In recent field research among the poorer strata of Pakistani society, Farhat Moazam and colleagues have found that expenditure related to life-crises and life-cycle events are a prominent motivation behind selling kidneys for transplantation. (The other main motivation is debt). Not only do people have recourse to selling their own kidneys as a last measure in order to pay for medical care of gravely ill family members, in order to marry off a sister or to recuperate from a crop failure, but also in order to provide a decent funeral to a dead relative.

Historians and anthropologists support this observation – the poorer the person, the higher is his or her spending (relative to income) on dignified care for his or her dead. The Talmud summarizes, “A [typical] person cares for [the dignity of] his dead [relative] more [than he cares for] all of his property” (Talmud, Yoma 85a).

With this cultural attitude in mind we should approach the problem of harvesting organs from the dead for the sake of life-saving and therapeutic transplantations. Since saving life is a quasi-absolute duty and since most legal systems do not recognize property rights in the dead, secular and religious ethics are likely to endorse non-consensual harvesting of organs from the dead for the sake of transplantation. The bioethics literature is replete with such opinions coming from as diverse traditions as utilitarianism and Orthodox Judaism.

The clinical reality is quite different, though. Doctors avoid using organs against explicit refusal of the next of kin, even in countries where such practice is legal (e.g. "opting out" schemes). Put in other words, this is probably a singular situation in contemporary healthcare in which doctors conscientiously avoid the saving of a human life even though neither practical (e.g. immunological mismatch) nor legal barriers stand in their way.

This interesting case-discussion does not allow for ethical and sociological criticism and exploration of policies and practices regarding organ transplantation from the dead. However, having this set of observations in mind we may find it easier to advocate cooling down the patient under question. Refraining from doing so will add one more difficulty to the tortuous enough pathway towards procuring organs from the dead.

Additionally, it is also possible that the patient wanted to donate his organs, so letting him become non-transplantable is offensive to his personal autonomy as much as procurement against refusal is.

Cooling down the body does not alter or disfigure the cadaver; nor does it alter the natural process of death. A dead person has no well being of its own, so anything done to it can be neither harmful nor exploitative (Barilan, 2010).

In my opinion, the medical team should proceed towards transplantation and contacting the family simultaneously. The former should not be abandoned for failure to execute the latter. In the worst case scenario the wife will be found after the organs have been transplanted and express much anger and grief over the situation. As much sympathy as we may feel towards her distress, the life or lives just saved and the agony spared another person and family should balance the picture.

Only lack of good faith in search for the wife is a valid reason to withhold transplantation. Deceit in matters of life-and-death cannot be justified and cannot serve as a means towards a system of transplantation.

In order to underscore my point, let′s imagine that the patient′s wife is found out after the organs have been removed, but before they were transplanted into the bodies of the recipients. It seems to me that the wife exercises no moral authority to stop the transplantations. If she has a power of refusal at all, it is the power to preserve the integrity and dignity of her dead husband. Once the organs are removed, they are even less likely to be considered part of the dead body or properties of the wife. In sum, I would advocate procurement of organs as long as the actions involved are legal and attempts at contacting the family and establishing the wishes of the deceased are vigorously conducted as well.

The validity of brain-death as a threshold permitting (or mandating) organ-transplantation is the most difficult question, because it is a metaphysical issue which predetermines morality. If a brain-dead person is a live person, then procurement of organs and even preparing the patient for being a source of organs are prohibited. Every manipulation of the person for the sake of another, even for the sake of saving other people′s lives, is immoral and highly dangerous as well.

Since death is a gradual process, the "moment" of death is a cultural construct that is not likely to be resolved by biological criteria. Although legal in most Western countries, the brain-death definition of death is controversial (Lock, 2002, Appel, 2005). Parents who refuse to recognize brain-death as death have been allowed to take their brain-dead child for home-care on a respirator.[1]

If the patient or the doctors involved do not believe in the validity of the "brain-death" criterion for death, they are morally entitled to resort to the cardiovascular criteria. Perhaps the patient may find it permissible (although not obligatory) to self-sacrifice at a stage of brain death for the sake of saving life. An Orthodox Jewish rabbi has published such an opinion in a rabbinic journal on medical ethics (Bar Ilan, 1989).

There is leeway for dialogue and compromise in ethics when a fundamental metaphysical question is at the heart of a problem. This is one reason why the abortion debate and the brain-death debate, are not likely to be resolved. Most systems of ethics endorse life-saving abortions and, as we have just seen, some think that by means of advance directive a person may self-sacrifice his or her future brain-death state of existence. Self-defense from threats and supererogatory self-sacrifice has both moral roots that reach deeper than the definition of the person.