Hostname: page-component-78c5997874-dh8gc Total loading time: 0 Render date: 2024-11-16T15:28:57.090Z Has data issue: false hasContentIssue false
  • English
  • Français

The Duty to Protect, Abortion, and Organ Donation

Published online by Cambridge University Press:  28 July 2022

Emily Carroll  and
Parker Crutchfield
Emily Carroll
Affiliation:
Medical Ethics, Humanities, and Law, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan 49008, USA
Parker Crutchfield*
Affiliation:
Medical Ethics, Humanities, and Law, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan 49008, USA
*
*Corresponding author. Email: [email protected]
Rights & Permissions [Opens in a new window]

Abstract

Some people oppose abortion on the grounds that fetuses have full moral status and thus a right to not be killed. We argue that special obligations that hold between mother and fetus also hold between parents and their children. We argue that if these special obligations necessitate the sacrifice of bodily autonomy in the case of abortion, then they also necessitate the sacrifice of bodily autonomy in the case of organ donation. If we accept the argument that it is obligatory to override a woman’s bodily autonomy for the sake of an unborn child’s survival, we must continue to override the bodily autonomy of parents to ensure the survival of their living children, until the parent no longer has a special obligation to their child to the same degree as their special obligation to the fetus. And if the life of a child is truly more important than the bodily autonomy of its parents, as must be the case to force women to carry unwanted pregnancies to term, this should remain true until such a time that their children are no longer considered their responsibility. Thus, parity of reasoning suggests that policies compelling the gestation of a fetus should be accompanied by policies compelling organ donation.

Keywords

abortionorgan donationparental dutiesfetusesduty to protect
Type
Research Article
Information
Cambridge Quarterly of Healthcare Ethics , Volume 31 , Issue 3 , July 2022 , pp. 333 - 343
Creative Commons
Creative Common License - CCCreative Common License - BYCreative Common License - NCCreative Common License - ND
This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.
Copyright
© The Author(s), 2022. Published by Cambridge University Press

Introduction

Some people oppose abortion on the grounds that fetuses have full moral status and thus a right to not be killed. Furthermore, many opponents of abortion claim special obligations of a parent to their child, whether born or unborn. These special obligations go beyond simply not killing the fetus or child. Rather, they place responsibility on the parents to keep the fetus or child alive at a cost to themselves. Pregnant women are therefore obligated to continue unwanted pregnancies, necessitating the sacrifice of their bodily autonomy. They are obligated to accept the medical risks of pregnancy and obligated to allow the fetus full use of their reproductive organs.

If abortion should be prohibited and a mother has a special obligation to her fetus and fetuses have full moral status, then parity of reasoning implies that a parent has a parallel obligation to donate organs to their child. For some, an obligation to donate may be an unacceptable intrusion upon one’s autonomy. People who think this cannot consistently maintain opposition to abortion, so long as fetuses have full moral status and a duty to protect holds between mother and fetus. For such people, our argument constitutes a reductio ad absurdum on the view that abortion is wrong. But our point is not merely conceptual: laws and institutional policies that restrict abortion, on pain of inconsistency, should also formalize the obligations to donate organs that mirror those restrictions on abortion. Parents’ willingness to donate organs to their child is irrelevant—they must donate whether they want to or not.

In the first section, we outline the duty to protect. In the section that follows, we argue that in virtue of a duty to protect common to the mother-fetus relation and the parent–child relation, to say that abortion is impermissible implies parallel obligations to donate. In the third section, we define the scope of the obligation to donate. At a minimum, a parent has an obligation to donate blood products, tissues, and marrow. We then outline the ways in which one can be excused from the obligation to donate and finish with concluding remarks.

A Duty to Protect

Our argument begins with one proposition and two of its implications. The proposition is that embryos and fetuses at any stage of development have full moral status. Though this is highly contentious,Footnote 1, Footnote 2, Footnote 3, Footnote 4, Footnote 5, Footnote 6, Footnote 7 the best possible case for the prohibition of abortion requires it. The first implication of this proposition is that there is no change in moral status once a fetus is birthed—they were a full-on person all along. The second implication is that the parents have a special obligation to the fetus. This is to say that there is something in virtue of which at least the mother and more probably both parents have obligations to the fetus that are over and above those moral obligations they may have toward others. That is, they have to do some things for the fetus that they do not have to do for other people. This recognition that parents have a special obligation toward their fetus follows from the notion that a fetus has full moral status and the notion that there are special obligations.

For the proponent of prohibition of abortion, denying either of these notions is unattractive. Denying that fetuses have less than full moral status obviously weakens the case for the prohibition. Denying that some special obligation holds between parent and fetus is the equivalent of claiming that what a parent owes to their fetus is the same as what they owe to others. Combined with the claim that fetuses have full moral status, the claim that no special obligation holds between parent and fetus extends to children: parents owe nothing to their children over and above what they owe to others. In other words, the proponent of the prohibition of abortion must accept that parents have a special obligation to their fetus, or else maintain some untenable claim.

