On Presumed Consent
Regarding the announcement that the U.K. may alter its organ donation system to provide for an opt-out approach, Kieran Healy offers a fascinating meta-critique of the paradigm that tends to dominate analysis of consent for organ donation:
If you look at cadaveric organ procurement rates in the OECD over the past 12 years or so, we find that presumed-consent systems do in fact perform better on average than informed-consent systems. The question is why they do so. Debate in this area is dominated by bioethicists, economists and lawyers. A consequence of this is that—thanks to the disciplinary interests and biases of these groups—the organizational and institutional machinery required to make something as complex as cadaveric donation happen tends to drop away in debates, and is replaced by considerations of the ethical implications of this or that policy in general (e.g., concerning consent) or arguments about the effect of this or that incentive or rule on individuals (e.g., concerning financial incentives or a legal regulation). But the organizations matter because they manage the logistics of procurement, and this is a very complex process. How a change in the law is implemented in practice, or how a rule is embedded in organizational process, can greatly affect the outcomes. This is more a question of organizational and institutional sociology.
I am not sure this is "more a question of organizational and institutional sociology" than of law, regulation, and ethics, but coming from a MH perspective, I absolutely agree with Kieran that using the tools and expertise of organizational sociology can shed some important light on why and how policies are executed and implemented. I'm reminded here of Latour's thesis in the Pasteurization of Medicine, which is, to grossly oversimplify, that Pasteur gets all of the credit for his discoveries but that his discoveries could never have been promulgated, socialized, and implemented without an extensive social network of actors and stakeholders.
Kieran continues:
Reform of the rules governing consent is often accompanied by an overhaul and improvement of the logistical system, and it is this—not the letter of the law—that makes a difference. Cadaveric organ procurement is an intense, time-sensitive and very fluid process that requires a great deal of co-ordination and management. Countries that invest in that layer of the system do better than others, regardless of the rules about presumed and informed consent.
As someone favorably disposed to critiques of the abstracting and atomizing tendencies in many dominant approaches to bioethics, this seems to make a lot of sense to me.
Finally, I should note that Kieran states in the comments that
Why separate the logistics from the ethics, and claim that one, and not the other, is the true cause of higher rates of procurement?
In part just as a matter of rhetoric, to redress a strong imbalance in current debate about procurement, which emphasizes very strongly a kind of idealized debate about consent, and attributes successes in other countries entirely to changes in the law governing consent rather than to the organizational changes that often go with them.
The issue, then, is not that legal rules and ethical analyses are irrelevant, but that much greater attention should be directed to the organizations that administer organ retrieval and donation. Finally, I would add that it is certainly possible to view issues relating to ethics in clinical practice and biomedical/scientific research as deeply important, while at the same time espousing dubiety at the dominant tradition of principlism in bioethics. It is important, IMO, to conceptually separate the critique many have lodged against traditional bioethics from a critique of the importance of Plato's question as applied to medicine and research.
Querying how we should live or what is the good in medicine and research remains as important as ever it did, IMO. On the other hand, Kieran's post nicely demonstrates just how crucial it is for those interested in thinking about the Platonic questions to expand the scope of inquiry beyond the confines of any one discipline. This, of course, is also an argument in favor of taking an interdisciplinary approach to studying ethics in medicine and research, which is also a theme of this blog.
Thoughts?
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