Intended for healthcare professionals

Feature Christmas 2015: Call to Action

The ghost of donor passed

BMJ 2015; 351 doi: (Published 16 December 2015) Cite this as: BMJ 2015;351:h6244
  1. David M Shaw, senior researcher
  1. 1Institute for Biomedical Ethics, University of Basel, 4056 Basel, Switzerland
  1. Correspondence to: David M Shaw{at}

Doctors’ first obligation is to their patients, even after the patient is dead, says David Shaw

I am an angry ghost. I died in a car crash last month. I’m not very happy about that, but that’s not why I’m angry. I was a registered organ donor, and my wife didn’t respect my wish to donate my organs. I’m a bit upset with her about that, but I’m really angry because the medical team let my wife, who was in great distress, over-rule my wishes without asking her to reconsider. When she told the medical team that she was too upset to agree to donation, they simply accepted that in order to avoid upsetting her further. I’m angry because they did that despite knowing that they are supposed to respect the wishes of registered donors. It was as if I wasn’t there. No-one spoke for me.

I’m also angry because my wife now regrets her decision and there’s nothing she can do about it. She hates the fact that she disrespected my last wish, and this has caused arguments with my parents too. She was denied the opportunity to use my death to save and improve lives. This is the medical team’s fault.

And I’m angry because two other people have died because they didn’t get my organs. They’re my ghost friends. We’re all angry that their deaths are partly due to the ease with which my wife was able to over-rule my wishes. They are angry because their families are in extreme distress. All of this is because of the failure of the medical team, which should not have given in to my wife without a fight. I am an angry ghost. I have very many reasons to be angry. And I have very many ghostly comrades in arms.

Listen to the ghosts

This ghostly example shows how ethically problematic the family over-rule can be, by reducing families’ and health professionals’ moral distance from the consequences of their actions.1 Ghosts are omniscient; they don’t experience moral distance and see all the moral ramifications of over-ruling donation for all the patients and family members involved. Use of the family veto is not rare: in the past year 120 UK families over-ruled the recorded wish of their dying family member to donate,2 despite the family having no legal right to veto.3 The veto is also commonly used in other countries.

It’s understandable that the ghost’s wife was too upset to permit donation. It’s also understandable to some extent that the medical team wanted to give this deeply distressed relative what she wanted; continuing with donation despite objections from a family can be traumatic for doctors and nurses. They did not want to upset the ghost’s wife further, but they did, just not while she was in the hospital where they could see her distress. The ghost’s wife was not a patient but they put her wishes before his; they failed in their duty to him and to the other patients who were in need of the organs that he wanted to donate.

Professionals dealing with families of registered donors have a clear obligation to ask families to reconsider a veto. Relatives should be reminded that the wishes of the deceased should be respected, people might die if they do not receive organs, and families often come to regret over-ruling donation.4 Sometimes families will still wish to veto donation, and allowing an over-rule might be permissible in some cases—but normally only if the deceased had changed his mind since registering as a donor.

Ghosts come back to right wrongs, and the ghosts of would-be organ donors have clearly been wronged. Allowing families to over-rule donation without challenging them not only risks making the ghost of their loved one angry but risks creating other ghosts by contributing to the early deaths of other patients. If such ghosts really existed to haunt medical teams and family members, it seems unlikely that the family over-rule would be so respected. The problem with the real world is that medical staff fear the living, not the dead. Hopefully, this ghost will haunt clinicians to the extent that they strive to exercise their moral imaginations and fully consider all the consequences of their decisions.


Cite this as: BMJ 2015;351:h6244


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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