Delicate Organ Transplantation, Euthanasia and the Correct Application of the Principle of Double Effect

As biomedical technology and skills get advanced, new ethical questions keep on arising. Currently, medical technology and skills may be utilized to transplant delicate organs like the heart, but the question is; where do we get the hearts for transplantation if not from live bodies? Besides, is such a practice ethical? In some circumstances, it may seem plausible for a physician to intentionally terminate life of a patient whose death is imminent and yet the patient is suffering incurably; but would such an action be ethically permissible? And if such practices would be legalized, could it be a lee way for some patients to be killed on the basis of quality of their life in order to legitimately harvest delicate organs like the heart from them? This paper illuminates concrete situations in biomedical practice and evaluates them in the light of practical application of the principle of double effect in relation to euthanasia and organ transplantation.


INTRODUCTION
Organ transplantation is "the surgical replacement of a malfunctioning organ donated by another human being. Kidney, heart Pancreas, liver, or lungs have already been successfully transplanted as well as organ parts or tissues such as bones, cornea, skin, or bone marrow (Schicktanz, 2010). In general, three types of grafts are distinguished: auto grafts which originates from the recipients themselves, allograft which are transplants between genetically non identical human beings, and xeno-grafts which are living animal organs or tissue transplanted into human beings (Schicktanz, 2010). The discussion in this paper will mainly dwell on allograft since, as already noted by Brawer et al (2005), it involves social and ethical questions which arise in the framework of the society to which the donor and the recipient belong On the other hand, euthanasia is etymologically derived from a Greek word "euthanatos" meaning good or painless death (from Greek, eu, 'good' and 'thenatos, 'death') which came to be used in the last decade of the 20 th century to mean a death that is perpetrated or accelerated with the help of medicine (Mystakidou, 2005). In other words, euthanasia is the physician's killing of a human being on the grounds that he is better off dead (Audi, 2001), or 'the art of painlessly putting to death persons suffering from incurable condition or diseases' (Pence, 1988). However, the act is supposed to be performed with the explicit consent of a competent patient. Similar to euthanasia, is assisted suicide, in which the patient is assisted to commit suicide as a way of alleviating pain. Euthanasia is distinguished from murder by the intention behind killing, in the sense that, murder would be committed for a reason other than kindness.
The act of administering a painless and merciful death to patients is classified as either active/positive or passive, and as voluntary, involuntary or non voluntary. Active euthanasia is when one brings about a patient's death directly by some means. It involves taking deliberate steps to end a patient's life (Audi, 2001). Passive euthanasia is a conscious act of withdrawing medical treatment with the deliberate intention of causing patient's death. The omission or termination of means of prolonging life is done on the grounds that the patient is better off without them (Audi, 2001). Voluntary euthanasia is done when the patient in question requests that action be taken to end his/her life, or life saving treatment be stopped, with full knowledge that this will lead to his death. In this case, a patient is mercifully put to death in order to end his suffering according to his own wish (Audi, 2001). Involuntary euthanasia is executed when a patient's life is ended without his/her knowledge and consent or against the patient's wish. Nonvoluntary euthanasia is painless death which is administered to subjects whose agreement cannot be obtained because of their physical or mental state. That is if they are not capable of understanding the choice between life and death, euthanasia would be neither voluntary nor involuntary, but non-voluntary (Singer, 1979).

