Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec

Julie Allard, Marie-Chantal Fortin

Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec

Résumé

Depuis décembre 2015, l’aide médicale à mourir, une pratique au centre de nombreux débats éthiques, est légalisée dans la province du Québec, au Canada. Ce nouveau type de décès a créé un tout nouveau contexte pour le don d’organes, soit le don d’organes après l’aide médicale à mourir. Le prélèvement des organes s’effectue alors suivant le protocole habituel du don d’organes après décès cardiocirculatoire contrôlé (catégorie Maastricht III), un protocole qui suscitait déjà de nombreux questionnements médico-éthiques. En outre, l’amalgame des deux pratiques soulève de nouveaux enjeux éthiques qui peuvent se traduire par des objections de conscience chez les médecins directement impliqués dans l’aide médicale à mourir et/ou le don d’organes. Or, une telle objection de conscience peut-elle être acceptable ? Nous tenterons de répondre à cette question en trois temps : d’abord, par un bref historique de l’objection de conscience ; ensuite, par une revue des débats actuels sur ce sujet ; enfin, par l’examen, à l’aide de critères recensés dans la littérature, de cas où les médecins refuseraient de participer au don d’organes après l’aide médicale à mourir.

Summary

Medical assistance in dying, a much debated practice in ethical literature, is practiced since 2015 in the province of Québec, Canada. Its practice has opened the door to organ donation after medical assistance in dying. This type of donation is possible through donation after controlled cardiocirculatory death (Maastricht III category), a procedure that also raises many ethical questions. Combining these two practices raises new ethical issues and could therefore generate conscientious objections from physicians directly involved in medical assistance in dying and/or organ donation. Would conscientious objection be acceptable in this context? To answer this question, we present a brief history of conscientious objection, an overview of the actual debates on conscientious objection and we will examine the case of the physician who would object to participate in organ donation after medical assistance in dying using existing criteria.


Allard J, Forin M.-C. Débats entourant l’objection de conscience : le cas du don d’organes après l’aide médicale à mourir au Québec. Éthique & Santé; 2019 Sep; 16(3): 125-132

Survival of Patients With Liver Transplants Donated After Euthanasia, Circulatory Death, or Brain Death at a Single Center in Belgium

Nicholas Gilbo, Ina Jochmans, Daniel Jacobs-Tulleneers-Thevissen, Albert Wolthuis, Mauricio Sainz-Barriga, Jacques Pirenne, Diethard Monbaliu

Journal of the American Medical Association

Abstract

Transplantation of organs donated after euthanasia may help alleviate the critical organ shortage.1 However, aside from preliminary data on lung transplantation,2 data on graft and patient survival following transplantation of organs donated after euthanasia are unavailable. Because donation after euthanasia entails a period of detrimental warm ischemia that hampers graft survival, similar to donation after circulatory death,3 results after transplantation of this type of graft need to be carefully evaluated.


Gilbo N, Jochmans I, Jacobs-Tulleneers-Thevissen D, Wolthuis A, Sainz-Barriga M, Pirenne  J, Monbaliu D.  Survival of Patients With Liver Transplants Donated After Euthanasia, Circulatory Death, or Brain Death at a Single Center in Belgium. JAMA. 2019;322(1):78-80. doi:10.1001/jama.2019.6553

Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy

James Downar, Sam D. Shemie, Clay Gillrie, Marie-Chantal Fortin, Amber Appleby, Daniel Z. Buchman, Christen Shoesmith, Aviva Goldberg, Vanessa Gruben, Jehan Lalani, Dirk Ysebaert, Lindsay Wilson and Michael D. Sharpe

Canadian Medical Association Journal

KEY POINTS

  • First-person consent for organ donation after medical assistance in dying (MAiD) or withdrawal of life-sustaining measures (WLSM) should be an option in jurisdictions that allow MAiD or WLSM and donation after circulatory determination of death.
  • The most important ethical concern — that the decision for MAiD or WLSM is being driven by a desire to donate organs — should be managed by ensuring that any discussion about organ donation takes place only after the decision for MAiD or WLSM is made.
  • If indications for MAiD change, this guidance for policies and the practice of organ donation after MAiD should be reviewed to ensure that the changes have not created new ethical or practical concerns. . .
  • [Full text]

Downar J, Shemie SD, Gillrie C, Fortin M-C, Amber Appleby A, Buchman DZ, Shoesmith C, Goldberg A, Gruben V, Lalani J, Ysebaert D, Wilson L, Sharpe MD.  Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy. CMAJ. 2019 Jun 3;191(22):E604-E613. doi: 10.1503/cmaj.181648.

Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands

Jan Bollen,Rankie Ten Hoopen, Dirk Ysebaert, Walther van Mook, Ernst van Heurn

Journal of Medical Ethics

Abstract

Organ donation after euthanasia has been performed more than 40 times in Belgium and the Netherlands together. Preliminary results of procedures that have been performed until now demonstrate that this leads to good medical results in the recipient of the organs. Several legal aspects could be changed to further facilitate the combination of organ donation and euthanasia. On the ethical side, several controversies remain, giving rise to an ongoing, but necessary and useful debate. Further experiences will clarify whether both procedures should be strictly separated and whether the dead donor rule should be strictly applied. Opinions still differ on whether the patient’s physician should address the possibility of organ donation after euthanasia, which laws should be adapted and which preparatory acts should be performed. These and other procedural issues potentially conflict with the patient’s request for organ donation or the circumstances in which euthanasia (without subsequent organ donation) traditionally occurs.


Bollen J, Ten Hoopen R, Ysebaert D, van Mook W, van Heurn E. Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands. J Med Ethics. 2016 Aug;42(8):486-9. doi: 10.1136/medethics-2015-102898. Epub 2016 Mar 24.

Dignity and the Ownership and Use of Body Parts

Charles Foster

Cambridge Quarterly of Healthcare Ethics

Abstract: Property-based models of the ownership of body parts are common. They are inadequate. They fail to deal satisfactorily with many important problems, and even when they do work, they rely on ideas that have to be derived from deeper, usually unacknowledged principles. This article proposes that the parent principle is always human dignity, and that one will get more satisfactory answers if one interrogates the older, wiser parent instead of the younger, callow offspring. But human dignity has a credibility problem. It is often seen as hopelessly amorphous or incurably theological. These accusations are often just. But a more thorough exegesis exculpates dignity and gives it its proper place at the fountainhead of bioethics. Dignity is objective human thriving. Thriving considerations can and should be applied to dead people as well as live ones. To use dignity properly, the unit of bioethical analysis needs to be the whole transaction rather than (for instance) the doctor-patient relationship. The dignity interests of all the stakeholders are assessed in a sort of utilitarianism. Its use in relation to body part ownership is demonstrated. Article 8(1) of the European Convention of Human Rights endorses and mandates this approach. [Full Text]

Foster C. Dignity and the Ownership and Use of Body Parts. Cambridge Quarterly of Healthcare Ethics / Volume 23 / Issue 04 / October 2014, pp 417-430

Whither Brain Death?

James L. Bernat

The American Journal of Bioethics

The publicity surrounding the recent McMath and Muñoz cases has rekindled public interest in brain death: the familiar term for human death determination by showing the irreversible cessation of clinical brain functions. The concept of brain death was developed decades ago to permit withdrawal of therapy in hopeless cases and to permit organ donation. It has become widely established medical practice, and laws permit it in all U.S. jurisdictions. Brain death has a biophilosophical justification as a standard for determining human death but remains poorly understood by the public and by health professionals. The current controversies over brain death are largely restricted to the academy, but some practitioners express ambivalence over whether brain death is equivalent to human death. Brain death remains an accepted and sound concept, but more work is necessary to establish its biophilosophical justification and to educate health professionals and the public. [Full text]

Bernat JL. Whither Brain Death? The American Journal of Bioethics, 14:8, 3-8, (2014) DOI:10.1080/15265161.2014.925153

Changing the Conversation About Brain Death

Robert D. Truog, Franklin G. Miller

The American Journal of Bioethics

We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between “legally dead” and “legally blind” demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike.

Truog RD, Miller FG. Changing the Conversation About Brain Death. The American Journal of Bioethics, 14:8, 9-14 (2014) DOI: 10:1080/15265161.2014.925154

The Case for Kidney Donation Before End-of-Life Care

Paul E. Morrisey

The American Journal of Bioethics

Abstract

Donation after cardiac death (DCD) is associated with many problems, including ischemic injury, high rates of delayed allograft function, and frequent organ discard. Furthermore, many potential DCD donors fail to progress to asystole in a manner that would enable safe organ transplantation and no organs are recovered. DCD protocols are based upon the principle that the donor must be declared dead prior to organ recovery. A new protocol is proposed whereby after a donor family agrees to withdrawal of life-sustaining treatments, premortem nephrectomy is performed in advance of end-of-life management. Since nephrectomy should not cause the donor’s death, this approach satisfies the dead donor rule. The donor family’s wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for the deceased. This proposal improves the likelihood of achieving these objectives.


Morrisey PE. The Case for Kidney Donation Before End-of-Life Care. American J Bioethics Vol. 12, Iss. 6, 2012