Robert GoodinFootnote 8 argues that these obligations are derived from the relationship between a vulnerable person and the person to whom they are vulnerable. Or, A has a duty to protect B just in case B’s interests are vulnerable to A’s actions. There are many ways in which a person might be vulnerable to another, or ways in which their interest satisfaction depends on the other person’s actions. In general, the vulnerability is in their material and psychological interests. Some people depend on others for the satisfaction of their material and psychological interests. When they so depend, the person upon whom they depend is obligated to protect those interests.

Goodin’s argument for this claim is rooted in common-sense morality. We all think we have these obligations; indeed, a common objection to utilitarianism is that it may ignore the special obligations we have to our family and friends and others who depend upon us. Given that we have these special obligations, what accounts for them? Goodin claims that we have these special obligations in virtue of others’ vulnerability to us. This view purports to not only account for why we have special obligations in the first place, but what we must do when we have them.

When a person has a duty to protect another person, they must protect the interests of that person. However, the degree to which one must do so can vary according to the degree of dependence and, as with all obligations, one’s ability to protect those interests. Thus, the person nearest the child drowning in a shallow pond bears the greatest duty to protect that child because the child is most vulnerable to that person’s actions. Children are highly vulnerable, and more so to their parents than they are to others. Parents’ duty to protect their children is strong, perhaps strongest of all special obligations. In contrast, elderly parents are highly vulnerable to their adult children, especially emotionally so. Adult children are therefore obligated to protect them.

Satisfying the duty to protect dictates very many of our behaviors, public and private. There are a few distinctive features of the duty. One is obvious: it can be violated even if no one is harmed. There are ways that a person can be wronged that are not harm-based, and among these ways is when one is entitled to protection from another agent but does not get it. Another distinctive feature is less obvious. A person may have a duty to protect, even if there is no specific protectee. We all have a right not to be harmed, and we have this right at all times. But the right to be protected comes and goes, and varies according to the relationships we have with others. Consider the ship’s captain. They have a duty to protect their passengers, even before they are on board. They have a duty to protect future passengers. Passengers may come and go, but anyone on the ship is entitled to some protection. The same can be said of states and corporations. The duty to protect requires that the duty-bound throw up a shield. In some cases that shield might only require the protection of certain, identifiable individuals (i.e., children and elderly parents). But in other cases, it might require the protection of people yet to be identified (e.g., future passengers on a ship).

Granting that the proponent of abortion prohibition accepts that parents have a special obligation to fetuses, they must accept some grounds for this special obligation. We adopt Goodin’s vulnerability model, but there are others, such as the voluntarist account. This account maintains that special obligations obtain in virtue of one person self-assuming them.Footnote 9 Importantly, the voluntarist account of the special obligation is prima facie incompatible with the outright prohibition of abortion. For example, a voluntarist account of the special obligation would, at a minimum, maintain that when a fetus results from rape, the mother may not have a special obligation to the fetus, which may rule in the permissibility of aborting the fetus. Similarly, if the voluntarist account of the special obligation is right, then even when a pregnancy is unintended—when a person fails to assume the obligation for themselves—the special obligation to the fetus is not present, which may rule in the permissibility of aborting unintended fetuses. These are not claims that the proponent of the prohibition of abortion is likely to make. They may be able to still maintain a voluntarist account of the special obligation, but they will have to manage this prima facie incompatibility. And even if they do, as we argue below it may not help.

Our claim is that if a special obligation grounds a parent’s duty to protect their fetus, and that aborting a fetus ought to be prohibited, then the same duty to protect obligates a parent to donate organs to their children. The wider the scope of the prohibition of abortion, the wider the scope of the obligation to donate. That is, if abortion ought to be prohibited in all cases, even when it requires that the parent die, then a parent must donate organs even when it requires that they die. Or, more generally, if the special obligation that holds between parent and fetus is strong enough to override the parent’s preferences for abortion, then it is also strong enough to override the parent’s preferences in the case of organ donation.

From Abortion to Organ Donation

The reasoning from the prohibition of abortion to the compulsion of organ donation is straightforward. If aborting a fetus wrongly violates the duty to protect, then because failing to donate one’s organs to one’s child also violates the duty to protect, failing to do so is similarly wrong. And if this wrongness is sufficient to coerce a person’s behavior in the case of abortion, then it is also sufficient to coerce a person’s behavior in the case of organ donation. That is, it should be sufficient reason to compel organ donation, if it is sufficient reason to prohibit an abortion.

This reasoning obviously relies heavily on the claim that a parent failing to donate organs violates the duty to protect. The duty to protect is violated when a protector fails to shield a protectee from preventable suffering. If two people are related in the right sort of way, with one vulnerable to the other, then the duty to protect kicks in. A parent is related in the right sort of way to their children, and so they are obligated to shield their child from suffering, so long as they are capable of doing so. Being incapable of doing something releases one from one’s obligation to do that thing. In the case of organ donation, there are many reasons why a parent may not be capable of donating. Foremost among these is that a parent might not be an appropriate match. In those cases, the parent’s obligation to protect their child in that way is excused. When the parent is not a match, their duty to protect is satisfied instead by facilitating the procurement of someone else’s organ, which can be satisfied by participating in the ordinary procurement process with a hospital.

