In the best interests of the deceased: A possible justification for organ removal without consent?

Opt-out systems of postmortem organ procurement are often supposed to be justifiable by presumed consent, but this justification turns out to depend on a mistaken mental state conception of consent. A promising alternative justification appeals to the analogical situation that occurs when an emergency decision has to be made about medical treatment for a patient who is unable to give or withhold his consent. In such cases, the decision should be made in the best interests of the patient. The analogous suggestion to be considered, then, is, if the potential donor has not registered either his willingness or his refusal to donate, the probabilities that he would or would not have preferred the removal of his organs need to be weighed. And in some actual cases the probability of the first alternative may be greater. This article considers whether the analogy to which this argument appeals is cogent, and concludes that there are important differences between the emergency and the organ removal cases, both as regards the nature of the interests involved and the nature of the right not to be treated without one’s consent. Rather, if opt-out systems are to be justified, the needs of patients with organ failure and/or the possibility of tacit consent should be considered.     

Ambivalence,Autonomy, and Organ Sales

Recent philosophical arguments in favor of legal markets in human organs such as kidneys claim that respect for autonomy justifies such markets. I argue that these arguments fail to establish the moral permissibility of commercialized organ sales because they do not show that those most likely to serve as vendors would choose to sell autonomously. Pro‐market views utilize hierarchical theories of autonomy to demonstrate that potential organ vendors may autonomously consent to selling their organs even in the absence of any practical alternative to doing so. But central to hierarchical accounts of autonomy is the idea that persons my experience volitional ambivalence, a condition in which the will is irreconcilably conflicted. Because commercialized organ sales would create volitional ambivalence in many of those who opt to sell an organ, the choice to sell an organ would not be an autonomous one.     

Can Consent be Presumed?

Opt‐out systems of postmortal organ procurement are often referred to as ‘presumed consent’ systems. A presumption directs us, in a case in which no compelling evidence is available to hold that P, nevertheless to proceed as if P were true, unless there is sufficient evidence that it is false. It is recommended to presume consent in this case, because, in the absence of registered objections of the deceased, it is held to be more probable that she consented than that she did not. Whether this suggestion makes sense, however, turns out to depend on the proper interpretation of the concept of ‘consent’. On a mental state conception of consent we are allowed to presume it if we have reason to suppose the deceased to have been in favour of donation. However, we should rather understand consent to be a public action of authorisation. On that view consent cannot be presumed, and the opt‐out systems as we presently know them on the European continent and elsewhere do not satisfy the requirement that the deceased should have consented to the removal of his organs.     

How to Reverse the Organ Shortage

Thousands of lives are lost each year because of a lack of organs available for transplant, but currently, in the UK and many other countries, organs cannot be taken from a deceased donor without explicit consent from the donor or his or her relatives. Switching to an ‘opt‐out’ (or ‘presumed consent’) system for organ donation could substantially increase the supply of organs, and save many lives. However, it has been argued in some quarters that there are serious ethical objections to an opt‐out policy, and that it would be better to adopt a different policy known as the ‘presumptive approach’, that requires explicit consent while also attempting to sway the choices of potential donors and family in the direction of donating, using various persuasive techniques. This article shows how reflection on the impact of a well‐known cognitive bias known as ‘status quo bias’ can explain (i) why moving from the status quo to an opt‐out policy might be effective in increasing organ availability, even without impinging on anyone's autonomous choices, (ii) why we might have overestimated the strength of the objections to an opt‐out policy, and (iii) why the presumptive approach is morally objectionable, while an opt‐out policy is not.     

Recovery of transplantable organs after cardiac or circulatory death: Transforming the paradigm for the ethics of organ donation

Organ donation after cardiac or circulatory death (DCD) has been introduced to increase the supply of transplantable organs. In this paper, we argue that the recovery of viable organs useful for transplantation in DCD is not compatible with the dead donor rule and we explain the consequential ethical and legal ramifications. We also outline serious deficiencies in the current consent process for DCD with respect to disclosure of necessary elements for voluntary informed decision making and respect for the donor's autonomy. We compare two alternative proposals for increasing organ donation consent in society: presumed consent and mandated choice. We conclude that proceeding with the recovery of transplantable organs from decedents requires a paradigm change in the ethics of organ donation. The paradigm change to ensure the legitimacy of DCD practice must include: (1) societal agreement on abandonment of the dead donor rule, (2) legislative revisions reflecting abandonment of the dead donor rule, and (3) requirement of mandated choice to facilitate individual participation in organ donation and to ensure that decisions to participate are made in compliance with the societal values of respect for autonomy and self-determination.     

