid removal of organs. Most donors in Switzerland donate after brain death (DBD); in such cases, there is more time to transplant the organs because they remain vascularized. In DCD, however, transplantation must take place almost immediately. A related general problem is that Switzerland’s capacity for DCD is relatively underdeveloped compared with its DBD capacity, with only kidneys routinely being removed from DCD patients (11), and only seven DCD donors in 2012 across the country (5). However, livers, lungs, and pancreases are frequently removed from DCD patients outside Switzerland, and this capacity could be extended. Improving Switzerland’s DCD capacity would be essential if this proposal was to be adopted, and this would require substantial investment in infrastructure.

A related problem is that not all organs can always be used following DCD. The Maastricht Scale lists five different categories of DCD (see Table 1). If no changes in infrastructure were implemented, assisted suicide patients would be category I cases, as they would be brought in after death at the location of the assisted suicide; only basic tissue like corneas and heart valves can be taken from this group, which would not address the main issue of the shortage of major organs. Resuscitation is clearly not desired in the case of assisted suicide, so no category II patients would result from the proposal being adopted (but see discussion about a new category VI below). Categories IV and V do not apply to cases of assisted suicide. Category III patients are normally those on life support in the ICU. When the machines are turned off, the transplant team must wait for cardiac death to occur before proceeding, and a subsequent 10-min period is also supposed to be observed before transplantation begins. All organs except the heart can be transplanted from such donors. With sufficient changes in infrastructure, DAS could become like category III controlled DCD. If the suicide took place in or near the hospital, the transplant team could be standing by ready for surgery very soon after death. Furthermore, the cooling-off period could be skipped to maximize organ viability in such cases because the patient wished to die. However, this raises some ethical concerns (see Ethical Issues section).

T2-4
TABLE 1:
The Maastricht Scale for classification of DCD cases (26)

A final objection is that it seems counterproductive to focus on facilitating donation from this “awkward” DCD group when efforts could be concentrated on increasing more donation from categories IV and V. However, there have been considerable efforts for several years to improve DBD donation rates, with little success. Whereas patients dying in general wards could be targeted instead, DAS donors offer the aforementioned advantages in terms of advance planning, organ matching, and avoiding family refusal. In these respects, DAS donors are actually less awkward than normal DCD or DBD donors.

Quality of Organs

There are two potential objections regarding the quality of the organs retrieved from those committing suicide. One concern is that the organs could be harmed by the administration of the lethal drug, which is usually sodium pentobarbital (12). However, the drug used to cause death does not normally cause any permanent damage to the organs (13, 14). Furthermore, organs (but no hearts) removed after euthanasia in Belgium have been transplanted successfully (7). The second objection is that cases of DAS will involve people who are seriously ill or dying, and whose organs might not be the best candidates for transplantation. Age itself is no barrier to donation, and terminally ill patients often have several organs that are in perfect working order (15); the average age of AS users in Switzerland is 74 (7), and kidneys have been taken from those aged over 80 (15). Nonetheless, it is true that older people are likely to have poorer organ function.

However, the main limiting factor in terms of medical contraindications is the fact that many people using assisted suicide services are suffering from cancer. Ideally, patients with active cancer are not used as donors. However, “there are very few absolute contraindications…even patients with known transmissible conditions may be able to donate organs if there is a recipient for whom the risk is worth taking (13).” Furthermore, less than 40% of people accessing assisted suicide services in Switzerland have cancer (16). A high consent rate among cancer-free DAS cases could itself allow an overall donation rate high enough to meet demand. Additionally, there would actually be more time to establish whether each person meets the medical requirements for donation in this context than in normal cases of donation.