But if biological compatibility allows for a parent to donate an organ to their child, who, in the absence of a donated organ, is likely to suffer or die, and the parent fails to do so, they have violated the duty to protect. The duty to protect is grounded in the degree of vulnerability between the protector and protectee. The interests of a child who needs an organ are extremely vulnerable to the actions and omissions of their organ-matching parent, not just physically but also psychologically. The parent failing to donate further undermines the child’s interests in not suffering or not dying.

Terminating a fetus similarly violates a duty to protect. If fetuses have full moral status, given that their interests are vulnerable to the actions and omissions of the mother, the mother has a duty to protect those interests, a duty to shield the fetus from things that undermine those interests. Terminating the life of the fetus certainly qualifies as failing to do this, so terminating a fetus is a violation of the mother’s duty to protect it.

It is a violation of this duty to protect that makes abortion wrong. Some might wish to resist this claim, and claim instead that some other duty is violated when one terminates a fetus, such as a duty to not harm persons. But such a claim limits the extent to which abortion is wrong. It is not always wrong to harm other persons. Some harms are justifiable, such as those that are required to protect one’s own interests. There are many circumstances in which a fetus plausibly undermines a person’s interests to the point that the only way those interests can be preserved is by terminating the fetus. If you wake up with a violinist attached to you, and you really do not want that, the duty to nonmaleficence proscribes unhooking him no more than it proscribes harming a home invader in the process of removing him from your house.Footnote 10 Because protecting one’s own interests so easily overrides the duty to nonmaleficence, and there are many instances in which a fetus undermines a person’s interests, there would be very many cases of morally permissible abortion, if the duty to nonmaleficence is what makes abortion wrong. For example, abortion would be permissible whenever the mother felt that the fetus significantly undermines her own interests. This is not a view that proponents of a prohibition on abortion typically like to advance.

Moreover, when one person has a duty to protect another, they also have a duty to not harm that person. The duty to protect implies the duty to nonmaleficence. However, unlike the duty to nonmaleficence, which only proscribes actions, the duty to protect also proscribes omissions. Thus, necessarily the duty to protect will place greater restrictions on a person’s behavior than will the duty to nonmaleficence.

Similarly, other values such as respect for persons are, though not mutually exclusive with the duty to protect, more easily overridden by a person’s other interests. Respect for persons might be foundational, but that does not entail that it always trumps other interests. Sometimes other values override respect for persons, such as when respecting a person, whatever that amounts to, requires a significant sacrifice of life or other important interests.

If the duty to protect holds between mother and fetus, there are strong grounds for a prohibition on abortion, even when the fetus results from rape. What establishes the duty to protect is the vulnerability that holds between two people. That the vulnerability results from rape does not undermine the relationship. The violinist is vulnerable to the person who wakes up hooked up to him, and significantly so. If you wake up with a violinist hooked up to you, regardless of whether you want him there, you have a duty to protect him. Unhooking him would violate that duty to protect, so it would be wrong to do that.Footnote 11

Our central claim is that the conjunction of the following three propositions entails an obligation to donate organs: (1) that fetuses have full moral status; (2) that a duty to protect holds between mother and fetus; and (3) that abortion should be prohibited. We assume, per the opponents of the permissibility of abortion, propositions (1) and (3). We have tried to motivate (2) in this section. In what follows, we outline how these propositions imply an obligation to donate organs.

A Duty to Donate

If the duty to protect that holds between mother and fetus is sufficiently strong to outweigh a mother’s interests in terminating the fetus (which it must be if abortion ought to be prohibited), then the same is true when a parent has a duty to protect their child who needs an organ. Suppose that a person holds the view that abortion should be prohibited in all cases, even if it is necessary to save the life of the mother. If abortion is wrong in those circumstances, and it is wrong because it violates the duty to protect, then parity of reasoning requires that where that same duty holds, a similar sacrifice is required. That is, where a person’s duty to protect is as strong as the duty that holds between mother and fetus, if satisfying the duty to protect requires the person to sacrifice their own life, then sacrifice they must.

A fetus is highly vulnerable to the mother. But children are similarly vulnerable, and not merely to the mother.Footnote 12, Footnote 13 While fetuses and infants are extremely physically vulnerable, as children age and their psychology develops they become additionally psychologically vulnerable to their parents. This combination of significant physical and psychological vulnerability to parents triggers a strong duty to protect. A parent, therefore, has a strong obligation to shield their child from suffering. There are no obvious reasons to think that the duty to protect that holds between parent and child, up to a certain age, is any weaker than that which holds between mother and fetus.

