R M Veatch. Georgetown University Press, 2000, £46.75, pp 427. ISBN 0-87840-811-8

Transplantation Ethics is a book that will be welcomed by teachers and students of medical ethics as well as health care professionals and policy makers involved in transplantation issues. The book provides a broad overview of recent and contemporary debates relating to organ transplantation, while also defending particular methods of approaching the ethical questions and using them to argue for particular policy proposals. Most of the book’s chapters are based on previously published material, and while this leads to a certain amount of repetition, the overall result is coherent and highly readable.

The book is divided into three parts. The first addresses the definition of death, a matter which is clearly of great importance for transplantation ethics, given the rule that vital organs may only be removed form a corpse, but on which opinions are highly divergent. Veatch reviews the debates surrounding the shift from cardiorespiratory to brain-oriented definitions of death, but argues that the currently favoured whole-brain approach is an unstable compromise, subject to the same kinds of objection that its advocates level against the traditional cardiorespiratory accounts. The whole-brain definition should therefore be abandoned in favour of a higher-brain oriented concept which acknowledges that a person is dead—and that “death behaviours” such as mourning and organ procurement are appropriate—once he or she has permanently lost the capacity for consciousness. Recognising, however, that this is not an issue where consensus can be expected, Veatch proposes a “conscience clause”, according to which individuals would have the right to choose, from a range of alternatives including traditional, whole-brain, and higher-brain accounts, which definition will apply in their own case. This is an interesting idea, though one wonders whether it would not better be formulated as a right to select the conditions under which lifesaving treatment will be ceased and organ procurement initiated, independently of the determination of death.

The second part of the book deals with organ procurement. Here Veatch focuses on the problem of how to increase the numbers of organs available for transplant, and considers proposals including a shift from donation to routine salvage of organs; transplantation from live donors, anencephalic infants, minors, and older persons; the use of tainted—for example, HIV positive organs, and xenografts. It is here that the underpinning moral theory becomes apparent. Veatch defends on grounds of beneficence the use of tainted organs, where this is better for the patient than no organ at all, suggesting that the reluctance of practitioners to perform such operations is understandable but misguided. For Veatch, however, the cluster of deontological principles which go under the heading of “respect for persons” has priority over the principle of beneficence, leading him to reject a policy of routine organ salvage as inconsistent with respect for autonomy. Veatch allows that sale of organs and other forms of rewarded procurement may be justified on grounds of autonomy and beneficence, and that a policy of routine salvage with provision for opting out may be justified as a last resort, but he firmly rejects the idea of “presumed consent” as an “outrageously unethical” attempt “to hold onto the consent and donation model by using the language of consent for what is really a policy of routine salvaging”.

A further non-consequentialist element in Veatch’s moral theory is a principle of distributive justice which requires priority to be given to the interests of the worst off even if the aggregate welfare in society is thereby diminished. Veatch uses this principle to defend xenotransplantation, arguing that while the widely discussed risks of transmitting viruses from “donor” animals into the human population (including non-consenting third parties if the infections, like HIV, prove to be transmissible between humans) may render xenografting hard to justify on consequentialist grounds, it may be justified on grounds of justice since those requiring organ transplants are among the worst off in society and are likely remain so even if infections are passed through them into the wider population. To me, however, this illustrates the implausibility of too rigid a policy of prioritising the worst off. In the worst case scenario (“another HIV epidemic or worse”) thousands might be made very nearly as badly off as those whom the policy is intended to help, while the value of the transplants would be diminished; thus a large aggregate disbenefit and an increase in the numbers of the seriously disadvantaged would be the price paid for what might be a fairly marginal benefit for a small subset of that group.

The same principle of justice is applied—to my mind more plausibly—in the third part of the book, which addresses the allocation of organs. Here Veatch sets out in more detail his egalitarian approach to distributive justice, and considers the moral relevance of such factors as self inflicted illness, age, and social worth, ending with a discussion of the vexed issue of “directed donation” (where an organ is donated with the proviso that it be given to a particular category of recipient—for example, a member of the same racial group as the donor). Much of the discussion in this part of the book will be of interest to those concerned with the allocation of heath care resources in general, and not just those with a particular interest in transplantation.

Overall, Transplantation Ethics is a valuable contribution to its field. It is accessible to non-specialists while providing a thorough treatment of the issues and a high standard of argument. Although the book has a strong US orientation in its discussion of law and policy issues, this does not detract from its interest or relevance to readers elsewhere.