Euthanasia in the Context of Human Rights and Organ Donation
According to some Ethicists, medics and lawyers, patients who request to be voluntarily killed have the right for their request to honoured and administered. Their request should be honoured as a fulfillment of respect for individual's right to privacy and autonomy. As Robert H. Binstok (1992) notes that "in the contemporary defense of active euthanasia, it is often argued that to determine the character and timing of one's own death, wherever doing so is possible, is a basic human right grounded in fundamental human right of self-determination and autonomy generally". According to Mclean (2006), the above argument is the reason why "self determination now more frequently referred to as 'autonomy', remains pitted against the culturally entrenched prohibition on killing innocent persons".
Furthermore, for other philosophers, physically or mentally defective infants, the sick, old people and people in an irreversible coma are not supposed to be helped medically to live longer. Rather, they are supposed to be helped to die quickly by killing them. Their general argument is that early death will benefit the irreversible ailing and suffering patients, their organs could also be used to benefit other patients with the hope of recovering (Camosy, 2012) and their death shall relieve their families of the burden of taking care of them that includes finance (Genslar et al., 2010). Moreover, the irreversibly comatose patients and defective babies cannot benefit from life and so they have no reason for living. The final reason is that, patients in an irreversible coma lack dignity and the right to autonomy since they are unconscious and cannot make any personal choice concerning the right to life and the right to die. Therefore, killing them does not violate any of the human rights.
It is very clear from the reasons given above that in the contemporary world; it might not be easy to decide on how to treat dying patients, especially the irreversible comatose, deformed infants and those who are in a severe intractable pain. For the pro-euthanasia like Peter Singer (1993), it might be ethically permissible to administer euthanasia to such individuals. This kind of judgment is mostly based on a utilitarian principle. Being that, a life which has no expected benefit, has no reason to be sustained by any medical treatment. Hence the only way that individuals in this state could be helped is by offering them a mercy killing to help them evade pain and die peacefully. Defense for euthanasia and assisted suicide for irreversible comatose and deformed infants is not an end in itself. It is of great important consequence, since the victims of euthanasia shall make delicate and essential organs like the heart available to those patients who may desperately need them to survive.
It is important to note that; Whether the intention of euthanizing a patient is solely for harvesting organs from him, or alleviating pain, death of the patients should be directly intended and executed for them to evade a painful or meaningless unconscious life or to donate a delicate organ like the heart which can only be transplanted immediately from living body to avoid its damage.
On the other side of the debate, the contra-euthanasia defenders like Luke Gormally (1994) hold on sanctity of life to reject any kind of intentional termination of an innocent life for what-so-ever reason. They hold that life has got an intrinsic value in so far as it is of a human nature. And because this intrinsic value belongs radically to the human nature, it belongs to all humankind equally, for they all (human beings) have the same nature.
When the contra-euthanasia argument is applied in bioethics, it implies that all patients, so long as they are living human beings, need to be treated with dignity and respect that all human beings deserve. In that regard, the sanctity of life can be summarized in three claims: "(1) There is an absolute right not to be killed, (2) that there is no entitlement to waive that right, (3) that there is a duty not to kill oneself" (Sheila, 2006). Furthermore, all patients have the right to life because the right to life is a metaphysical possession that belongs to man in his radical nature. Nobody can deprive or confer this right to man. One can only recognize this right, and failure to recognize it does not mean deprivation of it. These two positions as held by the contra and the pro-euthanasia leave the medical practitioners in a dilemma on how to treat the irreversible comatose, the deformed infants and those patients who request death. This is because life is at the core of biomedical ethics.