If in the case of abortion, this duty to protect is sufficiently strong to proscribe abortion in all cases, even when not terminating the fetus results in the mother dying, and the duty to protect between parent and child is just as strong, then it would be wrong for a biologically compatible parent to fail to donate an organ to their child in need. Suppose a child needs a lung or heart transplant, and their parent is a perfect match, and there are no other available donors. If a parent fails to donate an organ in this case, and the duty to protect is so strong that it requires the protector to sacrifice their own life in throwing up a shield (as it would have to be to proscribe abortion in all circumstances), then a parent failing to donate would violate the duty to protect. If the mother’s interests in her own survival are not heavy enough to outweigh the fetus’s interests that the duty to protect guards, then either parent’s similar interests in keeping their lung or heart are also insufficiently heavy.

One might object at this point that the duty to protect in the case of abortion proscribes an action, but that the relevant proscribed event in the case of organ donation is an omission. And since there is a morally relevant difference between acts and omissions, the reasoning that proscribes abortion cannot similarly proscribe failing to donate.

Granting the claim that there is generally a morally relevant difference between acts and omissions (which there may not be), the distinction is irrelevant in determining whether the duty to protect has been violated. Unlike the duty to nonmaleficence, which typically is only violated by actions, the duty to protect is violated by both actions as well as omissions. The fact that the proscribed event in the case of organ donation is an omission is irrelevant. By omitting action, they have done something wrong. Similarly, the parent who fails to donate their organ to their child has done something wrong, if the duty to protect is so strong as to proscribe all abortions.

The degree to which the duty to protect obligates organ donation is equal to the degree to which the duty to protect proscribes abortions. As the duty to protect varies in strength—as vulnerability varies between the protector and protectee—the actions and omissions it requires and proscribes vary. And since the duty to protect that holds between parent and child is as strong as that which holds between mother and fetus, the degree to which the duty requires self-sacrifice in the case of abortion is equal to the degree to which it requires self-sacrifice in the case of organ donation. Or, if a mother must give her life to protect her fetus, parents must give their lives to protect their child.

Scope of the Obligation to Donate

It is not common for people to advocate for the total prohibition of abortion, even when terminating the fetus is necessary to save the mother’s life. Most people allow that there are some morally permissible abortions. As we have discussed, the scope of the obligation to donate is proportional to the obligation to not terminate a fetus. As the range of circumstances in which abortion is impermissible narrows, so does the range of circumstances in which a parent is obligated to donate an organ.

Suppose that one holds that abortion is permissible only if the mother will die if the fetus is not terminated. In that case, the parallel obligation to donate would be similarly narrow, such that a parent would not be obligated to donate any organ the loss of which would cause their death. But the parent would be obligated to donate other organs, such as a kidney or liver, even if it means that donating will permanently and significantly burden the parent. This is the sort of obligation to donate that religious institutions such as those governed by the Ethical and Religious Directives for Catholic Health Care Services imply. When abortion is wrong, except when the mother’s life is at stake, failing to donate an organ is wrong, except when the parent’s life is at stake. Or, conversely, if a woman can permissibly terminate a fetus only when doing so is necessary to secure something else of great value to her (such as continued life), then a parent can permissibly refuse to donate only when doing so is necessary to secure something of great value to them.

Narrowing the scope even further, one might hold that abortion is permissible only if the mother would die or be permanently and significantly burdened if the fetus were not terminated. The parallel obligation to donate would then be determined by what burdens a mother must bear for her fetus. If the mother must bear great burdens for her fetus, then so must the parent for their child. This may still obligate them to donate a kidney or liver, or the obligation to donate may be limited to some tissues and blood products. But given that one can live a comparatively unburdened life without one kidney or without some of their liver, requiring a mother to bear a permanent but low burden in order to protect the fetus during pregnancy will still obligate the parent to donate these organs. What is the comparable burden to living a life without one kidney? It is hard to say. It may be equivalent to the burden of caring for a child. It may be equivalent to living with the permanent physical changes that can accompany pregnancy and childbirth. These changes may include pelvic floor damage resulting in persistent incontinence.Footnote 14, Footnote 15 Women who experience pregnancy complications such as gestational diabetes or preeclampsia experience twice the risk of coronary artery disease and stroke later in life.Footnote 16 Additionally, pregnancy-related changes may exacerbate underlying maternal health defects such as thrombophilia, glomerulopathy, or arterial aneurysms.Footnote 17 These are significant risks and burdens. Living a life without one kidney is plausibly less burdensome over a lifetime than permanent pelvic floor damage.

There is, however, a baseline obligation to donate that can be derived from the proscription of abortion. Some argue that abortion for the sake of convenience should be prohibited because the mother’s burden of inconvenience does not release the mother from her duty to protect. But there is no guarantee that childbirth, a major medical procedure, will remain simply inconvenient and proceed without serious harm to the mother. The maternal mortality rate in the United States, as of 2018, is 17.4 per 100,000 live births.Footnote 18 In a study of abortions between 1998 and 2010, legal abortions in the US carried a lower risk of mortality than childbirth at a rate of 0.7 per 100,000 abortions.Footnote 19 If a woman is pregnant, the numbers tell us that abortion carries less risk of death than does carrying the pregnancy to term. However, opponents of abortion argue that the risk to the mother is acceptable in comparison to the benefit the fetus receives—survival.

