Author’s Response

We appreciate the commending remarks by Weiss and Chaudhary on the algorithm showing the process of donation following the determination of death by neurological and circulatory criteria via clinical conditions of a pathway of end-of-life care: the transition from death to organ recovery and transplantation. The clinical conditions detailed in the algorithm did not include voluntary euthanasia as a pathway to organ donation. Although Weiss and Chaudhary noted that this approach has been undertaken in Quebec, Canada, the Netherlands, and Belgium, the legal permissibility, ethical acceptance, and international experience of voluntary euthanasia followed by organ recovery has not reached a sufficient threshold to become a standard practice—and thus, not included in the algorithm. THE LEGAL BARRIERS THAT PRECLUDE INTERNATIONAL STANDARDIZATION Voluntary euthanasia including euthanasia followed by organ donation remains illegal in the majority of European countries and in the United States (where some states do permit medically assisted suicide). In contrast, withdrawal of life-sustaining treatment under the circumstances of controlled donation after circulatory death is legally permissible and widely accepted internationally. This distinction regarding legal permissibility is the primary reason for omission of voluntary euthanasia and organ recovery into the algorithm. THE LACK OF INTERNATIONAL EXPERIENCE TO STANDARDIZE A SUCCESSFUL PRACTICE OF ORGAN TRANSPLANTATION AFTER EUTHANASIA There is insufficient data and experience to recognize a standard protocol for euthanasia followed by organ donation. The 2019 reference cited by Weiss and Chaudhary identifies the issue of insufficient data to develop further standardization in practice: “…although some authors have suggested that organ donation after medical assistance in dying might have a substantial impact on organ availability, the practice of organ donation after medical assistance in dying in Canada is still rare. More data about this practice must be collected to determine whether this guidance document is helpful or needs to be updated.”1 Without a recognized standard protocol with understood outcomes, the pathway of organ donation following euthanasia is not sufficiently developed to include into the algorithm. THE ETHICAL CONTROVERSY REGARDING EUTHANASIA COULD UNDERMINE PUBLIC TRUST IN THE SYSTEM OF DONATION Significant controversy remains regarding the ethical propriety of sanctioning voluntary euthanasia as a standardized practice. Until such ethical concerns regarding euthanasia are adequately addressed, introduction of a pathway to organ recovery following euthanasia may serve to amplify these ethical issues and erode the public trust in donation. Specifically, the public trust that the donation of organs remains independent of a decision to facilitate ending a patient’s life. Introducing these concepts together in the midst of unresolved significant ethical controversy over euthanasia might undermine public trust in donation. Given these legal, ethical, and experiential limitations, we conclude that the threshold for considering voluntary euthanasia to organ recovery as an international standard has not been sufficiently achieved and therefore it is appropriately excluded in an algorithm designed to derive consensus regarding recognized standard donation practices.

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