The Principle of Double Effect
It is at this point of dilemma in biomedical where the principle of double effect is invoked in order to be utilized in finding out what to do in such a situation. Double effect refers to the good and bad effects, which may be foreseeable, following from one and the same act. So, the principle is supposed to guide decisions about acts with double effect where the effect is something that must not be intended, such as the death of an innocent person. In some unique circumstances such acts are permissible only if the bad effect is unintended, not disproportionate to the intended good effect and unavoidable if the good effect is to be achieved. So, the principle of double effect is usually invoked to explain the permissibility of an action which causes a serious harm, such as death of a human being, as a side effect of promoting a greater good end (Craig, 1999).
The principle of the double effect, therefore, is summarized with the claim that sometimes it is permissible to bring about, as a merely foreseen side effect, a harmful event that it would be impermissible to bring about intentionally. For that reason, it is the most relevant criterion in determining the morality of euthanasia because, euthanasia always has foreseeable good and bad effects by those who defend and administer it.
Euthanasia is not an entirely religious affair; the principle of double effect is the best to use in evaluating its debate since the principle of double effect is derived from the Natural Law Ethical Theory, which is philosophical. The Natural Law Ethical Theory itself is philosophical because it is not derived from religious dogmas or variable emotions or personal opinions, rather it is objectively grounded in our objective knowable human nature. So, even though different thinkers may have different beliefs, the natural law ethical theory remains the best to evaluate the euthanasia debate since we are all human beings and the precepts of the natural law are grounded in human nature.
Before we proceed on with the principle of double effect, it is important to highlight that in the natural law ethical theory; there are three determinants of ethics of human actions as follows: i.
The act itself: this is an action that an agent does willingly. It could be good, evil or neutral in its very nature. For example, the action of intentionally murdering an innocent human being or committing suicide is evil in itself. ii.
The motive or intention: this is the goal behind an action consciously done. For instance, the intention for which a doctor kills a patient could be in order to relieve him from pain, or to harvest organs from him. iii.
The circumstances: this includes the accidentals surrounding the act and the consequences of a human action. For instance, if one gives a low dose of lethal pain killer injection like morphine to a patient because there is no other medical treatment available. The use of morphine as a painkiller will reduce the patient's pain but it will also hasten the patient's death. In such a circumstance, the doctor should have exhausted all other possible options since the option with foreseen bad effect should be the last one and the only way out.
According to the natural law ethical theory, for a human action to be considered good, all the above three determinants must be good. Austin Fagothey (1967) puts more emphasis on this by saying: "To be morally good, the norm of morality on all three counts: in its nature, its motive and its circumstances. Disconformities in any one of them make the act morally wrong". Furthermore, an intrinsically evil action cannot be made good by circumstance or intention but an intrinsically good action can be morally ruined by evil intention or circumstances. Peter Singer, a contemporary renowned ethicist who vehemently advocates for quality of life based on euthanasia, presents arguments, examples and analogies to defend euthanasia in some circumstances. For that reason, it is of great importance to analyze his arguments, examples and analogies in order to see whether they are in line with the natural law ethical theory and the principle of the double effect.
In our evaluation, the more relevant the quality of life ethic relates to the principle of double effect, the more ethical it is and the less the dilemma in action. But if quality of life ethic will not be palatable with the principle of double effect, then it will automatically be unethical, for it will not be in conformity with precepts of human nature.

Relevance of the Principle of Double Effect to Quality of Life Ethic
There are several cases and circumstances that have been fronted by several scholars who support quality of life ethic. These sample cases and circumstances have been considered to be some of the very good reasons in which a medical doctor would have been allowed to administer euthanasia. These examples that have been presented as paradigmatic cases are more related to the principle of double effect, even though the Proponents do not say it explicitly.
The principle of the double effect is used to determine the morality of an action that has two possible effects; the bad and good effects. One must have no other option for him to choose to do an action of this nature. And while executing such an action of double effect, one should not aim at the evil effect directly; rather the evil effect should occur incidentally and as an unavoidable by-product.
In Rethinking Life and Death, Peter Singer gives several circumstances where euthanasia could be permissible. He bases his argument on the good effects that might come out of euthanasia even though an innocent human being shall be killed. He presents several situations that might render euthanasia to be ethically executed. The best example that Peter Singer gives which, according to him, could warrant euthanasia basing on the principle of the double effect is drawn from Dr. Frank Shannon's encounter.
At this point, Frank Shanon's dilemma will be written verbatim as in Singer's book Rethinking Life and Death. Frank Shanon, the director of the Royal Children's Hospital, received a baby boy who had been brought into hospital with severe heart disease. After suffering repeated heart attacks he needed to be put on a ventilator and be given drugs continuously in order to keep him alive. Apart from his heart disease, the baby was quite normal; but because the disease was so serious, the outlook was, as Shanon said, 'hopeless' (Singer, 1993). At the same time , in the adjacent bed in the intensive care unit, was another baby who had been well until a sudden and catastrophic collapse occurred. He had some abnormal blood vessels in his brain and these suddenly burst; there was massive bleeding into his brain causing destruction of the whole of his cerebral cortex. However, his brain stem was partially functioning, and he made irregular gasping movements. These were not enough to enable him to survive off the ventilator but there were evidence that he did not have death of his whole brain, so he was not legally dead. There was, therefore, one child who was completely normal except for a dying heart in one bed, and in the next bed, a child with a dead brain cortex but a normal heart. As it happened the two children had the same blood group, so the heart of the child with no cerebral cortex could have been transplanted into a child with cardiomyopathy [heart disease] (Singer, 1993).
This incident happened in Australia and according to Australian law there was nothing that Shanon would have done since in the law, a person is only legally dead when his whole brain is dead. So, the child who was cortically dead could not be considered as a heart donor, for he was still alive. Therefore, the fact that no other heart could be found for the child with a heart disease, both children died after a short time. The question is, was Dr. Shanon fair to let the two lives be lost yet he could intentionally kill one of them in order to get an organ to sustain the other?
In order to avoid misconceiving, misinterpreting and misrepresenting Singer, as he usually complains, we shall take his evaluation of Shanon's dilemma directly from his own writings: I agreed with Frank Shanon that (as long as the parents were willing for organs to be donated) there was no point of allowing two babies to die when one could be saved. Several members of the panel shared my view that encephalics and cortically dead infants could be considered as potential organ donors (Singer, 1993).
Singer gave the above evaluation while discussing ethical acceptability of harvesting organs from the encephalics and the cortically dead human beings. For that reason, Singer does not only say that the cortically dead are potential organ donors but also that it is ethically acceptable to harvest organs from the cortically dead patients.
Basing on the above evaluation, Dr. Shanon should have taken the heart of the baby whose whole cerebral cortex had died and transplant it into the baby boy who had a severe heart disease. Basing on Dr. Shanon's dilemma, Singer derives the above ethical stand from the double effect of euthanasia. That it is ethical to get a healthy heart from a cortically dead patient or encephalic, who will never regain consciousness at all, in order to save another patient who only needs a heart to live a normal life. The double effect here is that, one hopeless patient with no potency of being conscious will die and another hopeless patient who is potentially conscious will live.
Up till now, Singer's evaluation might sound so convincing, but let us subject it to the principle of double effect and see whether it will still stand.