If we accept the view that the costs and potential risks to the mother are worth the benefit to the fetus, in addition to the view that a mother has special obligations to her fetus that mandate her taking on those costs, there are other costs that we then must mandate. If we maintain that it is wrong for a woman to abort a healthy, viable, planned fetus because she does not want to take the risk of dying in childbirth, it is also wrong for her to deny other medical procedures for the sake of her child’s survival that carry comparable risk of death. If it is wrong for her to abort because the risk of carrying to term is acceptably small in the face of benefit to the fetus, then it is also wrong for her to withhold donation of blood products or other organs, which carries a lower risk than childbirth and may similarly preserve the child’s life. It is wrong for her to not donate blood or tissues or a kidney, even if she does not want to, because it violates her duty to protect her child. This is the baseline obligation to donate. Prohibitions of abortion, by parity of reasoning, require a proportionate compulsion to donate. If elective abortions are restricted at all, then at a minimum a parent has a duty to donate blood products, which is not nearly as burdensome or dangerous as carrying a full-term pregnancy. They may also have a duty to donate other tissues in which the donation process carries a similar risk to pregnancy and childbirth. For comparison, 1.47% of mothers in the US experience a serious complication due to their pregnancy or childbirth.Footnote 20 Peripheral blood stem cell donors experience less than 1% risk of serious complication related to donation,Footnote 21 bone marrow donors experience a 2.4% risk of serious complication,Footnote 22 living liver donors experience a serious complication rate of 1.1–1.3%,Footnote 23, Footnote 24 and less than 3% of living kidney donors experience serious complications.Footnote 25

Some hold that the circumstances of the conception make a difference as to whether abortion is permissible, as when the fetus results from rape or incest. However, this view is not compatible with the view that special obligations arise out of vulnerability relations.Footnote 26 Thus, one must hold that something else grounds the duty to protect, such as the relation being self-assumed or voluntary (which in the case of rape it is not). But then doing so has costs of its own, as we discuss below.

Another common way that one might try to restrict abortion is according to gestational age. Such restrictions are compatible with the duty to protect. As long as we are presuming that fetuses have full moral status, the fetus’s gestational age is irrelevant. Considerations regarding development and gestational age, such as whether it has fingernails or a beating heart or can feel pain or is viable, are relevant only to the extent that they have implications for moral status. For example, one would not hold that a fetus at 8 weeks with full moral status can be permissibly terminated at any point. Note, however, that restrictions based on earlier gestational ages imply greater burdens for the mother, which in turn imply greater obligations to donate.

Restrictions upon abortions imply parallel obligations to donate organs. A parent must donate a heart or both lungs or kidneys or face, if abortion should be prohibited under any circumstance. A parent must donate one lung, one kidney, liver, pancreas, intestine, cornea, a hand, or skin if abortion should be prohibited in all circumstances except those in which continuing to carry the fetus requires the mother to make significant sacrifices. If only elective abortions are prohibited, then a parent must donate blood products, kidney, or anything else the loss of which carries burdens comparable to those associated with pregnancy and labor and delivery. Thus, where there are institutional or legal restrictions upon abortion there should also be institutional or legal requirements to donate.

How to Be Excused from the Obligation to Donate

There are a number of ways a parent may avoid having an obligation to donate organs. One is by simply not being able to. One is not obligated to do things that they cannot do. A parent might not be able to donate to their child for one of many different reasons. The most common reason a parent may be unable to donate to their child is that they are not an appropriate biological match. Or, to put it in terms of the duty to protect, when a parent is not biologically appropriate for donation, their child is not vulnerable to them in that particular way. Thus, there is no parental duty to protect their child in that particular way.

But even if a parent is excused from the obligation to donate because they are not a biological match, they still must satisfy other aspects of their duty to protect, such as by facilitating donation. Children in need of organs whose parents are not a match are nevertheless vulnerable to parents in other ways. They rely on their parents to help facilitate the donation. Parents must therefore do the things that they need to do to participate in exchanges or cooperate with organ procurement organizations. In most facilities, satisfying the duty would simply require cooperating with the treating hospital as they facilitate the organ transplant.

Another way a parent may be excused from the obligation to donate is by transferring the child’s vulnerability to another person by way of adoption. This excuse is limited, however.Footnote 27 An adopted child is primarily vulnerable to their adoptive parents. But the adopted child may still be biologically vulnerable to their biological parent. A biological parent of an adopted child may be the only person biologically appropriate for donation. If so, then the child is highly vulnerable to their biological parent and, therefore, that parent has an obligation to donate. Or there may be circumstances in which there are multiple matches, but too many candidate recipients are prioritized over the child. In that case, the biological parent does have a duty to donate, for they alone can repair that vulnerability. It is not as though there is some special duty that arises out of a biological relation or some notion of responsibility. Reproducing simply makes it more likely that there will be a person who is vulnerable to only the parent. So although giving a child up for adoption transfers most parental obligation to the adoptive parents (or the adoption agency, in the interim), some obligations may always remain.

