This article appeared in the November 1998 edition of the Catholic Medical Quarterly
Organ Donation: A Catholic Perspective
Peter J. Cullen
The text of a talk given to the 1998 National Conference of the Guild of Catholic Doctors
I must confess that I did not quite know where to begin when I was first asked to talk about the ethics of organ donation at this year's National Conference. My own academic expertise, such as it is, lies in the field of biblical study. I had not entered with any depth into the field of medical ethics since my days in the seminary. How could I, a practitioner of the art of biblical criticism and interpretation, find something meaningful to say to practitioners at the cutting edge of modern medicine? In the end, I concluded that, since many members of my audience would be practising Christians, the Bible might not be such a bad place to begin after all. So, like all good researchers today, I started my computer and began to search the 'MacBible' programme for relevant references.
My search revealed 5 references to 'donation' in the whole of the Bible, none of them of any use to me. Next, I tried 'transplantation'. Needless to say, this search simply revealed what I already knew in my heart of hearts; the word does not occur in the Bible at all! Aware that I was on my last chance, I anxiously typed in 'organ' and clicked the search icon. This time I got one reference - in the 4th Book of Maccabees! Now, this particular book is so obscure that it does not appear in most versions of the Bible.
I had never read the 4th Book of Maccabees; but I quickly discovered that it was written towards the end of the first century of the Christian era in order to encourage Jews to observe God's Law in all circumstances. I found the reference to organ removal hidden away in a story about the torture and death of one of the Maccabees - those doughty fighters against all things secular and pagan who had confronted the Greek rulers of Palestine some 175 years before the birth of Jesus Christ. An unfortunate Jewish youth had incurred the wrath of the ruler Antiochus Epiphanes by refusing to eat pig meat. The account in 4 Maccabees reads:
When he heard this, the bloodthirsty, murderous and utterly abominable Antiochus gave orders to cut out his tongue. But the youth said, "Even if you remove my organ of speech, God hears also those who are mute. See, here is my tongue; cut it off, for in spite of this you will not make our reason speechless. Gladly, for the sake of God, we let our bodily members be mutilated." (4 Macc. 10;18-20)
"That's it!" I thought, realising that the final line of the young man's speech pointed the way into my topic. It was less than twelve months since I had succumbed to the computer revolution; but now I felt indebted to the undergraduate students who had pushed their reluctant chaplain into spending so much money all at once.
Of course, there is quite a difference between the Maccabean fighters of the second century BC and those who offer their organs today. Modern donors do not do it in defiance and under duress, but freely and out of a desire to give others a better life.
Love and Communion are, in fact the very principles by which the Catholic Church has formed its attitude towards organ donation. Addressing participants in the First International Congress of 'The Society For Organ Sharing' on 20th June, 1991 Pope John Paul commented, "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. It is a decision to offer, without reward, a part of one's own body for the health and well-being of another person. In this sense, the medical action of transplantation makes possible the donor's act of self-giving, that sincere gift of self which expresses our constitutive calling to love and communion." (paragraph 3)
Three years later, in his encyclical Evangelium Vitae (Gospel of Life) Pope John Paul II summed up the thought of his predecessor Pins XII who, whilst speaking to a group of eye specialists in 1956, had made the first papal comment about organ donation. Echoing sentiments expressed nearly forty years earlier by Pope Pius, John Paul wrote, "The Gospel of Life is celebrated above all else in the daily living of life which should be filled with self giving for others. In this way our lives will become a genuine and responsible acceptance of the gift of life and a heartfelt song of praise and gratitude to God who has given us this gift...
"It is in this context, so humanly rich and filled with love, that heroic actions too are born. These are the most solemn celebration of the Gospel of life, for they proclaim it by the total gift of self. They are the radiant manifestation of the highest degree of love, which is to give one's life for the person loved (cf. Jn.15:13). They are a sharing in the mystery of the Cross, in which Jesus reveals the value of every person, and how life attains its fullness in the sincere gift of self Over and above such outstanding moments, there is an everyday heroism, made up of gestures and sharing, big or small, which build up an authentic culture of life. A particular praiseworthy example of such gestures is the donation of organs performed in an ethically acceptable manner, with a view to offering a chance of health and even life itself to the sick who sometimes have no other hope." (Evangelium Vitae, n.86)
Transplant Surgery and Moral Theology
Prior to 1950, the morality of transplanting an organ from one living person to another involved purely theoretical discussion among Catholic theologians. Many were of the opinion that such activity would he immoral. However, when organ transplants from living donors began to be performed during the 1950s, the need for moral guidance became urgent.
