Transplantation has long been recognized as a value-laden enterprise. However, although there have been innumerable pieces on ethical issues in transplantation, there has been no systematic treatment of the subject. Robert Veatch's newest book seeks to fill that void.
Veatch, a professor at the Kennedy Institute of Ethics at Georgetown University, draws on his extensive experience as an ethicist affiliated with various transplantation organizations. He has been a longtime board member of the Washington Regional Transplant Consortium, as well as served on their medical advisory committee. Veatch has also been a member of the ethics committee of the United Network for Organ Sharing and an ethics consultant to the North American Transplant Coordinators Organization. In addition, he has been a long-standing participant in the debate regarding the definition of death, dating back to his work with Henry Beecher and other members of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death.
Veatch suggests that ethical issues in transplantation fall into one of three areas: the definition of death, organ procurement, or organ allocation. His book is organized accordingly into three parts. Veatch begins with a quick foundation in two introductory chapters. The first outlines the stance of major religious traditions on issues ranging from organ donation to organ allocation. The second provides an overview of ethical theory, which is intended to provide the novice with some theoretical background.
The bulk of the book is devoted to an exploration of the three areas raising ethical issues in transplantation. Veatch's approach to these issues is grounded in his notion of autonomy; his is an ethic of rights and responsibilities of autonomous individuals acting within the social context of particular moral communities.
Veatch is at his best and most lucid in analyzing the issues surrounding death, its clinical criteria, and social meaning. He examines the evolution of the notion of brain death and highlights morally problematic issues related to both language and practice. In particular, his discussion of Tucker v. Lower (an early case in which a surgeon was sued for wrongful death attributed to an organ-recovery procedure) underscores the moral and legal ambiguities surrounding the definition of death; these issues were not fully understood in 1968 and remain unresolved.
Similarly, Veatch's application of the ``maxi-min'' theory of justice to the problem of organ allocation is a novel and useful approach. In essence, the principle is to maximize the position of the least advantaged (the minimum). Although the United Network for Organ Sharing couches its discussion of the ethics of organ allocation as striking a balance between equity and utility, the allocation policies themselves find no such balance. The maxi-min theory is not Veatch's creation, but his articulation of the particular premises as they pertain to organ allocation is certainly the most explicit of contemporary comments on the subject. For instance, giving the sickest patients priority in organ allocation seems less an effort to balance equity and outcome than a reflection of a ``rescue'' orientation. To articulate it more charitably, this approach seeks to maximize the position of those most disadvantaged (i.e., those at the greatest risk of imminent death).
Transplantation Ethics is a worthwhile contribution to the literature largely because of its unique attempt to present a systematic analysis of the ethical issues in transplantation. The only other book that covers similar terrain is Arthur Caplan and Daniel Coelho's anthology, The Ethics of Organ Transplants (Amherst, N.Y.: Prometheus Books, 1999). Although its breadth is valuable, the anthology lacks the unified systematic analysis that Veatch provides.
Veatch is a knowledgeable and credible commentator. This book will be useful to those who want a general overview of the ethical issues in transplantation. Ultimately, however, there are two main problems with the book. It is not clear who is the intended or appropriate audience. Many transplantation clinicians will find some of the discussion too obtuse for their needs or interests, while academic ethicists will find much of the content lacking. Certainly, it is a difficult balance to strike.
The problem is perhaps amplified because there is little new here. Much of the book has been adapted from previously published essays by Veatch. The essays are well informed by Veatch's legitimate experience in transplant issues, but the transitions between individual essays reflect little insight into the way in which the historical evolution of clinical transplantation has shaped the contemporary debate. A critical appreciation of history seems particularly lacking in regard to the development of a highly organized infrastructure for organ sharing. The issue of organ sharing, particularly as compounded by the proliferation of transplantation services, lies at the heart of much of the contemporary political and ethical debate in transplantation.
As a collection of Veatch's essays, this book provides bioethicists with a general view of the landscape and offers a one-stop resource for Veatch's writings on transplantation. Regrettably, the issues will be all too familiar to transplantation clinicians, but the essays themselves have not been reworked adequately to appeal to or serve the needs of a clinical audience.
Robert M. Arnold, M.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
--This text refers to an out of print or unavailable edition of this title.
" The book on transplantation ethics." -- Choice
"Without question, the best and most important book on this topic." -- James F. Childress, University of Virginia
"A comprehensive, knowledgable and thoughtful treatise on the critical ethical issues those of us in the transplant field wrestle with each day. Nice job!" -- Jimmy A. Light, MD, Director of Transplantation Services, Washington Hospital Center