The vulnerability relation depends in part on how far apart in time and space the two people are. If egg and sperm donors are near enough in time and space such that offspring who result from their gametes are highly vulnerable to them, then these donors must also donate organs or tissues. These responsibilities to donate organs continue even if the sperm or egg donor takes no other parental role and even if there is no relationship between child and donor parent other than biological. If special obligations and preservation of life override autonomy in the case of parent–child situations where bodily aid is required, the biological parent remains obligated to donate because they are the most likely to be capable of rendering such aid.

More challenging cases are those in which a mother who is, by neurological criteria, dead, but nevertheless pregnant. If fetal survival and special obligations override parental bodily autonomy enough so as to prohibit abortion, maternal brain death does not necessarily release a pregnant woman from her duty to protect the life of her child at the physical cost to herself. Being incapable of an act relieves one of the duty to perform it. This is often the case when pregnant women die, but there have been cases of maternal brain death where the fetus remains healthy and the mother remains capable of continuing her pregnancy after death with appropriate medical intervention.Footnote 28 As in the case of adoption, in these cases, there is no one else who is capable of satisfying the fetus’ needs other than the biological parent, specifically the mother. Because no one else can assume these obligations and as death does not change the fact that she is the only one physically capable of preserving the fetus’ life, her special obligations continue postmortem.

In cases of a pregnant woman who becomes brain dead, she should become an organ donor and remain on life support with all possible interventions given to keep the fetus alive until birth, if possible. This contradicts the most commonly followed view in organ retrieval practices, which holds that the prior wishes (if known) of an organ donor should determine what is done with their body once they are deceased,Footnote 29, Footnote 30 as their bodily autonomy remains intact after death. According to this view on postmortem treatment of bodies, pregnant brain dead women should be treated according to the woman’s advance directives or according to the wishes of their next of kin.Footnote 31 However, Christoph Anstotz argues that a fetus has a right to life strong enough to warrant mandating life support regardless of the woman’s wishes or those of her next of kin.Footnote 32, Footnote 33 We would add that parents have special obligations to protect their offspring’s interests and that the mother in such cases is uniquely capable of fulfilling this obligation to the fetus even after her death.

Objections

We have argued that the conjunction of the following three claims implies a parental obligation to donate to their child:

  1. 1) that fetuses have full moral status;

  2. 2) that a duty to protect holds between mother and fetus; and

  3. 3) that abortion should be prohibited.

If these three propositions are true, then what one says about restrictions upon abortions is what, by parity of reasoning, they should say about organ donation. If abortion is permissible in most circumstances, then organ donation is not frequently obligatory. But if abortion is permissible in few circumstances, then organ donation is frequently obligatory. Loose abortion restrictions imply a loose obligation to donate. Whether organ donation is obligatory depends on the degree to which a parent must sacrifice in order to satisfy it (i.e., the strength of the duty to protect), and this degree of sacrifice is fixed by what one says about the mother’s required sacrifice for her fetus. Or, the duty to donate is fixed both by what one says about the strength of the duty to protect a fetus as well as what one says is in the set of circumstances in which abortion ought to be prohibited.

There are several strategies one might use to object to this reasoning. One is to simply deny that the duties a mother has to her fetus are the same as those that a parent has to their child. If this is true, then what one says about abortion will be different from what one says about organ donation. But it is unclear how this argument could go, if fetuses also have full moral status and that a duty to protect holds between mother and fetus. One difference between a fetus and a child is that one is in the mother’s body and the other is not. Another difference is that fetuses are not conscious but children are. But these differences are morally relevant only to the extent that they imply differences in either vulnerability or moral status. Differences in consciousness are morally irrelevant, because such differences are only ever morally relevant for discriminating moral status, and we are presuming that a fetus has full moral status.

It may be that the fetus in the mother’s body is significantly more vulnerable to its mother than the average child is to its parents. But the child who needs an organ is just as vulnerable to their parent as the fetus is to its mother. Whatever a mother owes her fetus will be the same as what she owes her newborn. And what she owes her newborn will be what she owes her toddler (though how she pays these debts may differ). If she owes her fetus her life so that it may live, then the parent’s obligation to their similarly vulnerable child is the same. If she owes merely the burden of pregnancy and the temporary use of her organs, then the parent must pay the same to their child.

One may instead deny one of the propositions (1–3). The opponent of abortion cannot deny (3), or else they would not be an opponent of abortion. They may deny (1), but then the case that any abortion restriction is permissible is much weaker. Thus, to avoid the implication that parents must donate organs if a mother cannot terminate a fetus, one may deny (2) that a duty to protect holds between mother and fetus. Above we mention that someone might agree that a duty to protect holds between mother and fetus, but only if that duty is self-assumed, as the voluntarist about special obligations believes. Such a view might initially appear as a way to undermine the obligation to donate, but it does not. Parents, in virtue of continuing to parent their children, self-assume the duty to protect their children. Though a voluntarist foundation of the special obligations may help to define which abortions are permissible and which are not, in so doing it will also define when donating is obligatory and when it is not. Or, once the opponent of abortion declares an account of the duty to protect, the circumstances in which abortion is impermissible will be defined, and by parity of reasoning the circumstances in which organ donation is obligatory. The obligation to donate arises out of a duty to protect common to the mother-fetus relation and the parent–child relation. So adopting a different account of the duty to protect offers no protection for those opponents of abortion who also want to deny that organ donation is obligatory.