我国《人体器官移植条例》评析

我国《人体器官移植条例》对有推定同意权的“亲属”的限定范围过窄,阻却了第二、第三顺序亲属实施推定同意的权利;临床应用与伦理委员会的人员组成未排除实施器官移植的专家的参与,可能影响论证结果的客观性,且伦理审查时限不明;在违反《条例》的法律责任中,排除了公民生前未表示不同意捐献器官且其家属也未表示同意捐献尸体器官,而对其实施器官摘除的情形。缺失了医疗机构及其医务人员在明知器官来源不合法或实为买卖器官却加以利用并实施器官移植的法律责任。建议尽快根据《条例》制定具体的实施细则,以确保《条例》的正确实施。     

Caring for Bereaved Families: Self-Efficacy in the Donation Request Process

Motivated by an organ shortage, a primary objective of professionals involved with organ and tissue donation is to identify and modify key factors that facilitate or impede family consent. Procedural factors associated with the donation request process have been highlighted as target areas for change. Several studies have demonstrated that family consent rates increase when specific procedural knowledge and skills are incorporated into agency protocols and health care professionals become proficient with these procedures. Thus, training of these professionals heavily emphasizes development of procedural competencies, with relatively little time allocated to fostering affective helping skills or competencies. Given the lack of attention to affective competencies, this study was designed to examine perceived procedural and affective self-efficacy among health care professionals receiving training as designated requestors. Findings suggest trained requestors report greater confidence in their ability to perform procedural tasks associated with the donation request process than in their ability to manage affective or emotion-laden issues related to the process.     

How permissive consent works

Consent that is voluntary, informed and given by a competent person sometimes transforms a wrong into a right act. How does consent that meets these requirements change the moral property of an act, namely that of being a wronging of a person? This is the question this paper will deal with. Some authors argue that valid consent changes the moral property of an act by changing the reasons which speak against the act. This account of the normative force of consent will be critically examined and rejected. An alternative model will then be put forward and defended according to which consent changes the moral property of an act if and only if the wrong-making property of the act is that it is not consented to. The upshot will be that consent does not eliminate the wrong-making property if the unconsented act is wrong for other reasons than not being consented to.     

Presumed consent for organ preservation in uncontrolled donation after cardiac death in the United States: a public policy with serious consequences

Organ donation after cessation of circulation and respiration, both controlled and uncontrolled, has been proposed by the Institute of Medicine as a way to increase opportunities for organ procurement. Despite claims to the contrary, both forms of controlled and uncontrolled donation after cardiac death raise significant ethical and legal issues. Identified causes for concern include absence of agreement on criteria for the declaration of death, nonexistence of universal guidelines for duration before stopping resuscitation efforts and techniques, and assumption of presumed intent to donate for the purpose of initiating temporary organ-preservation interventions when no expressed consent to donate is present. From a legal point of view, not having scientifically valid criteria of cessation of circulation and respiration for declaring death could lead to a conclusion that organ procurement itself is the proximate cause of death. Although the revised Uniform Anatomical Gift Act of 2006 provides broad immunity to those involved in organ-procurement activities, courts have yet to provide an opinion on whether persons can be held liable for injuries arising from the determination of death itself. Preserving organs in uncontrolled donation after cardiac death requires the administration of life-support systems such as extracorporeal membrane oxygenation. These life-support systems can lead to return of signs of life that, in turn, have to be deliberately suppressed by the administration of pharmacological agents. Finally, allowing temporary organ-preservation interventions without expressed consent is inherently a violation of the principle of respect for a person's autonomy. Proponents of organ donation from uncontrolled donation after cardiac death, on the other hand, claim that these nonconsensual interventions enhance respect for autonomy by allowing people, through surrogate decision making, to execute their right to donate organs. However, the lack of transparency and the absence of protection of individual autonomy, for the sake of maximizing procurement opportunities, have placed the current organ-donation system of opting-in in great jeopardy. Equally as important, current policies enabling and enhancing organ procurement practices, pose challenges to the constitutional rights of individuals in a pluralistic society as these policies are founded on flawed medical standards for declaring death.     