Ethical Issues

In addition to the aforementioned practical issues, there are likely to be ethical objections to permitting organ donation after assisted suicide. For example, it might be argued that people who would otherwise not opt for assisted suicide might choose to die to donate their organs and help other people. This argument is a variation of the “burden” argument against assisted dying in general (9), and it is subject to the same responses. First, there are specific criteria for assisted suicide in Switzerland, and only terminally ill people and those experiencing extreme suffering are eligible. The decision about suitability for assisted suicide must be kept entirely separate from the decision to donate one’s organs, and existing safeguards could be strengthened further if this proposal were to be adopted. Second, sick people who are receiving life-sustaining treatment can choose at any point to refuse further treatment even if it will result in their death, yet the burden argument apparently does not apply to such cases. Furthermore, organs are already taken from people who die in violent unassisted suicides in Switzerland. In essence, allowing organ donation after assisted suicide simply provides an additional minor reason for choosing to die, and one that is unlikely to be decisive. A related concern is that taking organs from those committing suicide creates a conflict of interest for doctors (see Legal Issues section).

A second objection is that some people considering the option of assisted suicide might be put off by the idea of their organs being taken after their death. However, such people could simply refuse consent to donation, and many others might find the possibility attractive. Although surprisingly high proportions of the Swiss population are opposed to organ donation, it seems likely that citizens with the relatively liberal mindset required for acceptance of assisted dying would also accept the idea of donating one’s organs to benefit others. In fact, one of the main problems with acceptance of organ donation is that people do not like to think or talk about death; many potential organ donors never get round to getting a card or discussing the issue with their families. However, the inverse is true of people considering assisted suicide; the fact that they are doing so indicates a willingness to address end-of-life issues like organ donation.

In addition to concerns about the combination of assisted suicide and organ donation, there are several ethical issues specific to DCD. One of these is the worry (for category III donors) that pretransplantation procedures such as cannulation and perfusion might need to begin before relatives can be contacted. However, this concern does not apply in the case of DAS, as the relatives will already be involved and the patient will have consented to these procedures. Another concern about typical category III donors is that ICU treatment might be withdrawn before it is really futile (17). Again, this is not a concern for DAS donors, who by definition want to die. Therefore, these concerns about “instrumentalization” of the donor should not arise (18).

A particular ethical issue is raised by the unique situation of the DAS category III donor. As already mentioned, if the patient is allowed to die under normal AS circumstances, he will arrive as a category I donor at the hospital, and no solid organs can be used. If sufficient infrastructure were put in place to remove them quickly enough, all organs except the heart could be taken. However, the current Swiss Academy of Medical Science guidelines (and the law) stipulate that a 10-min waiting period is essential, along with several other criteria (19). The question is to what extent these normal category III precautions need to be respected in these new circumstances. Because the patient wants to die in DAS, the “cooling-off period” does not seem to be ethically required (although the family might want it). Indeed, there is increasing evidence that this 10-min period is frequently not observed in normal donation; no heart has ever restarted unaided after 60 sec, and some doctors have begun organ removal after cardiac death at 75 sec (20). This might seem ethically problematic in cases where the patient would have wanted to be revived, but this clearly does not apply in the case of assisted suicide. Therefore, it appears likely that the cooling-off period could be safely abandoned in cases of DAS. It might be sensible to designate such donors as a new category VI to make this distinction clear. Furthermore, it could even be argued that “organ retrieval euthanasia” where the patient is rendered unconscious before organs are transplanted would be the best option in terms of organ viability (21). However, this would require the legalization of euthanasia and could alienate potential AS donors, who would probably prefer to be dead before their organs were removed.

Finally, some healthcare professionals might themselves object to taking organs after suicide on ethical grounds. Many hospitals and doctors are opposed to assisted suicide (22) and might not want to cooperate in case doing so was seen as endorsing the practice, which they see as being contrary to the aims of medicine. Conscientious objection to helping patients commit suicide is perfectly understandable. However, objecting to using organs from this source is much more problematic, as doing so could contribute to avoidable patient deaths. If DAS were to become a reality, it would have to be decided whether doctors could conscientiously object to using organs from this particular source.