The alternative is to deny that a duty to protect holds between mother and fetus. But doing so is costly. It requires that one deny that we have special obligations like a duty to protect our children. If fetuses have full moral status and in general we have special obligations to others, then it is not clear how one can consistently maintain that a mother lacks a special obligation to her fetus but has one toward her child. Whatever one says grounds the special obligation—the protectee’s vulnerability, the protector’s self-assuming it—what is true of the child is also true of the fetus, so long as a fetus and child have the same moral status. If it is not moral status that changes upon birth, then there ought to be no difference in obligation from the last moment a person is a fetus to the first moment they are a child.

Conclusion

We have argued that if abortion is to be restricted, then there are parallel obligations a parent has to donate organs, tissues, or blood to their child. The strength of the obligation to donate is proportional to the strength of the restriction of abortion. If abortion is never permissible, then a parent must always donate any organ (presuming they are a match). If abortion is sometimes permissible and sometimes not, then organ donation is sometimes obligatory and sometimes not.

We are not arguing that abortion should be permitted or prohibited. Our concern is rather in how these permissions and prohibitions interact with other moral obligations, given other plausible claims, such as the claim that fetuses have full moral status or the claim that special obligations hold between parent and child.

It is also important to note that our argument does not imply that a parent is compelled to donate an organ to their child, regardless of what one says about abortion. One could easily and consistently maintain that satisfying the duty to protect does not require a child’s use of their parent’s organs, if that use is necessary to sustain the life of the child. It might be that organ donation goes above and beyond any duty to protect. However, this position is not open to opponents of abortion. If, along with their view that abortion should be prohibited, that a duty to protect holds between mother and fetus and that the fetus has full moral status—both claims that they should make—then they must also claim that organ donation is compulsory. Thus, as they advocate for laws that restrict abortion, they, on pain of inconsistency, should also advocate for laws that compel organ donation.

That opponents of abortion may additionally be committed to compulsory organ donation may constitute for some a reductio ad absurdum, leaving only the opposition to abortion to reject. But for others, the commitment to compulsory organ donation may be welcome. The point is not about whether a parent is willing to donate organs to their child; it is that they do not have a choice in the matter. We take no stand on whether the commitment to compulsory organ donation is an implausible commitment. But the extent to which a person opposes abortion is the extent to which they should be willing to donate their own organs.

References

Notes

1. Jaworska, A, Tannenbaum, J. The grounds of moral status. In: Zalta, EN, ed. The Stanford Encyclopedia of Philosophy [Internet]. Spring 2018. Stanford, CA: Metaphysics Research Lab, Stanford University; 2018 Google Scholar [cited 2020 Aug 27]; available at https://plato.stanford.edu/archives/spr2018/entries/grounds-moral-status/ (last accessed 26 Dec 2021).

2. Abortion, Dwyer S.. In: International Encyclopedia of Ethics [Internet]. Atlanta, GA: American Cancer Society; 2013 Google Scholar [cited 2020 Sept 2]; available at https://onlinelibrary.wiley.com/doi/abs/10.1002/9781444367072.wbiee226 (last accessed 26 Dec 2021).

3. Gibson, S. The problem of abortion: Essentially contested concepts and moral autonomy. Bioethics 2004;18(3):221–33CrossRefGoogle ScholarPubMed.

4. Simkulet, W. Substance, rights, value, and abortion. Bioethics 2019;33(9):1002–11CrossRefGoogle ScholarPubMed.

5. Jung, PB. Abortion and organ donation: Christian reflections on bodily life support. Journal of Religious Ethics 1988;16(2):273–305 Google ScholarPubMed.

6. Isaacs, D. Moral status of the fetus: Fetal rights or maternal autonomy? Journal of Paediatrics and Child Health 2003;39(1):58–9CrossRefGoogle ScholarPubMed.

7. Griffith, S. The moral status of a human fetus: A response to Lee. Christian Bioethics 2004;10(1):55–62 CrossRefGoogle ScholarPubMed.

8. Goodin, RE. Protecting the Vulnerable: A Reanalysis of Our Social Responsibilities. Chicago: The University of Chicago Press; 1985 Google Scholar.

9. Brake, E. Willing parents: A voluntarist account of parental role obligations. In: Archard, D, Benatar, D, eds. Procreation and Parenthood: The Ethics of Bearing and Rearing Children. Oxford: Oxford University Press; 2010 Google Scholar.

10. Thomson, JJ. A defense of abortion. Philosophy and Public Affairs 1971;1(1):47–66 Google Scholar.

11. Davis, M. Foetuses, famous violinists, and the right to continued aid. The Philosophical Quarterly 1983;33(132):259–78CrossRefGoogle ScholarPubMed.