The placebo phenomenon and medical ethics: Rethinking the relationship between informed consent and risk–benefit assessment

It has been presumed within bioethics that the benefits and risks of treatments can be assessed independently of information disclosure to patients as part of the informed consent process. Research on placebo and nocebo effects indicates that this is not true for symptomatic treatments. The benefits and risks that patients experience from symptomatic treatments can be shaped powerfully by information about these treatments provided by clinicians. In this paper we discuss the implications of placebo and nocebo research for risk–benefit assessment and informed consent.     

Real Donors, Real Consent: Testing the Theory of Reasoned Action on Organ Donor Consent

In an attempt to apply the theory of reasoned action (TRA) to the process underlying organ donor consent, participants completed questionnaires concerning their affective responses to organ donation, as well as their intentions to donate. Participants were given the opportunity to sign an organ donor card. Those who chose to sign the card had more positive attitudes about donation, perceived donation as something that their reference group would encourage, and had stronger intentions to consent to signing a card. The current investigation extends the organ donor literature by using a true behavioral outcome measure indicating consent. Moreover, the pattern of results between attitudes, norms, intention, and behavior illustrates the usefulness of applying the TRA to yet another health-related behavior.     

Resource orchestration and dynamic managerial capabilities: focusing on sales managers as effective resource orchestrators

Resource-based theory (RBT) posits that firms gain competitive advantage through bundles of valuable and rare resources and sustain that advantage over time when such resources are difficult to imitate or nonsubstitutable by competitors. Recent applications of RBT emphasize the role of managers in mobilizing and leveraging organizational resources and capabilities for achieving business objectives. The purpose of this research is to advance the sales literature by applying learning from two specific perspectives based on RBT that focus explicitly on managerial actions pertaining to resources and capabilities: resource orchestration and dynamic managerial capabilities. These perspectives provide insights into the role of sales managers as orchestrators of sales and nonsales resources for achieving sales, organizational, and customer outcomes. Consistent with the stated purpose, this research provides (1) a review of research on resources and capabilities in the sales literature, (2) an overview of resource orchestration and related research, (3) an overview of dynamic managerial capabilities and related research, (4) a research agenda and propositions based on research orchestration and dynamic managerial capabilities for further investigation on the role of sales managers as effective resource orchestrators in sales organizations.     

Marketing human organs: The autonomy paradox

The severe shortage of organs for transplantation and the continual reluctance of the public to voluntarily donate has prompted consideration of alternative strategies for organ procurement. This paper explores the development of market approaches for procuring human organs for transplantation and considers the social and moral implications of organ donation as both a “gift of life” and a “commodity exchange.” The problematic and paradoxical articulation of individual autonomy in relation to property rights and marketing human body parts is addressed. We argue that beliefs about proprietorship over human body parts and the capacity to provide consent for organ donation are culturally constructed. We contend that the political and economic framework of biomedicine, in western and non-western nations, influences access to transplantation technology and shapes the form and development of specific market approaches. Finally, we suggest that marketing approaches for organ procurement are and will be negotiated within cultural parameters constrained by several factors: beliefs about the physical body and personhood, religious traditions, economic conditions, and the availability of technological resources.     

The commercialization of human body parts: a reappraisal from a Protestant perspective.

The idea of a market in human organs has traditionally met with widespread and emphatic rejection from both secular and religious fronts alike. However, as numerous human beings continue to suffer an uncertain fate on transplant waiting lists, voices are beginning to emerge that are willing at least to explore the option of human organ sales. Anyone who argues for such a option must contend, however, with what seem to be largely emotional rejections of the idea. Often it seems that rebuffs offered on a secular ground are rooted in nothing more than vague discomforts. We suspect that these discomforts are often based in religious sentiments that have wound their way into the fabric of secular America. Therefore, in order to contribute further to those voices heard in favor of human organ sales, it is worthwhile to show that from a religious perspective, it is just as possible to affirm the appropriateness of human organ sales as it is from a secular basis. Since Protestantism has historically had a powerful influence in American society it is a proper starting point for such an investigation.     