The Application of the Principle of Double Effect to Quality of Life Ethic and Organ Transplantation
We have learned from Dr. Shanon's experience that, a medical professional could encounter a dilemma while undertaking his duties. The dilemma is mostly caused by an action that he is supposed to undertake urgently, yet the same action has a mixture of good and gravely bad effects. If such an action of double effect is not thought about and executed quickly, lives could be lost. The dilemma of such action intensifies when it becomes imperative that the doctor should do something to let one innocent human being die in order to save the other. It is not easy to make decisions while in such a situation because if one is not careful, he/she might violate both the law and the code of medical ethics.
The principle of double effect is one of the most useful ethical principles which we utilize in solving such dilemmas in medical practice. While writing on the principle of double effect, Fagothey (1967) notes that the principle of double effect implies that it is morally permissible to perform an act that has a bad effect under some conditions. The first condition is: The act to be done must be good in itself or at least to be indifferent. This is evident for if an act is evil in its very nature, nothing can make it good or indifferent. Evil will be chosen directly either as end or as means, and there could be no question of merely permitting or tolerating it.
Application: Some actions are intrinsically good, evil or indifferent. Murder or intentional termination of an innocent human life is one of the intrinsically evil actions. As we have already seen under the natural law, an intrinsically evil action cannot be made morally good by a good intention, circumstance or consequence. A person whose part of his brain does not function is actually not dead. So, it remains intrinsically evil to kill such a patient even if it is for a good consequence, circumstance or intention.
Considering Dr. Shanon's experience, it would have been unethical for him to kill one baby in order to take his heart and save another one. He would have intentionally and prematurely ended an innocent human life, which is an intrinsically evil action that cannot be made morally good by his good intentions, consequences, or circumstance. For this reason, Singer was not justified to conclude that Dr. Shanon should have transplanted a heart from a cortically dead baby to a baby with a heart disease. The action of taking one baby's heart before he dies is murder, which is an intrinsically evil action and cannot be made morally good by its good consequences or the agent's good intention. Intentional killing of an innocent baby is murder and murder remains murder for whatever reason.
The second condition is: The good intention must not be obtained by the means of the evil effect. The evil must be only an incidental by-product and not an actual factor in the accomplishment of the good. If the act has two effects, one good and the other bad, the good effect must not be accomplished by means of the bad, for then the evil would be directly voluntary as a means (Fagothey, 1967).
Application: while applying the principle of the double effect, the evil must not be intended but it should occur as a byproduct. Also, evil should not be used as a means to attain good. Singer's justification of euthanasia is based on the need to harvest organs from the cortically dead patients and deformed infants. But how do we get essential organs like the heart from such patients without killing them? While obtaining the organs, death does not come as a byproduct, rather as a means to harvest an organ.
Dr. Shanon's good intention of saving one baby with a severe heart disease would have only been obtained by him using the evil means of killing the other baby who was bleeding in the brain. However, according to this principle, the end does not justify the means; the good must not be achieved through or by the means of the evil. For that reason, Singer was not justified to propose Dr. Shanon's killing of one baby to save the other because by doing so, Shanon would have directly committed an evil action (murder) as a means to accomplish the good (saving the other child). Here, death does not come about as a by-product but as intended, for Dr. Shanon must have first of all intended to kill the baby who was bleeding in the brain for him to save the one with the heart disease. So, death would have been directly intended for the baby whose cortex was destroyed yet it is unethical to intend evil. The action of saving the life of the baby with heart disease would have been achieved by the evil means of killing the one with bleeding cortex.

