Ethics, Nudge and Organs

Regular commenter, Stephen has left a few comments in my absence. As they are related and cover more than one post, I thought that rather than answer them individually and repeat myself, I’d respond with a new post.

The issues in question are those relating to presumed consent in respect of organ donation and the nudge principle. The posts in question being here, here, here and here. Let’s start with nudge:

Speaking for myself, I am rather glad the state didn’t ‘leave us alone’ when it came to putting white lines on the road to allow traffic to better manage itself. I am sure hundreds of thouisands of lives have been saved by this simple measure. I don’t see how you can have a blanket opposition to ‘nudges’. Surely it depends on what it is?

And:

So to take the example you gave in your previous post about ‘nudges’, you think it would be better if local authorities had not placed white lines on roads, even though this lead to a measurably dramatic reduction in accidents and injuries?

In my original comment, I did say that white lines on the road was a good example of nudge. Given that the roads are a shared resource, drivers need commonly agreed standards in such things as road markings and signage. And, bear in mind that such things applied appropriately, are valuable information that assist with the driving task. So, white lines that denote lanes and the centre of the road are good things. Tweaking them so as to give visual clues of impending hazards is also a good thing. So, too are lines that denote priority at junctions. Local authorities are the ideal bodies to do this having a standardised approach and local knowledge. However, my comment about the state being better when it does less rather than more, stands. What we currently have is local authorities who appear to have over stocked on white paint and are determined to get as much of it onto the tarmac as they can before the sell-by date. The consequence is spiralling crisscross lines on roundabouts for instance that create confusion rather than clarity, once again demonstrating that given the opportunity and means, government will always find a means to completely fuck up whatever they touch. Which is why I object to the government deciding to use nudge to push us into its preferred lifestyle choices or charitable giving.

Cameron’s “Big Society” is clearly top down bureaucratic managerialism writ large despite protestations to the contrary. How I live my life and the personal decisions I take are nothing to do with him or his government. Nudge in the hands of politicians is a dangerous tool and they possess neither the competence nor the wit to use it appropriately. So, yes, I have a blanket opposition and it remains in place.

Moving onto organ donation:

Does that mean you are also making the resolution to never accept a donated organ at some point in the future?

This is a meme that is developing some momentum. I noticed it being trotted out over at CiF. There are two answers to this one. One is general and one is personal. Starting with the general; we have in the UK universal healthcare. We all pay in and when needed we take out according to such need. The only decision about who gets what should be clinical. It should not, ever, be rationed because of such matters as lifestyle or the perceived ethics of the recipient. Such an approach goes against the very principle of universal healthcare. Sure, a surgeon lecturing a potential liver recipient about their drinking habits is fair enough as they want the organ to last as long as possible, but to have in place a refusal to treat due to disapproval of lifestyle choices or declining to volunteer one’s own organs is deeply abhorrent as it is not the place of the universal healthcare provider to make such judgements –  we pay, they provide. If we do go down that route, I’ll have all that money back that I’ve been paying in for the past thirty odd years and I’ll buy my own healthcare, thank you very much. Unfortunately, that isn’t going to happen even though there is this increasing and nasty tendency to try and do just that.

I am also perturbed to see comment after comment that seems to regard our bodily parts as some sort of common resource to be raided for the benefit of others and anyone who disagrees is deemed to be selfish. Our bodies are not some sort of common resource. They are ours. The decision to allow parts of them to be recycled is a deeply personal one and no one has the right to dictate to us on the matter or expect us to comply with anything other than our own wishes and that decision should be free from any form of coercion or nagging or loaded questions that don’t include “no” as an option. There is no civic duty that requires us to donate and there is no right to a replacement for a failed organ. A refusal to donate is not condemning someone to die. They are going to die sooner or later anyway –  we all are. At best, all the refusal is doing is denying someone, somewhere, a few more years of life with that organ –  assuming that it takes and assuming that it works. It seems to me that some of those talking about opt-out have failed to understand what the word “donate” actually means.

On the personal, I’ll make the point that organ transplant is not a cure, nor is it a panacea. At best, it will give the recipient an extension of a few years before the new organ either fails or is rejected. Sooner or later the donated organ will fail, it’s all a matter of when, not if.

Mrs L and I have had some long discussions in the past about terminal illness following the loss of her father to cancer. Both of us regard death as being a part of living. It is something to be faced rather than kept at bay until the bitter end in a defunct shell that was once a useful body. When it comes, it comes, better that than life at any cost. What matters is quality of life. This is why you will not see us campaigning for “life-saving” drugs that in reality grant a cancer patient a few more months clinging onto a miserable life. It is why, given the choice between unpleasant chemotherapy and palliative care, we will take the latter and make the most of the last few weeks or months left us rather than try to squeeze a few extra out no matter what. We’ve seen first hand how it works and neither of us want it.

All of which is why, given the failure of a major organ and having to live wondering when the replacement will fail and pumping our bodies full of immunosuppressant drugs, we will, likely as not, prefer to go sooner with some dignity. And, frankly, I’m not sure I want someone to die so that I may live.

It’s a long answer to Stephen’s question, but on balance, no, I don’t want a donated organ.

I would also point out that in the original discussions, I said that I am prepared to donate organs as I have no principled objection to organ transplant. What I object to –  vigorously –  is the incessant screeching by the “right to an organ” brigade demanding that I go onto a register or have to tell the state that I do not want to. It is none of the state’s business what I want to do and I prefer to keep it that way. I am refusing to enter my name on a register. There is a difference between this and refusing to donate an organ. In the event of my untimely death, the surgeons are going to have to ask Mrs L if they can have my organs (and vice versa if it is she who is on the slab). Yes, it will be difficult. Yes, it will be emotionally painful. But it is the right thing to do, and doing the right thing is not always easy –  and if they want my organs, they are going to have to damned well gird their loins and do the right thing, which is; “please may we have what belongs to you?” The answer will be “Yes, and thank you for asking.”