people seeking assisted suicide have asked to gift their organs to loved ones, doctors say
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at least 155 people in canada have donated their organs and tissues after receiving a doctor-administered lethal injection since the country’s maid law came into effect in 2016.
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it’s an ethically fraught scenario that’s becoming more common as the number of canadians granted euthanasia grows: people pursuing assisted suicide are asking to donate one or more of their functioning organs upon their death to someone they know.
now a new, updated canadian guideline sets out criteria under which it could be permissible to allow people choosing a medically assisted death to gift their organs to a relative or close friend, an option some ethicists fear will unduly push people with a chronic disease or disability whose natural death isn’t “reasonably foreseeable” to follow through with assisted suicide even if they have a change of heart, knowing a loved one is waiting for their organs.
stories have been accumulating of people considering maid primarily because of poverty, or a lack of adequate health care or social supports. people who already feel they’re a burden to their family “may be unduly influenced to opt for maid,” believing that at least their organs will be useful to others, said university of toronto bioethicist trudo lemmens.
a recent dutch study found canada is already leading the world in ode — organ donation after euthanasia. at least 155 people have donated their organs and tissues after receiving a doctor-administered lethal injection since the country’s maid law came into effect in 2016.
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canada generally doesn’t allow organ donors to choose their recipients, except in cases of “living donations” — healthy people who willingly donate a kidney, or a segment of liver or lobe of a lung to a relative or friend, or, anonymously, to a stranger. there is no “directed donation” following death from natural causes. organs are allocated to the person most in need, and the best match. as well, in most cases of organ donation, the donor is generally comatose from a catastrophic brain injury. they’re not conscious, competent patients seeking to have their lives ended.
the guidance on organ donation after maid, developed by the canadian blood services and published monday in the canadian medical association journal, recommends organ donation organizations and transplant programs develop polices on directed deceased donations for people pursuing maid. it will be up to the provinces and organ donation organizations to implement the recommendations.
it provides a list of “core principles” to assist in the development of such policies, including that requests must be voluntary and considered on a case-by-case basis, that directed donations shouldn’t proceed if there’s any indication of “monetary exchange or similar valuable consideration” or “coercion,” and that the intended recipient be on a transplant waiting list and a family member or “close friend — an individual with whom the donor or donor’s family has had a long-standing emotional relationship.”
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the person can withdraw consent for maid, or donation, at any time, the authors wrote, and withdrawing consent for donation “does not affect their consent for, or access to maid.”
the paper also recommends approaching all track 2 maid applicants — people whose natural death is not reasonably foreseeable, a new category now eligible for maid since the first guidelines were published — who are potentially eligible for organ donation, once it’s been confirmed they’re eligible for maid, and at any time during the 90-day assessment period that’s intended to fully explore the reasons why the person is seeking assisted suicide.
“approaching patients for first-person consent for donation late in the maid process involved potential risks, including insufficient time to facilitate donation,” the authors wrote.
people should be fully informed of all options at end of life, including organ donation, they said, “and if patients are competent to make a decision regarding maid, they are competent to make a decision regarding donation after maid.”
lemmens said the recommendation to start discussing maid even before the assessment is finished “is, in my view, unconscionable.”
in 2021, 35 per cent of people receiving maid said that a significant component of their unbearable suffering was that they considered themselves a burden to family, friends and caregivers, he said.
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“now, even before we fully have a picture of what is driving this request — is it lack of social support? family pressures? depression? — we’re adding a very complicated potential issue of pressure to the equation, which is: ‘you should know that you can donate your organs.’
“imagine if that person has a family member who is waiting for an organ donation?”
“this policy paper suggests that not only do we not need to offer health care or support before offering death as therapy, but we should also tell them that we can use their organs to save other people’s lives,” lemmens said. “i think that creates a horrible dilemma and sends a horrible message.”
the guidance document makes clear that the decision for maid has to precede, and be completely separate from, the decision to donate.
and the same principles and rules around organ retrieval apply. after death occurs, and after a “no touch” waiting period to confirm death is irreversible, only then may organs be retrieved.
the old 2019 guideline said directed donation after maid should be neither offered nor encouraged, the worry being that, if the person had a relative or friend waiting for an organ, “it would be difficult to exclude the possibility that the decision to donate had driven the request for maid, either to facilitate the donation process or to enhance the function of the transplanted organ,” some of the same authors wrote then.
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what changed?
“basically, with more experience with maid-organ donation, more maid patients have requested it and we need to provide guidance how to manage the requests ethically, and avoid the scenario where a maid patient might consider, ‘if you don’t let me direct my kidney donation to a loved one, you’re going to force me to undergo a living donation procedure before i die,'” said dr. sam shemie, a mcgill university pediatric critical care doctor and one of the guideline authors.
“there were situations where people who wanted maid said, ‘well, i have a loved one who is on a transplant waiting list and i want to give him my kidney. why can’t i do that,’” shemie said.
“what we said in the guidelines was, basically, look: directed donation should not be offered or encouraged, but if it’s patient initiated, then we need to have a way to manage that request.” each request should be managed on an individual basis and “under exceptional circumstances with a few clear rules,” he said. the donor would also have to accept that his or her kidney, liver or other organ may end up going to someone else on the waiting list in more urgent need, meaning imminent threat to life if they don’t receive the organ.
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organ donation after voluntary euthanasia has been called the ultimate act of altruism, a gesture that could bring a profound sense of psychological comfort and solace to those seeking assisted death.
but canadian maid providers have also recounted cases of people changing their minds about maid, but being too afraid to admit it to family. with the added pressure of organ donation, “patients with second thoughts may feel, ‘i’d better go through with this because people are waiting for my organs,” dr. lisa rosenbaum, an associate professor of medicine at harvard medical school once wrote in the new england journal of medicine.
“i’m not going to pretend it’s not a potential ethical concern, which is why we don’t offer or encourage directed donation,” shemie said. “we don’t want anything to contaminate the decision around maid.”
“we’re not maid assessors or providers in the donation system,” shemie said.
“but you’re right: there is a kind of implicit pressure on a patient who has decided to pursue maid and wants to direct an organ to a loved one,” he said. “there is an ethical issue there — will that influence their decision around continuing with maid if they have reservations or uncertainties?
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“that’s a real issue that we need to manage.”
while most people who chose assisted death have cancer, which makes them ineligible for organ donation 25 to 30 per cent of maid patients have neuromuscular diseases or other conditions that don’t preclude donation.
in all, 63 experts were involved in crafting the updated guideline. two people who had requested and been found eligible for maid, and two family members of people who had donated organs after maid, also participated. also represented were professional groups, including the canadian critical care society, the canadian society of transplantation, the canadian association of critical care nurses and the canadian association of maid assessors and providers.
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