The third condition:
The evil effect must not be intended for itself but only permitted. The bad effect may be of its own nature merely a by-product of the act performed, but if the agent wants this bad effect, he makes it directly voluntary by willing it. The act then becomes evil in its motive (Fagothey, 1967).
In regard to Dr. Shanon's experience, the death of the cortically dead baby was not going to be a by-product of the process of saving the baby with the heart disease; it was going to be voluntarily willed. In fact, the death of the cortically dead baby was not going to occur as a by-product but as an evil means to acquire a good consequence. The first motive of Dr. Shanon would have been to kill the cortically dead baby in order to take the heart; so there would be no way it would have been a by-product at the same time. Therefore, the action of getting an organ from a cortically dead baby was going to be an intended murder, which would have remained intrinsically unethical and not a by-product of a good action.

The fourth condition is:
There must be a proportionately grave reason for permitting the evil effect. Though we are not obliged to prevent evil, we are obliged to prevent a serious evil by a small sacrifice of our own good. Hence some proportion between the good and evil is required, and if it is lacking the act becomes evil by its circumstance (Fagothey, 1967).
The interpretation of the fourth condition is that, if the good is slight and the evil great, the evil can hardly be called incidental. If there is any other way of getting the good effect without the bad effect, this other way must be taken. When a human being dies naturally, it's not as evil as when a human being is murdered. Natural death is a necessary evil because we shall all die at some given point in time, but murder is an unnecessary intrinsic evil action because it is a premature termination of an innocent human life. For that reason, it would have been unethical for Dr. Shanon to murder one patient who was still alive in order to attempt saving the one who was dying naturally. Furthermore, Dr. Shanon was not 100% sure that the heart transplant was going to be successful.
Singer should have also used the principle of double effect correctly to solve the Alkmaar's case. This is a case where a ninety five year old woman who suffered unbearably, was unable to eat and eventually lost consciousness. On recovery of her conscious, she requested the doctor to end her pain. Considering that her suffering was unbearable, the doctor decided to end her life after consulting both the assistant physician and her family. This incident happened in Netherlands in 1984 and the doctor was arraigned in High Court the same year. He was charged with mercy killing. As Singer (1993) notes: In his defense, the doctor said that he had faced an emergency situation: the legal duty not to kill had been in conflict with his duty as a physician to relieve his patient's unbearable suffering. Singer (1993) interprets the above court ruling as follows: This decision implied that where a patient was in an unbearable situation that would not improve, and the patient's suffering could not be relieved in any other way, a doctor who acted on the patient's explicit, persistent and well-informed request for euthanasia would not be guilty of an offence.
It is obvious that Singer thinks that the prevailing standards of medical ethics qualify the legality of voluntary euthanasia. In fact, he goes ahead to explain how Alkmaar's case was a process to legalize voluntary euthanasia in Holland (Singer 1993).
Basing on the principle of double affect, which in this case Singer calls it conflict of duties, Singer's conclusion was unethical. This is because; if termination of an innocent human life is unethical then, even voluntary euthanasia is unethical for it entails an intentional termination of an innocent human life. Beauchamp (1996) elaborates further on how a physician who is in a dilemma can correctly apply the principle of double effect for pain relief as follows: If the physician refuses to administer the toxic analgesia, the patient will suffer continuing pain; but if the physician provides the medication, the patient's death may be hastened. Under the doctrine of double effect, in providing the medication, the physician must intend to relive the suffering and must not intend to hasten death. If the lethal effect is not intended, then the act may not be prohibited.
A correct application of the principle of double effect prohibits intentional killings in medical care and promotes justified pain relief. The principle of double effect is not just a philosophical and abstract concept; it is also supported and used by some medical doctors like Michael Manning (1998) who holds that: Most patients with intractable pain can be helped with expert management of analgesia (understanding principles of the double effect, and the possibility, even the likelihood, that effective pain management will shorten individuals' life) the individual in terrible psychic distress who faces terminal illness or any other circumstance of life that he or she considers unbearable, deserves our care and compassion, not encouragement to put an end to suffering by ending his or her life.
It is for that reason that Adam Xener (1993) says, "It is not immoral to relieve the pain of the terminally ill even if the methods used unintentionally hasten death. Deliberately causing death, on the other hand, is gravely wrong and can never be tolerated in a civilized society".
The intention of one's action modifies morality. For that reason, intentionally killing a patient in the name of euthanasia is immoral, because it is the death of the patient that is intended and not the alleviation of the pain. It is different from the action of intentionally killing the pain in which death occurs as a by-product. According to Summerville (2002), people who advocate the legalization of euthanasia deliberately confuse ethically and legally acceptable refusals of treatment, and the provision of treatment necessary to relieve pain but which could shorten life, with intentionally killing the patient. They do so to promote the acceptability of the latter and without addressing the substantive argument that the former are different in kind from the latter.
As it had been initially discussed, the principle of double effect is rooted in the natural law ethical theory and it is clearly proved using the principle of double effect that euthanasia and physician-assisted suicide are unethical even if they might produce a source of organs. A summary of this discourse is illustrated in figure 1.

