Organ and Tissue Transplantation and the Catholic Moral Tradition: A Case Study in the Evolution of Moral Teaching
Issue 19, August 2006
"For Christians, Jesus' offering of himself is the essential point of reference and inspiration of the love underlying the willingness to donate an organ, which is a manifestation of generous solidarity."
--Pope John Paul II, 1992
John Paul II's description of organ and tissue donation in terms of the sacrificial love of Jesus Christ highlights the acceptability of organ transplantation within the Catholic Tradition. Yet, when it was first raised as a serious issue in the 1940's and 1950's, the morality of organ donation caused vigorous debate among Catholic moral theologians. Ashley and O'Rourke (1989, p.305) note that initially the question was discussed from a largely theoretical point of view because, prior to 1950, transplants were contemplated but not yet possible. The subject was therefore not included in the moral manuals of the time. However, as advances in medical science and surgical procedures made organ transplantation a viable option, ethicists and moralists were forced to give the matter closer scrutiny.
There are basically two types of organ donation possible – from a dead person to a living person and from a living donor to another living person. This article will trace the development of Catholic thinking about organ and tissue transplantation over the last sixty years.
Organ Transplantation from a Dead Person to a Living Person
The Catholic moral tradition, along with most other religious groups, readily endorsed the worth and ethical acceptability of transplanting organs from a dead person to a living person. Pius XII was an articulate spokesperson for the development of Church thinking on this matter. On May 14, 1956, in an allocution to a group of eye specialists, Pius XII informed his audience: "The public must be educated. It must be explained with intelligence and respect that to consent explicitly or tacitly to serious damage to the integrity of the corpse in the interest of those who are suffering, is no violation of the reverence due to the dead." He was clear that the practice of organ retrieval from dead persons should not be forbidden. Persons are free to "dispose of their bodies and to destine it to ends that are useful, morally irreproachable and even noble." In fact, Pius XII concluded, "This decision should not be condemned, but positively justified." (Tissue Transplantation. (May 14, 1956), in The Human Body: Papal Teachings, pp. 380-83.) In taking this stance Pius XII had in mind the needs of "medical science and the training of future physicians" as well as those with "the desire to aid the sick and the suffering."
Nevertheless, Pius XII's endorsement was not without its concerns. A key concern was that the body not be treated merely as a physical or biological entity. The human body deserves to be regarded differently than the body of an animal because human persons are formed in the image and likeness of God, and "something of this dignity still remains in the corpse." Another of his concerns was that "ordinarily the deed cannot be presented as a duty or as an obligatory act of charity." The liberty and spontaneity of the parties involved must be respected.
Other concerns that surfaced in discussions about the retrieval of organs from dead persons stemmed from factors other than the concept of transplantation per se. They included such things as: the high costs involved; questions about accurately determining the exact point of death of a donor and fears that some donors might not have actually died; and relatively high failure rates. (Ashley and O'Rourke, 1989, p. 305.)
Organ Transplantation by a Living Donor
Determining the moral acceptability of organ transplants between living persons proved to be a greater challenge for Catholic moral theologians of the 1940's and 1950's. The dilemma was initially framed in terms of the question as to whether a person could 'mutilate' him or herself for any purpose.
It has always been a fundamental tenet of Catholic teaching that the human body is under God's dominion and that we may not, therefore, dispose of it in any way we wish. Proper recognition of God's dominion calls for persons to exercise a sense of stewardship over their bodies. Consequently, all forms of mutilation - as well as suicide - were outlawed because they were deemed to be a violation of that dominion. In their attempts to resolve the quandary posed by "surgical mutilation", theologians such as St Thomas Aquinas (1225-1274) developed the Principle of Totality, a principle that by the middle of the 20th Century had become "an integral part of the moral methodology which had come to the fore in Catholic medical ethics." (Kelly, 1998, p. 305-306.) Put simply, the Principle of Totality, as articulated by Pope Pius XII in 1952, holds that the part exists for the whole. Consequently, it follows that the good of the part remains subordinated to the overall good of the whole. Therefore, the whole may be seen as a determining factor for the part, able to "dispose" of it in its own interest.
In its most common application, the Principle of Totality provided the logic used to justify the "surgical mutilation" of a person's body - for example the amputation of a gangrenous leg to save that person's life. However, its consistent application in this type of context also shaped the way in which the principle came to be understood, particularly when applied to other moral dilemmas. In Kelly's words, "the principle of totality had come to be limited to the physical good of the individual physical body." (1998, p. 306).
