A critique of the concept of autonomy in organ donation

The legal requirement for consent or authorization for the use of an organ for transplantation places donor autonomy as the prima facie ethical principle underpinning organ procurement in the UK. Donor autonomy is central to the ethical discourse of transplantation yet this concept remains poorly articulated in the legal and regulatory framework governing organ donation where it is framed narrowly in terms of consent or authorisation. I analyse the legal framework governing living and deceased organ donation in England, Scotland, and Wales and the regulatory processes for the approval of application for living organ donation and seek to identify whether these are consistent with a particular understanding of autonomy. I consider the adult donor and the child donor separately. I maintain that the choice to donate an organ is a deeply personal decision based on motivations and values that matter to the donor. I explore the understanding of autonomy in relation to decisions to donate an organ for transplantation from the perspective of the person whose organs are used. I am concerned with a substantive account of autonomy that goes beyond the decisional authority over the use of one’s organs. Starting from this premise, I examine the role of self-reflection, personal values and relationships, and moral responsibilities and commitments in decisions to donate an organ and focus on the idea of authenticity understood as a choice that the donor endorses as their own. I argue that consent or authorization that is lawful from a procedural perspective does not ensure that the decisions of the person whose organs are used for transplantation are respected and does not require that these choices are based on a decision-making process that engages with personal autonomy in a meaningful way.