Presuming consent, presuming refusal: organ donation and communal structure.

Donating, distributing and ultimately transplanting organs each has distinct ethical problems. In this paper I suggest that the first ethical question is not what should be done but what is a fair way in which each of these problems can be addressed. Experts--whether these be transplant surgeons, policy analysts, political scientists or ethicists--can help guide but cannot by themselves make such decisions. In making these decisions the difference between identified and non-identified lives is crucial. I suggest that an approach in which reason is tempered by compassion ("compassionate rationality") when dealing with unidentified lives and in which compassion is controlled by reason ("rational compassion") in dealing with identified lives must serve us well. Ultimately decisions of this sort are prone to sturdy democratic process which is possible only when the preconditions of person, economic and educational democracy are met.