The Role and Problem of Trust in Organ Transplantation and Donation

Abstract

Although organ transplantation and donation (OTD) is sometimes described as dependent on trust, within policy discourse, clinical governance and bioethics, trust is often treated as an instrumental condition for public participation, cooperation and approval or for institutional stability rather than as a primary object of ethical analysis and structural and ethical reforms. So while it is true that trust is an instrumental prerequisite for the functioning of the OTD field, trust forms the moral foundation and organising norm of transplant and donation ethics; this thesis contends that trust is the normative foundation that renders transplantation and donation practices and policies morally intelligible. This thesis presents trust as a normative stance of hopeful dependence grounded in shared values and moral expectations maintained under conditions of vulnerability, uncertainty, limited time, and asymmetrical power; herein we entrust – counting on others to act with integrity and care in matters affecting life, bodily integrity and wellbeing. This thesis develops a systematic philosophical account of trust tailored to the transplant context and suitable for application in transplant ethics. To this effect, trust is distinguished from mere reliance, prediction, or strategic expectation. It is this conceptual clarification that provides the basis for my analysis of organ transplantation as a network of reciprocal entrustments beyond procedural compliance, consent, and allocation rules. Given this framework, the thesis maps trust relations within the OTD system through a stakeholder-centred analysis and identifies five core objects of trust that articulate the normative expectations that structure participation in OTD: Autonomy, Usefulness, Good Treatment, Appreciated efforts, and Fidelity to Shared Commitment. It is these objects of trust that clarify what is at stake when trust is invoked, and how failures – whether procedural, communicative or structural – undermine the moral integrity of the transplant system.