The Politics of Masochism

This essay explores why people sometimes act against their economic interests, and, more particularly, why people sometimes knowingly and intentionally support economic inequality even though they are disadvantaged by it, a phenomenon I call masochistic inegalitarianism. The essay argues that such behavior is an inherent and widespread feature of human nature, and that this has important though previously overlooked practical and theoretical implications for any conception of distributive justice. On the practical side, masochistic inegalitarianism suggests that any theory of distributive justice with more than the most modest egalitarian aspirations is inherently self-defeating (or at least self-limiting) because it will naturally produce the background conditions necessary to trigger masochistic behavior among the very people it is designed to assist. On the theoretical side, masochistic inegalitarianism suggests that there are serious problems with any theory of distributive justice based on the idea of hypothetical consent. This is because people with masochistic tendencies would be unlikely to consent to the distributive arrangements these theories have presumed, and the arrangements to which they would be likely to consent would allow a far greater degree of economic inequality than we are prepared to acknowledge as intuitively just. Either we must rethink our intuitions, or, as I contend, there is something about masochistic inegalitarianism that robs hypothetical consent of its moral force.     

Customary Trade and the Complications of Consent

Global justice theorists have given much attention to corporations' purchases of state‐owned natural resources controlled by dictators. These resources, the common argument goes, belong to the people rather than to those who exercise effective political power. Dictators who rely on violence to secure their political power and who sell state‐owned natural resources without authorisation from their people, or from their people's elected delegates, are therefore violating their peoples' property rights. But many dictatorships also distribute natural resource revenue to the population, and stopping to purchase natural resources from them is therefore likely to produce relative deprivation for the people, even while increasing the chances of the people gaining control over their property. Given these circumstances, can corporations buying the people's natural resources from a distributive dictatorship appeal to the people's consent as justification for such purchases? I consider this question by inspecting three types of consent to which resource corporations might appeal. I show that, under the circumstances of natural resource trade with distributive dictatorships, none of these types of consent can obtain. Hence, resource corporations cannot appeal to popular consent to defend their transactions with distributive dictatorships.     

Book Reviews

For inexperienced sales representatives, success provides an important learning opportunity from which to build confidence and hone strategies. Such learning is derived from the attributions one makes for success and how those attributions shape future behavior. This research investigates the interpretation and behavioral intentions of inexperienced sales representatives following a successful sales call using a sample of financial services representatives. Surprisingly, we found that achieving success did not assure the adoption or future use of the strategy that garnered that success. These results suggest that inexperienced sales representatives may require managerial attention to fully understand and appropriately assimilate their sales successes. Implications for managers and future research are discussed.     

Stereotyping,Affiliation, and Self-Stereotyping of Underrepresented Groups in the Sales Force

This study adds theoretical and managerial insights to the sales literature regarding the unfortunate but prevalent issue of stereotyping in sales by supervisors toward underrepresented groups of sales employees. Specifically, we examine (1) the self-evaluative, social, and emotional consequences of being stereotyped by a supervisor, and (2) the moderating role of employees’ self-construal (i.e., the employee’s level of independence versus interdependence) as it relates to their responses toward a supervisor who holds stereotypical expectations. The results suggest that when a sales supervisor endorses stereotypical views, more interdependent (versus independent) sales employees will likely affiliate more with, and experience fewer negative emotions toward, the supervisor. The results also suggest that sales employees’ self-construal moderates the impact of intentions to affiliate with the supervisor on positive stereotypical traits (that are valued in the sales context) but not negative stereotypical traits. While not every sales employee comes from an underrepresented background, every company is interested in the success of their underrepresented sales employees. And, simply being interested in hiring underrepresented employees is not enough. Rather, firms need to understand how to effectively manage diversity and facilitate strong sales supervisor employee relationships. This research provides such understanding.     

The impact of sales contests on customer listening: an empirical study in a telesales context

Companies often use sales contests to achieve short-term objectives to motivate salespeople and to boost sales. However, sales contests also may encourage salespeople to adopt less relational behaviors and limit their ability to manage customer relationships, as manifested in their customer listening practices. Therefore, this study, based on a natural field experiment, examines the effects of a sales contest on customer listening. In so doing, four dimensions of customer listening (passive, active, adaptive, and assertive listening), associated with a process of listening (Hearing, Processing, and Responding), were identified. The study helps clarify the effect of a sales contest on these four dimensions of customer listening by telesales agents. The results reveal that this sales contest exerts negative effects only on the active and passive customer listening, not on the adaptive and assertive customer listening. The study sheds light on how sales contests influence important behaviors such as customer listening, as well as on the nature of customer listening itself.