12. Jung, PB. Abortion: An exercise in moral imagination. Reproductive Health Matters 1993;1(2):84–6CrossRefGoogle Scholar.

13. See note 5, Jung 1988, at 273–305.

14. Fonti, Y, Giordano, R, Cacciatore, A, Romano, M, La Rosa, B. Post partum pelvic floor changes. Journal of Prenatal Medicine 2009;3(4):57–9Google ScholarPubMed.

15. Wesnes, S, Hunskaar, S, Bo, K, Rortveit, G. The effect of urinary incontinence status during pregnancy and delivery mode on incontinence postpartum. A cohort study. British Journal of Obstetrics and Gynaecology 2009;116(5):700–7CrossRefGoogle ScholarPubMed.

16. Kaaja, RJ, Greer, IA. Manifestations of chronic disease during pregnancy. JAMA 2005;294(21):2751–7CrossRefGoogle ScholarPubMed.

17. See note 16, Kaaja, Greer 2005, at 2751–7.

18. National Vital Statistics System (NVSS) - Maternal Mortality – Homepage [Internet] 2020 [cited 2020 Sept 2]; available at https://www.cdc.gov/nchs/maternal-mortality/index.htm (last accessed 26 Dec 2021).

19. Zane, S, Creanga, AA, Berg, CJ, Pazol, K, Suchdev, DB, Jamieson, DJ, et al. Abortion-related mortality in the United States 1998–2010. Obstetrics & Gynecology 2015;126(2):258–65CrossRefGoogle ScholarPubMed.

20. Rubin, R. Rate of severe childbirth complications has increased. JAMA 2018;320(16):1630 Google ScholarPubMed.

21. Frequently Asked Questions (FAQ) | Blood Stem Cell [Internet]. [cited 2020 Aug 27]; available at https://bloodstemcell.hrsa.gov/about/faqs (last accessed 26 Dec 2021).

22. See note 21, Frequently Asked Questions (FAQ) | Blood Stem Cell.

23. Kim, PTW, Testa, G. Living donor liver transplantation in the USA. Hepatobiliary Surgery and Nutrition 2015;5(2):133–40Google Scholar.

24. Hwang, S, Lee, S-G, Lee, Y-J, Sung, K-B, Park, K-M, Kim, K-H, et al. Lessons learned from 1,000 living donor liver transplantations in a single center: How to make living donations safe. Liver Transplantation 2006;12(6):920–7CrossRefGoogle Scholar.

25. Lentine, KL, Lam, NN, Segev, DL. Risks of living kidney donation: Current state of knowledge on outcomes important to donors. Clinical Journal of the American Society of Nephrology 2019;14(4):597–608 CrossRefGoogle ScholarPubMed.

26. See note 11, Davis 1983.

27. Brandt, R, Wilkinson, S, Williams, N. The donation and sale of human eggs and sperm. In: Zalta, EN, ed. The Stanford Encyclopedia of Philosophy [Internet]. Winter 2019. Stanford, CA: Metaphysics Research Lab, Stanford University; 2019 Google Scholar [cited 2020 Aug 27]; available at https://plato.stanford.edu/archives/win2019/entries/gametes-donation-sale/ (last accessed 26 Dec 2021).

28. Said, A, Amer, AJ, Masood, UR, Dirar, A, Faris, C. A brain-dead pregnant woman with prolonged somatic support and successful neonatal outcome: A grand rounds case with a detailed review of literature and ethical considerations. International Journal of Critical Illness and Injury Science 2013;3(3):220–4CrossRefGoogle ScholarPubMed.

29. Wilkinson, M, Wilkinson, S. The donation of human organs. In: Zalta, EN, ed. The Stanford Encyclopedia of Philosophy [Internet]. Spring 2019. Stanford, CA: Metaphysics Research Lab, Stanford University; 2019 Google Scholar [cited 2020 Aug 27]; available at https://plato.stanford.edu/archives/spr2019/entries/organ-donation/ (last accessed 26 Dec 2021).

30. Almassi, B. Trust and the duty of organ donation. Bioethics 2014;28(6):275–83CrossRefGoogle ScholarPubMed.

31. Stapleton, G. Qualifying choice: Ethical reflection on the scope of prenatal screening. Medicine, Health Care and Philosophy 2017;20(2):195–205 CrossRefGoogle ScholarPubMed.

32. Anstötz, C. Should a brain-dead pregnant woman carry her child to full term? The case of the “Erlanger baby.” Bioethics 1993;7(4):340–50CrossRefGoogle ScholarPubMed.

33. Kukla, R, Wayne, K. Pregnancy, birth, and medicine. In: Zalta, EN, ed. The Stanford Encyclopedia of Philosophy [Internet]. Spring 2018. Stanford, CA: Metaphysics Research Lab, Stanford University; 2018 Google Scholar [cited 2020 Aug 27]; available at https://plato.stanford.edu/archives/spr2018/entries/ethics-pregnancy/ (last accessed 26 Dec 2021).