A tree in Paradise

Some years ago, John Harris (not the pundit) proposed a thought-experiment called the Survival Lottery. The premise was that the supply of organs for transplant is currently inadequate to meet the demand. Moreover, the whole business of harvesting organs for transplant is fraught with practical and emotional difficulties, putting both the bereaved and potential recipients under a lot of stress which both parties could do without. The result is inevitably that people die who could have lived, and that many who do live have shorter and less satisfactory lives than anyone would wish on them.

How much better it would be, in terms of the greater good of the greater number, if the government organised a consistent supply of transplanted organs, which could be calibrated to meet the demand. The mechanism would be the Survival Lottery: every citizen would have a number assigned to them (the NHS number would do nicely), and a periodic random draw would be made. The unfortunate individual whose number came up would be killed and his or her transplantable organs harvested.

This would be an outrageously cruel and arbitrary system, which would probably cut short the lives of several blameless citizens every year. However, it could be guaranteed to save more lives than it cost – making it less outrageously cruel and arbitrary than the state of affairs we live with now. It’s true that, under this system you’d live under the constant threat of having your number come up and becoming an organ donor against your will. But you’ve already got that risk hanging over you every time you cross the road – and you’ve also got the risk of sustaining an injury (or developing a condition) which would put you in need of a donor organ, which might not be available. Viewed in this light, the phrase ‘Survival Lottery’ is a rather pointed misnomer – we already live with a survival lottery. Harris’s system, as unthinkable as it may seem, wouldn’t create the lottery or even exacerbate it; in point of fact, it would improve the odds.

And yet, unthinkable is just what it does seem. This is a real ethical problem, gifted to us by the development of medical transplants (not that uninventing them would be much of an answer). Kazuo Ishiguro’s heartbreaking novel Never let me go looks at one science-fictional solution, the development of cloning to the point where people could be created to become donors. Kathy, Ishiguro’s narrator, looks at the life of the human clones from the inside: we follow her through childhood (lived in a kind of year-round boarding school), through adolescence and into training to be a ‘carer’. (It’s a self-sustaining system: people like Kathy look after their friends, as they go through a series of donations and finally ‘complete’, before they become donors in turn.) Throughout the book, Kathy muses – brightly and not very reflectively – on what it’s like to remember someone who’s not there any more; what it means to leave something that you’ll be remembered by; whether it matters if you haven’t left anything to be remembered by, providing that you live on in people’s memories; and whether even that matters in the long run, since after all those people won’t be around forever – and in any case you won’t be there to know about it.

In other words, Kathy shows us life as framed by death – the same life we all live, albeit for most of us with a much longer timespan. (Clones are sterile, of course.) Along the way, Ishiguro raises the unanswerable question – would it be tolerable to treat an identifiable group of people like this – as a harvestable resource – for the sake of giving the rest of us a bit longer? Surely not – but if it were possible, how could you justify not doing it? And, to ask a darker and more political question, if we were doing this to an identifiable group of people, what could persuade us to stop? We can be thankful that transplant technology wasn’t available to the Nazis – or to the eugenists of Britain and America for that matter.

The ghastly flaw at the heart of Ishiguro’s clone-based solution also disqualifies the seemingly obvious solution to the donor organ shortage, permitting organ sales. The question is, can we guarantee that the costs and risks of organ donation would not bear disproportionately on an identifiable minority? If there’s money changing hands, clearly not. A similar, albeit less obvious, flaw disqualifies Larry Niven’s ghoulish fantasy of ‘organlegging’, which makes organ donation a corollary of capital punishment. (A typically lip-smacking description is quoted here – ‘cardiectomy’, indeed.) You only need to look into the issue of differential access to justice – and differential likelihood of coming to the attention of the police in the first place – to see the flaw here.

What makes the Survival Lottery interesting, and differentiates it from ideas such as these, is precisely that it has the merit of equity: everybody’s number would be in the hat. (Even the Queen’s, presumably.) There’s something distasteful about it, all the same. In his poem “The Latest Decalogue” the Victorian poet Arthur Hugh Clough offered a gloss on each of the Ten Commandments, including the sixth:

Thou shalt not kill; but need’st not strive
Officiously to keep alive

(Ouch.) The Survival Lottery seems to start from the identical assumption, that failing to keep alive is morally equivalent to killing – but Harris moves from this to the utilitarian (and very un-Cloughian) conclusion that killing so as to keep alive might be allowable, as long as there’s a net increase in the number of people who survive overall. Philosophically, it comes down to whether we think the taboo on killing in cold blood is there for a good reason, and whether that taboo is strong enough to trump utilitarian considerations. Politically, the question is whether we have sufficient trust in the wisdom of the state to empower it to answer either of those questions in the negative. Personally I’d prefer the question of state killing to have fewer grey areas rather than more.

Having said all of that, the idea of introducing ‘presumed consent’ for organ donation – in effect, switching from opt-in to opt-out – seems eminently sensible. As Rob says, it’s hard to see whose interests could possibly be set back by this change, as anyone who cared enough to object would be able to express their preference in binding form by opting out (“I would not like to help anyone live after my death”). I suppose there’s a case for saying that understanding of the policy couldn’t be presumed – in the absence of which presumed consent would be meaningless – but surely this is a case for public education, not for pitching policy to the level of the voters’ lack of awareness. (It took my grandfather a couple of months to get the hang of decimalisation – he still had to live with it.) What appears to be an honourable refusal to take decisions in the name of an uninformed electorate is really the refusal to trespass on the voters’ apathy and ignorance; it may be what those voters would prefer, but it’s hardly in their best interests. I’m particularly disappointed in Harry Burns – Andrew Lansley’s comments were predictable, but Burns should have known better. (I’d never even heard of Harry Burns before this morning, and now this – I ask you.)