Application of the Principle of Double Effect to Urgent Heart Transplantation Process:
Action: The act to be done must be good in itself or at least to be indifferent. With heart transplantation, the evil action of killing one innocent patient will be chosen directly and executed as means; it will not be merely permitted or tolerated. This is murder by definition and murder is intrinsically evil.

Intention:
The good intention must not be obtained by the means of the evil effect. Heart transplantation process violates this principle for a doctor has to intend to kill one innocent human being in order to harvest an organ and save another one.

Consequence:
The evil effect must not be intended for itself but only permitted. In the heart transplantation process, the doctor voluntarily and directly wills to terminate a patient's life. In such a case, the act is evil in its motive.
Circumstance: There must be a proportionately grave reason for permitting the evil effect. A Medical practitioner is not obliged to kill one patient in order to save the other. If he does so, the proportionality between the evil action of deliberate killing of an innocent person and the good action of saving another will be lacking. Such an action will be evil by circumstance.

CONCLUSION
Human life, as has been always the case, is the foundation of all human values, hence it deserves to be treated with high respect and dignity. It is for this reason that the medical practitioners have the noble duty to take care of human biological aspect of life. By doing so, and according to the Hippocratic Oath they swear, they seek to sustain life and not to diminish or eradicate it. The right to life is universally inherent in all innocent human beings, since it emanates from human nature which we all share. For that reason, any intentional killing of an innocent human being is murder, and murder is a felony by its nature and therefore, it is unethical. Any act that involves loss of human life should be subjected to critical and rigorous thought. This is the reason why we have to utilize the principle of double effect effectively and correctly when it comes to delicate organ transplantation. As it has been well discussed in this paper, there could be some circumstances of dilemma within the practice of medicine. For instance, a doctor could be provoked to harvest a heart from one patient whose death is imminent in order to save a patient who only needs the heart to survive. This might look possible, plausible and permissible at first sight, but if one gives it a close and a critical eye, one will find that it is possible but not plausible, permissible nor ethical. If such a practice would be allowed in the contemporary society, it could create a loophole to euthanize people basing on their quality of life in order to harvest organs from them. The fact that the intention of doing this would be to save other lives does not change the intrinsic evil action of murder involved. It still remains a crime. All innocent patients have a non negotiable right to life which cannot be eliminated by an arbitrary desire of a doctor to save another patient's life.