Interpreting the Principle of Totality in a physicalist and individualist way, most moral theologians were convinced that the surgical mutilation of any part of a person's body could only be justified for the better functioning of the person suffering the loss. Because persons are not related to each other as part to the whole (they each possess an innate and equal dignity), they drew the conclusion that surgical intervention was only ever permissible when an organ was harmful or useless to a particular person. The outcome seemed clear cut. The Principle of Totality ruled out live organ donation for philanthropic motives. It was on this basis that Pius XII proclaimed to a group of military surgeons in 1953: "The patient ... has no right to dispose of his own existence, of the integrity of his organism, of his particular organs and their functional capacity, except in the measure demanded by the good of the whole organism." Thus Kelly notes: "For a period of time Catholic moral theology was more apt to forbid [living donor] organ transplantation than to permit it." Indeed, there was almost unanimous agreement from Catholic moral theologians that the practice was morally unacceptable.
As early as 1944, however, (writing before organ transplantation was even possible) Bert Cunningham CM had posited an opposing point of view. Drawing on accepted Catholic thinking that recognised the validity of a person sacrificing his/her life in order to save the life of their "neighbour", Cunningham speculated that charity should be able to authorise something "less" than the taking of a human life. He therefore offered the "probable opinion" that living donor transplantation involved no opposition to the "natural or supernatural moral law" and that they were therefore licit.
In arguing his case Cunningham's central thesis was that living donor transplantation was not a violation of the Principle of Totality. The key problem, as he saw it, was that the Catholic Tradition was interpreting the principle in too narrow a way. Cunningham then proposed that the "body" be redefined to include not only the individual physical body from which the organ is removed, but the entire Mystical Body of Christ. Drawing moral implications from what was essentially a theological doctrine, he concluded that "... men are ordinated to society as parts to a whole, and, as such, are in some way ordinated to one another." This spiritual ordering would, he thought, allow any person to "mutilate" themselves physically for the overall good of the Mystical Body.
In analysing Cunningham's approach, other theologians seeking to develop a Catholic rationale for a more liberal opinion were wary of Cunningham's thesis that individuals are ordained to society as parts to the whole. In particular, his approach appeared unable to properly uphold the dignity and rights of the individual over their body and life, a failure that left the way open for the needs of individuals to be sacrificed in favour of the common good of the community. In the end, Shannon notes that it was Cunningham's "highlighting of the principle of charity rather than arguments about the unity of the human body – mystical or physical – that carried the argument supporting living organ donation." (2001, p. 289)
By 1955, there were enough moral theologians of sufficient stature within the Catholic community for Gerald Kelly SJ to conclude that living organ donation may be permitted. Kelly thought the Principle of Charity validated living donations provided that there was only "limited harm" to the donor. More recently, other theologians such as Ashley and O'Rourke have sought to justify the practice by drawing a distinction between "anatomical integrity" and "functional integrity": if one kidney is missing from a person's body, there is a lack of anatomical integrity, but if the other healthy kidney is present and working, the body retains its functional integrity because one healthy kidney is more than able to meet the body's needs. (Ashley and O'Rourke, 1989, p.306)
Most recently it was Pope John Paul II who articulated Catholic thinking on organ and tissue donation. In 1991 he described the therapeutic use of organ and tissue transplants as one of the many remarkable achievements of modern medicine. "It is surely a reason for satisfaction that many sick people, who recently could only expect death or at best a painful and restricted existence, can now recover more or less fully through the replacement of a diseased organ with a healthy donated one: We should rejoice that medicine, in its service to life, has found in organ transplantation a new way of serving the human family, precisely by safeguarding that fundamental good of the person." "We are challenged to love our neighbour in new ways; in evangelical terms, to love 'to the end' (cf Jn 13:1), yet within certain limits which cannot be exceeded." ("Many ethical, legal, and social questions must be examined in greater depth" (June 20, 1991) Dolentium Hominum, Vatican Press n. 3 pp. 12.)
For John Paul II, the limit which cannot be exceeded "above all" is that organ donation must remain "a human act of donation. In effect, transplantation presupposes a prior, explicit, free, and conscious decision on the part of the donor or of someone who legitimately represents the donor, generally the closest relatives." John Paul II exhorts health professionals involved not to lose sight of the donor's act of self-giving and "the mystery of love involved" in what they are doing. "Nor should the recipients of organ transplants forget they are receiving a unique gift from someone else: the gift of self made by the donor ... The progress of the biomedical sciences has made it possible for people to project beyond death their vocation to love." Subsequently, the donation of tissues and/or organs has come to be described by many as an "enduring gift".
