Bioethical Expertise

There's an interesting, though perhaps slightly obscure, Guardian column on the notion of expertise in bioethics here. The author, Nathan Emmerich, suggests that we should be wary of making professional bioethicists into a 'priestly caste'. I'd suggest that professional bioethicists may be better than priests, but I think he has a point about moral knowledge/expertise and deference.

The moral or political philosopher doesn't have the kind of expertise that delivers answers that others must simply defer to. I frequently stress to my students that an argument from authority is worthless and that they need to assess what they read critically. Does this mean that there is no such thing as moral expertise? Well, not exactly - it all depends what you mean by 'expertise'.

All of us are capable of thinking deeply and careful about important moral questions. Those who research, or have studied, moral philosophy have an advantage in that they have spent more time than most engaged in such reflection and will presumably be familiar with certain argumentative moves (e.g. slippery slopes) and common fallacies. Thus, we might hope, they will be less likely to reach the conclusions that they do on the basis of bad reasoning and so, hopefully, less likely to reach bad conclusions.

To the worry that relying on moral experts is undemocratic, I think the appropriate response is the broadly Millian one, that the value of free speech is that it allows bad arguments to be confronted by better ones. Experts shouldn't be able to silence ordinary people in virtue of their expertise - our basis for trust in their judgements should rest on the fact that they cannot be defeated by opposing arguments. (There is, of course, a problem here is saying who wins an argument; the quality of public debate is often lamentably poor.)

I don't think that anything I say here challenges Emmerich's position. He concludes "Expert bioethicists cannot allow themselves to become a priestly caste. They must engage with the public and, in doing so, become more fully engaged by and with their concerns", which is not to say that there is no expertise in bioethics, but only that expert bioethicists must engage with the public. That's something I wholeheartedly agree with and one of the purposes of this blog, to facilitate engagement and exchange of view.

David Hunter has his own response to Emmerich on the BMJ blog.

Nudge, Nudge

I discovered a 'new' (as in, new to me) weblog about nudging here, run by a group of geographers (mostly) from Aberystwyth. I've not thoroughly explored yet, but it looks interesting. In particular, of relevance here, are their comments on organ donation. (Richard Thaler's own favoured position is 'prompted choice', rather than 'presumed consent'.) Another interesting point is that the term 'nudge' was suggested by the publisher. Perhaps this explains why Thaler and Sunstein (infamously) don't clearly define it...

This all came to my attention because one of the blog authors, Jessica Pykett, is speaking at Stirling next week.

Regrowing Livers

The fact that livers can regrow means that it's sometimes possible to take a liver lobe from a healthy donor, transplant it to someone suffering liver failure, and for both to end up with a fully functioning liver - as reported here. Recent evidence, however, suggests that this same ability means that some people's need for a transplant is only temporary, since their damaged livers may repair themselves.

Despite the focus on transplants saving lives, it shouldn't be forgotten that it's preferable if people don't need a transplant at all, saving them from major operations and a lifetime of immunosuppressant drugs. Perhaps the gap between supply and demand can be reduced, in part, by reducing demand. And, of course, it's preferable that livers that are available for transplant go to those that really need them (long term).

Back From the Dead?

I think stories like this, about people being brought back from the dead, fuel unease about posthumous organ donation. People quite reasonably worry that, if they register as donors, they will be left for dead, when they could have been saved/revived.

It's worth emphasising that the story here is about cardiac death ("Most people regard cardiac arrest as synonymous with death, he says. But it is not a final threshold"). The definition of death used for organ donation is brain death. As the article goes on to say, "[Dr Jerry] Nolan stops short of saying that Carol was brought back from the dead. Hospitals do not declare death, he says, until they have ruled out all processes that can be reversed."

Nonetheless, this article serves to highlight the ambiguity and confusion surrounding death. Of course, public misunderstanding is somewhat to be expected, given current medical practice - e.g. the family may be informed that, since their relative is [brain] dead, doctors intend to turn off life support, in order to 'let them die'.

In the words of Dr Nolan, as quoted in the article, "We used to think death was a sort of sudden event - we stop the oxygen going to the brain and after a few minutes that was that. But actually, we know that the dying process at the cellular level goes on for a period of time". Our understanding of, and attitudes towards, death and dying are obviously crucial for organ donation (provided, of course, we continue to accept the assumption that it is only permissible to take organs from the dead, except in special circumstances).

Lab-grown Kidney

The reason for encouraging organ donation is to enable life-saving (and life-improving) transplants, but future technological breakthroughs might make this unnecessary. If scientists could produce artificial organs in labs, then we wouldn't need other people to donate their organs, since it would be possible to grow new organs to meet the demand.

This optimistic image may have come a step closer today, with the news that scientists have successfully grown a rat kidney. This is, however, only one step along a rather long road. The BBC article points to several unknowns, such as how long this artificial kidney will last. There's also the issue of cost: even if organs could be grown on-demand, if the technology is much more expensive than traditional transplants, then the latter are likely to continue. Finally, it seems that this particular mechanism requires an old organ in order to grow a new one, so this method will never avoid the need for donation in any case. That, I assume, is something that scientists will keep working on; in the meantime, donation is as useful as ever.

An Economist's Perspective

Economist Tim Harford considers some of the measures to increase organ procurement and suggests the importance of asking people to give their consent. (Thanks to Chris Bertram for directing me to this, on Twitter.)

I think Harford is right to say that many people, given the opportunity, will consent, so it's a good thing to ask people's views when, for instance, they apply for driving licences. It's unclear, however, whether this is sufficient to address the organ shortage. It's interesting that one reason he offers for 'rejecting presumed' is that it will not assure relatives of their loved one's wishes. As he asks, rhetorically, "If we fill our donor registry with auto-enrolled donors, will that really persuade distraught families to support transplants?"

This is all very well, but the unspoken assumption here is that family consent should be needed, along with that of individuals. Granted, perhaps in the opt-out system he was considering, this makes sense: the family should have the option to express an objection that the deceased may have had but never registered (a 'soft opt-out'). The danger, however, is that such systems potentially allow the family to override the wishes of the deceased. There have been a number of papers (for instance, this one) arguing that, even in an opt-out system, we ought not to consult the family: that the absence of objection from the deceased should be sufficient to license donation.

The appropriate role, if any, of families and next of kin is something we intend to explore in the next RSE Workshop.

Grayling on Respect for the Dead

There's a piece by A. C. Grayling criticising the notion of respect for the dead in the Independent. It isn't directly related to organ donation, since it's really concerned with the (im)propriety of speaking ill of Margaret Thatcher, but it occurs to me that 'respect for the dead' is a more general notion.

It's often assumed that we ought to respect someone's wishes concerning what happens to their organs after they die, hence why we give people the opportunity to record their wishes through donor registers and the like. It's sometimes pointed out that we don't think this respect, if demanded at all, is an absolute demand on us. Imagine a militant vegetarian who said that, after their death, they would like their rotting body to be left outside their local McDonalds, or something. We wouldn't feel any obligation to comply with these wishes, since we also accept that people's rights over their bodies can be circumscribed on grounds of public health (or perhaps even decency).

Unsurprisingly, there's much controversy about the implications of this for organ donation. Burying or cremating someone with their organs, which could have been used to save lives of those needing transplants, could be said to be similarly objectionable. That is, there's a case that could be made that, given what's at stake here, we ought to be prepared to override the wishes of the deceased. I'm not endorsing this position, just pointing out that we need to confront issues of the respect owed to the dead.