Legal Issues

In addition to the aforementioned practical and ethical problems, there are several potential legal issues concerning this proposal. One minor issue is that, as mentioned above, the law and guidelines would have to be changed before the cooling-off period of 10 min could be omitted. Although this change is not necessary for organ donation after assisted suicide to be workable, it could improve the viability of organs obtained in this way. This change does seem to be ethically justified in this context.

A second issue is that all cases of suicide in Switzerland are checked by the cantonal attorney general (or public prosecutor) because they constitute violent deaths. As such, organ procurement following assisted suicide would have to be approved by these attorneys. However, this does not pose any particular difficulties. Attorneys in some cantons have previously approved the use of organs from violent non-assisted suicides who died in hospital (23). If it is possible to donate organs in such unexpected circumstances, the controlled context of assisted suicide should make donation quite simple. Assisted dying organizations already need to cooperate with the cantonal legal authorities, and getting quick or even advance approval for organ donation should be feasible. It would seem odd if donation were permitted after “irrational” violent suicide when the deceased’s wishes can be ambiguous, but not after rational assisted suicide where the deceased’s wishes are clear.

Third, assisted suicide is only legal in cases where the assister(s) will not benefit from the death (4). The fact that several Swiss patients will benefit from DAS could be seen as creating a potential conflict of interest for the assisting parties, but given that they do not stand to benefit personally or financially, it appears that DAS is actually entirely compatible with the Swiss laws governing assisted suicide and transplantation (4, 24). In fact, current practice fails to respect the law sufficiently, as the wishes of people who wish to donate after death are supposed to be respected. In most cases of death, this is unavoidable because of the circumstances, but the extremely controlled context of assisted suicide in Switzerland provides the perfect opportunity to solve the organ scarcity problem, while also enhancing the autonomy of those who seek assistance in ending their lives.

CONCLUSION

Organ donation after assisted suicide would be permitted by Swiss law (4, 24). If the necessary infrastructure were put in place, Swisstransplant cooperated closely with the assisted suicide organizations, and 50% of those committing assisted suicide each year met medical criteria and consented to donate, no one would need to die or suffer while waiting for an organ. Even a consent rate of 20% would double the number of organs available in Switzerland; if 60% consented, organs would soon not be required from any other source. Indeed, it appears that any country (or region within a country, such as Oregon) (25) that permitted donation after assisted dying could solve its organ scarcity problem. Quite apart from the impact that donation after assisted suicide could have on reducing waiting lists, it is worth noting that enabling DAS would allow hundreds of people to fulfill their wish to donate their organs after death; a wish that cannot be fulfilled under the current system. Although the combination of these two end-of-life issues might make some people uncomfortable, it would be unfortunate if Switzerland did not take steps toward solving its historic organ shortage by utilizing the precious resource of organs from people who want to die but want to help others to live.

Organ donation after assisted suicide would be permitted by Swiss law (4, 24). If the necessary infrastructure were put in place, Swisstransplant cooperated closely with the assisted suicide organizations, and 50% of those committing assisted suicide each year met medical criteria and consented to donate, no one would need to die or suffer while waiting for an organ. Even a consent rate of 20% would double the number of organs available in Switzerland; if 60% consented, organs would soon not be required from any other source. Indeed, it appears that any country (or region within a country, such as Oregon) (25) that permitted donation after assisted dying could solve its organ scarcity problem. Quite apart from the impact that donation after assisted suicide could have on reducing waiting lists, it is worth noting that enabling DAS would allow hundreds of people to fulfill their wish to donate their organs after death; a wish that cannot be fulfilled under the current system. Although the combination of these two end-of-life issues might make some people uncomfortable, it would be unfortunate if Switzerland did not take steps toward solving its historic organ shortage by utilizing the precious resource of organs from people who want to die but want to help others to live.

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Keywords:

Organ donation; Assisted suicide; Ethics; Switzerland

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