On the question of living donations, John Paul II states that "a person can only donate that of which he can deprive him or herself without serious danger or harm to their own life or personal identity, and for a just and proportionate reason." "Vital" organs should only be donated after death.
Organ Transplantation and Compensation
In his 1956 teaching Pius XII was ambivalent as to whether one should "refuse on principle all compensation" for organ donation. While he did not doubt that grave abuses could occur when payments are demanded, he concluded that it was commendable for a donor to refuse recompense but "not necessarily a fault to accept it". John Paul II, meanwhile, advocated a firmer line; the provision of an organ should be "a decision to offer without reward a part of one's own body." John Paul II adopted this stance because of his belief that the commercialisation of body parts would amount to a materialist reduction of the human body.
Such a reductive materialist conception would lead to a merely instrumental use of the body, and therefore of the person. In such a perspective, organ transplantation and the grafting of tissue would no longer correspond to an act of donation but would amount to the dispossession or plundering of a body. (Address to participants in a conference on organ transplants, June 20, 1991)
Within New Zealand there has developed a strong culture of resistance to the notion of commercialising transactions involving human tissue. Unlike other parts of the world, New Zealanders have never received compensation for giving blood, for example. This attitude has been most recently enshrined in legislation such as the Human Assisted Reproductive Technology (HART) Act which prohibits the commercial supply of human embryos and human gametes and also prohibits commercial surrogacy arrangements.
One of the ways in which the notion of organ and tissue donation as 'gift' may continue to be upheld in law and practice in New Zealand is by ensuring that there are robust processes for recording a person's positive consent to be a donor.
The absence of specific consent raises the question as to whether anyone else can make a proxy decision in favour of organ donation for a dying person. At first glance, the concept of organ donation as an act of 'self-giving' might seem to rule out any notion of substituted or surrogate consent. In line with this, from the time of Pius XII, Catholic teaching has consistently maintained that "public authority" has no direct right to dispose of the existence and integrity of the organs of its innocent subjects. Nevertheless, Catholic teaching continues to affirm the right of the family or next-of-kin to make such a judgement. It does this on the basis that such persons are in a genuine position to know what their loved one would have wanted, and provided that the person concerned had not previously made known their opposition to such.
Moral theologians of the 1950's and 1960's faced new dilemmas as a result of technological and medical advances. The history of Catholic moral teaching on organ transplantation shows how the Catholic position on ethical issues sometimes develops over time. In this case there has been a movement from condemnation to commendation, from describing it as mutilation to describing it as donation, and from a very individualistic approach informed by the principles of Totality and Stewardship to a more social view of the issue informed by the principle of Charity. (Jonsen, 2005)
The initial responses of many theologians to the possibility of organ and tissue transplantation were both informed by, as well as limited by, existing principles and ways of thinking inherited from the moral tradition. In the light of condemnations of the practice, a few theologians were prepared to challenge the conclusions of the majority, among other things motivated by an "intuitive" sense that it seemed wrong to forbid transplantations. In developing a rationale for a more positive assessment of transplants they refined accepted principles and extended Catholic moral thinking.
In our own time we are facing many new dilemmas related to new advances in technology and medicine. We would do well to recall the history of the debate over organ and tissue transplantation as we seek to apply established moral principles to issues raised by reproductive technologies and developments in genetics and biotechnology.
The experience of theologians of the 1950's and 1960's should inspire us with boldness to contribute to the debates of our own time based on a confidence in our rich moral tradition. At the same time we should also bear a healthy sense of humility and scepticism, even (and perhaps especially) towards those solutions that seem so "obvious" and clear cut. We are also challenged to listen openly to those who propose alternative solutions.
In the meantime, the debate over how best to promote a more effective organ donation system in New Zealand continues. The legacy of John Paul II, Pius XII and many competent moral theologians places Catholics and others in an excellent position to contribute to the discussion. While the moral acceptability of organ and tissue transplantation is now a given, risks remain and ongoing ethical vigilance is required. In particular, future developments such as xenografting and transgenesis will surely require us to revisit the basic principles in order to resolve new questions and dilemmas that are bound to arise.
John Kleinsman is a Researcher for The Nathaniel Centre