The Jesuit theologian, Gerald Kelly, was one of the first to give the issue serious consideration. In an article entitled The Morality Of Mutilation: Towards A Revision of The Treatise, he pioneered a more liberal approach, based on the Christian command to love. "It may come as a surprise to physicians that theologians should have any difficulty about mutilations and other procedures which are performed with the consent of the subject but which have as their purpose the helping of others. By a sort of instinctive judgment we consider that the giving of a part of one's body to help a sick man is not only morally justifiable, but, in some instances, actually heroic." (Theological Studies 17, 322-344,1956)
It was, specifically, the consideration of transplantation in the light of fraternal love or Christian charity that led Kelly to his conclusion. Although his view was not unanimously accepted, there were some theologians who agreed with his opinion and attempted to develop it further by testing it against the well established principle of totality and integrity. Making a distinction between Anatomical Integrity and Functional Integrity, they affirmed that it was the latter which was necessary to ensure the integrity of the human person. Anatomical Integrity refers to the material or physical integrity of the human body, whilst Functional Integrity refers to the systematic efficiency of the human body. Two simple examples will help to make sense of the distinction. In the case of a person who has only one
kidney, it can be said that there is a lack of Anatomical Integrity. However, since one healthy kidney working efficiently is enough, there is Functional Integrity. By developing the principle of integrity in this way, they were able to argue effectively that there was nothing morally wrong with kidney transplantation. In contrast, however, if a cornea were to be taken from the eye of one living person and given to another, there would be a destruction of both anatomical and functional integrity because the loss of sight in one eye severely diminishes 'in depth' perception.
The Conditions for Ethical Transplant Surgery
The development of the concept of Functional Integrity was a key factor in the emergence of a consensus among Catholic theologians which accepts the morality of organ donation and transplant surgery. In the latest edition of their book Health Care Ethics, the Dominicans Benedict M. Ashley and Kevin D. ORourke have summarised the current attitude of the Catholic Church as follows: "The transplanting of organs or tissues from a dead person to a living person does not offer any intrinsic ethical problem. Transplanting organs from one living person to another is also ethically acceptable, provided that the following conditions are met:
- There is a serious need on the part of the recipient that cannot be fulfilled in any other way.
- The functional integrity of the donor as a human person will not be impaired, even though anatomical integrity may suffer.
- The risk taken by the donor as an act of charity is proportionate to the good resulting for the recipient.
- The donor's consent is free and informed." (Health Care Ethics, page 334)
Transplant Surgery and Catholic Social Teaching
Pope John Paul II began his Address to 'The Society For Organ Sharing' by applauding the development of transplant surgery.
"Among the many remarkable achievements of modem medicine, advances in the fields of immunology and of surgical technology have made possible the therapeutic use of organ and tissue transplants. It is surely a reason for satisfaction that many sick people, who until 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 of life, has found in organ transplantation a new way of serving the human family, precisely by safeguarding that fundamental good of the person." (Address, paragraph 2)
The Pope went on to make clear that the "only legitimate context" in which organ transplantation can take place must be one of "love, communion, solidarity and absolute respect for the dignity of the human person."
Taking inspiration from the text of John 13, he commented:
"With the advent of organ transplantation, which began with blood transfusions, man has found his way to give of himself, of his blood and of his body, so that others may continue to live. Thanks to science, and to the professional training and commitment of doctors and health care workers... we are challenged to love our neighbour in new ways; in evangelical terms, to love 'to the end' (cf. John 13: 1)".
This quotation from John's gospel represents the opening of the second part of the gospel in which the writer sets out to help the reader to understand the implications of the death and resurrection of Jesus for the Christian disciple. Pope John Paul sees this self offering of Jesus as "the essential point of reference and inspiration of the love underlying the willingness to donate an organ.
At the end of his address, the Pope contrasted the generosity of organ donation (an act that he described as a "concrete gesture of solidarity and self-giving love") with the selfishness of abortion and euthanasia. His use of the term "solidarity" sets organ donation firmly within the context of Catholic social teaching. The chief and guiding principle upon which this social teaching is formulated has been summed up in the expression 'The Common Good'. To put it in biblical language, we are, in the eyes of the Church, our sisters' and our brothers' keepers.
Setting organ donation within the contexts of the Christian command to love and the Church's social teaching, subjects it to all the principles associated with Christian charity and the exercise of our obligations towards others. Clearly, these principles would render the selling of an organ by a donor an immoral act. They would also preclude any consideration other than medical need as the basic factor in assessing the suitability of potential candidates for transplant surgery.
In the gospel of Luke - an evangelist who displays a flair for understanding the needs and condition of people who are sick - we read at 6:38: "Give and it will be given to you. A good measure, pressed down, shaken together, running over, will be put into your lap; for the measure you give will be the measure you get back." This is Luke's way of telling us what Matthew spells out so clearly in the parable of the sheep and the goats, that whatever we do to our neighbour who is in need we do to Our Lord Jesus Christ.
Perhaps our Bibles are not so vague about organ donation and transplant surgery after all!
Ashley Benedict M. O.P. & O'Rourke Kevin D. O.P., Health Care Ethics, Georgetown University Press, Washington 1997. Press, Washington. 1997.
Pope John Paul II, Address To The Participants Of The Society For Organ Sharing, Transplantation Proceedings, Vol.23, No. 5 (October), 1991: pp.xvii-xviii. - Evangelium Vitae (The Gospel Of Life), encyclical, 1996.
Kelly, Gerald S.J., The Morality Of Mutilation. Toward A Revision Of The Treatise, Theological Studies 17, pp. 322-344,1956.
Fr. Peter Cullen is Chaplain to the Guild's Sheffield Branch.